All in One...

ALL IN ONE
MASTERING RUBBER DAM &

COMPOSITE RESTORATION.
BY: AHMED HESHAM ABO BAKR

RESIDENT DOCTOR AT FACULTY OF DENTISTRY TANTA UNIVERSITY.
All in
one
Dedication
To those who cannot afford courses fees,
To those who don't hide the knowledge
which Allah hath bestowed on them,
To my dearest colleagues.
This book contains information obtained from mainly
composite courses and other sources like layers and
style Italiano website…etc.
My role only is to collect and edit this information to
make rich source for me first then I decided to share
this source with you.
This book contains QR codes that if you scan it, you
will get access to learning videos.
I am using smart QR app for android to scan these
barcodes.
)‫ وإن يك خطأ فمن قبلي والشيطان‬،‫(فإن يك صوابا فمن عند هللا‬
Please
For any comment (to add or modify) contact me on:
WhatsApp (+002) 01141015573 (Egypt)
Contents:
Section 1: Rubber Dam
3. Contact tightness testing. 21
History: 2
4. Marking holes. 22
Advantages of rubber dam: 2 5. Punching. 23
Disadvantages of rubber dam: 2 6. Suitable technique. 23
Indication & contraindication: 2 7. RD inversion. 24
8. Floss tie. 24
Components of rubber dam: 3 9. Suction pocket. 24
A. Sheets. 4
10. Practical notes. 25
B. Template. 6
Modification: 27
C. Punch. 6
▪ From winged to wingless.
D. Forceps. 9 ▪ From silver to matt.
E. Frame. 10 ▪ Fixation of 212.
F. CLAMPS (retainer). 11 ▪ From 212 to B4
▪ KSK 12 Special cases: 28
▪ Brinker. 13 ▪ Prepared tooth.
▪ Ivory. 14
▪ Split dam technique.
▪ Pakistani. 15
▪ Remaining root.
▪ Most used clamp. 16
▪ Rules in class V.
▪ Recommendations. 17 ▪ Rubber dam inversion in DME.
G. Accessories: 18 ▪ Larger molar.
▪ Dental floss. ▪ Holes addition.
▪ Elastic chain (ortho) ▪ Heavy contact.
▪ Wedgets. ▪ Leakage.
▪ Bite block. ▪ Role of rubber dam in cementation.
▪ Opaldam.
Recent trends in rubber dam. 31
▪ Teflon. 19
▪ Lubricant. 19 Rubber dam is obligatory or not.31
Rubber dam application technique: 20 Other isolation modalities. 32
1. Anchor tooth selection. 20 Gingival tissue management. 33
2. Clamp selection. 20
Section 2: COMPOSITE
Posterior composite: ▪ Class II classification. 139
1- Composite material: 37 5- Cases from A to Z. 141
▪ Composition. 37
▪ Recent trends in composite. 41 Interesting topics: 153
▪ Composite in market. 45 A. Postoperative composite complications:
▪ Expired composite. 46 154
2- Bond systems: 48 ▪ Immediate postoperative complications.
▪ Adhesive generation. 49 ▪ Late postoperative complications.
▪ Adhesive strategy. 53 ▪ Follow-up complications.
▪ Recent trends in bonding. 58 B. Composite repair. 158
3- Posterior Composite procedure: 60 C. Porcelain repair with resin. 159
A. Diagnosis. 61 D. The oxygen inhibited layer. 161
B. Systemic analysis. 61
E. Finishing and Polishing Time. 162
C. Local anesthesia. 62
F. Base & subbase that can be
D. Preparation of operating site. 62
used under composite. 163
E. Shade selection. 62
G. Glass ionomer. 164
F. Preoperative occlusal assessment:63
G. Prewedging. 63 H. Deep marginal elevation. 167
H. Isolation. 64 I. I-CON. 171
I. Caries removal. 64 J. Fiber reinforced composite. 175
J. Cavity design. 70 K. Indirect composite restoration. 177
K. Sandblasting. 76 L. Bleaching. 180
L. Etching. 77 Anterior composite: 194
M. Bonding. 81 A. Function. 195
N. Composite placement. 83 B. Shade. 196
• Composite layering technique. 87
C. Shape & texture detection. 211
• Snowplow technique. 91
D. Anterior preparation. 217
• Injection moulding technique. 92
• Guided cuspal reconstruction. 93
E. Waxing up. 219
O. Final layer painting. 95 F. Class IV. 220
•
Tips to minimize occlusal corrections. • Vanini's stratification technique.
•
Occlusal anatomy reproduction. 98 • Simplified layering technique.
•
Stamp technique. 100 • other Stratification Techniques:
•
Posterior composite staining. 101 G. Class III &V. 226
P. Curing: 104
H. Diastema closure. 230
• polymerization shrinkage. 108
I. Veneer. 235
Q. finishing and polishing. 111
J. Flow injection technique. 237
4- Class II mastering: 117
▪ Proximal regaining concept. K. Finishing and polishing
A. Ring. 121 armamentarium. 241
B. Proper wedge. 125 L. Anterior composite finishing and
C. Matrix band. 128 polishing. 248
▪ Tricks. 138 References: 253
ALL IN ONE 1 AHMED HESHAM
History:
 Rubber Dam was first introduced by Barnum, a New York Dentist in 1863.
Advantages of rubber dam:
 Patient related factors:
▪ Provides comfort to the patient.
▪ Protects the patients from swallowing or aspirating foreign bodies.
▪ Protects the patient’s soft tissues by retracting them from the operative field.
 Operator related factors:
▪ Stress free environment.
▪ Dry, clean operating field.
▪ Magnification is better to be used with rubber dam.
▪ Improved properties of dental materials (Composite & GI).
o Contamination of composite material lead to decrease in physical properties.
▪ Prevents contamination of tooth preparation.
o Contamination of itched enamel and dentin lead to decrease bond strength.
▪ Moisture control (saliva, sulcular fluid & gingival bleeding).
▪ Avoid any delay.
▪ Infection control by minimizing aerosol production.
▪ Increased accessibility to operative site (access to 2nd molar).
▪ Keeps the teeth saliva-free during the endo procedure, so the canals cannot be
contaminated by bacteria.
o Increase success rate by 30%.
o Prevent NaOCL to reach mouth tissues & swallowing it.
▪ Less fogging of the dental mirror.
Disadvantages of using a rubber dam:
▪ The L.A must be perfect (especially in cases of endodontic TTT)
▪ Takes time to apply (but saves more time during procedure)
▪ Cost.
▪ Communication with the patient can be difficult.
▪ Incorrect use may traumatize the gingival tissues.
▪ Insecure clamps can be swallowed or aspirated.
Indication & contraindication:
 Rubber Dam is indicated for any case and for every case, except:
▪ Asthmatic patients.
▪ Epileptic patients.
▪ Mouth breathers.
▪ Extremely malpositioned tooth.
▪ Third molar (in some cases).
▪ On porcelain crowns.

Components of rubber dam:
1. Sheets. 8. Accessories:
2. Template o Dental floss.
3. Frame. o Rubber dam napkin.
o Elastic chain (ortho)
4. Forceps.
o Wedgets.
5. Punch. o Lubricant.
6. Clamps. o Opaldam.
7. Scissors. o Teflon

Sheets:
 Colors:
▪ silk blue, intense blue, green, white, purple, black.
o Silk blue: provides…
 Better contrast.
 More light.
 Good photos.
o Black: photodam (by style Italiano). Also, provide the contrast
color to allow clear visual of the tooth or teeth during
procedures &photographing.
 Avoid it in deep margin elevation (DME): you can't see if
there is leakage (open margin) or not.
 Flavors: some rubber dam sheets are flavored ex: mint flavor. Is it only for show or not?
 Latex or non-latex:
▪ Non-latex (from Bibodent or coltene):
 It is better than latex for increased flexibility, high tear resistance. But the cost is more double
than cost of latex.
 for allergic patients.
o May use non-latex gloves & modify it to be used as sheet.
o Or use latex sheet with rubber dam napkin.
• Apply Vaseline to face (act as separating medium & adhesive to napkin) then apply napkin.
• May modify handkerchief to be used as napkin.
 Sizes:
▪ 5X5 inch (52 sheets):
o For pedodontics.
o Single tooth isolation.
o May used in anterior case due to its low cost (more sheets = low cost)
▪ 6X6 inches (36 sheets): for single & multiple tooth isolation & may modified by cutting to be used
for pedodontics.
 Thickness (may differ according to manufacture):
▪ Thin (0.15mm): avoid using it as it is easily teared.
▪ Medium (0.2mm): good to be used in cases of very tight contact or endo cases.
▪ Heavy (0.25-0.30mm): the most used in restorative procedures.
o Better isolation and retraction of soft tissue.
o Provide better inversion.
o Better control during preparation.
o But it can't pass tight contact: especially in cases of bruxism &clenching cases.
 Surface:
▪ Dull surface: avoid reflection of light during photographing.
▪ Shiny surface.
 Shelf life of rubber dam:
▪ More than a year in latex dam:
o Aging is accelerated by heating characterized by brittleness and easy tear.
▪ Can be stored in refrigerator to extend shelf life.
▪ Healthy/ strong dam will be difficult to tear when sheet is grasped with thumbs and index fingers.

Recommendation:
1- Nic tone latex: one of the best rubber dam sheets (high stretching 800%) from SEDRA dent 295LE.
2- Sanctuary dental dam from Bibodent.
• Silk blue / black: 225 LE. (photo dam)
• Blue / green: 150 LE
3- Coltene rubber dam sheet.
4- DuraDam: it is value for price (buy heavy one) 95 LE
5- Solo dam: from SEDRA dent 85 LE.
Coltene rubber dam

Usage
Type of Dam Benefits Recommendations
endo restoration
▪ increased transillumination.
Light: ▪ Enhanced view of clinical field. ✓
▪ Vanilla scented/greater patient acceptance
▪ Color contrast of clinical field.
Dark: ✓
▪ Increased visibility
▪ Color contrast of clinical field.
Green: ▪ Increased visibility. ✓ ✓
▪ Mint scented/greater patient acceptance.
▪ Improved photographic contrast of clinical
Blue: ✓
field.
Fiesta Dental Dam ▪ Fruit-scented, Greater patient acceptance.
✓ ✓
(pink, blue, purple)
▪ 100% latex-free & powder free.
▪ No patient or staff reaction to latex.
HYGENIC Non-Latex ▪ Increased transillumination.
Dental Dam ▪ Enhanced view of clinical field. ✓ ✓
(teal green) ▪ Extensive shelf-life.
▪ More tear resistant elastic than latex dam.
▪ No offensive odor.
▪ 100% latex-free & powder free.
▪ No patient or staff reaction to latex.
HYGENIC Flexi-Dam ▪ Increased transillumination.
Non-Latex Dental Dam ▪ Enhanced view of clinical field. ✓ ✓
(purple, teal green) ▪ Extensive shelf-life.
▪ More tear resistant elastic than latex dam.
▪ No offensive odor.

Hole positioning guide:
 Teeth as guide:
▪ In this dam is placed on teeth in mouth or on a cast of patient and then teeth under
treatment is marked with pen and then holes are punched.
▪ Advantages: precise positioning especially in cases of mal-aligned or multiple
spacing.
▪ Disadvantages: time consuming, dam is punched after the seating of patient.
 Template:
▪ Come with rubber dam sheets (of same size and shape of unstretched dam).
▪ template is placed over dam and tooth is marked with
pen which is then punched.
▪ Advantages: dam is punched before the patient and less
time consuming.
 Rubber dam stamp:

▪ They are very convenient and efficient way of marking the
dam for punching.
▪ Max centrals are positioned approx. one inch from the
top of dam.
Punch:
 Formed from:
1- Rotating metal disc:
▪ with holes varying in sizes.
o Largest size (5): for clamped molar (clamp 1st then dam sheet)
o Hole (4): for molar or clamped premolar.
▪ If hole larger than tooth, results in no seal (leakage).
o Can be sealed by Teflon.
▪ Narrower hole may be teared.
▪ Narrower hole better than larger one.
2- plugger:
▪ it should be very sharp & very smooth to make well defined hole
margin (clean cut = traumatic cut) 
▪ if it is blunt: (incomplete cut = neck or tag that causes easy tear or
improper seal)
o you may sharpen it by bur then finishing & polishing it.

 Two designs:
1. Ainsworth-design (Hygienic) rubber dam punch.
PAKISTANI
2. Ivory-design (Heraeus Kulzer) rubber dam punch:

o Has self-centering coned piston or punch point: This prevent partial punching of holes.
▪ IVORY (Alex dent)

▪ SEDRADENT
5- Anchor molar
4 – molar & Clamped premolar
3- Premolars & Upper canine
2 – upper incisor & Lower canine
1 - mandibular incisors

Dental tips by DR: Gurvinder Bhither.
Holes that are punched too close together. Use a variable size hole punch.
When placed both look identical from occlusal view.
If the dam is stretched between the teeth too much it will leave a space.
The smaller holes spaced further apart will self-seal the dam around the tooth, which can be
further secured by a floss tie.

Forceps:
 Function: To place clamp in position and remove it.
 There are two designs of forceps:
1- Straight one.
2- S-shape one: it is better than straight one as it is widely opened.
Clamp holder with undercut as a mean clamp holder without undercut

of retention (ball shape): (needle shape):
 not to let clamps fly.  Easy to remove it after
 But it stucks when removed. clamp application.
 But it is easy to fly.
 Balls forceps modification:

▪ Because the ball results in hanging especially in tissue retractor clamp.
o So, it is better to reduce it by bur. (easy to fly, so just reduce not completely remove)
o Or remove inner half of ball completely & reduce outer half.
 Notched forceps modification:

o round lower border of V shape by diamond stone.

Frame:
Used to maintain tension in rubber dam.
So, it helps in retraction of lip and cheek and tongue.
 Metal (Young frame):
▪ Not collapsed (unlike plastic) so more retraction.
▪ More durable than plastic.
▪ Removed during x-ray. 
▪ U-shape with curve to rest on chin.
 Plastic (autoclavable)
▪ Radiolucent.
▪ U-shape.
▪ star shape: better to be used in cases of
anterior (veneer) to tie floss in nose-side arm.
 Optradam:
▪ Frame + marked sheet
▪ Single use.
▪ Cost (65 LE) 
 Articulated / foldable frame:

▪ Foldable, so we don’t need to remove it during X-ray.
▪ The Egyptian one from DR. DENT PRODUCTS. (box has three frames = 200 LE)

Clamps (retainer):
Anchor/retain dam on teeth.
The Clamp is placed on most distal part of your field & the bow is always directed
distally.
 Serration:
 Give more retention especially in badly decayed tooth (Tigger clamp -ivory)
 Not used with crown to avoid crown fracture.
 Winged clamp: for more retraction & easy for application (in single step)
 Wingless:
▪ Used when matrix & wedge to be used.
o May modify winged clamp by cutting its anterior wings.
o Or place winged clamp on more distal tooth.
 Tissue retraction clamp = active clamp:

▪ For more apical positioning in cases of cervical cavity.
Active (tissue retractor) Passive ( non-active )
 Soft clamp (resin clamp):

▪ radiolucent in x-ray.
▪ Decrease force on tooth.
▪ One shape for molar.
Bracket or bow
Hole for forceps Jaw
Serration Central wing
Anterior wing Beaks

KSK (from Bibodent).
W/N= wingless.
A = active clamp.
T = tiger clamp (serrated)
Universal = used R & L
Unilateral = only R or L
 26 clamp: (joker clamp)

▪ Wingless clamp for upper & lower molars (universal molar).
▪ Passive clamp. (can be modified to be active)
 212 clamp: (butter fly clamp =double arch)

▪ Anterior &premolar clamp.
▪ Double arch for more stability of clamp in anterior.
o Not used with angulated anterior Teeth.
o prevent placement of clamps on adjacent teeth.
▪ Modified 212 clamp:
o Bending to be more active.
o Sectioning to be like 44/B4 clamp.
 W2A clamp:
▪ Universal premolar clamp.
▪ Active clamp.
 W3 clamp:
▪ Wingless clamp for upper &lower small molar (universal molar).
▪ Passive clamp.
▪ More distal bow. (to allow operation of the same clamped tooth)
 44 clamp (= Brinker B4)

▪ Active clamp for anterior and canines.
 W8A clamp: (joker clamp)

▪ Wingless clamp (universal molar).
▪ active clamp (short crown, class 5, badly destructed teeth)
▪ Small jaw (catch tooth M or D not both so allow operation of distal surface of last tooth).

 138 & 139 clamp:
▪ Wingless clamp (unilateral molar = 138 used with right upper and left lower).
▪ Active clamp.
▪ Can be used with third molar.
▪ The best for class v in molar:
o serrated. L
o Strong.
o More accessible area in cervical (small jaw).
 12A & 13A clamp:

▪ Unilateral clamp.
▪ Serrated.
▪ Used with third molar.
 24 & 25clamp:
▪ For deep buccal cavities of molar.
▪ Wide fringe for buccal side.
 G1 & G2:
▪ Not for rubber dam but used with cotton rolls.
▪ Very big wings are for tongue and check press.
Brinker/hygienic clamp.
6 active clamps.
 B1:
▪ For lower molars and may be used with all molars.
 B2 & B3:
▪ B2 for upper left molar – B3 for upper right molar.
 B4:
▪ active clamp for anterior & canines.
 B5 & B6:
▪ high arch to give space to you for operating adjacent.
▪ Class V restoration.
▪ It is enough in multiple isolation unlike B4.

Ivory clamp (TOR VM)

Pakistani:
You can find most of other brands of clamp in Pakistani clamps: ex: 26 – 27 – B4…etc.
But it is better to use only passive one.
 Premolar clamp: (206 – 207 – 208 – 209)
▪ Universal premolar, vary in size.
 Molar clamp: (200 – 201 – 202 – 203 – 204 – 205)
▪ 200 clamp: for lower molar with broad fringe.

▪ 201clamp: similar to 200 with festooned beaks
▪ 202 clamp: for larger molar.
▪ 203 & 204 clamp: for small lower molar right and left.
▪ 205 clamp: for upper molar.
 Anterior clamp: (210 – 211 – 212)
212
210 211
▪ For labial cavities on anterior.

▪ Passive clamps.

Most used clamps
Molar clamps:
26
27 W8A 12A 138 &139 W14A B1
(passive)
 Pak  PAK  KSK  KSK  KSK  KSK  Brinker
 KSK  IVORY
Premolar clamps:
206 (passive) B4 W2A

 Pak  Brinker  KSK
 KSK
 Ivory. (serrated)
206 KSK 206 IVORY W2A KSK
Anterior clamps:
B6 44 (KSK) /
210 (passive) 212 (KSK) or
(Brinker) modified 212
or B4 (Brinker)
 Pak ▪ Double arm covers adjacent tooth. ▪ Secondary clamp: Used in multiple
 Ivory. ▪ Primer clamp: Used in single isolation isolation (as they cannot withstand
instead of B4/44. single isolation)
▪ Modified 212: can be used with molar.
210 (6) IVORY 212 KSK 44 KSK B4 Brinker
▪ Secondary clamp:
o mostly active clamp used for more retraction or adaptation of dam.
o If used as primary clamp. It will be deformed after several times.
o Ex: 44 or B4 / W8A / W2A / modified 212.

Recommendations:
 Passive clamps:
▪ We can use Pakistani clamps instead of brands here (no action needed so decrease possibility
of fracture, decrease cost)
o For anterior: 210 – 212.
o For premolar:206-207-208.
o For molar: 26 (wingless) -200-201-202.
 Active clamp:
▪ Using cheap / Pakistani clamp is not favorable here (easily fracture / poor quality), so by
brands (high quality).
o For anterior: 212 - 44 (KSK) or B6 – B4 (Brinker)
o For premolar: 212-44-W2A. (KSK) or B4 (Brinker)
o For molar: W8A -138 &139 (KSK)
 Clamps in market:
▪ HYGENIC BRINKER. (Starting from 260- 300 L.E.) ➔ ???!
▪ KSK (DENTECH). (150 – 350 L.E.) ➔ Bibodent
▪ IVORY. (150 L.E.) ➔ Alex dent (weak metal than original one)
▪ Sedradent clamp: (75 L.E) ➔ Sedradent Egypt.
▪ PAKISTANI: (25 – 30 L.E.) ➔ Everywhere.
Make your clamps kit:

Anterior clamp:
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
Premolar clamp:
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
Molar clamp:
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………
▪ ………………………………………………………………………………………………………………

Accessories:
Floss:
 Used to tie clamp before insertion in oral cavity to avoid accidental aspiration.
 Facilitate RD insertion between teeth (pass contact).
 FLOSS TIE to secure RD or retract it more gingival.
Elastic chain:
 Can be used for retain dam in position in cases of anterior
teeth.
Pic: by ahmed kutainy.
Wedjets:
 Dental dam stabilizing cord: Used to secure
rubber dam in position.
▪ may use strip of rubber dam instead of it.
Bite block:
 to avoid fatigue of muscles due to mouth opening
(muscles is relaxed rather than to be in tension)
liquidam / Opaldam / flowable composite:

 used to make extra seal (seal any leakage) by injection all
around tooth.
▪ In case of using flowable composite:
o Dry then add bond drop without curing (optional) then
add flowable &curing.
 Or used to fix R.dam in position (flowable wings), especially in cases of prepared tooth
when stabilizing dam is difficult.
▪ It is better to use self-adhering flowable (Vertise flow kerr).
o It needs fresh surface (refresh your surface by diamond tip)
o Dry then add flowable and wait for 5 to 10 seconds to
achieve the specific adhesion required. (If you wait 20 seconds
as constructor says, the self-adhering process will be completed and you
will need to cut with a bur the wings) then cure.

Teflon
 Autoclavable: Roll Teflon on metal handle and place it in autoclave.
 Uses of Teflon:
▪ Make extra seal (seal any leakage) as it is hydrophobic.
o Deep marginal elevation.
o On wedges: put Teflon 1st then wedge.
o In cases of class V: place Teflon M&D to avoid any surprise if frame or dam moved.
▪ Used with wedges to increase its size. (wrapped around wedge)
▪ Increase adaptation of sectional band.
▪ Provide lateral / horizontal retraction to expose the margin.
▪ Used as retraction cord.
o May used before application of clamp to avoid biting on gingiva.
✓ It will be difficult if you try to roll Teflon to insert it in sulcus, but use it as tab and
gentle pack it by wetted instrument.
✓ Place drop of water on instrument to avoid adherence with Teflon (hydrophobic).
. .
Lubricant:
 To facilitate RD passing through the interproximal contact.
 Using soup (ex: Dettol hand wash) or KY gel as lubricant is better than Vaseline.
▪ As soup is water soluble so it is easy removed rather than Vaseline (non -water soluble) so
it will act as separating medium (interfere with composite bonding).

Rubber dam application technique:
1- Anchor tooth selection:
Single VS multiple isolation
VS
 Single isolation:
▪ Easier & simpler.
▪ Used in:
o Cases of endo and the tooth is sound or previously built up.
o Cases of class I, class v.
• But it is better in class 1 cases to make multiple isolation to have a guide from
neighboring teeth for occlusal building.
 Multiple isolation: .
▪ More area = more visibility.

▪ Easy to have a guide from neighboring teeth.
▪ Let the door open for many solutions.
▪ Used in: (most cases) .
o Cases of contact reconstruction.

o Taking adjacent tooth as a guide for occlusal building.
▪ two teeth before and after.
Working area Multiple isolation
Two centrals. 4– 4
4 anterior. 5– 5
6 anterior. 6-6
2- clamp selection:
 Select clamp that match tooth size.
▪ Maintain four-point contact with the tooth’s proximal surfaces.
▪ Test it by placing clamp on tooth & ensure there is no rocking (clamp is
stable in position).
▪ If a clamp is too large, it will impinge on the soft tissues.
▪ If it is too small, it will not properly grasp the tooth’s surface, and will be unstable.
 In cases of class II & V:
▪ the clamp peak must be below 
cavity margin.

Clamps for anterior teeth isolation:
 Primary clamps:
▪ Single isolation: o 212 has no wings so place sheet 1st
o Class V: 212 or B5. (difficultly in application).
o Endodontic treatment: 210 o 210 has wings so it is easier to be used
in single isolation (all in one).
▪ Multiple isolation: on premolar 206 / 207
 Secondary clamps:
▪ Multiple isolation:
o Class V: 212 or B5
o Class V and veneers: 44 / B4
Clamps for posterior teeth isolation:
 Primary clamps:
▪ Single isolation:
o premolar: 206 or W2A or 210 or 212.
o molars: 26 or 27 or W2A or B1
▪ Multiple isolation (on 2nd molar): 26 or 27 or W2A or B1
 Secondary clamps:
▪ Used in multiple isolation: for extra isolation and gingival retraction.
o Premolars:
• Class V or deep class II: B4 / 44.
o molars:
• Class V or class II: W8A.
• Deep class II: modified 212 (smaller jaw, so not interfere with matrix)
3- Contact tightness testing (by dental floss):
 Types:
▪ Extremely tight (floss can't pass).
▪ Tight (pass with resistance).
▪ Normal (pass with slight resistance).
▪ Loose.
▪ Diastema.
 Clinical significance:
▪ Application technique.
▪ Sheet thickness: medium in cases of very tight contact.
▪ Inter-holes distance:
o Tight contact: make holes closer than that in template (decrease inter-hole distance)
o Normal: no changes in template holes.
o Loose: make the distance between the holes slightly wider than that in template (increase
inter-hole distance)
o Diastema (1mm or more): add the diastema distance to that distance between template
holes.

4- Marking holes:
 Template holes: in cases of normal alignment.
▪ Upper teeth: divide the sheet into two haves horizontally and three vertically.
o If the tooth in left quadrant: let left vertical third empty and start your marking from left
vertical line. (to control excess)
▪ Lower teeth: divide the dam into two haves horizontally + horizontal third superiorly and
three vertically.
o The closer the tooth (more anterior), make the hole more superior (so decrease superior
excess).
Mandibular Mandibular
2nd molar 1st molar
Mandibular Mandibular
2nd premolar anterior
 Custom made holes:

▪ Marking on teeth (inside patient mouth) in cases of
crowding.
o Marking on framed sheet (stretched).
o Mark on incisal edge (anterior) and central fossa
(posterior).

5- Punching:
 Make hole size matches the selected tooth.
▪ Narrower hole better than larger one.
o When using Non-Latex Dental Dam, it is advisable to punch one-hole size smaller
than recommended for latex dam.
▪ If you make larger hole = leakage.
o Apply Teflon or liquidam for extra seal.
▪ Make your hole definite with sharp margins:
o After punching, don't release your hands and pull the dam up over the plugger.
o Improperly cut hole will result in a tag or
neck that may cause the dam to tear while it
is being placed or leakage after placement.
.
6- Suitable technique:
All in one (one step):
 Helpful in most distal tooth.
 Wing technique: with winged clamp. .
▪ Hang RD sheet on middle wing of clamp and place both in patient mouth.
▪ Then by plastic instrument place dam under clamp wings.
 Bow technique: with wingless clamp:

▪ Hang RD sheet on bow of clamp.
.
Sheet 1st:
 Need four hands (dentist + assistant): .
▪ The sheet is inserted first over the anchor tooth, the clamp is then placed
on the tooth and finally the sheet is stretched over the frame.
 Clamp less technique:
▪ Indicated in cases of multiple isolation anterior (at least 3 teeth) .
▪ The middle tooth is passed through sheet 1st then mesial one and finally
distal tooth (anchor)
▪ Sheet is fixed in situ by sheet strips, Wedjets, wooden wedge …etc.
Clamp 1st:
 Lubricant is important to facilitate placing dam sheet. .
▪ The clamp is inserted first over the anchor tooth, the sheet is then slide
over the clamp and finally the sheet is stretched over the frame.

7- RD inversion:
 It means placing the rubber around the cervical area and in the sulcus, and keeping it
there until the end of the restorative process. (protecting from sulcular fluid)
 the rubber should sit around the cervical area passively (not in tension).
 Four levels of inversion according to style Italiano:
▪ Level 1 = air inversion:
o By blowing air around the cervical area and,
at the same time, pushing the rubber into
the sulcus with a spatula.
o Not possible in cases of:
• When excess saliva is under the rubber (use cotton in vestibule)
• when teeth are not completely erupted, and the maximum convexity is placed at the
gingival area (use floss)
▪ Level 2 = dental floss inversion:

o By using multiple isolation with floss.
o Not just around the teeth that are operated, to prevent
surprises during our adhesive procedures, such as drops of
saliva appearing in the area where the inversion was not properly made.
▪ Level 3 = floss tie / knot ligature inversion:
▪ Level 4 =Teflon inversion:
o Teflon tab used in proximal area (DME =
Deep Marginal Elevation)
 Simple steps:
▪ 1st make inversion interproximal (M & D) by dental floss.
▪ Then B&L by air inversion with plastic instrument (angulated by 45 to tooth)
▪ Then for operated tooth use floss tie/knot or active clamp.
8- Floss tie (self-ligating floss ligature):

 Used to secure rubber dam in position or inversion
guard: to ensure long standing inversion and also
some gingival retraction.
.
 Or with class V cases.

 In cases of labial veneer, you can make tie lingually.
9- Suction pocket:
 Make Pocket by sheet to be area for water collection and so for
placing low suction tip. (if not, may place cotton)

Practical Notes:
 In multiple isolation.
▪ It is advisable to let 2 teeth before and after the
operated tooth.
▪ Stop at area where you can pass sheet in contact easily
(canine or centrals).
▪ Start with last distal tooth (anchor), stretch the dam so
that the remaining holes line up with the teeth. Begin
with the most anterior hole and work back.
▪ Mesial fixation (most mesial tooth in multiple
isolation):
o There are 5 options:
1- No fixation: just pass contact in cases of tight contact.
2- Floss ligature.
3- Wedge.
4- Rubber dam strips.
5- Reverse clamp: in cases of diastema (but it is better to expand your field until reach
optimum contact or in area where clamp is away from your field).
▪ Knife edge technique:

o When you are trying to push the dam through the
contact, don't push it as one unit in the same time,
tearing will occur easily. Instead, knife the edge
through the contact, and if the contact is not so tight,
the sheet will pass.
▪ Loop technique:
o Using double floss to make sheet pass contact.
o If the dam is not totally carried through the contact,
the lingual end of the waxed floss is looped over and
carried through the embrasure again. The floss, now
doubled upon itself, can be removed by pulling both
ends buccally without disturbing the dam. This
process can be repeated until the septum is
completely through the contact.
▪ In cases of upper anterior:
o It is better to use star shape frame so now you can tie floss on it & keep tension of
dam on upper area.
• Other options are:
- inverse your U-frame (make chin side on
nose).
- use double frame technique.
- Plastic frame (Kerr) and make holes by bur for floss.

 It is better to avoid using active clamp (deeply reached clamp) routinely to avoid
gingival trauma.
 Squeezing sheet with clamp:
▪ In cases of gingival inflammation, and inversion cannot be
done, place clamp that anchor sheet with tooth (sheet is
squeezed between tooth and clamp) to avoid any
leakage.
 Clamp instability:
▪ Place facial and lingual composite button to secure clamp in position.
o Apply self-etch bond and make composite button than place clamp.
 Orthodontic wire:
▪ Positioning the clamp below the orthodontic
attachment, the dam straddles the wire and
therefore does not seal.
▪ So, place The clamp above the orthodontic
attachment and wire; thus, the dam seals
perfectly.
 Active tongue:
▪ Cross arch stabilization: provide tongue splinting (especially in lower arch), also
provide more visibility and decrease tension in working field.
o By placing two clamps on 6 or 7 molar on both sides.
 Mouth breather:
▪ Central hole in rubber dam sheet (in most cases it is psychotic so it is difficult to use rubber dam).
 Optimization: the role of 5.
▪ Just sealed: there is no leakage.
▪ Just white: only teeth appear.
▪ No transparent: no saliva.
▪ No pink: no gingiva.
▪ No red: no blood.
 How can we optimize:
▪ Pass contact: by knife edge or floss.
▪ Clamp rocking: Shake the clamp Bucco-lingually to get more adapted sheet around
the tooth you clamped.
▪ Rubber dam inversion.

Modification:
From winged to wingless:
▪ As winged clamp interferes with matrix band and wedge so we can make our
clamp wingless by removing anterior wing then polish it.
▪ Using premolar clamp (make it wingless & widen it) to be used with molar give you
the advantage of small jaw.
From silver to matt or black:

▪ Matt or black clamp less reflection to light than silver one.
▪ Can be achieved by sandblasting silver clamp (But it increases chance of rusting ).
black matt silver
Fixation of 212 clamp:

▪ Can be fixed in position by cotton or flowable composite to avoid rocking.
▪ Or use compound for fixation.
From 212 to B4/44:

▪ modified Pakistani 212:
o 1st: make 212 more active by bending.
o Then by sectioning turns into B4 or 44.

Special cases:
Prepared tooth
▪ The tooth becomes smaller so use premolar clamp.
▪ Due to preparation (tapering) the tooth cannot retain
clamp so use serrated clamp to be secured in position.
▪ Or make multiple isolation and use flowable wings on
prepared tooth.
Split dam technique:
▪ Indication:
1- Remaining roots subgingival (not all cases).
• We can make crown lengthening and use active clamp
2- Extremely tight contact.

3- Crown preparation (rubber dam to protect tongue & check)
4- Fixed prosthodontics Bridge.
5- Amalgam bridge removal.
6- Gingivectomy.
▪ Use liquidam or flowable for area isolation.
Rules in Class V:
1. Make the space between two holes of adjacent tooth larger:
o Increase the distance between this tooth hole and both mesial and distal holes than
in template by 1mm.
o As RD in class V is more positioned apically, so need more dam to cover interdental
papilla.
2. Punch hole of class V slightly labial by 0.5 – 1mm:
o As class V more buccal.
3. Retraction cord is a must.
o Apply teflon cord (better than retraction cord) before drilling and dam application to
provide gingival retraction and create hydrophobic gate that prevents cervical
leakage.
4. Use active clamp (44/B4 or 212) to give more retraction
and retain dam below gingival margin.
o Floss ligature may be used before clamp installation for
more retraction and secure.

 Anterior class V and index will be used:
▪ Use floss tie guided by clamp:
o Pass floss tie under clamp, then remove clamp and build palatal shell.
o Now you can use clamp again after removing index.
Case by: Dr Ahmed Saad
Rubber dam inversion in deep margin cases:

 In deep margin: make space between two holes larger.
▪ The deeper the margin, the larger the space between two holes.
 Hakim's trench technique (act as sulcus for rubber dam inversion) is needed.
 Inversion can be done by:
▪ Teflon. ▪ wedge. ▪ Active camp.
▪ Note: using active clamp in

adjacent tooth is a must.
Larger molar:
 When the molar needs hole larger than the largest hole in
punch use twin hole punching.
Holes addition:
 After rubber dam application and you need to add one more hole to include other
tooth/teeth in your isolation field, use tweezer & scissors technique.
▪ Lift the dam above the tooth by tweezer then cut it by scissor.
Heavy contact:
 Prewedging:
▪ For all teeth included in isolated field.
▪ May be uncomfortable to patient.
 Split dam technique.
▪ May use light rubber base material to seal around the emerging teeth.

Leakage:
 Leakage around tooth:
▪ Improper hole alignment: custom made holes is indicated in this case.
▪ Overstretching the sheet, so over widening the holes.
 Inter dental dam tearing: due to over forcing the dam with the floss through the
contact.
▪ Avoid it by: using lubricant & gentle insertion of septum.
▪ Solving it by: teflon mini-dam or double sheets technique.
 Around the clamp:
▪ Causes: improper clamp rocking or in cases of subgingival clamp (W8A).
▪ Solved by: clamp rocking or teflon / flowable composite between clamp peaks.
 Gingival seat in class II:
▪ Proper inversion and/or teflon tab.
 Gingival seat in class V:
▪ Use teflon cord before rubber dam application (may be used after, if needed).
Roles of rubber dam in cementation:
 Retraction cord before dam.
▪ As retraction cord absorb water so used under dam.
 Multiple isolation.
 Active clamp (B4).
 Check crown if full seated or not.
 Then cementation &curing
 Finish margin from any excess of resin cement to avoid gingival inflammation.
 Remove dam.

Recent trends in rubber dam
To provide more simplicity.
 Pre-contoured dam:
▪ To decrease tension on sheet so may no need for clamps.
▪ Has dots can cut it to provide holes (no need for punching).
 Relaxed fit dam:

▪ Relaxed dam works well for hard to reach posterior teeth
▪ Folds easily to the side so radiographs may be taken without
removal of the dam
▪ Compact design fits outside patients lips
▪ Single use only
▪ Comes pre-assembled
 Mini dam: only inter dentally.

▪ Reliable local protection of the proximal region
▪ Quick and easy
▪ comfortable for patients
▪ Secure hold without clamps
▪ Latex-free
Is Rubber dam obligatory or not?
It is your decision to use rubber dam or not.
▪ Rubber dam is the most effective isolation modality.
▪ “SMALES concludes that there is no difference between the use of the rubber
dam and cotton roll isolation; each relates to restoration quality and survival”
▪ Achieving effective isolation is more important than the specific technique
used. (RASKIN ET AL, FUSAYAMA)
▪
There is some evidence indicating that rubber dam use during resin bonding
procedures involving enamel leads to improved bond strengths and reduced
micro leakage, while other studies have shown no difference in outcomes for
restorations placed with rubber dam or good cotton roll isolation (in cavities
with enamel margin).
Summit’s fundamentals of operative dentistry

OTHER ISOLATION MODALITIES:
COTTON ROLLS.
SALIVA EJECTORS AND HIGH-VOLUME EVACUATORS (HVE).
RETRACTION CORDS.
ANAESTHESIA.
DRUGS.
ADVANCES IN ALTERNATE MODALITIES:
COTTON ROLL HOLDING DEVICES.
 Note: You may use G1 clamp (KSK) or any
winged clamp is enough for holding cotton.
 Haller camp:
▪ control of tongue and cheek.
▪ Fixation of cottons.
▪ Retraction of gingiva.
▪ Use x-ray film in the Haller Clamp to
prevent gingival trauma and
hemorrhage in a challenging second
molar
ISOLITE & ISODRY (MR. THIRSTY).
 Single use.
 Not popular in Egypt.
 Components:
▪ Bite block.
▪ Tongue shield.
▪ Check shield
▪ Illumination path.
▪ Vacuum channel
HELpie:
▪ Bite block.
▪ Housing for suction tip.
▪ Tongue cone.

Gingival tissue management:
Especially in class V & class II.
STRATEGIES TO MANAGE GINGIVAL TISSUES:
1. Rubber dam in conjunction with prewedging.
2. Teflon / PTFE napkins.
3. Retraction cords and astringents.

▪ Self-impregnated retraction cords are less potent as
vasoconstrictor than non-impregnated one that need to be dipped
in astringents immediately before placing.
▪ Astringents:
o Viscostat (20% ferric sulphate): (75 LE)
• one of most potent astringent (stop bleeding
immediately in cases of deep marginal elevation).
• Severe discoloration.
• Interfere with bonding.
o Viscostat clear (25% aluminum chloride): (95 LE)
• less potent astringent.
• Not cause discoloration or interfere with
bonding (used in esthetic zone).
• If you use viscostat with epinephrine impregnated cord causes violet percipetate.
4. Specialized hand instruments.

▪ DEDICATED HAND INSTRUMENTS: Developed to have removable disposable end
instead of metal. (LM.gingiva)
o Retract the gingiva from the restoration.
o Allow better working angle for class V restoration than
in clamp retraction.
o The plastic tips allow certain flexibility for more
adaptation while pressured.
o The tip acts as a tight seal between the gingiva and
tooth.
o Protects the gingiva and diminishes the debonding
failures.
o Possible to customize with bur in order to fit a convex or concave root detect.

5. Soft tissue lasers.
▪ In cases of gingivectomy or crown lengthening.
▪ High cost.
6. Gingival modelling:
▪ It is papillectomy or trench technique (class II) used when gingival margin of cavity is
equigingival or the soft tissue covers the margin with insufficient space for wedge
separation. (Deep Margin Acquisition = DMA).
HAKIM trench technique.
▪ Instead of removal all papilla, only make trench by thermacut bur adjacent
to the operated tooth. (this trench act as sulcus for rubber dam inversion)
▪ Advantage here is maximum preservation of ID. papilla.
o Done by:
• Thermacut bur (Dentsply) or dull round diamond bur without coolant (So, the
.
action is peeling of gingiva without bleeding).
• Soft tissue laser.
o technique:
• Infiltration anesthesia in papilla to decrease bleeding and pain. .
• Papillectomy or hakim trench technique.

• try wedge: if below the margin, acquisition is completed.
Papillectomy by thermacut bur.

Notes
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Composite material
Composite
material Composition.
Recent trends in composite.
Composite in market.
Expired composite.

Composite material
 It is not only matter of material:
▪ Failure due to material is only 1-3% per year, so the procedure is more important
than type of composite.
▪ The main reasons for the failure of posterior composite restorations are:
o Secondary caries.
o Fracture.
o Incorrect cavity design.
So, we notice that causes of
o Bad diagnosis. composite failure mostly due to
o Incorrect finishing and polishing. the technique not the material.
o Operator skills.
Filler:
 Amount: (by volume not weight)
▪ Increase amount of filler lead to increase mechanical properties and decrease shrinkage &
stickiness. (should not be less than 60% by volume) High filler containing composite:
▪ Also lead to decrease curing depth & manipulation. Grandio & GrandioSO from voco.
o Bulk fill composite has ceramic filler (that has light
conducting properties) & increase in photo initiator so increase curing depth.
o flowable composite has decrease in amount of filler so lead to:
• Increase shrinkage, wear and stickiness.
• Decrease strength.
 Size:
▪ Decrease in size give more esthetic but less strength.
1. Macro: good in strength but bad in esthetic.
2. Micro:
• Poor in strength (not used in region of high occlusal stress: posterior and class IV).
• Good in esthetic (highly polishable = enamel like: as if filler is removed from composite let
small area in surface = less roughness = less stain)
- Used in direct veneering (as single layering in partial veneer or as final layer in all veneer)
- Class III & class IV (not receiving a lot of stress)
3. Micro hybrid:
• Better in strength and esthetic (mix between different size of filler in micro range)
• Indicated to be used in anterior and posterior but it is better to be used posterior only as it
is not polishable like micro or Nano and subjected to luster loss with time.
- Ex: 3M Z250, coltene swiss tec, voco polo fill.
4. Nano hybrid (universal): is the best in strength and esthetic.
• Also has Chameleon effect: match neighboring tooth color, it is universal composite for
posterior and anterior.
- Ex: 3M Z250 XT (390 LE).
5. Nano pure: (clusters of Nano particles to form micro one + clusters form macro)
• So high polishability (Nano) & high mechanical property (clusters).
• Used for anterior and posterior.
• Only by 3m: Z350 XT (680 LE).

Voco Composite classification
Filler degree
product Material class
(% by weight)
Amaris Micro-hybrid. 80
Amaris flow Micro-hybrid. 64
Grandio Nano-hybrid. 87
Grandio flow Nano-hybrid. 80
grandioSO Nano-hybrid. 89
grandioSO flow Nano-hybrid. 81
grandioSO heavy flow Nano-hybrid. 83
 Composition:
▪ Zirconium filler (3M – IVOCLAR….) better than silica/quartz or barium filler.
o DX composite (dentex):
• has barium filler that has high water sorption so causes hydrophilic degradation of bond.
• But has good manipulation and high filler so can be used as core for crown.
Silane: Links between filler and matrix.
Initiator and light curing unit (LCU):
Initiate polymerization reaction when subjected to light.
 Camphor Quinone (CQ):
▪ The peak sensitivity of CQ is near 470 nm in the blue wave length (led curing unit)
▪ Disadvantage:
o It makes composite yellowish.
o Has peak absorption in the visible range, resulting in fast photo polymerization under dental
lamps.
 Phenylepropanedione (PPD) or lucirin (TPO):
▪ Its peak near 360-420 nm in violet wave: Not use led curing unit & if used you must
increase time of curing and decrease increment thickness.
▪ Overcome problem of CQ (no yellowing) so used in bleaching composite.
o (PPD) Reduces the rate of stress development without decreasing the final material
performance properties.
Light curing unit (LCU):
 QTH LCUs: have a broad spectral range so can cure composite that contains CQ and TPO.
 Dual peak LED LCUs:
▪ Have a primary emission peak at around 460 nm to cover the absorption spectrum of the
CQ/TA.
▪ And an additional peak at around 400 nm to match TPO and PPD.
o This should be considered when curing bleached shades, even if the manufacturers do not
indicate the presence of TPO in their materials.
o Most major dental supply manufacturers market their own composite and LCUs.
• Ex: voco bleaching composite & Blue-phase Style light curing unit.

Inhibitor:
Pigmentation.
Matrix:
 BisGMA (traditional monomer):
▪ Low polymerization shrinkage due to High molecular weight.
▪ Less degree of conversion due to the stiff bisphenol A core.
▪ Poor handling (hard) & less filler incorporation due to high viscosity.
 BisGMA + TEGDMA (diluent =lower viscosity)
▪ The high flexibility of TEGDMA due its low molecular weight structure.
o Compensates the rigidity of BisGMA & increase conversion rate.
▪ But TEGDMA is responsible for an increase of the water sorption by the material and
shrinkage.
 UDMA:
▪ Used alone with TEGDMA, or associated with BisGMA and/or some other monomers.
▪ High molecular weight (somewhat not far from that of BISGMA) & lower viscosity:
o Increased conversion rate and flexural strength. (due to the greater flexibility and weaker
intermolecular bonds promoted by UDMA than BisGMA)
o Good handling and decrease shrinkage.
▪ UDMA with other monomers as in low shrinkage composite.
o ex: GC KALORE (that formed from (UDMA),dimethacrylateco-monomersand DX 511monomer
(low shrinkage monomer))

Recent trends in composite material:
Self-adhesive flowable composite:
 Product benefits:
▪ Self-adhesive: bonds to dentin and enamel without a separate bonding agent.
▪ Radiopaque: easily stands out on an x-ray for quick and easy diagnosis.
▪ Seals dentin: offers the potential for reduced sensitivity.
 Indication according to manufacture:
▪ Self-Adhesive base liner under higher viscosity restorative materials.
▪ Blocking out undercuts.
▪ Class III restorations, Class V restorations, Restoration of small Class I cavities.
▪ Pit and fissure sealant.
 Examples:
▪ Vertise flow. (Kerr)
▪ Fusio Liquid dentin.
 Comment:
▪ It acts as self-etch bond, so it has weak bonding to enamel.
▪ It has property of flowable composite (weak in mechanical property), so to be used as a
final restoration??
 Technique:
▪ It needs fresh surface so refresh your surface by sandblasting or etching.
▪ Dry then add flowable and wait for 20 seconds till the self-adhering process completed
then cure
Organically Modified Ceramic (ORMOCER):
 Composition:
▪ Organic molecules segment having methacrylate groups which form a highly cross-linked
matrix.
▪ Inorganic condensing molecules to make three-dimensional network which is formed by
inorganic polycondensation. this forms the backbone of ORMOCER molecules.
▪ Inorganic silanated fillers.
 It is described as three-dimensional co-polymer (the ORMACER matrix is polymer
even prior to light curing).
 Advantages:
▪ More biocompatible than conventional composites.
▪ Higher bond strength.
▪ Polymerization shrinkage is least among resin-based filling material.
▪ Low residual monomer release.
 Comments: (by some researchers)
▪ Less surface microhardness compared to conventional Nano-hybrid composite.
▪ It needs longer curing time.
▪ Not get affected in terms of roughness or microhardness after it is bleached by many
systems, it doesn't need to be changed as the inorganic part of the matrix protect it from
debonding by bleaching.

VOCO ORMOCER.
product Material class Filler degree (% by weight)
Admira Micro-hybrid ORMOCER. 78
Admira flow Micro-hybrid ORMOCER. 63
Admira fusion Nano-hybrid ORMOCER. 84
Admira fusion flow Nano-hybrid ORMOCER. 74
Admira fusion X-tra. (bulk-fill) Nano-hybrid ORMOCER. 84
Admira fusion X-base (bulk-flow) Nano-hybrid ORMOCER. 72
Bulk fill composite:

 Change in composite material according to different manufacture:
▪ Decrease polymerization shrinkage by:
o Use modulators in organic matrix: Something which to modulate polymerization reaction to
decrease polymerization reaction.
o UDMA only (no BIS-Gama).
• Decrease polymerization shrinkage.
• But decrease wear strength.
o Low modulus filler: so more flexible = shrinkage stress reliever.
Shrinkage stress reliever: Modulus of

elasticity 10 GPa.
Glass filler: Modulus of elasticity 10 GPa.
Monomer chain.
Force.
▪ Increase curing depth by:

o Increase initiator so more curing depth.
o CERAMIC FILLER: Decrease shrinkage, increase curing depth to 4mm due to its
conducting properties. (translucent)
• But now it is very sensitive to light so need light sensitivity filter to be sensitive only for
light cure light.
▪ In class II restorations as they allow easier establishment of physiological contact points.
 Types:
▪ Bulk flow:
o Avoid using it in occlusal due to high wear.
o Used as base rather than traditional flowable due to high curing depth.
▪ Bulk fill packable / sculptable:
o Used only in posterior as in anterior we need layering technique for natural look.
▪ Sonic-fill (Kerr):
o sonic activated & bulk fill composite.
o The only one can be applied in 5mm
o Use composite heater for maximum adaptation.

Traditional layering Bulk fill flowable Sculptable bulkfill with Sonicfill system.
technique. with universal cap. flowable liner. Only one layer.
Several layers. two layers. two layers.
Single-fill
The true single step bulk
fill to 5mm.
Increment
Product Manufacturer Consistency Application
thickness
Tetric evoceram bulkfill Ivoclar Sculptable 4mm Single layer possible
Quixfil DENTSPLY Sculptable 4mm Single layer possible
SDR & SDR plus
Over layered with
(smart dentin DENTSPLY Flowable 4mm
conventional composite
replacement)
Xtra fil VOCO Sculptable 4mm Single layer possible
Xtra base VOCO Flowable 4mm To be overlayed
Venus bulkfill Heraeus kulzer Flowable 4mm To be overlayed
Flowable, sound
Sonicfill Kerr 5mm Single layer possible
activated sculptable
Filtek bulkfill 3M espe Flowable 4mm To be Over layered
Capo bulkfill SHUTCZ (250 LE) Flowable 4mm To be Over layered with
Sculptable composites. flowable composites.

Bulk fill. conventional. Bulk fill. conventional.
Volume shrinkage %.
There are Just minor difference in polymerization shrinkage between bulkfill &
conventional one.
 It is better to use bulk fill composite to avoid problem of conventional one:

▪ Time consuming.
▪ Air voids incorporation in layering technique.
 Limitation:
▪ Cavity depth: In optimum cases, you can use 4 mm as one layer but keep it in the safe
zone and use 2.5mm.
▪ Efficiency of curing unit.

Recent trends in composite (technique):
Compothixo (Kerr):
Modelling instrument suitable for all classes of restorations.
Technology enhances the thixotropic properties of composites by changing only its
viscosity, not the chemical and mechanical characteristics of the material.
 Smart vibrations provide:
▪ Better wettability.
▪ Superior adaptation of composite to cavity walls.
▪ Reduction of air bubbles.
▪ Precise application.
▪ Layer thickness control.
▪ Improved sculptability.
▪ Reduced stickiness.
 Indications:
.
▪ Modelling of composite. Pointed tip.
▪ Layer application technique. Spatula tip.
Plugger tip.
▪ Direct veneering. Semi-sphere tip.
▪ Occlusal modelling, fissures, and removal of excess.
 Benefits :
▪ Superior cavity and matrix adaptation.
▪ Easy thin layer stratification, especially in anterior restorations.
▪ Reduced pressure required for packing of composite.
▪ Reduced stickiness of the composite versus traditional instruments.
▪ Easy composite placement on the tooth wall; no pull-back effect.
▪ Reduction of air bubbles.
Sonic fill (Kerr):
 It formed from a specialized sonic hand piece attached to unit + unidose tip contains
sculptable bulk fill composite.
 It is unique bulk fill composite.
▪ By the sonic energy, it turns into flowable enabling quick placement and precise
adaptation to the cavity walls.
▪ When the sonic energy is stopped, the composite returns to a more viscous (sculptable -
non-sticky) that is perfect for carving and contouring.

Composite in markets & which type to use:
Less than 150 LE:
▪ Most of them are micro composite, very poor property & very sticky.
▪ Can be used for training or temporary crown.
▪ Also, there are nanohybrid types in this category, but still have poor property.
o Ex: charm composite (100 LE), Meta (nexocomp) (95 LE), any com (110 LE).
from 150 to 200 LE:
▪ Micro hybrid composite, sticky.
▪ Can be used for core build up or for students.
o Ex: swiss TEC (150), Kerr classic, DIAFIL (180 LE), TE ECNOM (200 LE).
From 200 to 300 LE:
▪ Micro hybrid composite, non-sticky.
▪ Can be used in for economical purpose & core buildup.
o Ex: composan LCM (190), TE ECNOM plus (230), 3M Z250, capo universal (6 gm = 260),
Ventura nanolux (nanohybrid=290).
Class A composite (more than 300 LE)
▪ Nano pure or Nano hybrid.
▪ Used for anterior and posterior.
▪ Examples.
o NanoPaq (Schultz) (4g=350)
• Easy handling & high compressive strength.
o KERR HERCULITE XRV ULTRA NANO (KERR) (4g= 380)
• One of the cheapest nanohybrid composite to be used in your clinic.
• Not the best regarding the strength and wear resistance.
o CLEARFILL AP-X. (KURRARY) (4.6g= 415)
• Better in manipulation and bond strength (especially with CLEARFILL SE bond).
o Estelite alpha (TOKUYMA) (3.8g= 380)
• Outstanding polishability, high gross retention over time wide shade matching
range (Chameleon effect) offered by Supra-Nano Spherical Filler which have
controlled refractive index.
o OLIDENT OLICO XP (3g= 325)
• It is nanoceramic composite with high abrasion resistance (medico dental supply).
o TERTIC N CERAM (IVOCLAR) (3.5g= 400)
• Semi-gloss need Ivoclar polishing system to be highly gloss.
o Z250 XT (3M) (3g= 390)
• Used more in posterior.
o CERAM X SPHERTEC (DENTSPLY) (3g= 470)
• Fast and easy polishing (better in polishing and manipulation than CERAM X ONE)
o GRANDIO (VOCO) (4g= 560)
• High filler containing composite & better in manipulation.

o COLTENE BRILLIANT EVER GLOW (COLTENE) (3g= 680)
Coltene brilliant NG 4g(400 LE) is also nanohybrid composite but it is very hard after polymerization
so difficult in polishing and difficult in adaptation.
o Z350 XT (Nano pure) (3M) (4g= 680)

• More in anterior (but its shade is slightly opaquer than other composites).
o OMNICHROMA. (TOKUYMA) (4g= 820)
• Shadeless composite (matches all shade) but in some cases you need to place
blocker beneath it.
• High polishability and exceptional handling.
o ESTELITE SIGMA QUICK (TOKUYMA) (3.8g= 820)
• Quick curing time - 10 sec. with a halogen light (≥400mW/cm2)
• Extended working time - 90 sec. under ambient light (10,000 lx)
• Wide shade matching range (chameleon effect)
o G-ænial Sculpt (GC)
• CHAMELEON EFFECT.
• Expensive.
o TETRIC EVO CERAM (IVOCLAR) (1375)
• Better in manipulation, more polishability and chameleon effect than TETRIC N
CERAM.
The amount of Isofiller (prepolymer) is less inside the Tetric N-Ceram, the amount of glass filler
(size: 0.7 micron) is higher, this could have an effect on the polishability.so there is difference in
polishability chameleon effect and ease of adaptation during manipulation.
If you will buy one syringe, buy A2 shade.
Note: Most prices taken from (dentalcarts.com)
Expired composite:
 Can I use expired composite in my daily work??
▪ No, only used in training and temporary crown.
o One of composite components is inhibitors that stop any reaction of initiators to form
free radicals. This inhibitor plays an important role in expiry date of materials.
o A long time contact between organic matrix and inorganic filler is not favorable,
deboning of fillers from matrix with time that's cause leakage of its ions in uncured
monomer.
o Decrease shelf life of photo initiator that subjected to degradation so decrease curing.
o So, this composite becomes friable, initially set and low mechanical and physical
properties.
▪ Do not use the composite or any resin material 6 months before expiration date, it
is preferable to be at least one year.

Notes
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Bond system
Bond system
Adhesive strategy:
Adhesive generation.
Recent trends in bonding.
Recommendation.

Adhesive generations:
1st, 2nd, 3rd generation not used now.
4th generation: etch & rinse (multi-step/ three step= Etch + primer + bond )
▪ Bond strength 17 -25 MPa (high bond strength).
▪ Requires moist dentin (wet adhesion)
o Ex: Optibond FL (KERR) – Scotchbond Multi-purpose (3M) –
Bisco All bond 2 (its dual cured bond that can bond to a multitude of substrates
▪ Disadvantages: Multi step, increase sensitivity, pooling around margin and
CHX application for MMP inhibition is necessary.
5th generation: etch & rinse (two steps= etch + bond (primer +bond in one bottle) )
▪ Requires moist dentin (wet adhesion).
▪ Bond strength is less than 4th generation.
o Ex: one step plus (Bisco) – Optibond solo plus (Kerr) – Adper single bond
plus or Adper Scotchbond 1XT (3M) – primer & bond NT (Dentsply) – Excite
F (IVOCLAR) – solo bond M (VOCO).
▪ Disadvantages: multiple layers needed, bond strength loss over time due to
hydrolytic degradation, pooling around margin and CHX application for MMP
inhibition is necessary.
6th generation: (two step self-etch= two different compartments: Self-etch primer + bond )
▪ Bond strength 17 - 22 MPa.
▪ Requires dry dentin (dry adhesion).
o Ex: Adper prompt L-pop (3M) – Xeno III (Dentsply)- AdheSE (Ivoclar) – Clearfil SE bond
(kurary) - Optibond XTR (Kerr)
o Note: there are some confusion in generation classification between 6th generation
and 5th B generation (by some authors) but here we consider all 6th generation.

7th generation: self-etch (all in one)
 All in one (one bottle shaken before usage or two bottles then added together as in
futurabond NR)
▪ Bond strength 23-30 MPa.
▪ Requires dry dentin (dry adhesion).
o Ex: Optibond all in one (Kerr) - clearfil S3 bond (kurary) – G-bond (GC) –
xeno IV (Dentsply) – Adhese one F (has anti-bacterial + fluoride) (Ivoclar)-
futurabond NR.
Universal bond (multimode adhesive):

 Not a new generation, but it is a variant of 7th generation.
 Why universal:
▪ As in selective etching technique, we cannot limit etch to be in enamel only (some etch
come in contact with dentin) that makes dentin etched twice (acid etch + self-etch bond)
results in dropping in bond strength of that dentin. (non-bonding zone).
▪ From this point, it was necessary to make bond that can be used as self-etch and total
etch technique.
 What meant by universal:
▪ Used in all etching protocols (total etch, selective etch and self-etch).
o Water &ethanol based so used in wet & dry bonding.
▪ Can be used with direct and indirect restorations (post & core...).
▪ Compatible with self-cure, light cure and dual cure resin cements. (without separate
activator).
o If not: add DCA (dual cure activator) to the bond = dual curing (to be
used with dual curing resin cement).
• Ex: futurabond M plus (+) from voco.
o Ability to bond to different substrates. (MDP)
o Use as a primer for silica-based and/or zirconia based and metallic restorations.
Note: not all universal bond has all these features, but if bond has one or more of these
features, the manufacture called it universal, so be alert.
 Most of universal bond containing 10-MDP (10-methacryloyloxydecyl dihydrogen phosphate. 1st

used by kurary):
▪ Decrease bonding disintegration increase marginal integrity (less leakage and so less
sensitivity) by:
o Promoting chemical adhesion to calcium of hydroxyapatite (direct chemical bonding +
micromechanical).
o The MDP containing bond become hydrophobic after polymerization so it is more durable
▪ Ability to bond to different substrate (metal, lithium disilicate (e-max) and zirconium….)

Scotchbond universal (3M espe):
▪ Somewhat expensive (5ml = 1200 LE).
▪ It is viscous enough to coat the tooth without being runny and wets the tooth
well (but need to increase dryness time to avoid pooling at line angles).
▪ Adhesive is heavily tinted.
▪ Has silane coupling agent so can be used in veneer cementation.
o Mild acidity (ph. = 2.7) affects curing time (increased) and strength (decreased).
All bond universal (BISCO) (the best)
▪ Cheap (6 ml =1050 LE / 0.5 ml = 155 LE)
▪ Low film thickness. .
▪ Only adhesive that satisfy all 4 conditions:

1. Chemical adhesion (MDP)
2. Hydrophilic penetration.
3. Hydrophobic transformation after polymerization so improves bond durability. (Azeotropic =
water evaporation in 5 sec)
4. Ultra-mild acidity (ph. =3,2 as has no silane) that not interfere with polymerization of resin
above it. (decrease curing time)
Gluma universal:
▪ Expensive (4 ml =1800)
▪ No silane coupling agent.
▪ Desensitization so decrease postoperative sensitivity.
Adhese universal vivapen.
Tetric N bond universal.
Futurabond U: not need additional activator.
Dental advisor, summery for indication of universal bond.
Bonds to
Bonds to lithium zirconia and
Dual cure materials
Total-etch Self-etch disilicate metal
product company Without separate
technique technique without without
activator
separate primer separate
primer
All-bond
Bisco    ** **
universal
Peak
Ultradent     
universal
Scotchbond
3M espe   *  
universal

Optibond
Kerr  (two   
XTR
bottles)
Prime &
DENTSPLY     
bond Elect
(*) = requires separate activator unless it is used with rely X ultimate (3M) adhesive resin cement.
 This problem found also with ((clearfil universal bond /quick (kurary), one coat bond (coltene)) as the
manufacture obligate you to buy separate activator or use its resin cement that contain activator.
(**) = all bond universal(bisco) bonds to lithium disilicate and zirconia, but the manufacturer recommends using
a pure silane with lithium disilicate and Z-Prime plus with zirconia for optimum bond strength.

Note: read manufacture instructions to know what he means by universal & contraindication.
Example (1): Optibond from Kerr:
• Optibond is contraindicated to be used in combination with chemical cure or dual cure resin cement
when there is insufficient light curing as in indirect restorations.
- Except NX3 resin cement either self-cured or dual cured, is compatible with Optibond.
Example (2): futurabond M plus from voco.
- If you read the indication you will find that it is used with direct & indirect restoration (with self-cured
or dual cured cement), but in the bottom of page with smaller size it is written that, it needs dual cure
activator to be used with self-cured & dual cured cement.
So be alert.
Futurabond U VS Futurabond M plus.

Futurabond U:
▪ It is a two-component universal adhesive supplied in a single-dose form.
o One compartment contains the acidic monomers while the other includes the DC catalyst.
o To avoid any premature reaction with the adhesive's acidic monomers
under unfavorable storage conditions. (It actually takes over the role of the
composite's tertiary amines to enhance their reactivity with benzoyl peroxide in case of
light attenuation or with self-curing mode)
Futurabond M+:
▪ Universal bond supplied in bottle – need dual cure activator (DCA) to be used with
indirect restoration.
Other dual cured bond: (light and chemical cured, so can be used with indirect restoration)
▪ Futurabond DC (voco): (dual cured, self-etching bond (7th generation)) available in single
dose blisters or 4 ml bottles system (two bottles= bond + activator).
▪ Excite F DSC (Ivoclar): dual cured, total etch bond (two steps) available in the unique
VivaPen, in bottles and in Soft TouchTM Single Dose vessels.
o Has special patented applicator, which is coated with the initiators required for the dual-curing
action.
Note: In (all in one) bond or universal one that is not cmpaitable with dual curing resin.
▪ That is because the bond has component that interfere with chemical initiator, so the layer
in contact with bond will not be cured chemically.
▪ Solution:
1- Use DCA with bond.
2- Or put one layer above bond and cure it with light 1st : to ensure it is light cured rather
than chemical cured. (used only in cases of core build up not cementation)

Adhesive strategies:
Total etching (etching and rinse 4th & 5th): wet adhesion.
 Three steps E&R:
▪ Etching with phosphoric acid and rinsing off with water.
▪ A solvent-rich primer is applied (hydrophilic functional monomer) and air-dried.
▪ Followed by a bonding resin (hydrophobic cross-linker resin), which must be polymerized.
o Optibond FL (Kerr) may be considered the golden standard of its class, as Optibond FL
resulted in higher micro tensile bond strengths, lower Nano leakage, and higher degree of
conversion compared to Scotchbond Multi-Purpose (3M ESPE), All-Bond 3 (Bisco Inc.).
 Two step E&R:
▪ Etching with phosphoric acid and rinsing off with water.
▪ Dentin and enamel are simultaneously primed and bonded (the hydrophilic primer and
the hydrophobic resin are blended in one solution), followed by air-drying and
polymerization.
Wet adhesion:
▪ Dentin contain 20% water by volume, and after etching 50% of minerals is solubilized and
replaced by rinsing water. That results in 70% of water surrounding collagen matrix and
prevent it from collapsing.
▪ Over drying will lead to collagen matrix collapse (blocking primer & bond infiltration), so
rewet dry dentin to allow collagen matrix to re-expand.
▪ Over wetting will also result in lower bond strength due to dilution of adhesive.
▪ So, in wet adhesion we use alcohol (ethanol or acetone) based adhesive to completely
displace the residual water and allow the adhesive resin to fully infiltrate and hybridize
collagen after polymerization.
▪ Drawbacks of wet adhesion:
o Water replacement by resin is far from ideal due to the presence of residual solvent and
dentin transudation during solvent-evaporation step, and before and after polymerization of
the adhesive resin.
o The primer/adhesive resin has hydrophilic and hydrophobic monomers. Due to the high
hydrophilicity this mixture cannot provide a hermetic seal in deep dentin.
o Two-step etch-and-rinse adhesives behave as semi-permeable membranes after
polymerization, allowing continuous transudation of the dentinal fluid. If the residual water is
incompletely removed from the solvent, added to the diffused water from dentin, water filled
channels or water trees form.
o Additionally, water reduces the degree of conversion of adhesives, resulting in sub-optimal
polymerization of the polymer due to the residual water within the hybrid layer and adhesive
layer.
o This water also results in worse mechanical properties of the polymer and, consequently,
lower bond strengths.
o If the adhesive system is applied in extreme conditions (overdry/overwet), more voids will be
formed at the base of the hybrid layer, which will not be fully infiltrated by resin, leaving a
pathway for extrinsic and intrinsic water-flow over time. (Nano leakage & hydrolytic
degradation of bond).

Alcohol based adhesive:
 Acetone or ethanol solvent:
▪ Used in cases of wet adhesion (etch& rinse) to remove excess water.
▪ Ideally solvent should be totally evaporated before polymerization, to augment proximity
of reactant molecules and prevent residual monomers from plasticizing the polymer.
▪ Acetone:
o It is not able to re-expand air-dried demineralized dentin.
o Under overdry conditions, the infiltration rate of acetone-based adhesives within the hybrid
layer may be reduced to 50%.
o Acetone is more sensitive to dentin moisture than ethanol.
- Ex: One-Step Plus (Bisco).
▪ Ethanol: higher retention rate and better performance.
- Ex: Optibond FL (KERR), Adper Scotchbond 1XT (3M ESPE).
Three-step E&R followed by two step E&R (less bonding strength than three step)
bonding systems are still the gold standard in bonding.
Drawbacks:
▪ It is the most technique sensitive (multi step).
▪ causes post-operative sensitivity (etching dentin)
Tips:
▪ Used it with enamel and shallow cavity.
▪ Applied on enamel, minimum of 30 secs. And on dentin maximum of 15 sec,
then rinsed well.
▪ Avoid over dryness.
▪ Double the number of coats or layers of the primer/bonding solution for two-
step etch-and-rinse adhesives, mainly for acetone-based adhesives.
▪ Use ethanol-based adhesive as Optibond FL (Kerr).
▪ After etching dentin, MMP enzyme is activated (causes collapse of collagen).
So, inhibit it by application for CHX for 30-60 sec after etching.

Self – etching (6th &7th generation): dry adhesion.
 Self-etch adhesives are classified according to their acidity:
▪ Strong (pH ≤ 1): Allowing an interaction of some micrometers depth.
o Xeno III (Dentsply)
▪ Intermediately strong or moderate (1 < pH < 2): Allowing an interaction depth of 1–2 μm.
o AdheSE One F (Ivoclar Vivadent)
▪ Mild (pH ≈ 2): Allowing an interaction depth of 1 μm.
o Clearfil SE Bond (Kuraray).
▪ Ultra-mild (pH > 2.5): Nanometric interaction in depth, allowing a true Nano-interaction
zone, in opposition to the traditional and thicker hybrid layer.
o Clearfil S3 Bond (Kuraray).
 Mild- or ultra-mild self-etch adhesives:
▪ Micromechanical interaction: due to polymerization in situ of the infiltrated adhesive
monomers.
▪ Chemical interaction: due to ionic bonding between functional monomers (phosphoric
acid esters and carboxylic acids) of adhesive systems and the calcium in residual dentin
hydroxyapatite. (Adhesion–decalcification concept)
 Two bottle system: (two step self-etch)
▪ Self-etch primer + bond.
▪ Enamel and dentin are simultaneously conditioned and primed with an acidic self-
etching primer, followed by the application of an adhesive resin (hydrophobic resin),
which must be polymerized.
▪ Clearfil SE Bond (CSF-Kuraray) the golden standard for self-etch adhesives, due to:
o It is a mild self-etch (PH=2), so slightly demineralizes dentin, allowing some residual
hydroxyapatite to evolve and protect collagen fibrils.
o containing the functional monomer (10-MDP) that can chemically bond with Ca+ so make the
adhesive interface more resistant to degradation over time.
o Presence of a hydrophobic coat, the application of a filled hydrophobic layer as second step
for CSE improved the conversion rate of the adhesive as well its mechanical properties.
 One bottle system (one step self-etch)
▪ All in one (etch +primer +bond).
▪ Two step self-etch is better than one step self-etch due to:
o When one-step self-etch adhesives are applied onto dentin, air-drying the solvent may not be
able to remove all the water and solvent, compromising the monomer polymerization and
bond strength. Blisters are formed in the adhesive layer due to a rapid monomer-phase
separation.
o One-step self-etch adhesives behaved as permeable membranes after polymerization as two-
step etch-and-rinse adhesives.
• Allowing water from the hydrated dentin to crossover the adhesive layer, forming blisters
at the adhesive - composite resin interface and water-trees.
• Likewise, hydrophilic monomers in the oxygen inhibition layer enhance water sorption
through osmosis.
o One-step self-etch adhesives are more prone to degradation of the resin–dentin interface by
hydrolysis than two-step self-etch adhesives.

o In enamel, one-step self-etch adhesives also result in water blistering, which may compromise
enamel bonding.
▪ Tips for bonding to dentin using one step self-etch.
o Apply more than one coat.
o Actively apply the one-step self-etch adhesive scrubbing vigorously onto the dentin surface.
o Apply an extra hydrophobic resin coating to improve clinical performance of one-step self-
etch adhesives, transforming them in two-step self-etch adhesives.
Self-etching technique is used in deep cavity:

▪ As it does not remove the smear layer but just infiltrate within it to make small resin
tags (0,5 – 1 um = infiltrated altered smear layer) so no sensitivity.
Self-Etch bonding approach may solve some clinical problems:

▪ Difficult isolation situations (class V in lower 7) when rinsing the etchant can invite
contamination.
▪ Cavities approaching the gum margin where etchants can induce bleeding when no
rubber dam is used.
▪ Pedodontics:
o Avoid multi step & fear of etch syringe.
o Deciduous teeth no need for strong bond.
Two-step SE systems yield comparable results to Two-step E&R when bonding
to dentin but not enamel.
▪ Has lower bond strength to enamel than total etching. (so, use selective etching)
Multimode / universal bond: wet & dry adhesion.

 Used with all modes of etching (etch & rinse – self etching – selective etching).
 Micromechanical and chemical (10- MDP) bonding.
 it is better to be used in selective etching:
▪ self - etching dentin: as residual Hydroxyapatite is needed to achieve optimal dentin–
resin hybridization (decrease Nano leakage).
o This is more needed with (Scotchbond Universal Adhesive, 3M ESPE) which includes both 10-
MDP and the polyalkenoic co-polymer, molecules capable of ionic bonding with calcium in
Hydroxyapatite.
▪ Etching enamel: as universal bond is mild or ultra-mild acid so cannot etch enamel as the
same depth as phosphoric acid.
 All simplified adhesives behave as permeable membranes (either two-step E&R or
one-step self-etch adhesives). As universal adhesives are one-step self-etch
adhesives, they behave in the same fashion, so:
▪ Apply more than one coat.
▪ Actively apply the adhesive scrubbing vigorously onto the dentin surface.
▪ Apply an extra hydrophobic resin coating to improve its clinical performance.

Selective etching:
 Due to lower bond strength of self-etch bond to enamel and sensitivity after etching
dentin, use selective etching:
▪ Etching enamel: for 30 sec as minimum, then rinse it double the etching time, then air
dryness.
▪ Apply self-etching bond or universal on enamel and dentin.
 It is safer to use such technique with universal bonding systems rather than self-etch
bond.
▪ As self-etch bond is water based, so it is mandatory to be applied on dry surface (dry
bonding).
o So accidental etching of dentin (wet dentin) when selective-etch technique is employed with
self-etching bonding systems may reduce dentin bond strength.
o And if you try to dry dentin (over dryness occur, so collagen collapse) so increase sensitivity &
bond failure.
▪ In other hand, universal bond is water & ethanol-based adhesive so used in dry & wet
bonding.
▪ When bonding to enamel, phosphoric acid etching is always preferred (E&R or selective-
etch).
▪ This fact is more crucial in restorations with aesthetic enamel margins (marginal staining)
▪ Restorations relying mainly on enamel bonding are not good candidates for SE bonding
systems (Veneers & fissure sealants)

Recent trends in bonding:
 Recent supply forms to:
▪ Avoid Solvent evaporation problem: In conventional bond bottle with opening &
closing bottle several times lead to solvent evaporation.
▪ Single dose (hygienic).
o Examples:
• Vivapen.
• Flip top.
• L-pop.
Recommendation:
 Three steps etch & rinse:
▪ Optibond FL (Kerr)
 Two step etch & rinse: (Here we need good and cheap one)
▪ Optibond solo plus (375 LE)
▪ IVOCLAR TETRIC N-BOND (350)
 Two step self-etch:
▪ Clearfil SE Bond (CSF-Kuraray).
▪ Clearfil SE protect:
o The same as CLEARFIL SE BOND with two additional features: long-term fluoride
release and the MDPB monomer with an antibacterial, cavity cleansing effect.
▪ Optibond XTR (Kerr).
 Universal bond:
▪ All bond universal (BISCO).
▪ 3M ESPE Scotchbond Universal Adhesive.
Buy:
1- Universal bond: that can be used in all situation.
2- Total etch bond: as it is cheap so can be used in situation that dentin sensitivity is
not a matter (core build up cases…)

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Composite procedure
Posterior composite
procedure
Diagnosis.
Systemic analysis.
Local anesthesia.
Preparation of operating site.
Shade selection.
Preoperative occlusal assessment:
Prewedging.
Isolation.
Caries removal.
Cavity design.
Sandblasting.
Etching.
Bonding.
Composite placement.
Final layer painting.
Curing & polymerization shrinkage.
finishing and polishing.

Composite procedure
A. Diagnosis.
 History:
▪ Pain with sweat: exposed dentin.
▪ Pain during eating may be due to:
o High spot.
o Cuspal deflection (due to composite shrinkage so draw cusps toward each other)
o Gab: so, pressure on dental tubule occurs during eating.
• Use flowable composite for good adaptation.
• Round the angles to avoid bond pooling.
 X-ray:
▪ For proximal caries that cannot be seen clinically.
▪ Proximity of caries to pulp.
▪ Periapical pathosis.
B. Systemic analysis:
 Host analysis:
▪ Dentition: opposing teeth, morphology…
▪ Oral hygiene: bad oral hygiene (must control case first except in emergency)
▪ Caries index: high caries index needs aggressive treatment (extension for prevention) &
low caries index needs conservative treatment.
▪ Occlusion: occlusal load. Occlusion points, cross bite (functional cusp?)
▪ Diet nature: hard food & composite fracture.
▪ Habits: bruxism, clenching & biting on objects.
 Substrate analysis:
▪ Enamel (nature, thickness, rods geometry):
o Rods formed from rod sheath (more resistant to acid etch) and rod core (less resistant to acid
etch so demineralized and resin tags formed in its place)
▪ Dentin (nature, thickness, tubules geometry):
▪ Caries extension: (complete or partial caries removal)
▪ proportionality of resin mass to enamel mass:
o Increase enamel mass lead to increase bonding.
o In cases where there is no enamel (old age), so 1st line of treatment will change from
composite to amalgam or resin modified glass ionomer.
▪ Cracks or fracture.
o If crack in non-stress bearing area and there is no complaint, not involved in cavity.
o But if crack in stress bearing area, involve it.
▪ Old filing.
 Material analysis:
▪ Modulus of elasticity.
▪ Bond ability.
▪ Polymerization shrinkage and microleakage: any composite subjected to shrinkage.
▪ Co-efficient of thermal expansion and contraction :
o Composite expand from 3-7 more than tooth.

▪ Adhesion (bond): the weakest phase (so don't increase thickness of bond).
▪ Proportionality of resin mass to enamel mass.
▪ Biocompatibility with periodontium: composite is not biocompatible so in deep class II,
composite may lead to gingivitis as it leads to plaque accumulation (so must be highly
finished)
▪ Strength and fracture toughness.
▪ c-factor effect.
CASE BY DR AHMED ALHAKIM.

Preoperative situation :
▪ Intact occlusal surface.
▪ Defective distal surface (ditching in distal marginal ridge).
▪ Preoperative IOPAR (intraoral periapical radiograph):
o Showing the proximity of caries to pulp horn.
o No apical lesion.
Case analysis:
▪ History: only pain with sweat (no pain with hot or cold).
▪ no pain with percussion & palpation.
▪ +ve response to sensitivity test.
▪ +ve response to thermal pulp testing.
▪ 3 mm probing depth at the distal area .
Conclusion: The pulp is still vital
Treatment plan: Partial caries removal.
C. Local Anesthesia:
when required, local anesthesia is given in many cases since it makes the procedure
pleasant, time saving and reduces the salivation.
D. Preparation of operating site:
 Scaling and polishing:
▪ Inflamed gingiva is very sensitive to etching & more subjected to bleeding so make one
visit for cleaning to permit period for gingival healing.
▪ Operating site is cleaned using slurry of pumice (fluoride free) and brush in order to
remove plaque and superficial stains prior to the procedure.
o Avoid fluoride application before bonding, as flouroapatite is more resistant to acid attack 6
times than hydroxyapatite.
▪ Or use air abrasion by aluminum oxide particles: provide better result for bonding.
E. Initial Shade Selection. (will be discussed in details in anterior)
 Mono shade: selected from central of tooth.
 Layering:
▪ Dentin shade is selected from the cervical third.
▪ Body shade from center / body of tooth.
▪ Enamel shade from incisal third.
 Tips:
▪ Teeth should be clean (no plaque or stain).
▪ Teeth and shade guide should be wet to simulate the oral environment as dehydration
will cause the shade to be too whitish.

▪ Shade matching should be carried in natural daylight especially afternoon so switch off
the light of the dental unit.
▪ may use adjacent for shade selection.
▪ Imply the 5-second rule.
▪ No lipstick or bright-colored clothes.
▪ Use a neutral patient towel (blue or grey, never yellow nor pink).
▪ Patient’s back reclined 45º.
▪ Observe the shade at an arm-length distance.
▪ Patient’s corner of the mouth at the level of dentist’s eye.
▪ To confirm the final shade, a small increment of selected composite (full cured without
bonding) is placed adjacent to the area to be restored. (incisal for enamel or cervical for
dentin).
▪ We can make our shade guide by: (full cured composite buttons)
o Apply 1 mm of each shade to stick and cure it, write the shade on stick.
F. Preoperative occlusal assessment:
 Before caries removal make patient bite on articulating paper to know the occlusion
points that help in:
▪ Building anatomy of tooth without interfering with occlusion.
▪ Functional cusp determination.
▪ Thickness of remaining cusp to be covered or not.
 Hints:
▪ Use the blue articulating paper side for centric contact
(most important) and red side for eccentric contacts.
▪ The tooth must be dry before occlusal assessment.
▪ Use a drop of varnish or bond (cured) on the registered
points to protect them from being washed out during
drilling or rubber dam application.
G. Prewedging in (class II):
 To compress gingiva:
▪ Stop bleeding.
▪ More exposure of gingival margin of cavity so can be finished to provide regular margin
for band adaptation (use one side ortho stripper for finishing the margin).
▪ Open the contact in tight contact cases and allow conservative access into the
interproximal.
▪ Preservation of rubber dam during cavity preparation. (may use split dam technique)
▪ Easy Rubber Dam inversion.
▪ Knowing the part of gingiva to be removed, in cases of deep margin acquisition.

H. Isolation: Rubber dam application.
 Isolation is a must as:
▪ Contamination of composite material leads to decrease in physical properties.
▪ Contamination of itched enamel and dentin lead to decrease bond strength.
 Isolation before caries removal is better for:
▪ Better composite adhesion (decrease possibility of saliva contamination)
▪ In cases of pulp exposure (successful pulp capping)
 Use wooden wedge to protect dam during caries removal.
I. Caries removal.
Cavity drilling:
 Tungsten Carbide burs:
▪ Cutting burs (6-8 flutes): high cutting especially in dentin (make chips).
o Due to easy removal of dentin chips, decrease smear layer.
o Decrease heat generation so decrease post-operative sensitivity.
o Chipping of enamel especially unsupported one 
o Unnecessary removal of tooth structure. 
▪ Finishing bur (12-30 flutes):
o Decrease cutting efficiency (so remove composite only, not enamel so used in finishing)
 Diamond burs:
▪ Controlled cutting efficiency (stop with high pressure or high resistance).

▪ No chipping of enamel.
▪ High heat generation.
▪ Make dentin dust that forms dentin mud so thick smear layer.
▪ Increase clogging of bur.
Which to use?
Diamond burs: used with
▪ Cutting in enamel (controlled cutting efficiency so preserve enamel margin).
▪ Finishing the cavity:
o Yellow or red diamond bur: used with enamel to make it smoother.
o Dentin cavity in cases of total etching (smear layer is not problem here):
• Coarse diamond bur: used to make some roughness and so increase bonding.
• Copious coolant is mandatory to avoid the problems of high heat generation and dentin mud
so no clogging and decrease smear layer.
Cutting carbide bur: used with
▪ Caries removal: use large bur in removal of deep caries due to controlled heat generation.
▪ Finishing dentin cavity in cases of self-etching (sensitive to thick smear layer):
o Carbide bur control the smear layer.

Infected and affected dentin:
 Moderate to deep cavity: remove infected dentin only, not remove affected one.
▪ Affected dentin:
o Pain: It is vital, so patient feels pain (if worked without anesthesia).
o Excavation: Cannot be easily scooped up (with a sharp hand excavator) and some pressure is
required to lift it.
o Probing: Normal sound of dentin (glass sound).
 Deep cavity (radiographically extending to pulpal third of the dentin):
▪ Selective removal to soft dentin should be performed. (leaving some soft carious dentin
in the pulpal aspect of the cavity where pulp exposure upon further excavation is
anticipated)
Sound dentin.
affected dentin.
Infected dentin
0.5 mm
remaining.
Soft Dentin:
▪ Deforms when a hard instrument is pressed onto it.
▪ Can be easily scooped up (with a sharp hand excavator) with little pressure being required to lift it.
Leathery Dentin:
▪ It is the transition between soft and firm dentin.
▪ Does not deform when a hard instrument is pressed onto it.
▪ Can be easily scooped up (with a sharp hand excavator) without much pressure being required.
Firm Dentin:
▪ Does not deform when a hard instrument is pressed onto it.
▪ Cannot be easily scooped up (with a sharp hand excavator) and some pressure is required to lift it.
Hard Dentin (sound dentin):
▪ Cannot be easily scooped up (ewith a sharp hand excavator) and heavy pressure is required to lift it.
▪ A scratchy sound or “cri dentinaire” can be heard when a straight probe is taken across the
dentin."

Caries excavation procedures:
 Start carious dentin excavation from the periphery towards the center of the lesion to
minimize the risk of infection in case of accidental pulp exposure.
 Use sweeping motion to avoid pulp exposure.
 We can use for caries removal:
▪ Tungsten-Carbide bur (large rose head):
o It is cutting bur so less heat generation.
o Start with high speed 1st then use low speed in the deeper area of cavity.
o Saves time.
▪ Polymeric bur (smart bur)
o Not cut in sound dentin.
o Single use (55 LE).
o Cut from center 1st to avoid sound dentin in periphery, as it quickly
becomes dull and produces undesirable vibration, making further cutting
impossible. 
▪ Ceramic burs.
▪ Chemo-mechanical excavation.
▪ Air abrasion.
▪ Caries detector dyes:
o Stain organic (increase in infected dentin) but it also increases in circumpulpal dentin so recent
stain is higher in molecular weight (to stain only surface infected dentin not circumpulpal one).
o Apply drop in cavity, wait 10 sec. then washing, excavate stained area, if not removed confirm
by: probe (normal sound & no catch) / bitewing x-ray.
Management of deep caries lesion:

Complete caries removal:
 Indirect pulp capping: In cases of remaining dentin thickness is less than 0,5 mm.
 Direct pulp capping:
▪ Conditions:
o Tooth completely asymptomatic.
o Controlled bleeding.
o Pinpoint exposure.
o Procedure done under rubber dam.
o Cavity disinfection by chlorhexidine for 30 sec to 1 minute.
▪ Material:
o Calcium hydroxide (Dycal):
• Has antibacterial activity and provides alkaline medium (exchange of minerals).
• High solubility and degradation over time (causes gab = stress concentration).
• Formation of tunnel defects inside dentinal bridge.

•
Should only be used in the deepest spots in the cavity where the remaining
dentine thickness is ≤0.5 mm. A protective layer of resin-modified glass ionomer
should always follow the application of calcium hydroxide liners.
• Light cured dycal (resin): no dissolution occur but has less antibacterial effect and
minerals exchange than chemical one.
o Theracal (Bisco).
• Light-cured, resin-modified calcium silicate. Its unique apatite
stimulating ability makes it ideal for direct and indirect pulp capping
and as a protective base/liner.
• It is light cured so no dissolution occurs.
• It is applied to the clean, dry tooth in layers of 1 mm or less. Light
curing time is 20 seconds. In the case of a direct pulp cap, bleeding must be
controlled by applying a cotton pellet dampened with sterile saline over the
exposure. TheraCal LC must extend 1 mm beyond the exposure onto sound
dentin.
• Peripheral seal is better than MTA so it is preferred in cases of indirect pulp
capping.
o Mineral trioxide aggregate (MTA).
• MTA is more effective than Ca (OH)2:
- Less solubility.
- Induces proliferation of pulp cells.
- Forms a superior dentin bridge with less underlying inflammation than Ca (OH)2.
- The new dentin bridge that is formed has thickness and a hardness far higher than that
which is obtained by dressings with calcium hydroxide; also, this is done in a shorter
time compared to the time taken from Ca (OH)2
• Clinical notes:
- A minimum thickness of 1.5 mm of MTA is recommended to be placed over the
exposure site.
- Bleeding is normally controlled by placing a cotton pellet soaked in a solution on the
exposed pulp.
✓ A variety of solutions have been used, including saline, sodium hypochlorite (concentrations
ranging from 0.12% to 5.25%), hydrogen peroxide, ferric sulfate and chlorhexidine.
✓ Saline or calcium hydroxide solutions are the most benign to the pulp in cytotoxicity tests.
- MTA is adapted easily by using a moistened micro brush.
- Wait 72 hours for complete setting.
- Or after initial set (5-15 min) put theracal above it then use composite.
• There are two types of MTA available: Gray and White.
- Gray MTA gives a discoloration to tooth and gingiva So, Gray MTA is not used where
aesthetic is the prime concern. Because Gray-colored MTA contain tetracalcium
aluminoferrite (ferrous oxide).
- The absence of significant FeO in White MTA causes the color change from Gray to
White. SO, lower iron oxide content used in the White MTA (less discoloration)
o Light cured capping material precautions:
• Make the tip of light cure away from the pulp.
• Use pulsating mode for 20 sec to decrease heat generation.

Partial caries removal & peripheral seal concept:
 Partial caries excavation, stepwise excavation, indirect pulp capping, caries control
restoration and the peripheral seal concept, all are used interchangeably and refer to
the same principle, involving medical management of deep carious lesions, instead of
the traditional process of mechanical removal.
 Conditions:
▪ Very Small soft deep caries that might be reaching up to the pulp.
o the soft carious dentin wall covering the pulp although softened by acidic demineralization, yet
is not grossly infiltrated with bacteria i.e. not necrotic, and therefore is capable of
remineralization.
▪ the tooth is asymptomatic (healthy pulp).
▪ This must be done under good isolation, either with suction and cotton rolls or under
rubber dam, also dentin desiccation should never be allowed to occur.
▪ Very clean cavity:
o Partial caries excavation entails total excavation of caries from all side walls and gingival seats,
leaving at least a 2mm wide rim of super clean dentin below the DEJ throughout the whole
cavity peripheries.
▪ Adhesive restoration bonded to super clean hard dentin wall surrounding the soft
pulpal dentin.
o This creates a hermetic seal (adequate marginal seal) surrounding the soft pulpal wall, and
totally isolates the remaining carious lesion from the external environment.
o thus, the bacteria are deprived from all nutritional supplies, so it either die or become
dormant. This gives the chance for the dentin-pulp defense system to arrest the carious lesion
and remineralizes the soft dentin.
 Risk of failure:
▪ The success of the peripheral seal concept is dependent on the maintenance of the
hermetic seal around the carious dentin and totally preventing any bacterial irritation to
the pulp.
▪ The same risk of failure of direct pulp capping.
 Deep spot to be exposed or partial caries removal.
▪ Rubber dam.
▪ CHX disinfection (30-60 sec) before excavation.
▪ Cotton dryness.
▪ Excavation.
 Indirect pulp capping:
▪ In cases of the thickness of the remaining carious dentin wall is judged to be 0.5mm or
less (pulp shadow can be seen).
▪ Then we are confident that it's thin enough for the dentin-pulp defense systems to fully
infiltrate it and remineralizes it, besides laying down of reparative secondary dentin to
further isolate the pulp from the lesion.
▪ So, a final restoration is placed, and the tooth is followed up, but never to be re-entered
again.

 Follow up:
▪ 28 days for dycal or MTA.
▪ Three months for thercal.
▪ May test capping within 4 days to one weak by percussion (If exposed pain occurs).
Step wise excavation: (2 step procedure)
▪ If the remaining carious dentin wall is judged to be more than 1mm, then there is a
chance that the dentin-pulp defense mechanisms may not be able to fully infiltrate it and
remineralizes it.
▪ So, an interim restoration (glass ionomer) is placed for 6-12months to allow for a
reparative secondary dentin bridge to be deposited that separate the pulp from the
carious lesion.
▪ A second entry is then scheduled to fully excavate the remaining carious dentin, now
without endangering the pulp integrity because by this time enough of secondary dentin
would have been deposited that will separate the carious lesion from the pulp.
Caries control restorations:
▪ Indicated in cases of rampant caries, where multiple acute carious lesions are present,
where the priority is always given to stopping the progression of the lesions, and to
elimination of the septic foci of infection to control the caries disease as fast as possible.
▪ This is best achieved through restorations utilizing the above-mentioned techniques and
these are termed caries control restorations.
▪ Glass ionomer cement is preferred to be used with this approach because it is pulp
friendly, can better bond to and seal caries affected dentin than resin adhesives, has an
antibacterial action and can enhance the remineralization process by its fluoride and
mineral content.
Case:
Pre-operative picture showing the deep caries.
chief complaint of the patient just slight pain with cold or air and cannot chew
well in this side.
Pre-operative radiographic picture had been taken to aid in diagnosis to see

the extension of the lesion in 2D way, somehow, I know that I am very close
to pulp horn.
Proper isolation to keep all the procedures under clean and dry field heavy
rubber dam sheet in blue color wingless clamp N 26 (Ash) soft interproximal
(Bioclear) aid in the retention of the rubber dam.
Removal of the caries starting laterally not vertically, I did not go to dig
vertically; caries should be removed totally form the wall first like in this
figure and the pulpal decay still exist.

After all the boundaries became clean, the excavation started by excavator
size 51/52 (maillefer). using the lateral cutting side not the front cutting tip
in a peeling motion. All the infected dentin had been removed.
Complete caries removal. I am so lucky that there is no exposure there

is other school that support partial excavation of caries unless there is
no pain and depend on the outer enamel seal (peripheral seal).
Cavity had been re-wetted, cleaned and toileted by chlorohexidine

gluconate 2% it is a matrix metalloproteinase inhibitor and preserve
adhesive bond from degradation.
Selective enamel etching for 30 sec. followed by chx application

again on dentin. Then apply two-step self etch. And composite after
that.
J. Designs of Tooth Preparation for Composites: (adhesive cavity)

Cavity design in molars:
 Composite restoration not strength the tooth as it is brittle material, so all
undermined enamel should be removed except cervical enamel at gingival seat.
 Less extension and walls are made rough (make walls rough using diamond abrasive
for increase bonding).
 Multiple cavities:
▪ Don't connect (if tooth islands are 1mm or more).
▪ If oblique ridge is less than 1mm, reduce it till reach optimum thickness (at least 1.5 mm
reduction)
 If you are planning to do a two-visit composite filling, finish the cavity prep on the
second visit to provide fresh enamel and dentin.
 Use water coolant: to prevent enamel and dentin burn out even in non-vital tooth.
 The proximal slot preparations without any occlusal dovetail provide similar or
greater longevity than traditional class II preparation.
▪ When gingival step is found no need for dovetail or extra mean of retention.
▪ the traditional class II is better than saucer shape that has no gingival step (fracture of
composite occurs due to increase shear stress between bond and tooth structure).

Guidelines for cavity design:
1. Floor of cavity:
▪ Rounded internal line angles to avoid pooling of bond so avoid gab formation (stress
concentration & area for bacteria colonization)
o Can be done by large size rounded end diamond bur.
▪ Saucer shaped floor: to decrease stress concentration.
▪ Flat or irregular (no difference), this can be managed by flowable composite)
Sharp & definite. Smooth & rounded
2. Cavo surface margin (CSM):

 Conventional design: Preparation located in root surface or large class 1 & 2.
▪ Butt joint Cavo surface margin is made on root surface (no flaring or beveling in cementum)
▪ CSM be 90 or more (flared) (no bevel) as it will be subjected to fracture so lead to micro
leakage.
o May beveling occlusal in cases of no
opposing or long beveling as in cases of
calla lily design. Strong enamel margin
 Modified conventional design (parallel or Flared wall 100-110)
▪ Remove any weak/ undermined enamel (not supported by dentin).
▪ More exposure of enamel rods.
▪ Make the tip of bur touch flour to make full bevel and keep it
highly finished (by finishing bur –red coded).
o If not finished = irregular margin: that cause microleakage that
permit passage of particles during finishing give white line between
composite and tooth after finishing.
 Calla lily cavity design by David Clark:
▪ Indefinite cavosurface margin so:
Strongest enamel margin
o Maximum exposure of enamel rods so increases bonding force.
o Allows perfect visualization of the cavity, and minimizes the potential for crack initiation
o Avoid line of demarcation.
o Tooth splinting (Restoration on the tooth not in): So, decrease polymerization shrinkage and
marginal leakage.
(Straight walls & long bevel)

 Ensure there is no forces on CSM (by occlusal assessment).
▪ CSM (TRI) must be placed away from any occlusal load to protect TRI from any
mechanical failure (debonding – ditching – restoration cracking or fracture).
3. Cusp thickness:
▪ At least 2mm thickness (measured by caliper).
o If less than 2mm, make cuspal coverage (change tensile forces to compressive one).
o This role mainly related to non-functional cusps (but in functional cusp there are other rules to be
considered as depth of cavity and forces on CSM)
o No undermined enamel.
▪ Buccal and lingual intercuspal walls in molars can kept with 1 – 1.5 mm thickness (even it
is undermined enamel).
Cuspal coverage:
▪ when:
o Cusp thickness less than 2 mm.
o Functional cusp of opposing tooth occlude in cavosurface margin.
o When depth of cavity more than 4 mm and width more than ½ of occlusal surface.
o Upper premolar with MOD cavity & endo treated.
• Ideally cuspal coverage for two cusps.
• But, if cavity width is less than 1/2 occlusal surface (from
cusp tips), you can make cuspal coverage for only functional
cusp (palatal).
▪ Except in cases of: Upper premolar more
o No opposing. subjected to splitting
o Very light occlusal load (opposing is partial denture). forces.
▪ How:
o Make cuspal reduction until reach sufficient thickness, then cuspal coverage. (change tensile
forces to compressive one)
o Minimum thickness of composite on occlusal surface to withstand mastication forces is 2mm.

4. Marginal ridge:
▪ Preserve marginal ridge as possible.
In Some papers the least marginal ridge thickness
▪ Marginal ridge thickness: at least in
is 1mm as it is subjected to vertical forces.
premolar 1.6 mm & in molars 2mm
▪ If there is thin enamel, enough dentin & optimum depth:
o Make enameloplasty (minimum reduction) during finishing the restoration:
• To decrease forces on marginal ridge.
• But it is still in occlusion to avoid food impaction.
▪ If less than 2mm, and not enough dentin or in cases of cracks or caries.
o make class II box.
Marginal ridge can be measured by
periodontal probe or tip of fissure
bur (1mm)
5. Class II box:
▪ Box shape is the best design (convergent) to avoid weakening cusps.
▪ Should be in self-cleansable area.
o Gingival step below contact area by 0,5- 1 mm at least.
o Gingival step width not less than 1mm (can be done by straight fissure diamond)
o Gingival step finished by (modified high speed finishing bur) to avoid the irregularity that
causes gab.
o B&L reach embrasure (open the contact).
o The contact area can be partially opened in cases of:
• Excellent oral hygiene.
• Very low caries index.
• The proximal wall just in the occlusal embrasure.
▪ Rounded internal line angles.
▪ pulpal axial transition (isthmus) should be rounded or beveled.
▪ U shape box: in cases of center area of box in cementum but B& L in enamel, so preserve
enamel and make U shape cavity.
▪ Saucer shape: in simple class II (only proximal box) (see David Clark design)

6. Cervical enamel (as in gingival step):
▪ Do not remove it even if it is very thin: as…
o Enamel rod in different direction so not undermined.
o No forces applied on it.
o bonding to enamel is gold standard.
o Fracture strength of class II that extended under CEJ is lower than
when restoration above CEJ (with cervical enamel)
▪ Some opinions say, in cases of deep marginal elevation & there is no sound enamel on
the seat of the proximal box, do margin elevation using resin modified GI filling material.
DAVID CLARK CLASS II DESIGN
 The most causes of cracks in restoration replacement (G.V cavity design) are:
▪ Joining the occlusal to the interproximal is the worst possible design for crack avoidance and the
most common area for crack initiation.
▪ Interrupted cavities were more crack resistant than connected cavity preparations.
▪ Sharp internal line angles are only a small part of the problem.
▪ Most fractures initiate in dentin at the line angles.
 Hints to avoid many problems with posterior composites:
▪ Composite is a poor biological space filler; it needs to be sealed 360° and from inside to out.
▪ The best margin is no margin, and when composite extends slightly past the Cavo-surface margin,
it is generally well-sealed with no white line.
o “Composite sealing” with thin resins applied after filling the cavity may reduce wear.
o However, trying to seal an imperfect margin after the fact is futile. As I have explored these
white lines, they generally extend completely to the pulpal floor, far beyond the reach of a
sealer.
▪ Posterior composites should go “on” not “in” the tooth.
▪ Tunnel preparation: lead to Incomplete caries removal (as it impedes clinical visualization)
combined with excessive tooth weakening are unacceptable in expense of saving marginal ridge
enamel.
 Class II David Clark:
▪ The saucer shape with serpentine/disappearing margins (infinity edge preparation).
o So, more exposure of enamel rods for better marginal seal (composite hates sharp margin).
o Steps:
• Prewedging for interproximal access.
• Making saucer shape cavity.
• Infinity edge preparation by any finishing diamond bur or fissurotomy bur.
• Finishing margin by finishing strips (one side)
▪ No junction between occlusal and interproximal (isthmus area) the most common area for crack
initiation.
▪ More conservative so less weakening to the tooth.

7. Buccal box:
▪ No forces so may bevel it as it is esthetic zone.
8. Cavity finishing:
▪ Make final smoothening to all cavity margin by white
stone burs / finishing burs or tapered rubber cups.
▪ Enamel margin of gingival step by finishing strips.
One side Metal finishing strip (ortho strip)
▪ B & L wall of proximal box finished by discs.
9. Class V consideration:
▪ Butt joint in gingival margin.
▪ Long skittered enamel bevel for all margin except gingival one.
▪ Bevel to the middle third of tooth, WHY?
o Problem:
• Proximity of the cervical 1/3 of the tooth to the alveolar bone (fulcrum).
• The gingival margin of any restoration undergoes a considerable amount of flexure
during masticator process.
• This Stress concentration Is the problem Especially in patient who grind or clench their
teeth. (Bruxism)
• Enamel is brittle but dentin is resilient so, the enamel in this area can
cleave, forming a notch like abfracted area. Without treatment, these
abfraction lesions can progress toward the center of the tooth, and
eventually weaken the entire natural clinical crown so, Long-term
restoration of this area is difficult because of the continued stress on
the gingival margin of the restoration.
o Benefit of extending bevel to Middle 1/3:
• Maximize the amount of micromechanical retention to enamel so the effects of flexural
stress on the restoration will be minimized.
• Allow the composite material to better blend aesthetically with the natural tooth surface
eliminating the appearance of demarcation line between composite and natural tooth
structure.
10. Postoperative Occlusal assessment:
▪ After caries removal.
o To know cavosurface margin (TRI=tooth restoration interface)
• The occlusion must be away from TRI, so if occlusal point at TRI, you should extend cavity
beyond it or make cuspal coverage if less than 2mm remaining)
o Indicated for direct or indirect composite restoration:
• It must be at least three stop points (occlusion points) on enamel surface not composite.
• If two points, may modify cavity to be like onlay preparation or overlay preparation,
especially in premolars where cavity is deep, so the restoration won't strength the tooth.

K. Air abrasion / sandblasting:
 Using air abrasion in conditioning of tooth surface before bonding:
▪ It increases the bond strength to enamel and dentin (normal & carious dentin).
▪ And it provides round margin that favors adhesion and restoration placement, which reduces
microleakage, and considered important for the longevity of adhesive restorations.
 Alumina trioxide particles AL2O3 (27- 30 μm or 50 μm):
▪ Using 27 – 30 μm gives you more control but more time consuming than 50 particles (increase
particles size – work faster)
 Hints:
▪ It is advised to start with the smaller (27 -30 micron) particle size and with lower pressure even if
it is more time-consuming.
▪ Coolant is mandatory.
▪ Rubber dam isolation is mandatory for air abrasion procedures.
▪ Not forget to offer protective glasses for patients.
▪ Typical operating distances from the tooth range from 0.5 to 2 mm.
▪ Apply acid etch on dentin for only 3 sec for cleaning any powder remnants not for etching, then
use self-etch bond.
Air abrasion unit:
 Jeep air abrasion master (DAN DENTAL: HAITHUM ATEF):
▪ It is economic air abrasion unit = 3500LE
By: DR MOSTAFA TAHA

 AQUACARE: (single = 35000 / twin =65000)
▪ one of the best air abrasion unit in market.
▪ Has three types of powder:
o A prophylactic powder (sodium bicarbonate): Air polishing to
remove staining.
o Two powders suitable for preparation (aluminum oxide 29 micron and 53 micron particles).
o Sylc Novamin, the active bio glass used for dentin desensitization.
Particle abrasion with 29 micron alumina

to remove aprismatic enamel and
improve bond strengths prior to no prep
direct bonding.

L. Etching
Total Etching:
 Phosphoric acid 35% - 40% (37% most common), when decrease concentration, more
etching time is needed.
 Green etchant = 35%  Blue = 37%  Red = 40% (Decrease time)
 Etchant may be polymer thickened or silica thickened (to make consistency = gel)
▪ Polymer thickened is better (Ivoclar, Bisco, SDI, 3M espe, ultra-etch, META), as
o Polymer is easy to be washed, leaving no residue.
o silica based is difficult in removal by washing, causing silica contamination resulted in slightly
higher bond strengths but may leads to postoperative sensitivity.
▪ Semi gel (easy rinsing) is better than gel.
 Agitation or active application (using bond brush) of the acid etch increases the bond strength when
etching 15 sec (etching for 30 sec or more, has no difference between passive or active application).
 Etching bubbles: indicate that the etching is in action (chalky appearance not indication for etching).
Enamel etching with 37%:
 Etching time:
▪ Virgin enamel or in cases of fluorosis = 60 sec.
▪ Primary teeth enamel = 60 sec. (as it has prismless enamel surface)
▪ Prepared enamel = 30 sec.
▪ Young permanent enamel = 15 sec. (more retentive than 60 sec)
 Role of etchant on enamel:
▪ Exposure of fresh enamel with high surface energy so increase wettability.
▪ Increase surface area by dissolving interprismatic substance.
▪ Microscopic roughness of enamel 30 -50 micron.
o So, we make selective demineralization of enamel (not total demineralization that caused by
increased time & concentration than usual)
Dentin etching with 37%:
 Etching time: For dentin 10 -15 sec ((7.5 - 10 µm)).
▪ 15 secs are absolute maximum (mot more 15 sec), as over etching of dentin causes:
o The same reason as enamel (denature collagen).
o It creates more depth of demineralized colleague and adhesive can't reach this depth (not
more 7.5 µm) so let space not occupied by bond (after that degradation of collagen occurs so
gab formation & bond failure) that’s cause:
• Postoperative sensitivity.
• Pain with biting
o Formation of di-calcium phosphate instead of mono-calcium phosphate that participate in
dental tubule and difficult to be removed by washing so decrease retention.
▪ If decrease etching time. no sufficient micro porosities for retention.
 Role of etching in dentin:
▪ Complete removal of smear layer and smear plug.
▪ Demineralization of outer surface of dentin (collagen exposed).
▪ Dissolution of peritubular dentin of orifice of dental tubule (funnel shape).
▪ But decrease surface energy of dentin.
o So, dentin need primer (adhesion promoting monomer)
▪ Make more space that bond cannot complete obturate it. (Nano leakage):
o Space filled with enzymes that attack bond and weaken it.

No etching for cementum:
 As cementum is very thin & weak so dissolved by etch & root dentin will be exposed, causes post-
operative sensitivity.
 It is better to use universal bond with cementum.
Steps:
1. Protect adjacent teeth by Teflon or strip.
2. Apply etch (gel) on enamel for 15 secs.
▪ Apply etchant 0.5 -1 mm beyond cavosurface margin of unprepared surface (it will remineralize
within week). Etch dentin for 5- 10 sec then
3. Then apply etch on dentin for another 10 -15 secs (now enamel rinsing:
is 30 and dentin is 15 secs) As just we place drop of etch on
▪ Denuded collagen mech. dentin, the etch is in action. (so,
take in concern the time between
▪ Collagen mech is supported by water, so avoid over dryness.
1st drop to final drop – and the
▪ use alcohol-based bond to get rid of water. time that we start rinsing).
▪ Moist surface is mandatory.
Self-etching bond:
 Two step self-etch is better than one step (one bottle).
 Contain acidic monomers (weaker than phosphoric acid) so used in deep cavity.
▪ To avoid sensitivity, as it doesn't remove smear layer but just make microscopic pores in it.
▪ Avoid problem of over dryness.
▪ Penetration of bond is the same space made by acid so avoid Nano leakage phenomena.
▪ Acidic monomers are active until formation of by-products.
 Self-etching bond apply on dentin by rubbing action for 1 minute to enhance action of acid.
 Weak on enamel, so use selective etching.
Selective etching technique:
 Steps:
▪ Apply sponge or Teflon on your cavity (to avoid etching of dentin).
▪ Apply etch on enamel for 30 secs.
▪ Washing and dryness.
▪ Remove Teflon.
▪ Apply bond. (universal bond is better than self-etch bond in selective etching technique)
 Dentin conditioning (optional)
▪ It is just for modification of smear layer to increase the bond strength without causing
postoperative sensitivity.
▪ Done by application of acid etch on dentin for only 3 sec then washing.
▪ It is now wet adhesion that needs alcohol-based bond, so the universal bond is a must in this
situation.
Rinsing:
 The best-recommended rinsing time is 15 seconds (not more 30 sec, increase rinsing time leads to
decrease the bond strength).
 Rinsing (by air & water) for removing all mono calcium phosphate and avoid letting any
remnants that affect retention and sensitivity.
 Rinsing is not an excuse for contamination:
▪ Saliva contaminations decrease the bond strength.
▪ So, It is better to use rubber dam & high suction with water syringe.

Drying:
 Remove the gel by water & high suction then apply gentle air by pressing gently on air-
syringe at distance from 5 – 10 cm
 Gentle air (avoid excessive dryness):
o To make dentin somewhat moist (shiny moist surface is a must) for bonding that its
hydrophilic (primer action).
o To avoid collagen collapse. (lose almost 80% of bond strength)
o To avoid hypersensitivity as result of removing water from
dental tubule so squeezing odontoblast, severe pain.
 Ways of dryness:
▪ High volume suction:
o Used to remove excess water, not all water.
o May use air syringe to help in removing excess water around tooth (not direct air to tooth)
o May use flowable composite tip on it to reach narrow area.
▪ Foam sterilized by alcohol/ or sponge that come with gutta percha or humid gauze.
▪ Avoid drying dentin with cotton as cotton fibres interfere with bond.
 Ground glass or frosted appearance of enamel:
▪ Seen after dryness of enamel (seen after over dryness so avoid it after etching dentin).
 Over dryness occur:
▪ you can rewet it by moist applicator tip (may use primer or chlorohexidine before bonding) but
this can't reverse the collagen collapse completely.
 Dryness depend on solvent in bond:
▪ Alcohol based: Enamel: dry bonding.
Dentin: wet or dry bonding.
o Etch & rinse or universal bond.
o Used with moist surfaces (wet adhesion): to get rid of water.
• Ethanol based: gentle dryness
• Acetone based: no dryness.
▪ Water based:
o Self-etching or universal bond.
o Used with dry surface. (dry adhesion).
o Excessive dryness.
Cavity disinfection
 Place CHX cotton for 30 - 60 secs for disinfection and inhibition of MMP.
▪ MMP Enzyme is already in the structure of dentin, when activated by etching it causes collapse of
collagen fibers which may harm bonding strength in the future.
▪ So CHX used after etching to inhibit collagen collapse.
▪ Then just remove CHX excess (no washing) then apply bond.
 In cases of self-etch bond CHX used only for disinfection (studies say that is no significant
difference).

Acid etch in market:
 BISCO SELECT HV-ETCH 35%: (250 LE)
▪ Polymer thickened: Rinses away cleanly and quickly leaving no residue to
interfere with bonding.
▪ Blue in color for easy visualization and contrast.
▪ Published research proves that BISCO etchants produce higher bond
strengths to (wet or dry) dentin and enamel.
▪ Contains benzalkonium chloride (BAC), an antimicrobial agent. not been
shown to correlate with a reduction in secondary decay in patients.
▪ Other: 32% UNI-ETCH WITH BAC - BEST-ETCH™ 37%.
 Ultra-etch 35% (ultra-dent): (55 LE)
▪ One of the best acids etch.
▪ Precise Placement:
o Ultra-Etch etchant's ideal viscosity, along with
the use of the Blue Micro™ or Inspiral™ Brush tip, facilitates precise placement and superior
control. Ultra-Etch etchant also rinses clearly and cleanly, leaving no residue.
▪ Self-limiting:
o Ultra-Etch etchant is proven to be uniquely self-limiting in its depth of etch, with an average
depth of 1.9 μm with 15-second etch (acids with this greater depth of etch go beyond the optimum
level and increase the potential for incomplete resin impregnation).
 Super Etch 37% (SDI):
▪ It is inorganic silica gel thickener.
▪ Thixotropic gel:
o Super Etch non-slump gel offers precise placement.
o Agitate the gel to lower its viscosity.
 VIVADENT N- ETCH 37%: (refill 2x2 gm = 95 LE)

 Kerr etchant 37.5%: (60 LE)
 Meta etchant 37%: (3gm = 35 LE)
▪ Polymer thickened.
▪ Thixotropic.
Buy small refill syringe not jumbo one (if etch stored for long time,
separation occur between the acid and the gel so no action)

M. Bonding:
 Always respect the storage temperature.
▪ Some products not stable at room temperature, should be refrigerated (tokuyma
universal bond).
 Use quickly after dispensing when no solvent has evaporated.
▪ New drop for each single cavity.
 Protect adhesive from light.
Clinical application:
▪ Bonding time 40 secs for penetration and evaporation of alcohol.
▪ Enamel bonding:
o Be gentle with enamel by applying the bond in one direction without scrubbing or
pressing to avoid breaking enamel prisms.
o Thinner layer of bond on enamel is required.
▪ Dentin bonding:
o Total etching three steps:
• Primer application & agitation for 20 sec.
• Drying for 5 sec to evaporate solvent.
• Bonding application (blotting – agitation – accentuation).
• Thicker layer than that of enamel.
• No light curing & wait for 20-30 sec.
• Then curing.
o Total etching:
• Blotting: hitting floor of cavity by brush.
• Agitation of bond for 20 secs to facilitate infiltration of bond in micropores.
• Accentuation: walk along line angles of cavity.
• Multiple coats are necessary in two step E&R to provide sufficient hybrid layer.
o Self-etching:
• Blotting: hitting floor of cavity by brush.
• Gentle rubbing: active brushing for 20 - 40 sec to facilitate penetration of bond in smear
layer and making micropores.
• Accentuation: walk along line angles of cavity.
▪ Removal of excess by dry brush to avid thick bond layer especially on enamel (one of
causes of white line)
▪ Air thinning: apply light air stream in oblique direction by air syringe at distance of 5 – 10
cm, with aid of high suction to remove excess for 5 sec to:
o Evaporate solvent.
o Distribute or spread bond on wide area and push it in pores.
o letting thin layer of bond on enamel.
▪ Apply multiple layers of bond (Multiple coats concept):
o Number of soldiers VS number of enemies.
• Increasing size of cavity so more dentinal tubules so need more bond (more layers)
o Total-etch technique:
• First coat infiltrates deeply in the opened tubules and may leave a denuded dentin
surface behind, only one denuded dentinal tubule may lead to post-operative
hypersensitivity.

o Self-etch technique:
• Hydrophilic monomers render the superficial layer semi permeable and another coat is
needed to overcome this problem (water trees).
o Multiple coats will ensure complete seal / coverage of dentin and uniformly of bond
layer and also decrease post-operative sensitivity.
o At least two applications of one layer especially with self-etch bond.
• Evaporate solvent from 1st application first. (apply bond layer then gentle air then
another layer then gentle air until non-movable shiny / glossy bond seen then curing)
• Never apply layer on cured bond as it is increasing thickness that
.
subjected more to shear stress.
• If there is pooling of bond should be eliminated by applicator or endo
paper point not air to avoid over dryness.
▪ Curing for 40 sec:
o In deep cavity:
• Use pulsating technique. OR
• Two steps curing for 20 sec then another 20.
• Or initially curing, then complete curing with flowable layer.
o In large cavity:
• Cure mesial & distal separately.
▪ After curing, notice the formed shiny layer, avoid touching it by your hand or any
instrument as it is oxygen inhibiting layer, it is very important for composite adhesion.
▪ DCA is a must when dark curing is needed.
o In case of universal bond used under dual curing composite.
Ivoclar vivadent disposable bond brushes.

Ivoclar brush with hairy long bristles to ensure bond delivery to all narrow and strict areas.

N. Composite placement:
Composite application & Modelling instruments:
Composite application instruments:
▪ Used for composite insertion.
▪ Round ended instrument.
▪ Examples:
o LM Arte Applica.
o LM Arte condensa.
o May use plastic instrument for application.
Composite modelling instruments:
▪ Used for sculpting.
▪ Pyramidal shape (for posterior) & spatula like instrument (for anterior)
▪ Examples:
o For anterior =wider SA (spatula like instrument)
• LM Arte Modella.
• Plastic instrument.
o For posterior.
• LM Arte fissure: Very pointed, used to make deep fissure for staining.
• Heliomolar P1 instrument: Smooth & pyramidal end.

• Or use anatomical burnishers of amalgam.
Coated instrument:
▪ Most recent composite now is non-sticky, so no need coated instrument.
▪ Moreover, coating may be peeled off with time during composite application and affect
esthetic of composite so not recommended.
▪ Examples:
o Gold plated instruments.
• LASCOD ZEFFIRO PLASTIC INSTRUMENT = 350 LE
• Nordent PLASTIC INSTRUMENT = 410 LE
• Nova plastic instrument = 450 LE
o Black coated instruments.
• HELMUT ZEPF ONYX-COATING = 350 LE
o Titanium oxide coated instrument.
• CARL MARTIN = 300 LE
o Bond coated instruments.

Detachable & replaceable tips:
▪ Autoclavable handle with many non-stick tips.
▪ Precise and predictable.
▪ High modelling ability.
▪ Examples:
o Optra sculpt & Optra sculpt next generation.
o Optra sculpt pad (for anterior)
o Kerr Compo Roller (600 LE): seven tip shapes available.
Multi-functional instrument:
▪ One instrument with multi-functional end.
▪ Condenser tip, pyramidal tip & spatula like instrument.
Applicator brush (micro brush of bond).

▪ Give good adaptation.
▪ Must be clean (no bond).
▪ New, to avoid hair ends separation.
Artist paint brushes:
▪ For more adaptation of composite (draw composite toward margins)
▪ Precautions:
o Must be wetted before use by wetting agent as resin modular:
• Because modeling liquids lack fillers, they can reduce the physical properties of the
composite and change it completely from the optical and mechanical points of view.

• However, if they are used carefully and with the right technique, they give the brush an
optimal consistency that prevents composite from sticking to it, maintains the bristles
uniformly together, and helps the brush to stay clean.
o Subjected to hair end separation during composite placement.
Resin modular:
It is a hydrophobic and filler free resin act as a thinner of composite resins.
EX: Ena Seal, Micerium, or Fortify, Bisco.
Two main objectives:
▪ As a modeling liquid.
▪ Recover the oxygen-inhibited layer after diamond burs are used to make corrections on the already
polymerized composite.
▪ Examples:
o Compo brush (style italiano) =280 euro
o Ena brush (2 brushes =240 LE)
o Painting brush 5 LE (single use)
The technique for ensuring a correct amount

of moisture in the brush is to soak the brush
completely in the modeling liquid and then
delicately pass it over an absorbent surface
until it leaves no trail
The simplest kit:

▪ Plastic instrument: composite application & modelling (anterior cases).
▪ Micro brush: for adaptation & rounding.
▪ Probe / endo spreader: For making artistic anatomy.

To overcome adaptation & voids problem:
▪ Compothixo (Kerr).
▪ Decrease layers by bulk fills.
▪ Injection molding.
▪ Snowplow technique.
Avoid stickiness by:
▪ Apply composite gently by clean instrument (not scratched).
▪ Plastic instruments coated by Teflon or cured bond or alcohol.
▪ May coat instrument by resin modular.
▪ Gold plated instruments. (not completely eliminate stickiness)
▪ Use non-sticky composite (most recent composite)
▪ Heating composite (40° - 50°C).
o Making it easier to adapt in thin layers and in small cavities.
o Reduces the risk of incorporating air bubbles in the material.
o Increase handling and decrease stickiness.
o Even grainy and highly viscous composites become shiny, smooth and manageable.
• By composite heater (expensive).
• Or putting syringe (paste or flowable) on halogen lamp of unit.
• Or wax devise (from pharmacy used by girls).
- Switch it for 10 minutes then put syringe for 5 minutes and switch it off it keeps the
heat for enough time.
• Or baby food heater.
ENA heater = 6000 LE

Composite layering technique
 Why to layer?
▪ Decrease c-factor.
▪ Decrease volume of layer so decrease volumetric shrinkage.
▪ For more curing (curing depth).
▪ Development of correct anatomy for esthetic and function.
A. Centripetal buildup technique:
▪ Building missing wall first to converge it to simple class one.
o Building proximal wall 1st using matrix band (support & good contact).
• Build the missing wall by snowplow technique. (flowable + packable)
- May Use Misura instrument to determine the level of marginal ridge according to adjacent.
• Curing from inside cavity & through the matrix if it is transparent (bioclear).
▪ Types (according to Fabianelli):
o Closed sandwich technique: placing flowable after construction of interproximal wall.
o Open sandwich technique: placing flowable before construction of interproximal wall
• Produces more effective seal at the cervical margin of Class II resin composite
restorations than the centripetal closed-sandwich technique, with better marginal
adaptation and less voids.
▪ Advantages:
o Excellent marginal adaptation: decrease gingival gap and if formed, it will be closed
by the 2nd layer.
o Forming occlusal ring (guide for border) so decrease possibility of overfilling &
decrease finishing time.
B. Successive cusp buildup technique:
▪ Building cusp by cusp till central groove guided by adjacent.
▪ Start with the simplest one (most regular-shaped and medium-sized) cusp and working
toward the most difficult (irregularly shaped and large- or very small sized) cusp.
▪ Build anatomy from inner side to outer side.
▪ Decrease finishing time.
▪ Cure each cusp for 10 secs then cure all for 40 sec.
▪ Modeling of an occlusal surface requires three specific instruments:
o Rounded micro plugger to develop slopes.
o Sable brush soaked in modeling liquid to smooth the slopes and remove roughness.
o Spreader, probe, the tip of the Fissura instrument (LM Arte) or a No. 11 scalpel
blade to create a groove.
C. Oblique technique:
▪ The most used layering technique.
▪ Wedge shaped layering: so, each layer touch only 2 walls.
▪ Curing each layer twice to make polymerization vectors toward adhesive side so decrease
distortion of cavity walls.
o From occlusal side.
o From lateral (cavity wall) side.

D. Vertical technique:
▪ Building vertical layers from buccal to lingual (or L to B).
▪ Decrease gap formation.
E. Horizontal technique:
▪ The worst: Each layer touch all walls so increase c-factor.
F. Split horizontal:
▪ By dividing the horizontal layer to 4 layers, each layer is triangular in shape and touch only
two walls.
▪ Avoid difficulty in building the occlusal surface in oblique technique.
G. Stratified technique:
▪ Layering with different Chroma (dentin and enamel).
H. Separate dentin and enamel technique:
▪ Using dentin shade by oblique technique till DEJ.
▪ Then apply enamel shade.
I. Separate dentin and enamel technique by index:
▪ Building enamel layer by index technique.
Bonded cavity steps:
Bulk Fill Method:
 Composite increment near pulpal floor or gingival seat (in class II) must not exceed 1
mm in thickness to ensure sufficient curing that it is far from light cure, even if it was
bulk fill composite.
▪ So, apply bulk flow as 1st layer after bonding (0.5 mm)
▪ If not, the pulpal side would not be completely polymerized that increase pulp
temperature .and sensitivity and decrease hardness.
 Then apply bulk fill to most cavity (in two steps for precautions).
▪ the depth of cure of bulk fill (4 mm) is only in zero distance from light cure tip.
o So, in clinical condition. There is an increase in the distance between composite and
tip of the light cure so must decrease increment thickness to 2.5 mm for bulk fill.
o In real life no material exceeded 2.5mm of full curing under clinical conditions. At
zero distance in the lab some may reach 8mm for depth of cure.
 Make the last increment of them u-shaped so it gives you space to reproduce the
anatomy with the occlusal nano hybrid or nano-capping layer.
 Leave a 2 mm space below the CSA for the nano-hybrid or true nano composite
capping.
▪ May draw the grooves by the spreader.
▪ Ensure there is no high spot before curing:
o By make the probe lean on the composite and tooth structure.
o If sink in composite, it is excess (remove it).
▪ May put stains on groove (remove excess by brush and lighten it - if want - by flowable).

Fill the entire cavity altogether or leave 2mm for body layer.
(sonic fill system)
Successive cusp buildup technique: (case by AMR ELDEEB)
▪ The first layer being A3 dentin allow the operator upon retreatments to better
distinguish the composite/tooth interface by its high chroma and low translucency.
o It is critical to ensure good condensation for the first layer against the cavity walls,
therefore it's never applied in a thickness more than 1-1.5mm which is suitable for curing
of an A3 dentin composite.
▪ The bulk increments building the cusps being laid down in A2 enamel ensures the deepest
light penetration during curing and the best esthetic match to occlusal tooth enamel.
▪ The incremental technique employed that we call individual cusp build up ensures
excellent shrinkage stress reduction by virtue of its favorably low S-factor.
▪ Body shades A1 and A4 can still be used to add lighter or darker effects if a more
esthetically complicated shading outcome is required.
▪ After mastering the technique in the described form, the operator can take a simpler step
further by combining the increments into only 3 steps without affecting the shrinkage
stress.
o Combine the first buccal and lingual dentin increments into one u-shaped increment with a
very thin base. The S-factor is almost the same and is nearly 1 in all increments.
o Build all cusps simultaneously together in enamel composite without touching each other.
o Add in between the cusps and refine the buildup.

Sectional technique (pizza technique): (layers textbook)
1) The procedure will be started on an occlusal Class I cavity with very few
anatomical references.
2) The mesiobuccal cusp is initiated with a small increment of composite.
o This is the easiest cusp on this molar because of its regular shape.
o Before polymerization, slopes will be developed, and the limits, which must be
located at the main sulcus where the rest of the cusps will converge, will be
defined.
3) Once the first cusp is cured, the next is modeled. Before polymerization,
the buccal sulcus must be defined.
4) When all the buccal anatomical references are finished, the palatal cusps
are developed, in this case the transverse ridge.
5) Once the transverse ridge is polymerized, the distolingual cusp is modeled,
and the distal sulcus will be defined at the same time.
6) The larger cusp (mesiolingual), which at the beginning was the most
difficult to model, now will be easy to develop from all the previously
created anatomical references.
7) The final appearance should be a molar with rich anatomy, multiple
elevations and depressions, and a harmonious, regular surface.
Unbounded cavity steps:

Centripetal technique: (build proximal 1st in cases of class II) to turn it to bonded cavity.
 Build the proximal wall by snowplow technique:
▪ Apply flowable composite without curing then apply packable and condensation by
plastic instrument.
▪ Use the brush for adaptation and remove excess flowable on surface.
▪ Use Misura instrument to determine the level of marginal ridge according to adjacent.
▪ Then curing (curing depth is 2mm)
▪ Curing from inside cavity & through the matrix if it is transparent (bioclear).
Another method: (bulk fill & bulk flow)
▪ Apply a very thin layer of flowable composite preferably to be bulk-flow around 0.5 mm
in thickness to seal sharp line and point angles if present, then adapt and cure.
▪ Then apply a thin horizontal layer of bulk-fill restorative composite around 1 mm in
thickness over the gingival seat, then adapt, smooth and cure it. You will benefit from the
bulk-fill composite ability to be cured enough with such thickness at this very critical area
in which most of class ii failures occurs.
▪ Horizontal layers of bulk-fill restorative composite will depend on cavity depth, however
usually you will need only two horizontal increments, each is 2.5 mm in thickness and
although they will be wall to wall bonded, the shrinkage stress won't be high.

▪ Make the last increment of them u-shaped so it gives you space to reproduce the
anatomy with the occlusal nano hybrid or nano-capping layer.
▪ Leave a 2 mm space below the CSA for the nano-hybrid or true nano composite capping.
Notes:
 Use incremental layers less than 2 mm (1- 0.5 mm increment) U- shaped layering technique
in pulpal floor (it is very important that 1st layer after bond application is 0,5 mm only and
it is preferable to be from bulk flow / flowable composite).
▪ Flowable composite in pulpal flour as it has good adaptation to sharp angles and fine
undercuts, decrease micro leakage so decrease sensitivity.
 Co-curing: add bond + flowable and curing together (that’s Increase tensile strength of bond).
▪ It is preferable to be used with enamel or composite repair rather than dentin.
There was no clear explanation, most of the cited papers said that the microporosity of the acid etched
enamel were enough for a stable adhesive joint in both curing modalities unlike the hydrophilic dentin in
which the pre-curing was much better than co-curing because shrinkage of the overlying flowable
composite might have disrupted the unstable adhesive joint.
 Use opaque flowable composite in cases of dentin stain like after amalgam removal.
 Then use mix of horizontal and oblique layering technique.
▪ To decrease c- factor so decrease shrinkage.
▪ Depth of curing only 2 mm.
 Avoid overfilling the cavity beyond the margins:
▪ As this tooth surface is not conditioned by the bonding agent, so this area is more
susceptible for discolorations and secondary decay.
▪ The overfills frequently cause premature contacts during static and dynamic occlusion.
Videos of Class II restoring by different method:
. . . .
Snowplow technique:
 It is type of layering technique by using flowable composite below packable composite, to get
advantage of good adaptation of flowable composite (decrease marginal leakage in class II)
and mechanical properties of packable composite.
 Technique:
▪ Place thin increment layer of flowable composite without curing then apply a layer of packable
composite and press it for adaptation then curing together.
o Pressure applied by packable composite displace most of flowable composite (and its
potentially disadvantages) and push it outside to be removed by microbrush.
o The remaining flowable composite found in area that packable composite cannot reach it,
thus decrease voids and micro leakage especially in class2.
 Used more in building proximal wall of class II.
 Avoid use it in body of cavity to avoid cuspal deflection that will be resulted from high
shrinkage.

Injection moulding:
 It depends on using heated bulk flow + heated packable bulk fill composite together
to fill cavity and cured in one shot.
 Armamentarium:
1- Packable and flowable bulk fill composite:
2 brands are universal shade

2 brands have A1, A2 and A3 shade.
(transparent shade)
▪ Quixfill packable. ▪ Filtek bulkfill
DENTSPLY: 3M ESPE
▪ SDR flowable ▪ Filtek bulkfill flowable
▪ Tetric evoceram bulkfill

▪ Xtra fill. Ivoclar-
Voco: ▪ Tetric evoceram bulkfill flow
▪ Xtra base vivadent
▪ Tetric n ceram bulk fill
▪ Tetric n ceram bulk fill flow
2- Composite Heater:
o the most famous 2 brands are: Heat: sync by Bioclear & Calset by AdDent
• you need to heat the composite to 155 Fahrenheit = 70 Celsius.
• unfortunately, the 2 brands aren't available in Egypt.
o The composite heater is expensive so, you may use instead:
• A conventional wax warmer and it works fine.
• Wax devise (from pharmacy used by girls) = switch it for 10 minutes then put syringe for
5 minutes and switch it off it keeps the heat for enough time.
3- Transparent sectional matrix:
o Biofit from Bioclear... but it is really expensive
o Transparent contoured matrix from TOR VM. (cheap).
4- Three light curing devices
o As it is recommended to cure the whole filling from buccal, lingual and occlusal at the same
time.
 Technique:
▪ Infinity edge margin cavity: to provide a very wide enamel area for bonding to prevent
micro leakage.
▪ Use transparent matrix to allow curing.
▪ We adjust matrix to get contour and contact.
▪ Apply bond then cure.
▪ Apply 2nd layer of bond without curing to increase wettability of composite.
▪ Apply heated bulk flow then heated packable bulk fill composite to fill cavity.
▪ Curing from three point (occlusal, buccal, lingual) as one shot (by three Light curing units).
▪ Once the separator (ring) has been removed, repeat the three-point curing again to
assure full curing.
▪ Finishing and polishing.
 Important notes:
▪ If you’re curing with 2 or 3 lights, please use air to cool because this generates a lot of
heat!

▪ Curing is done in one shot: as curing every part of this large restoration alone increase
stress concentration inside the filling which weaken it.
▪ Polymerization shrinkage is at its minimum in bulkfill composites and even decreased by
heat, especially in class II when the c factor is lesser than class I.
David Clark sandwich
(single load fill) . .
technique.
David Clark injection
Apply 1mm of bond in molding technique.
proximal slot without
curing (air thinning only
for occlusal portion)
 Does this technique affect pulp?

▪ Composite temp is 70 Celsius and decreasing fast:
o Pulp can tolerate more than that before going into pulpits.
o Heat loss happens rapidly so you need to be fast in the application (not more 15 sec after
heating).
o Besides that, composite has low specific heat and no thermal conductivity, so it doesn’t
really affect the pulp.
 Advantages:
▪ Easy, Simple and Fast.
▪ Less porosity so more strong filling than conventional.
Direct overlay (guided cusp reconstruction):
 Indication:
▪ When the cusp/cusps are to be reduced due to insufficient tooth structure remains after
tooth preparation and the patient can't afford indirect restoration.
 How:
▪ In cases of the natural cusp morphology is still intact:
o Make silicon partial impression index.
• Use trays because they provide stability and the volume for your material.
• Index should contain at least one mesial and one distal reference tooth and imprints the
cusps morphology (tip position, slope angulation if available).
• Cut index with a blade to maintain only the side of the cusp to be reconstructed (buccal
or lingual index)
• Pay attention to clamp position and remove silicone material that interfere index passive
positioning.
o Steps:
• Cuspal reduction to level where the cuspal tooth structure is enough (2 mm or more).
• Following all bonding procedures cusp should be reconstructed first.
• Adapt your index and mark the margins of your preparation with a probe.
• Then remove the index and put enamel shade composite inside it.
• Distribute thoroughly and extend your margins a little to provide material sticking to the
tooth.
• To prevent material sticking to the instrument while its distribution it is recommended to
use micro brush applicator wetted in modeling resin.
• Adapt your index with composite on the tooth, push it firmly and polymerize.

• Carefully remove the index, polymerize again and add some dentin composite at the base
of your shell to prevent its accidental breaking.
• After your cusps are build up and reinforced with dentin material you can proceed to a
proximal wall.
▪ In cases of the natural cusp morphology is missed: (flat restoration or destructed)
o Make silicon impression & waxing up (lab) then make index.
o Or may free hand building.
 Case by Dr/ Иван Кузнецов:
▪ Old composite restoration with the presence of marginal leakage and secondary caries,
very thin buccal wall and quite sharp mesio-palatal cusp.
▪ Buccal and palatal index try in:
▪ Occlusal reduction (1.5 mm was enough here).

▪ Adapt index with composite on the tooth.
▪ After your cusps are build up and reinforced with dentin material you can proceed to a
proximal wall.

O. Final layer painting:
Tips to minimize occlusal corrections:
1) Preoperative occlusal assessment:
▪ To see where the contact points are, in which areas you have to be very careful during the
sculpting of the final layer.
▪ You can also inform about the type of occlusion, possible cross bite, etc.
▪ You can quickly take a photo with the marks in place to record it, so you can have a look at it
during the restoration as well.
2) Use multiple isolation:
▪ Landmarks on the adjacent teeth give me guidance about position of cusps and groves, shapes,
cuspal inclination, the position and depth of fossae and morphology of marginal ridges, further
small details like wear facets, etc.
▪ Many times, the improper angulation of the cusp slopes can cause premature contacts after
finishing the restorations.
3) Know the anatomy.
▪ The most effective tool for minimal occlusal corrections is to be familiar with the teeth you are
restoring.
▪ Anatomy of tooth is divided into:
1- Primary anatomy: functional elevation & depression (done by bur).
•Cross match with patient comfort.
•Saves dentist chair time.
2- Secondary anatomy: cusps slops & developmental grooves.
•Patient needs defined anatomy & dentist seeks attractive shot.
3- Tertiary anatomy: developmental & supplemental grooves.
•The most time consuming. (dentist seeks a glamour shot)
▪ Every tooth is individual, but they are all built around same basic structures (guidelines).
Guidelines:
1. All posterior teeth cusp tips nearly are on one line parallel to the arch curvature.
2. All posterior teeth central developmental grooves nearly are on one line:
▪ So, cusp slopes must stop at this level (except oblique ridge) to avoid high
spot.
3. 3. All the cusps slope down to the central groove at a level lower than the
marginal ridge level by 0.5-1mm.
4. Do not make sharp and deep grooves to not retain stain and plaque. So,
after drawing grooves use brush.
5. For artistic anatomy may make for each cusp two supplementary grooves (arbitrary).
6. Keep developmental grooves map in your mind to help you correctly constructing your anatomy.
Upper essential lines lower essential lines

The most convenient way to learn these characteristics is to observe nature. Make pictures, impressions of
natural teeth, look at them carefully and you can find the similarities. It is a good exercise to take pictures of
healthy teeth and make drawings over them (right hand side image) to mark tooth outline, cusp tip positions,
primary and secondary grooves. You will find that teeth of different patients have the basic characteristics in
common, what is all driven by function. Once you find these common rules, it will be much easier to sculpt the
correct anatomy and the need for occlusal correction will drop dramatically.
After learning anatomy, the

next step is recreating it.
Modeling teeth in wax is a
very good exercise to
become familiar with teeth
shapes.
Teeth are created perfectly functional by nature: every groove, fossa and ridge have their role in functional
contacts and movements. If you know these rules, you will know how to reconstruct occlusal surfaces and
minimize the need for possible corrections.
The concept of the occlusal compass was created to visualize functional movements of opposing teeth, to help
understand the relationship between anatomy and function.

The occlusal compass in case of a lower molar tooth.
▪ The central green point is indicating the cusp of the antagonist tooth.
▪ The arrows show movement of antagonist cusp during different jaw movements.
▪ If you look carefully you can observe, that every fossa, primary and secondary groove is there for a
reason, to allow room for opposing cusp movement and ensure an effective chewing function.
Droodle technique: By Dr: Barbalace Domenico.
2nd 1st 2nd 1st 2nd 1st

Occlusal anatomy reproduction (two methods):
1) Cure then sculpt:
▪ In cases of Simple anatomy production (make grooves).
▪ Steps:
o Final contouring with hand instrument is ideal for decrease trauma of shaping with bur.
o After curing you can modify your anatomy by finishing burs ex:
• 830 bur = pear shape bur (yellow or red) & flame shaped finishing bur.
• Modified carbide bur for making grooves.
Principles of the non-edge technique:

- The composite must be completely polymerized.
- The composite should be milled with a superfine multiblade bur, because it is the only bur capable
of milling composite with such a fine tip. Diamond burs, even the thinnest flame-shaped burs, usually
have a very thick tip.
- The speed of the handpiece should not surpass 10,000 rpm.
- Pressure should be feather-light.
- The restoration should be sandblasted before stain application.
- The technique is completed with mechanical polishing to a high gloss.
An old tungsten bur is modified with
a diamond disk. Both instruments
must be rotating during this
procedure; trimming should
continue until a fine tip is created.
- A map of the main grooves is drawn with a pencil.

- Sharp groves are created
- A rounded No. 1/2 diamond bur is used to develop the slopes that characterize each ridge from each
cusp, widening from the bottom to the surface.
- The main sulci are redefined a second time with the modified bur.
- The restoration is sandblasted at 2-bar pressure from a 10-cm distance to remove the debris from
the milling.

2) Sculpt then cure (with or without stamp):
▪ Used with Complex anatomy (fissures & stain). The best finishing of
▪ Stamp technique or free hand. composite is not to
▪ Avoid using bur after curing (use it minimum as possible): finish.
o As you will remove the fissures and stain.
o It is better technique as it avoids using burs to finish so avoid microcracks.
Hints:
1) A key point is not to lose information about the tooth, from the residual anatomy. Certainly, the best
way to find information is to not to miss it!
▪ Follow the Inclination of residual cusps.
▪ Location of the sulci or what is left of them.
2) Fill your cavity with layering technique or with Posterior misura

bulk fill up to 1.5 mm from the cavity edge (for LM Arte
the final layer =enamel).
3) After placing the final layer, lay the instrument (Condensa LM Arte or
probe) on the cusp to copy its inclination. This way we also remove the
excess material.
4) A key point is to determine the center of the modeling, it is the correct base to orient the essential
lines. It will be the starting point
of the lines while the tooth tells
us where it should end, we just
have to connect the dots
following the design of the
Essential Lines.
5) Once the sulci are drawn, we can
decide whether to add secondary slots
like the one in blue if the tooth
anatomy requires it.
6) With the Fissura instrument we can draw the sulci and improve the marginal adaptation of the
material, to reduce the finishing time and the restoration.
7) The instrument movement to trace the groove must be from the center to the periphery for a more
proper displacement of the material.

Stamp technique:
Direct stamp technique:
 The tooth should be with fully anatomic structure.
 Technique:
▪ Dry the tooth.
o Some left saliva as separating medium or use Vaseline especially in cases of undercuts.
▪ Apply 1st layer of flowable composite (or soft dam/ liquidam) to fossa and grooves. .
o No bonding or etching needed. Just flowable.
▪ Then apply 2nd layer with bond brush on occlusal surface (cover cusps tips) then
cure.
o May cut the tip of brush for better handling characteristics.
o Prevent the brush from touching the tooth underneath.
▪ Make mark, by pen as example, for accurate repositioning.
▪ Remove the stamp and begin your cavity preparation and restoration.
▪ After building dentin, apply enamel layer then use stamp.
o Cover the tooth by teflon or cover the stamp, as teflon act as separating medium between
two resins so prevent any stickiness of uncured resin to stamp, provide uniform surface.
▪ Then remove the stamp and remove the excess beyond your margin (may repeat this step until
you complete your restoration) then curing. .
▪ Final layer is not completely polymerized so:

o use glycerin or (oxyguard/oxygone) then 2nd curing.
o Or use water soaking method.
o Or cure through stamp or Teflon 1st to prevent oxygen inhibited layer formation, then
remove Teflon and 2nd curing.
Indirect stamp technique made after lab waxing up.

 Individual stamp.
 Multiple stamp:
▪ made by segment rubber base impression.
▪ Not advisable: as it is not accurate and has difficulty in excess control.

Posterior composites staining
To stain or not:
 Most patients complain about unpleasant brown spots on their restoration.
 May be mistaken diagnosed as caries.
 Dentists are very happy and exciting with brown stains on composites in the posterior region.
 Staining procedure defines and enhances the 3D perception of the occlusal morphology. As a
perception for the patients very often they appreciate the detailed work (if the doctor explains why
he used the stains).
 So, if you use it make ensure that the intensity of the brown should be chosen very carefully regarding
to the natural stained adjacent or homologue teeth.
Occlusal Stain Classification
 Characterization: light stains to give shadow of developmental grooves & cuspal slopes.
▪ Can be made by painting sub final layer of slopes and grooves to lighten the stain and appear as shadow not
extensive one.
 Intensive: dark- patches or spots-obvious in-patient mouth, may be mistaken diagnosed as caries.
 Stain colors:
▪ Orange: A slight chromatic stain that blends with the dentin and looks almost transparent (A flowable A3
composite is suitable as well).
▪ Ocher: An intermediate-intensity stain that is visible as a reddish (light brown) stain.
▪ Brown: A high-intensity brown stain that is the most common stain. (ENA stain)
▪ Black: The highest-intensity stain, representing the most opaque mass, normally modified.
▪ White: used where enamel is thicker as in occlusal ridges.
Layers staining:
1) After dentin is modeled and before the enamel layering begins, small increments of white intensive (+) are
placed in a "roll "shape.
▪ Each cusp can hold many rolls, depending on its size, but normally there are one to four.
2) Enamel composite is placed on the external walls to create a fish mouth and enable building of the occlusal
surface with the sectional technique.
3) With the same enamel composite, each cusp is covered one by one, starting from the easiest.
4) A brown-ocher stain is developed, with brown in the center and ocher in the periphery.

The external stained technique:
 It is done after the last layer of composite (after the morphology is finished).
 Apply it on quite smooth composite surface. So, if the composite surface is too rough first do a
finishing procedure and after that stain.
 Steps:
▪ A small quantity of brown stain applied at the level of the groves and fissure with a sharp instrument (fine
probe, Fissura, 10 k-file, etc.) Or using an ultra-fine needle tip applied directly to the stain syringe.
▪ Before light curing, the stain excess is removed with an adhesive microbrush tip.
▪ If needed, additional layers can be used until the desired characterization is obtained.
▪ The stain can also be lightened by flowable composite.
.
Correctly placed occlusal

Incorrectly placed occlusal stains create a sharp and clean
stains often result in a smear sulcus. The color becomes
effect and fading spots
stronger, and the effect lasts
longer because the layer of
stain is thicker.
Staining during morphology design:

 Style italiano Steps:
▪ After dentin layering (building vestibular part of cavity), A small quantity of the stain is applied on the base
(into the cavity) of the vestibular cusp.
▪ Before light curing the stain, apply the composite for the oral cusp then push the composite against the
cured vestibular cusp.
▪ The stain will flow up to the surface, following the groves and fissures.
▪ With an adhesive tip, the excess of the stain can be removed.
o You are forced to defined very good your morphology. This why this technique is more operator sensitive.
o The stain line is more delicate and well defined.

P. Curing:
Modes of curing in available devises:
1- Pulsating: Using soft start curing (set cure or ramp
▪ used with high shrinkage composite. cure) or discontinue curing (pulse delay
▪ In deep cavity (to avoid increasing in heat generation) cure) lead to decrease stress and micro
2- Ramping: it is increasing in intensity, used with high leakage by giving chance for composite to
shrinkage composite. flow during 1st stage of polymerization.
3- Constant: used with low shrinkage composite ex: bulk fill.

Time:
 In most cases time of curing ranges from 20 -30 sec for each layer and let it for short time
before application 2nd layer for complete curing.
 Depends on:
▪ Power of light cure according to (Time x power = 16.000 m joules/cm2).
o If intensity decreased, increase time.
▪ Distance:
o Light cure tip should be away from composite 0.5 mm (increase distance, decrease intensity so
increase curing time.
o Each 1mm distance, the intensity decreased by 25%.
o In deep cavity (more than 3mm) and class 2 (gingival step) increase time of curing may reach
40-60 sec as complete polymerization needed to be done in one shot.
▪ Shade of composite:
o Enamel or transparent shades incremental layer 2mm or less then curing for 20 secs.
o Dentin or more opaque shade make layer 1.5 mm or less then curing for 40 secs.
▪ According to manufactures.
Increasing time does not affect composite. (over cured better than under cured)
Composite cannot be over polymerized; we can affirm that. the more light the material
receives, the better conversion and physical properties it will have.
Wavelength:
 2nd generation: mono-wavelength from 420 – 480 nm.
▪ Most traditional & bulk fill composite containing initiators (CQ) that its peak sensitivity near
wavelength 470 nm.
▪ Most devises in market is 2nd generation: (Elipar 3M – SDI radii plus – Kerr demi ultra – MONITEX)
 3rd generation (Dual peak LED LCUs): poly-wavelength from 400 – 510.
▪ Bleaching shade composite has different initiators (TPO) that its peak sensitivity around 400 nm.
▪ Dual peak LCU have two emission peaks:
o Primary emission peak at around 460 nm to cover the absorption spectrum of the CQ/TA.
o Additional peak at around 400 nm to match TPO and PPD
▪ Expensive devises: BLUE phase style Ivoclar (17000 LE) -VALO ultra dent.
Note: ensure that the Tip is clean and not broking (change wavelength)
Power density: intensity per unit area
 Power output of your devise recommended to be more than 1000 mW /cm2.
▪ Minimum power required for curing BULK FILL COMPOSITE is 1000 mw / cm 2 for 20 sec.
▪ Mnium power for curing conventional composite is 600 -800 Mw/cm2.
 Devises power in market is ranged from 1000 -6000 mW/cm2 (6000 as in flash max P3 by CMS)

 Power density stability:
▪ Full battery power (decrease in power leads to decrease in intensity).
▪ With time battery efficiency decreased son decrease intensity. (you should check your devise
intensity continually).
Test for curing:
 Radiometer (Curing light intensity meter device) ex: woodpecker radiometer.
▪ It reads 400mW on a radiometer from a 7mm distance then it is ok.
 Or cure 2mm layer at distance of 7 mm:
▪ Get a metallic coin or any opaque material of a 2mm thickness and make a hole in
its middle. Place your composite in the hole and cure it from a 7mm distance.
▪ With a sharp explorer scratch the composite on the top surface that was facing the
light cure tip and compare it to the bottom surface of the composite disc that was away of the light-cure
tip. Both top and bottom surfaces of the cured composite disc should have the same scratch resistance.
Direction of light curing:
▪ Light must be directed toward tooth wall not composite.as shrinkage occur in direction of light.
▪ Also make right angle with tooth surface. If less than 90 affect polymerizations.
 Note: now there is new concept about the direction of polymerization shrinkage.
1- If adhesion is less than 17MPa, the shrinkage occurs toward the center which pull
the restoration material away from the cavity walls.
2- If adhesion is more than 17MPa, the shrinkage occurs toward cavity wall.
Curing consideration
▪ Material opacity. ▪ Light collimation .
▪ Photo initiator% and type. ▪ Position of tip.
▪ Distance of tip. ▪ Distribution of Light energy
▪ MW/cm2 Power. ▪ Type and depth of restoration
▪ Heat Buildup.

Which light cure devise:
 To buy 2nd or 3rd generation light curing unit?!
▪ If you do not commonly use bleaching shades in your clinic so 2nd generation devises are enough.
As 3rd generation devises are expensive.
▪ 2nd generation devises can cure bleach shades but in 1mm increments and 40 secs time.
o As bleach shades have also CQ photo initiators (430-490nm) besides the TPO (375-410nm) but
in a lesser amount.
 Turbo light curing advises.
▪ Turbo light curing unit (1 sec curing – 5 sec curing) is not practical and not advisable to use this
mode due to:
o Increase intensity in this mode leads to increase heat generation that affect pulp status.
o This rapid curing results in short polymerization chains with increases in stress.
 Heat generation:
▪ All high intensity curing lights (over 1100 mW/cm2) cause a certain amount of heat.
o Polymerization with external cooling from an air flow.
o Polymerization at intermittent intervals (2 exposures lasting 10 seconds each instead of 1
exposure lasting 20 seconds).
 What about curing of the adhesive?
o Problems with curing of the adhesive comes from incomplete evaporation of the water in the
adhesive and not from inadequacy of the light cure device.
o How to ensure complete evaporation of the water and hence proper curing of the adhesive?
o Drying for 5secs of azeotropic adhesives is enough to evaporate water.
o Non-azeotropic adhesives may need up to 90secs of drying or use of hot air for 15secs to
evaporate water.
▪ What's an azeotropic adhesive and which of the adhesives in our market are azeotropic?
o It's the adhesive that has the water/solvent ratio that ensure complete evaporation of water
with the organic solvent.
o In our market, the only adhesive that i know to be azeotropic is the All Bond Universal (Bisco).
 Protective light filter:
▪ Protective eyewear or a shield to cover the light-curing unit (LCU) is a must.
Ophthalmic research shows that short wavelength light like that commonly
used in dental curing lights may contribute to premature aging of the eye’s
retina and to senile macular degeneration.
 Flip-up composite filter:
▪ Avoid composite curing when prepping for restorations/adhesives
 Recommended light curing devises in market:
▪ 2nd generation devises:
o Monitex: wavelength range 420-490 nm / Intensity 1000 mW/cm2.
o Premium plus: wavelength range 440-480 nm / Intensity 900 -1500
mW/cm2.
o SDI radii plus.
o Kerr demi ultra.
o Elipar 3M: wavelength range 430-480 nm / Intensity 1470 mW/cm2.
▪ 3rd generation (poly-wave) devises:
o VALO (ultra-dent).
o Blue phase style (Ivoclar Vivadent)

 Chinese light curing units:
▪ Most of Chinese brands do not meet half of the intensity output specified on their brochures or
fail to maintain it for more than a year.
▪ Buy known Chinese brand as (woodpecker or eightieth) with intensity more than 1000 mW/cm2.
o You must keep its battery full charged otherwise you get half the intensity.
o Also, in deep cavities or in class II gingival seats you must keep your increments not more than
1mm because it loses most of its intensity at distances more than 5mm from the tip.
▪ Recent Chinese light cure in market: poly wave devises.
o Eightieth Curing pen:
• Fast one sec curing option.
• Wavelength: 385-515 nm (can be used with bleach shades)
• Maximum Intensity: 2300 mW/cm2.
• detect mode 600 mW/cm2: detec caries and cracks.
• DC-drive mode: the same intensity despite the battery power.
o WOODPECKER LIGHT CURE I LED plus:
• Fast one sec curing option.
• Wavelength: 385-515 nm (I-led was 385- 420 nm).
• Maximum Intensity: 2300 mW/cm2.
o Woodpecker X cure: (4500 LE)
Premium plus CO1 – C LED curing unit

TURBO 1500 mW/cm2 for 5 sec Super-fast curing.
FULL 1200 for 10 -20 sec General application.
st
1 5 sec from 0 -1200 mW/cm2
RAMP General application.
Next 5, 10 ,15, 20 sec 1200 mW/cm2
1st 5 sec from 0 -900 mW/cm2 To avoid post-operative
SOFT CURE
Next 5, 10 ,15, 20 sec 1200 mW/cm2 sensitivity.
VALO recommended curing time

Mode Standard mode High power mode Xtra power mode
Per layer One 10 sec cure Two 4 sec cures One 3 sec cure
Final cure two 10 sec cures Three 4 sec cures two 3 sec cures

Polymerization shrinkage
 Composite shrinkage is restricted by the adhesion of the material to the cavity walls
which generates stress at the interface.
 In the pre-gel phase, the reactive species present enough mobility to rearrange and
compensate for the volumetric shrinkage without generating significant amounts of
internal and interfacial stresses
 When the degree of conversion approaches 10-20%, the network is extensive enough
to create a gel, leading to the start of the post gel phase.
 In general, an increase in conversion during the polymerization reaction elevates
shrinkage and elastic modulus, which causes greater stress.
Pre-gel. Post-gel.
M P
No stress Stress build up O
O
N L
O Y
Polymerization
M M
E shrinkage E
R R
Polymerization shrinkage sequelae:

1) Lack of adaptation (marginal gab) microleakage.
2) Marginal Staining.
Polymerization shrinkage cannot be avoided
3) 2nd caries.
but the target is:
4) Postoperative sensitivity. 1- Decrease shrinkage stress.
5) Stress built up. 2- Bond strength stronger than
▪ Cuspal deflection/ flexure. shrinkage stress
▪ Enamel margins microcrack.
▪ Breakdown of adhesive bond.
o If shrinkage stress is high and exceeds the initial bond strength of the restoration, de-bonding
may occur at the cavity wall resin interface.
▪ Propagation of hairline cracks in the remaining dental tissues.
(Debonding)

How to reduce shrinkage stress?
1) Altered light curing cycles.
▪ Pulse delay or soft start polymerization instead of high-intensity light curing.
▪ If you have not soft start mode in LCU, you may initial set by decrease intensity (by
increasing distance).
o The flowability of a material, during an extended preset stage, may have minimal
consequences, because most shrinkage stress is developed during and after the vitrification
stage.
2) Three-sited light curing.
3) Controlled stress reduction.
▪ Optimizing the C-factor (the ratio of bonded surface of the restoration to the unbonded
surfaces):
o The higher the value of C-factor, the greater is the polymerization shrinkage.
o Realistically a number of 2 or above is a problem when it comes to performance of the
composite.
o Incremental layering optimizes the configuration factor (Use multi-layering technique) to
provide more free surface for flow.
C-factor =1/1 =1 C-factor =2/1 =2

▪ Application of “elastic” bonding resin (1st stress breaker layer).
o Stretching of the elastic resin leading to stress relaxation from polymerization of the stiffer
composite filling.
▪ Application of a “low elasticity module” base-lining (2nd stress breaker layer).
o The material will absorb the volumetric changes and can stretch or flow to allow stress
relaxation.
• Flowable: low modulus of elasticity (modulus of rigidity) so more flexible.
• RMGI.
4) Composite heating:
▪ Increased temperature decreases system viscosity and enhances radical mobility,
resulting in additional polymerization and higher conversion.
▪ At raised temperatures, in theory, it would be possible to obtain higher degree of
conversion before the vitrification point, decreasing the magnitude of stress.
5) The newly introduced materials and techniques.
▪ Bulk fill composite.
▪ Low shrinkage composite.
o N’Durance. (septodont)
o GC Kalore.
o Filtek P90.

Low shrinkage composite used in
posterior and anterior.
. pre-polymerized fillers and DX-511
low shrinkage posterior composite (the

first composite to shrink less than 1%)
use “ring-opening” silorane chemistry
Nano dimer low shrinkage & high

conversion composite that used in
anterior and posterior composite.

Q. Finishing and polishing:
 Finishing: All steps that used to contour and eliminate excess of composite.
▪ Importance:
o Removal of composite flashes (non-bonded) that may cause caries recurrence due to bacteria
accumulation beneath it.
o High spot removal.
 Polishing: All steps that used to make the restoration smooth and gloss.
▪ Importance:
o Create a smoother surface with lower levels of adhesion:
• Reducing the risk of plaque build ups and staining, leaving the tooth healthy for longer.
• Minimize the risk of irritation to the gums, reducing sores, bleeding, and maintaining the
health of the tissue.
o Esthetic: it provides a shinier, more reflective surface, encouraging a natural smile.
 Finishing and polishing in posterior teeth:
▪ 90 % of finishing steps done before curing the last layer.
▪ All steps done with little water to avoid heat generation and so debonding.
Occlusal refinement:
Adverse effects of high spot:
1) Restoration fracture.
2) Traumatic occlusion.
o Inability to chewing. Notes: during eating the space between occlusal
o Apical periodontitis. surfaces lies in range of 20 micron, so if high
o Sensitivity. spot is less than 20 microns, it may be accepted.
o Mobility.
3) Bruxism.
4) Muscle disorder.
5) Temporomandibular disorder.
6) In multiple restoration:
o Headache.
o Earache.
o Sensitivity to noise.
o Sensitivity to light.
o Neck & shoulder pain
Articulating paper types:
▪ Thickness:
o Ultra-thick: 200 microns plus.
o Thick: 41 -100 mm micron (glazed / metal prothesis or two steps method)
o Thin: 19 -40 micron (restoration and natural teeth)
o Ultra-thin (Arti-foil): 8 -12 micron (implant prothesis)
o Shim stock: gauge occlusal stops.
▪ Shape:
o Straight articulating paper.
o U- shape articulating paper: In cases if you work in both sides (removable prosthesis or bridge
cases).

Clinical steps:
 Preoperative:
1- Occlusal stops / references: Use one tooth before and after the tooth to be restored as an
occlusal reference.
• In this step we use the shim stock in centric occlusion (maximum intercuspation = zero
space).
• If we will restore 6 so we will take 7 & 5 as occlusal references.
• Put the shim stock above 6 and ask the patient to bite in centric occlusion, then try to pull it.
(not pulled = occlusion)
• Repeat it for premolar 5. (if it is pulled take tooth from opposite side)
2- Preoperative occlusal assessment:
• Use articulating paper: blue one in centric occlusion and red one in eccentric occlusion.
• Take photo as reference for occlusion.
 Postoperative:
1- Check occlusal stops by shim stock: if pulled then there is high spot.
2- Check centric occlusion: by blue articulating paper & compare it by preoperative one.
3- Remove high spot:
• remove eye spot 1st then check occlusion.
• If not occluded then remove heavy spot… etc.
4- Check eccentric occlusion: mostly on slopes of cusp.
Remove from:
centric then eccentric.
All Functional cusp first.
Eye spot  heavy spot  medium spot  smudge.
We stop only when the reference tooth occluded not when
the patient says enough.
Clinical tips:
▪ Don’t ask the patient during occlusal assessment.
o The patient may be not sure about high spot (anesthesia work).
o This Repeated step make the patient suppose that you have little experience in what you do.
▪ Eye spot: is viewed as blur circle (blue surrounding area indicate no contact) with white center (actual
high contact).
o White area indicating, high pressure in this area so no marking. (so, the thicker the paper the
bigger the eye)
o To ensure it is the high spot, use ultra-thin red articulating paper (Arti-foil), the white area will be
marked by red.
o Eye spot in natural teeth indicating wear facets. (not marked by Arti-foil)
▪ Thinner (19 – 40 micron) articulating paper is better to avoid guiding patient bite.
o But you can use two thickness for optimum results: use ultra-thick for centric and ultra-thin for
eccentric with different colors.
▪ Use a full quadrant articulating paper pre-operative & post-operative.
o To know how occlusion of patient looks like.
o Occlusal stops.
▪ The more time you spend in sculpture, the less time in occlusal adjustment.
▪ Both centric (blue side) and eccentric checks (red side) are mandatory.

▪ Dry the teeth before using articulating paper.
▪ Always check the contra-lateral side.
o If occlusal stops in contra side occluded or not.
▪ Know the borders of your restoration.
o To avoid removal of tooth structure.
▪ Avoid over deepening the anatomy with meticulous patients.
o Make space for food retention in occlusal surface and so recurrent caries.
Examples of good quality articulating papers:
▪ Bausch articulating paper (40 micron / ZAF dent):
o No-Smudge articulating papers with progressive color transfer are pressure sensitive.
o They are impregnated (not coated) for marking in wet or dry fields.
.
Dr: ahmed Elhakim case.

Pre-operative occlusal assessment showing
normal centric contact.
 Note the blue color depth on functional palatal
cusp, marginal ridge & oblique ridge (molar).
 The mark on buccal cusp (nonfunctional) is not
true mark, it is just smudge resulted from poor
quality of articulating paper or incorrect bite.
High spots
 Note the difference in blue color depth of
molar buccal cusp (high spot) & distal marginal
ridge of 2nd premolar (normal contact).
 High spot: is viewed as blur circle (blue
surrounding area indicate no contact) with
white center (actual high contact).
High spot VS normal contact
 High spot: on mesial marginal ridge of 2nd
premolar.
 Normal contact: on 1st molar.

Finishing steps:
 Scalpel: to remove any buccal & lingual composite excess in class II cases.
 Disc (yellow & white = less aggressive): to round marginal ridge and remove buccal and
lingual excess composite.
 Round Arkenstone: for removal high spot.
 flame shape Arkenstone bur: on low speed to remove cuspal excess.
 Or use Perio komet bur: finishing excess composite without removal of enamel.
 May use amalgam polishing kit (only brown & green = the smooth one): to remove the
excess & high point.
▪ Use brown 1st then use green one.
▪ Disc for proximal area and flame shape for occlusal.
Polishing steps:
1- Pre-polish (initial gloss):
▪ To remove roughness in occlusal surface.
▪ By rubber cups as: Kenda polishing kit. (or Microdont – Opti step Kerr – Toboom)
o Kenda 3 step polishing system: used with water.
• White (coarse grit): for contouring.
• Green (medium grit): for finishing.
• Pink (fine grit): for polishing.
2- Final gloss (by impregnated brush with or without polishing paste):

▪ Optishine (Kerr) or Astrobrush (ivoclar).
o Used with or without paste at low speed.
o It is silica impregnated but the silica removed after multiple usage so use spiral wheel better.
▪ Soft Lex spiral wheel (3M):
o Use brown wheel 1st (finish) then white one (polish).

3- Extra gloss (Dr: Ahmed Saad protocol)
▪ Goat hairbrush:
o Used with diamond paste 1-3 micron
• With polishing paste and water.
• Then with paste only.
• Then use brush only.
▪ soft felt wheel:
o Used with aluminum oxide paste ex: Prisma gloss (one system 1300LE from Dentsply).
• Start with low speed (without water & with intermitted action) then increase speed with
water)
o May use bur on low speed surrounded with cotton instead of felt wheel.
ENA shiny system (style italiano protocol)

1- Shiny A (diamond paste):
▪ Apply a 3 micron diamond paste (Shiny A, Micerium, Italy).
▪ We spread the paste with the goat hair brush without rotation.
▪ Then we start at 3,000 rpm with no water, doing really slight touches otherwise
extreme heating can happen and ruin something more than the restoration.
▪ And then at 15,000 rpm with water.
2- Shiny B (diamond paste):
▪ We repeat exactly the same steps but this time with a 1-micron diamond paste (shiny B,
Micerium, Italy)
3- shiny C (aluminum oxide paste):
▪ For the high gloss polishing, we switch to the felt wheel and apply a 1 micron aluminum
oxide paste, repeating the spreading, 3,000 rpm with no water and 15,000 rpm with
water.
Ena shiny system available in dental town / credere (polishing system for 330 LE contains:
Diamond polishing paste - one shiny brush - felt wheel brush - felt wheel mandrel - goat brush.
Read more about finishing and polishing armamentarium in anterior section

Notes
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Class II mastering
Class II
mastering
Proximal regaining concept.
Tricks.
Class II classification.

CLASS II MASTERING
Proximal regaining concepts:
 Proximal surface is the most challenging surface.
1- Marginal ridge level.
2- Contact area position.
3- Proximal profile & contour.
Marginal ridge (MR):
 Normally, each adjacent two MR at the same level (Distal MR OF 5 = Mesial MR OF 6).
▪ Can done by probe or posterior Misura or Egyptian Misura (modified plastic instrument).
 MR composed of two planes (B&L) meeting in a very obtuse angle: it is

essential when an opposing functional cusp occludes with the marginal ridge.
▪ If flat & low: food impaction.
▪ Flat & high: premature contact.
 MR should be restored to normal width mesio-distally (not thin or thick) and normal depth
bucco-lingually & size of triangle fossa to ensure stabilized occlusion.
Mistakes of marginal ridge restoration:
A B C
D E
(A) absence of a marginal ridge in the restoration, (B) marginal ridge with an
exaggerated occlusal embrasure, (C) adjacent marginal ridge not compatible in
height, (D) marginal ridge with no occlusal embrasure, (E) a marginal ridge with no
triangular fossa

Contact area:
 Contact area position:

▪ Occluso-gingivally: Located at the junction between middle and occlusal 1/3.
o The More anterior, the more occlusal.
o Proper position from crest bone level 4-7 mm: to ensure maximum filling of interproximal
space by interdental papilla.
▪ Bucco-lingually: Slightly buccal or at the middle 1/3.
 C.A must be rebuilt to its cleansable tightness to:
▪ Maintain arch stability.
▪ Prevent food impaction or stagnation interproximally.
▪ Premature restorative failure does not occur if stable proximal contact is
present.
 C.A must be restored to its normal size bucco-lingually and Occluso-gingivally to give the
embrasures their normal width.
▪ Contact area in posterior teeth is about 1.5-2mm.
▪ Over tight C.A will decrease embrasure sizes resulting in:
o Unhealthy gingiva due to lack of stimulation.
o Food impacted occlusally will be difficult to be removed (tweezer like).
▪ Under tight C.A will abnormally increase embrasure sizes resulting in:
o shifting of teeth (mesial drift)
o food impaction interproximally that result in:
• Patient discomfort.
• Gingival recession/inflammation.
• Periodontal complication (acute abscess or bone loss).

 There are three forms of the teeth: tapering (A), square (B) and ovoid (C).
Each form has different position and size of contact area.
A B C
Proximal profile:
 proximal profile is slightly concave at the cervical third and then become convex at the
occlusal view (may divided to convex in middle third and somewhat flat at occlusal third
especially in square teeth)
▪ Concavity is done by wedge & convexity by contoured band.
 Correct proximal profile =correct contact area = correct marginal ridge position.
 Flat matrices produce straight profile that means:

▪ C.A at the occlusal third.
▪ No occlusal embrasure.
▪ Increased height of gingival embrasure.
▪ Flat marginal ridge.
▪ Food impaction interproximally.
Flat band Contoured band

CLASS II TIGHT CONTACT RETRIVAL
 Matrix system:
1- Ring.
2- Proper wedge.
Band then wedge then Ring.
3- Matrix band.
Ring
Function:
▪ Adaptation of matrix band on Buccal & Lingual wall.
▪ Make separation (compensate thickness of band to avoid open contact).
Types:
Palodent V3-ring (Dentsply): 2200 LE
▪ V shape to permit passage of wedge.
▪ Two sizes:
o Universal (medium blue, premolar & molar) 200LE.
o Palodent Plus narrow (premolar).
Twin ring (bioclear) 2000 LE

▪ Twin NiTi wire allow very strong separation to compensate thicker band.
▪ Two sizes:
o Molar (violet) 2000 LE
o Premolar (yellow).
▪ Tetra ring (bioclear):

o Used for two cavities back-to-back.
ENA ring: 1300 LE

▪ Two sizes:
o Molar (black).
o Premolar (red).

Triodent V ring (Ultradent):
▪ Two sizes:
o Universal.
o Narrow.
Garrison ring:
▪ Composi-Tight® Soft-Face™ 3D XR Ring:
o Tip design improves results on difficult dentition & short teeth.
▪ Composi-Tight™ CLEAR Soft-Face™ 3D Ring:

o Apply your curing light from both the buccal and lingual surfaces without
interference from opaque separator rings.
o This easily allows for proper curing of deeper proximal boxes and bulk-
filling Class II restorations.
▪ Garrison ring 3D fashion: 2150 LE

o Blue: short (Occluso-gingival height)
o Orange: tall.
o Green: wide mesiodistal preparation. (2200 LE)
Re-invent NITI ring: 1650 LE

▪ Nitinol drawn-wire nickel-titanium is superior to
stainless steel or laser-cut, solid NiTi.
▪ NiTin™ starts stronger and stays stronger.
▪ PEEK reinforcement reduces ring stretch.
▪ Two sizes:
o Standard (white)
o Long (black)
Tor VM ring:
▪ The cheapest one. (delta ring = 120 LE from Alex dent).
▪ It is not NiTi, so distortion occur with time.
▪ Can be used with add on silicon wedges (TOR VM).
▪ Three types:
o MD ring: (more separation)
o Delta ring.
o Standard (Customization) ring:

 Notes:
▪ MD ring gives more separation.
▪ TOR VM Kit has two rings: delta ring & standard ring.
o Delta ring:
• Notched, so can accommodate the wedge.
• Due to approximation of its ends, can't be used with larger molar so use standard ring.
o Standard ring:
• It is solid, so it is difficult to be used with wedge: the dentist should place it deep down next
to the wedge as illustrated, but this usually leads to breakage of the wedge.
▪ Take care that there are two types from delta ring in market:
o Copy (Chinese one)
o Original (Russian one)
 
 Customization ring:
1- Wedging.
2- Placing liquidam on B&L embrasure.
3- Then put the ring, may place other liquidam.
4- Then light curing.
.
TOR VM Spring clip & saddle matrix: (TOR VM) 95 LE

▪ It is benefit in cases of Distal caries on last molar.
▪ Causes no separation between teeth so causes open contact.
Resin ring: 100 LE

▪ Resin rings autoclavable from ZT dental.
▪ Two sizes: molar & premolar.

Ring selection:
Any ring can work with any matrix band and wedge except bioclear HD band (thick) needs
bioclear twin ring.
Ring forceps:
Palodent forceps: TOR VM forceps: 250 LE
▪ Locking function and angled grip arms
hold the ring securely.
▪ Built-in grooves for resetting rings.
As ring forceps is somewhat expensive, there are some solutions:

 Modified rubber dam forceps:
▪ May modify clamp forceps to be similar to TOR VM forceps.
 Hakim's stabilization buttons:
▪ To achieve strong grip with clamp forceps. (no slippage any more).
Pin Tweezers:
Palodent pin tweezers:
▪ Pin-in tip positively grips hole in matrix and wedge
for control.
▪ Naturally closed position minimizes risk of
dropping matrix band or wedge.
▪ Built-in ball burnisher tip.
Triodent pin tweezers:

Wedge
 Position: Placed in wider embrasure (buccal in lower & palatal in upper).
 Function:
▪ Used for adaptation of matrix on gingival margin to avoid overhanging.
▪ Forced insertion to give more separation (compensate thickness of band & composite
shrinkage)
Wooden wedge:
▪ Gives more separation (water absorption).
▪ It should be at the same level of gingival step or slightly lower.
▪ If it is higher, trim it. (wedge modification)
Orange: super thin – short.

White: thin -short.
Yellow: thin -long.
Blue: medium – short.
Pink: medium – long.
Violet: thick – long.
Plastic wedges:
Palodent wedges:
▪ Three sizes: small (dark blue) – medium (light blue) -large (white).
▪ Anatomical wedges that have:
o Wings compress & flare for easy placement and seal.
o Hollow underside to allow placement of 2nd wedge from opposite side.
o Holes to be inserted by pin tweezer.
o Can use with it wedge guard:
• Used to prevent damage to adjacent teeth during
class II cavity preparation.
• Easy removed & leaving wedge in place.
Bioclear diamond wedges:

▪ It is autoclavable.
▪ Plastic, hollow & high anatomical adaptation.
▪ 5 sizes: small (pink) – medium (orange) – large (yellow) – extra-large (blue) _ deep
cavities (green).
You can buy the green & yellow one
▪ Notes: and if you need the larger size, wrap
o The green diamond wedge has lateral extension enables the yellow one by Teflon give you
it to adapt concaved area (deep concave profile near CEJ) the size of blue one.

o If the wedge is higher than gingival step, not problem.
o For more adaptation, wrap the wedge by Teflon.
o Test wedging first, then draw it partially (not completely) and place the band.
Diamond wedge magic by DR:

ABD ELRAHMAN TAWFIK
Adapt luciwedge (Kerr):

▪ 4 sizes (ultra-small – small- medium- large).
▪ Stiff: ensures a high separation capability.
▪ High elastic: so, the matrix band can easily adapt and remain in
place (continuous adaptation) even with irregular, highly curved
and convex tooth surfaces.
▪ Transparent so allow passage of curing light so it is ideal for
proximal curing.
▪ The curved tip facilitates the positioning of the wedge.
Tor VM plastic wedges:
▪ Compact.
▪ Thin & medium, size only.
▪ three types:
o Opaque (colored)
o Elastic.
o Transparent.

Composi tight 3D fusion (garrison): ultra-adaptive wedges.
▪ Formed from firm inner core that covered by soft face material with retentive fins.
o Firm inner core: for easy insertion and tooth separation like traditional wedge.
o Retentive fins: fold down during insertion and spring back when clear of interproximal space so
give more adaptation to interproximal irregularities.
▪ 4 sizes (color coded).
Wedging technique:
Single wedge wedging:
▪ In traditional cases.
▪ Medium sized bucco-lingual cavity width.
Double wedge wedging:
▪ wide sized bucco-lingual cavity width.
▪ And cases of wide interproximal space.
▪ One from buccal & one from lingual.
o Palodent or Triodent (wave one) wedges are hollow underside to allow placement
of 2nd wedge from opposite side. (double wedging)
Piggy pack wedging:
▪ In some cases of high gingival margin (just below contact area).
▪ In cases of interproximal pocket or with gingival recession.
▪ A large wedge inserted first & small wedge inserted above.
Delayed wedging:
▪ In cases of wide interproximal area to preserve your emergence profile and maintain
the contact, without creating a black triangle.
o If we use wedge first, it will change the proximal profile.
o So, use band only 1st (Biofit band is better due to its self-sealing property)
o Use snowplow technique (bulk fill flowable + conventional composite) to make overmolding &
elevate margin.
o Make level of composite below level of contact area (to make contact the wedge is necessary)
o After elevating margin, it is time to use wedge & band.
▪ In cases where the wedge cannot be placed below gingival margin (wedge above GM).
o So, margin elevated first (with band supported by Teflon) then wedge is inserted.

Wedge selection:
 Which wedge?
▪ With thick band, it is better to use wooden wedges for more separation.
▪ With thin bands, you can use plastic wedges (bioclear, garrison…) for more adaptation.
 Wedge size:
▪ Tightly inserted with adequate pressure force: to ensure adequate separation and
stabilize the band in place.
▪ Should be at the same level of gingival margin:
o If higher: matrix deformation.
o If lower: marginal overmolding.
▪ Keep the band in an intimate adaptation to the gingival margin: to prevent gingival
overhanging or marginal over molded restoration.
 Bioclear wedge system selection:
▪ 1st bitewing radiograph is required to know:
1- Crestal bone height.
2- Root proximity & shape.
▪ 70% of posterior embrasures are ideal for large wedge (yellow), the most common
mistake is to use too small wedge.
▪ Small wedge (pink): used in very tight embrasure cases.
▪ Extra-large (blue): in cases of very wide embrasures.
 May use different techniques or teflon to achieve optimum adaptation.

▪ Teflon with wooden wedge: (more adaptation and more dry).
Teflon to adapt wedge and have more

apical seal.
(By DR: ABD ELRAHMAN TAWFIK)

Wedge insertion:
 Wedge inserted by tweezer by 45 degree to gingiva as suture needle, so it goes above soft
tissue.
 Then push it by other end of tweezer.
Wedge modification:
 Wooden wedge modification (trimming):
▪ When wooden wedge fulfills all the needed criteria, but it is slightly higher than the
gingival margin. .
▪ When prober size is not available (it is larger).

▪ How?
o Use diamond stone or scalpel to trim it to a concave profile from the
upper border or/and the side walls.
• It is better to trim one side wall (that opposite to cavity) to a Wooden wedge
concave profile, rather than two sides to avoid weakening the modification
wedge and so fracture.
Matrix band
Matrix bands classification
contoured Non-contoured (flat)
circumferential Sectional
With lock Without lock
metal
VS Clear (transparent)
With gingival extension Without gingival extension.
soft hard
Thickness: micron 35 50 70
Height: mm 5 6 7
Flat matrix bands: Produces straight profile.

Tofflemire bands:
▪ It is metal, hard, circumferential.
▪ Without extension:
o Shape no.#1 (universal).
▪ With extension:
o Shape no.#2 (molars).
o Shape no.#3 (premolars).

Ivory bands:
▪ It is metal, hard, sectional.
▪ With extensions.
Molar band (three holes) Premolar bands (two holes)

Shape no.#79 (molar, wide). Shape no.#82 (premolar, wide).
Shape no.#78 (molar, medium). Shape no.#81 (premolar, medium).
Shape no.#77 (molar, narrow). Shape no.#80 (premolar, narrow).
Flat saddle bands:

▪ It is metal, hard, sectional.
▪ With extension:
▪ Three sizes:
o 1.301 (narrow)
o 1.302 (medium)
o 1.303 (wide)
contoured matrix bands:
Bioclear band:
 Posterior matrices:
▪ Clear hard band (HD = 76 micron or blue =50 micron)
▪ Used in injection molding technique. (permit passage of light)
▪ Three height of band (4.5 -5.5 -6.5 mm).
o The most used one is 5.5 mm.
▪ Has great curvature so can be used with deep gingival step.
▪ Used with twin ring = more force to compensate thicker band.
▪ occlusal tab: aids in matrix placement and control when wedging.
o Hold and fold the occlusal tab down very aggressively during placing the wedge to avoid
sliding the band buccally or lingually.

 Anterior matrices (9 matrices):
A system (5): Less cervical curvature, so used in class III &IV (small black triangle)
ID curvature
A101 0.5 MM INCISOR MESIAL:
▪ Intended for mesial of upper incisors.
▪ Has straight incisal.
A102 0.75 MM INCISOR distal:

▪ Intended for distal of upper incisors.
▪ Has curved incisal.
A103 0.5 MM SMALL INCISOR:

▪ Intended for all lower incisors and small
lateral incisors.
A104 0.3 MM STRAIGHT INCISAL:

▪ Intended for canines, more open matrix,
has straight incisal.
A105 0.45 MM CURVED INCISAL:

▪ Intended for canines.
▪ more open matrix.
▪ has curved incisal.
D system (4): More cervical curvature, so used for space closure (diastema)
▪ Diastema Closure matrices are for creating a new and exaggerated emergence profile.
▪ These matrices are for closing diastema larger than 1mm and for large black triangles.
ID curvature
DC201 0.9 MM INCISOR MESIAL:
▪ For mesial diastema closure up to 2 mm.
DC202 0.9 MM INCISOR distal:

▪ For distal diastema closure up to 2 mm.

DC203 0.9 MM SMALL INCISOR:
▪ for space closure on lower incisors.
DC204 1.8 MM Extreme diastema closure:

▪ for space closure on spaces larger than 2
mm. (XL)
Palodent system:
▪ The band is thin 35um & soft so it is deformed easily during insertion & removal.
o Therefore, we find that all system has hole for easy insertion & removal + pin tweezer.
▪ Recent types are coated to be non-sticky.
▪ With & without extension.
▪ 5 Sizes (color coded):
o 3.5 mm: pedodontics & superficial case in premolar. (thin)
o 4.5 mm: medium size in premolar.
o 5.5 mm: medium in molar. (medium)
o 6.5mm & 7.5 mm: wide & deep size in molar + cusp coverage. (wide)
Garrison bands:
▪ Metal, hard, sectional & non-stick.
▪ Wrap it up: Full curve bands wrap further around the tooth and have optimum anatomy
built right in.
▪ Deep or wide: Improved subgingival areas (red and blue band with extension for deep
margin restoration) and increased width (extra-wide prep).
▪ 40-micron thickness.
▪ 5 sizes (color codes):
o Gray: 4.6 mm height (premolars)
o Red: 3.8 mm height (premolars, deep margin)
o purple: 5.5 mm height (small molars)
o Green: 6.4 mm height (large molars)
o Blue: 6.4 mm height (molars, deep margin).

▪ Garrison has different matrix bands:
o Composi-Tight® 3D Fusion™ Full Curve Matrix Bands.
o SM-series Slick Bands: eliminate the problem of difficult to remove matrices. Developed as an
improvement to the Composi-Tight® 3D Sectional Matrix System.
o Slick Bands™ XR Matrices: Wider sub-gingival extension than the SM-Series.
TOR VM:
1- Sectional matrix system: kit 450 LE.
▪ Good and cheap sectional matrix system.
▪ Soft or hard.
▪ Use 35 or 50 um, hard one. (not soft one as it is subjected to deformation).
▪ Preferable than contoured saddle in narrow cases as it is less contoured than saddle one.
▪ 3 Sizes & 6 shapes:
o Small & small with ledge (gingival extension).
o Medium & medium with ledge.
o Large & large with ledge.
▪ Concave side (occlusal) and convex one (gingival) as it is contoured to make the
maximum height of contour in middle 1/3.
2- Saddle contoured matrix: Kit 400 LE. Refill (one size) 90 LE.
▪ Hard, metal, with extension.
▪ 35 -50 micron thickness.
▪ Increased in height & great curvature so can be used in wide & deep margin cases
where sectional matrix cannot be used (in one step method).
▪ Three sizes & nine shapes:
▪ Form (2) & (3): means more gingival extension so more height used in DME.
Form Form Form
Sizes
(1) (2) (3)
Increase in width (B-L) Increase in length
1.311
(lower premolar)
1.312
Medium Tall Extra tall
(upper premolar)
1.313
(upper & lower molar)

3- Contoured transparent matrices:
▪ Hard, transparent with extensions:
▪ Two sizes:
o No 1.192: Universal: molar & premolar.
o No 1.191: molar
▪ 4 shapes:
o With central ledge.
o With 2 central ledges.
o Right ledge.
o Left ledge.
4- Sectional contoured Transparent matrices:

▪ Two sizes (color coded):
o Green: narrow (no 1.922)
o Blue: wide (no 1.923)

Matrix band feature:
1- Contoured one: to reproduce the correct proximal surface profile.
2- Thickness from 35-50 micron.
3- Hard: to avoid deformation.
4- Well adapted to gingival step.
5- Can go below gingival margin by 1mm.
6- Its height at same level of adjacent tooth MR or just above by 0.5-1 mm.
o As each band has maximum height of contour, that should follow that of tooth.
o If not, matrix trimming: when band is higher than 1mm trim it gingivally to keep max-height of
contour at it is correct place.
7- Highly polished & smooth (no irregularities, inner scratch or deformation).
8- Well locked.
9- Centralized bucco-lingual.
10- Close contact and perfectly adapted to adjacent tooth.
Matrix customization:
 Customization means trimming or reshaping.
 When:
▪ When band is higher than MR by > 1mm. (trim it gingivally)
▪ If you don't have a matrix with gingival extension (or when saddle band arms prevent it
from being placed more gingivally) and you want to reach deep margin. (trim it from
periphery to make gingival extension)
o Bioclear, saddle or Tofflemire modification.
▪ If you have overlapped teeth and want to build the proximal wall on two or three steps.
o Saddle or sectional modification.

Matrix selection system:
According to Maciej Czerwiński (measure the distance between the lower margin of cavity
and the upper margin of adjacent tooth)
Thin:
▪ The is no or minimum distance ( -2mm to +1mm):
o The negative number indicate that there is tilting (when mirror is perpendicular to cavity, the
line of separation between two teeth can't be seen.
▪ Superficial case: the gingival step below contact point by 0.5mm.
o It is at the level of occlusal / flat part of proximal profile, so can use flat band.
▪ Matrix used:
o Tor vm Sectional matrix 50 µm hard: (small for premolar & medium for molar)
o Tofflemire (in cases of -1 or -2)
o Flat Saddle matrix. (1.301 -1.302).
Medium:
▪ The distance is (+1mm to +2mm)
▪ Has cervical enamel.
o It is at the level of middle / convex part of proximal profile, so use contoured band.
▪ Matrix used:
o Tor vm Sectional matrix 50 µm hard: (medium for premolar & large for molar)
o Saddle matrix. (1.311 -1.312- 1.313)
o Bioclear biofit.
Wide:
▪ The distance is (> +2mm)
▪ Deep case = no cervical enamel.
o It is at the level of cervical part of proximal profile, so all proximal profile needs to be restored,
so use highly precontoured matrix.
▪ Matrix used:
o Saddle matrix. (2) or (3)
o Bioclear (6.5 mm).
o Two step technique (with large sectional matrix).
Two step technique:

 It depends on changing the case from wide to medium if I have only sectional matrix.
▪ 1st step:
o Using large sectional matrix.
o Etch & bond for gingival step.
o Build gingival step.
o Finish it by bur.
▪ 2nd step:
o Etch all again (to remove smear layer after using bur)
o Use sectional matrix as in medium cases.
o Use universal bond.

-2mm to + 1mm + 1mm to + 2mm >+ 2mm
▪ TOR small 50 um hard. ▪ TOR small 50 um ▪ TOR medium.
▪ Bioclear flat. H&S. ▪ TOR large.
▪ Tofflemire matrix. ▪ TOR small 35 um ▪ Bioclear curved.
H&S. ▪ saddle matrix.
▪ Palodent.
▪ Bioclear average.
Tricks:
 Adjusting band:
▪ Push your band by ball burnisher against adjacent tooth at contact point. (just pushing
not burnishing). .
▪ Or (expand and adapt) as in cases of biofit matrix:

o By tweezer, insert it in closed position in proximal box then let it go to
expand band buccolingually.
o Then rotate it mesially to push the band to adjacent tooth surface.
 Delayed ring:
▪ In cases of deep marginal elevation to avoid leakage caused by ring in some cases.
o So, use band only and fix in position by flowable composite on adjacent.
o After marginal elevation, use the ring to build contact.
 Ringless cases:
▪ In cases of negative space (-2 or -1) if ring is used the band will be distorted, so depend
on wedge only.

 Over molding:
▪ Build your composite below gingival step (the most cervical part) this gives broad
contact to close diastema between teeth.
▪ This made by adapting the band below gingival step by using:
o Delayed wedging & ring technique and stiff band that can make sealing without causing
overhanging. (ex: Biofit)
• Fix band tab in position by flowable composite.
• And may use teflon tab for more adaptation.
o Or use wedge that adapt below gingival step.
▪ After over molding cervical margin by bulk flow composite & curing.
o You can then use wedge & ring and build the proximal wall by snowplow technique.
 Back-to-back: (no contact)
▪ Back-to-back in the same visit used only with composite as amalgam will be fractured
during condensation of adjacent one.
▪ Start with difficult cavity (Deep gingival step, wide box, difficult in manipulation).
▪ Place the two matrices band together:
o To divide the space & preserve profile.
o Save time.
o Don’t contaminate the neighbor cavities.
o And don’t have the need to refine the restorations one by one before putting in place the other
matrix.
▪ No need for ring during building the 1st cavity (no contact).
▪ After building the 1st cavity, remove its band to avoid open contact (caused by thickness
of 2 bands) and then place ring.
.
 Double or triple band:

▪ When there is no adaptation between the band and tooth. .
o Sectional band surrounded by saddle one and between them

Teflon for more adaptation.
▪ In tribble band there is more space occupied by the bands
so use two step technique to build contact.
 Teflon wedge:
▪ In cases of deep margin and wedge will deform the matrix so use Teflon as a wedge.
o For easy insertion of teflon as a wedge and for more adaptation, use teflon floss technique
(wrap teflon on dental floss, insert floss 1st then band and ring, after that draw floss until teflon
come interproximally and push band toward gingival margin for more adaptation).
. .
Demo www.tec-it.com

Class II classification:
 Class II classification according to isthmus width.
1- Small class II:
▪ Cavity confined only to proximal surface.
▪ Cavity including the whole marginal ridge with slight occlusal extension:
o No pulpal axial angle.
▪ Cavity design: saucer shape cavity.
▪ Restorative approach: Injection molding technique with:
o With transparent band (Bioclear matrix band (HD, blue) - Clear matrix from TOR VM)
2- Medium class II:

▪ Cavity including the whole marginal ridge with large occlusal extension:
▪ Restorative approach: centripetal technique (using snowplow technique to build the
proximal wall first then complete cavity)
3- Large class II:

▪ Cavity including the whole marginal ridge with large occlusal extension & include a part
of buccal and/or lingual walls or include whole cusp/cusps.
▪ Restorative approach: build the missed wall first.
o With free hand or matrix band to convert the large to medium.

Notes
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Cases from A to Z.
Cases from
A to Z.

Cases from A to Z
Case 1 style Italiano
▪ Preoperative picture of the quadrant to treat, after the anesthesia.
▪ First rule: a correct isolation with the rubber dam

starts before the cleaning of the caries. You reach a
better adhesion without the contamination done by
the saliva.
o TIP #1: use the wooden wedges to protect the rubber
dam while cleaning the caries otherwise you will
probably break it using the burs on the cervical step,
and you will need to change it before the bonding
procedures.
▪ Second rule: prepare the cavities, cleaning all the
caries and refining the enamel with fine grained
diamond or multiblade burs, so to have a perfect
bonding to the enamel and avoid the detachment of
unsupported enamel and microleakage.
o TIP #2: it could happen that after the removal of the
wedges a little bleeding occurs as in distal 2.4 mesial
2.5. Pay attention to wash properly to disinfect and to
control the wetness before putting in place the matrix
and the new wedges
o TIP #3: clean the dentin with glycine (clinpro by 3M) and
disinfect it with chlorhexidine at 2%.
o TIP#4: there’s no preference in putting one matrix by
one or all together. It depends on what you prefer and
are able to do and nobody can say that one way is
better than the other. The advantage in putting them all
together is that you save time, you don’t contaminate
the neighbor cavities and don’t have the need to refine the restorations one by one before putting in
place the other matrix. The disadvantage is that you have less control and need a little more
experience in doing this .
o TIP#5: use a selective etching procedure and a universal (8th generation) adhesive in a self-etching
mode, for the bonding procedures.

▪ Third rule: start building the interproximal wall first so to
change the class II in a class I (centripetal technique)
o TIP#6: before removing the matrix apply a little of flow
between the dentine and the interproximal wall you’ve
done previously, otherwise you risk to remove the wall
while pulling the matrix.
▪ Fourth rule: do not remove the wedges until the end of

the layering and modeling work, so to avoid the risk of
bleeding from below
o TIP#7: use a flow on the adhesive to have a better
conversion of the adhesive itself and to counteract the C
Factor, before start layering the packable composite.
▪ Fifth rule: there’s no best one among layering

techniques. You can choose a horizontal, a vertical or
an oblique one.
o But keep in mind that what you have to reach is a good
result, nothing else, and you can get it with each and
every layering technique.
▪ Details after the modeling, before the finishing and

polishing procedures.
o TIP#8: use an easy modeling technique, no need of
reproducing something that in nature doesn’t exist. The
essential is more than enough.
o Remove proximal excess with surgical blade.
▪ Details after finishing and polishing.

o TIP #9: use a multiblade bur (komet burs) on the
composite instead of a diamond one for finishing, it’ll be
more gentle and it won’t damage the enamel while you
are finishing your restorations.
o TIP #10: use a supercharged diamond paste to polish
your restorations, only one is sufficient. Use it with a
brush or with the spirals.

Case 2 style Italiano
▪ First of all, we should apply a rubber dam. For this
particular case we use (Non-Latex Flexi Dam,
Coltene/Whaledent) As preparation is done, it is time to
think about how to restore proximal wall at the same
height with adjacent tooth.
▪ For measuring the height of the adjacent

proximal wall may use:
1- A perio probe and then a mark of the
marginal ridge is made (complicated)
2- Or use misura instrument. (easy)
• The fork shaped tip of the
instrument allows measuring and
modeling of the composite wall Misura instrument with 2 tips on it
with the presence of a matrix.
• Another tip designed for the
horizontal and vertical measuring
of thickness of last composite layer
on posterior restorations. To block
the color of the bottom layer we always need minimum 1,5 mm of Body shade composite.
3- Black matrix (lumicontrast Sectional Matrices, Molar
0.025mm / 6.4mm) wedge and myring Classico with
delta tubes (Polydentia).
▪ Now we can start adhesive protocol. First step is to etch

enamel for 30 second with selective etching technique –
in this case we use 35 % phosphoric acid Etchant Gel S
(Coltene).
▪ After rinsing the etching gel from enamel, it is time to

place self-etching One Coat Universal Adhesive
(Coltene) We start to apply the new generation of
adhesive (multilayer) by brushing actively, more on the
dentin and less on the enamel. We must wait minimum
20 seconds for the exposition of the adhesive followed
by 5-10 second air drying for removing the solvent.

▪ Light curing for adhesive layer will be minimum 20
seconds. We have to finish adhesive layer with a small
drop Bulk fill flowable composite for creating
hydrophobic protection layer. For Light curing we used
S.P.E.C.® 3 lamp (Coltene) In these lamps we have 3
curing modes (Standard Mode), (3K Mode), (Ortho
Mode) • Standard Mode: Ideal for most composite
curing scenarios. • 3K Mode: For rapid curing when time is an issue, like pedo or patients with
gag reflex. • Ortho Mode: Cures an entire full-arch of brackets with 2 three second intervals per
bracket.
▪ For great sealing of the margins we need to apply a little drop of Bulk-flow composite between
the matrix and tooth. Then immediately to place regular composite above flowable composite
without curing. (snowplow technique)
▪ Little drop of Bulk-flow composite between the matrix and tooth, spreading with Fissura (LM
Arte).
▪ Placing regular body shade composite from Brilliant Ever glow (Coltene).
▪ Applying to the vestibular and palatal walls with LM condensa instrument (LM Arte) U can notice
that the height of the new wall is more than our line.
▪ To have the same height of wall with adjacent tooth use the Posterior Misura instrument.
▪ We can easily eliminate excess material with half of fork when the second part is controlling the
height.
▪ And then we apply material and smooth the surface with Compo Brush (Smile Line).
▪ The wall is ready and now we can check the height with the same instrument. U can notice that
both approximal walls at the same level.

▪ After we transferred class II cavity to the class I it’s time to fill
all cavity. For these we can use incremental layering technique
but using this technique will take too much time. Today we have
a lot of bulk fill composites in the market. In this case, we use
Fill-up! (Coltene) because we can place this dual curing bulk
composite in deep cavities for one layer. No matter what layer
thickness is applied, there is no need to worry about thorough curing, as Fill-Up! consists of both
light and chemically curing properties. Light-curing for just 5 sec.
▪ As the dentin layer is finished, it is time to switch to enamel layer. As we mentioned we need
just 1,5 mm thickness of the last layer If we want to avoid to have high spots after restoration.
Another Tip of this instrument gives us a chance to leave this space for final layer.
▪ Final occlusal anatomy is always a problem for the dentist. But we think that it is important to
follow the nature. Occlusal map is always guiding us. You can see on the picture occlusion map.
This show us the place where the sulcus will be between the cusps.
▪ For this case we use easily polishable Brilliant Ever glow composite material (Coltene).
▪ Occlusal view after applying composite to the walls with Condensa (LM Arte) instrument and
with Compo Brush (Smile Line).
▪ Now it is the time to follow to the natural GPS. You can see that with these essential lines we
can easily recreate the anatomy. Today we have a new FMT with Essential lines technique by
Style italiano which give us a chance to model the last layer just for 2 minutes.
▪ Stain application with Fissura instrument (LM Arte).
▪ This stage is the final polymerization after glycerin. We need minimum 1 minute of
polymerization for blocking of oxygen inhibition layer.
▪ Finishing and polishing starting with abrasive rubber cups for cusps then the rubber points for
deep fissures and finished with a silicone abrasive wheels without any polishing paste at low
speed. (Diatech Polishers by Coltene).

Case 3 (DR: AHMED ALHAKIM)
▪ Glass ionomer restoration in 6 & mesial of 7.
o Broken restoration: lead to leakage so recurrent caries and pain.
o Food impaction in broken area.
▪ Preoperative occlusal assessment = occlusal registration: to know occlusion points, so make

Cavosurface margin (CSM) away from stress bearing area.
▪ Note the crack in glass ionomer restoration.
▪ After removal of glass ionomer of 6.
▪ Note: there is remaining caries in mesial area of box (MMR). (arrow)
▪ So, to avoid itragonic mechanical trauma to neighboring tooth (5) use wedge guard. Or use
wooden wedge (beside the tooth to provide more visibility of gingival seat during preparation) +
band (act as guard, resting on neighboring tooth).
▪ The distobuccal cusp thickness is 1.6 mm (less than 2) so need to be reduced then cuspal
coverage.
▪ The distolingual cusp thickness is 2.2 mm (but it is only undermined enamel) so for precaution it
is needed to be reduced then cuspal coverage.
▪ Cavity design:
o Cuspal reduction, flared wall and the walls in self-cleansable area.
o Cavity cleaning with CHX and then Thercal to be placed in deep area.
▪ Building the distal box:

o Guided cusp rebuilding for distolingual cusp.
o Bioclear band 6.5 (supported by teflon to give good contour an absence of 7 proximal wall).
o Bioclear blue wedge (extra-large).
▪ Building the mesial box:
o Bioclear band, yellow wedge and ENA ring.
▪ Build 7 contact area guided by 6 proximal wall.
▪ Finishing and polishing.

Case 4 (DR: AHMED ALHAKIM)
▪ Case: with amalgam restoration.

o Fractured cusp: lead to leakage so recurrent caries.
o Sharp margin.
o Bitewing x-ray showing: large recurrent caries.
▪ After removal of amalgam,: gingival enlargement occupies cavitation.
▪ Mesial marginal ridge is cracked (ensure by transillumination (light cure from lingual): there are
one major & two minor cracks).
▪ Occlusal registration and gingival enlargement removal.:

o To check CSM (TRI) position and its relation to stress bearing area. (the forces mainly on MMR)
o After removal of gingival enlargement by surgical blade & thermacut bur.
o There is very deep distal gingival margin & deep distal caries (partial caries removal).
▪ Mesial marginal ridge is removed (cracks) :
o The isthmus was flared to buccal and lingual embrasures.
o Very wide bucco-lingual cavity?
▪ The distal cavity is very deep and take U shape, after trying to isolate it, there is not possible.
With bone sounding approach (by periodontal probe), we found that, there is osseous crater
(B& L bone higher than proximal bone = U SHAPE), So, we make:
o Interdental bone re-contouring to remove the crater (till I had one plane B-L).
o Surgical crown lengthening with subsequent surgical marginal acquisition
o Stitch and temporary restoration.
▪ It is better to wait from two to four weeks after surgery for complete healing to avoid any
inflammatory exudate.
▪ But the patient has no time, so come after 4 days.
▪ Very tough case to be isolated.

o W8A clamp (as secondary clamp).
o Teflon tab for localized isolation extremely & inversion.

▪ Four customized saddle matrices with teflon tab in-between to get perfect adaptation.
o Saddle band is customized by cutting its extensions; so, the clamp can't hander its placing.
▪ The deep gingival margin was elevated using snowplow technique & high filler containing
composite (voco grandio).
o Adaptation.
o Decrease polymerization shrinkage
o Note that: after DME, the band is removed and the composite margin is finished.
▪ Structural integrity VS structural conservation.
o The lingual cusp thickness is 2mm, but the cavity is very wide BUCCO-LINGUALLY, So, reduction (1.5
mm was enough here) and cuspal coverage.
o So, converge the deflection forces to compressive one.
o Note: Indirect ceramic overlay is the ideal treatment.
▪ Lingual cusps re-built with guided cusp rebuilding technique.
▪ Matrix adapted for 2nd step (proximal wall build-up).
▪ Here we elevate the margin by 1mm to change the band position into correct one that save
space to build the distal cusp.
o What if we don't elevate the margin & correct band position?
• We cannot restore the distal cusp. So, altered anatomy - very wide buccal embrasure & very
narrow contact area (contact point) = food impaction on interdental papilla.
o The band was pushed and stabilized in position till curing the second increment.
▪ Delayed wedging: After DME we can use larger wedge for separation & matrix adaptation.
▪ Twin ring: used for more separation.
▪ 5.5 HD band + twin ring + wooden wedge.
▪ Finishing and polishing: Just functional anatomy (primary one): done by finishing burs.
▪ Waiting for papillary regeneration.
o The composite is highly polished.
o The space between crest of bone and contact area is 5mm or less.
o Periosteum is maintained.
o Patient should maintain very good oral hygiene and use dental floss.
▪ Post-operative bite-wing showing marginal adaptation.

I recommend this video to watch: Class II by DR: Ahmed Khiry.
1- Cavity preparation and design.
2- Cavity disinfection & thercal application.
3- Adhesion protocol.
4- Over-molding.
▪ Delayed wedge & ring.
5- Snowplow technique.
6- finishing and polishing protocol.
Injection molding by DR: Ahmed Khiry.

 Case 1: back to back class II
1. cavity design.
2. matrix selection and adaptation.
3. cervical overmolding and delayed wedging.
4. injecting heated bulk-fill flowable and packable
composite in one step.
5. finishing and polishing.
 Case 2: class II saucer shape.  Case 3
.
.
Direct overlay by DR: Ahmed Khiry.

.

How to create esthetic composite restoration:
Class II by DR: ABD
DR: AHMED KHAIRY.
ELRAHMAN
TAWFIK (IMP)
Finishing and polishing:
DR: ABD ELRAHMAN

TAWFIK
Mastering posterior composite:
DR: WASEEM RIAZ

Notes
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INTERESTING TOPICS
The capacity to learn is a gift; the

ability to learn is a skill; the
willingness to learn is a choice.
BRIAN HERBERT

Post operative Composite complications:
Immediate postoperative Late postoperative Follow up
complication. complication. complication.
▪ White line. ▪ Sensitivity. ▪ Discoloration.
▪ Ditch. ▪ Fracture. ▪ Fracture.
▪ Fracture. ▪ Debonding. ▪ Debonding.
▪ Light contact. ▪ Pain. ▪ Recurrent caries.
▪ Loss of anatomy. ▪ Gingival inflammation.
▪ Sealing.
Immediate postoperative complications:

White line:
Causes:
▪ Improper adaptation (rough cavosurface margin) leads to Improper sealed margin so microleakage.
▪ Traumatic finishing & polishing without coolant increases the heat generation so debonding.
▪ Thick bond layer.
Avoid it by:
▪ Finish cavosurface margin or make full bevel = indefinite margin.
▪ Good adaptation by dry micro brush.
▪ Finishing and polishing under coolant.
▪ Thin bond layer on enamel is a must.
Ditch:
Gab area between composite restoration and tooth structure.
Avoid it by:
▪ Proper adaptation of composite to the margin.
▪ Ensure there is no excess or deficient area by probe resting on cuspal slopes.
Fracture:
In cases of class II when patient bite strongly on high marginal ridge, fracture occur.
Avoid it by: remove high point and ask patient to bite on articulating paper gently.
Light contact:
Test the contact in the 2nd visit (wedging action in 1st visit gives mistaken result).
Loss of anatomy:
Avoid it by:
▪ Preoperative occlusal assessment.
▪ Layering technique.
Sealing:
Take bitewing x-ray: overhanging restoration or increase voids in restoration (radiolucent area)
Management:
▪ Overhanging margin: can be removed by using finishing strip (below contact area)
▪ Increase voids requires composite replacement.

Late postoperative complications:
Post-operative sensitivity:
Causes:
▪ Original pulp condition (stressed pulp: the pulp has less repair potential so with cavity preparation
trauma, it will turn into irreversible one).
▪ Cutting in healthy dentin.
▪ Insufficient coolant (use multidirectional coolant).
▪ Etching of dentin in deep cavity.
▪ Over dryness of dentin, that lead to movement of fluid in dental tubule, squeezing odontoblast.
▪ Insufficient penetration of adhesive.
▪ Insufficient evaporation of solvent.
▪ Heat generation due to curing of adhesive.
▪ Lack of adaptation of 1st composite layer with adhesive.
▪ Residual monomer of composite (incomplete curing).
▪ Micro leakage.
▪ In gingivectomy case (sesnsitivity is temporary due to exposed cementum).
How to avoid postoperative sensitivity with posterior composite:
A. Finish all enamel walls with red code diamonds to obtain sound strong margins.
B. Etch enamel margins for 30 secs to improve marginal seal.
C. Bonding step:
o Use self-etch bonding to avoid etching of dentin.
• In case of etching dentin, apply etch only for 10 -15 secs and avoid over dryness.
o Apply bond in layers (apply layer then thinning by air then another layer…etc.)
o Dry the adhesive till no movement is seen on the surface when the air syringe is moved to
ensure evaporation of all the solvent.
o Cure the adhesive in two steps or use pulsating technique.
o Some bonds now contain desensitizer that prevent post-operative sensitivity:
• Ex: GLUMA comfort (bond + desensitizer).
o Or apply desensitizer (glutaraldehyde containing) after etching and before bonding. Ex: GLUMA
desensitizer, G5 or MICROPRIME.
• Most of the desensitizer containing glutaraldehyde & HEMA:
 HEMA: to aid bonding primers to penetrate etched dentin.
 Glutaraldehyde:
- Desensitizes the tooth by blocking fluid flow (coagulating plasma proteins within the
dentinal tubules and block D.T with coagulation plugs to a depth of 200 microns).
- It inactivates harmful enzymes that break down bond strength like MMPs.
- re-wetting agent to plump up the collagen fibers for monomer penetration.
- It is anti-bacterial.
• How to use: (used after etching dentin, when DT is exposed, not recommended with self-etch)
- Apply the smallest possible amount of desensitizer using brushes and then leave for 30–
60 seconds.
- Lightly dry the surface carefully by applying a stream of compressed air until the fluid
film has disappeared and the surface is no longer shiny.
- Deep cavities and/or areas near the pulp should be covered with a suitable cavity lining
before the desensitizer is applied.

D. Spread with a burnisher a very thin layer of flowable composite then cure to ensure good
adaptation. Or may use resin modified glass ionomer as a base in sandwich technique.
o Flowable composite is required as a hydrophobic overcoat over single layer adhesives.
• In two-layer adhesives (two bottles) the 2nd layer serves this purpose well.
E. 1st layer must be sufficiently cured to avoid residual monomer.
F. Add the composite incrementally to avoid buildup of contraction stresses that might cause cuspal
deflection.
G. Keep all finishing under water coolant to avoid debonding due to overheating.
o Debonding appears as a white line, due to overheating during finishing but other reasons are
more common as uncontrolled shrinkage stress.
o Polishing is better done dry under very low speed only finishing should be done under water
coolant.
ADVANTAGES
• Quick & Easy Application
• Universal Compatibility
• Antimicrobial Agent
MICROPRIME IS IDEAL FOR:
• Abrasion, cervical erosions and preps
• Applications to vital crown preparations
prior to luting with cements
• At the “prep” appointment to
desensitize during temporization
The best protection is the dentin itself:

▪ So, try to preserve sound dentin: 0.5 mm of dentin able to protect the pulp under composite, provided
that the composite will be done with perfect technique.
▪ May use liner under composite: the most suitable is resin modified glass ionomer (commercially
vitrebond from 3M).
▪ If remaining dentin thickness less than 0.5, use dycal or theracal then vitrebond then composite.
Using sandblasting for decreasing postoperative sensitivity:
▪ Using aquacare with Sylc bio glass powder provides a bio glass rich smear layer occluding the
dentinal tubules.
▪ Bio glass-rich smear layer is still available for conversion into apatite at the resin-dentine interface; the risk for
post-operative sensitivity is very low.
 Sensitivity resolution up to 3 weeks, if not:
▪ Composite removal.
▪ Temporary filling until pulp is relieved.
▪ composite replacement / or endo.

Fracture:
Management:
▪ According to extent of fracture and the quality of restoration.
o Composite repair.
o Total replacement.
Debonding = dislodgement of restoration:
Causes:
▪ Improper bonding (insufficient curing, improper isolation, insufficient bonding …etc.)
Management:
▪ Composite replacement.
Pain:
Pain with biting:
▪ High spot: to be removed.
▪ Cuspal deflection: increase polymerization shrinkage.
o Management:
• Make central groove on your restoration and fill it by flowable composite, wit 3 days if pain
relieved replace flowable (not to be leaved on occlusal surface) by paste composite.
• Continuous pain: replace restoration.
Pain with sweet: exposed area or ditch.
Pain on specific point:
▪ Patient complaint that the restoration is good except when biting on specific area (voids).
▪ Avoid it by place 1st layer flowable composite for better adaptation.
Pain with hard food.
Follow up complications:
Recurrent caries:
Causes:
▪ Incomplete caries removal.
▪ Microleakage.
▪ Improper finishing & polishing (rough composite surface).
Management:
▪ Composite replacement.
Discoloration:
Causes:
▪ Incorrect shade selection.
▪ Microleakage: improper marginal seal.
▪ Improper finishing & polishing (rough composite surface or increase anatomy
of restoration that difficult to be finished)
▪ Improper oral hygiene /smoking ...etc.
Management:
▪ According to extent of discoloration: (Resurfacing, veneering, or Total replacement).
Gingival inflammation:
▪ Concaved area below contact area due to improper wedge position (wedge is above marginal
seat) leads to food trap.

Composite repair:
Why do we repair a failed restoration rather than totally replacing it?
▪ The total replacement requires a larger preparation than the previous one (risk of pulp injuries).
▪ Repair is less expensive.
▪ More gentle on the tooth substance (less exhausting).
To replace or repair? Decision depends on:
Don't repair composite you didn’t do
▪ The quality of the remaining restoration.
▪ The size of the restoration requiring repair.
▪ The risk for complications.
▪ Procedural difficulty.
Notes:
▪ During the polymerization reaction 30% of total amount of c=c bonds remain unreacted, and this
quantity is correlated with the amount of Bis-GMA in the system.
▪ The amount of free and unreacted radicals that bond to another resin monomer is a crucial factor in
direct composite repair.
▪ Time of repair ∞1 / Repair strength.
▪ Universal bond is the best in repair cases (if not, use silane coupling agent then traditional bond)
IF you know the type of composite:
Immediately before finishing & polishing:
Tips:
▪ Dryness. ▪ Use UNIVERSAL bond containing MDP.
▪ Add bond &composite and cure together. ▪ Add bond + flowable and cure together
After finishing & polishing (less than 72 hours) (co-curing) to increase tensile strength of bond.
▪ Roughness by diamond bur.
▪ Acid etching 30 sec with activation (act as cleaner not for etching).
▪ Add bond &composite then cure together.
Late (after 72 hours)
▪ Sand blasting for micromechanical retention: AL2O3 ,50 μm, 2-3 bar -30 sec.
▪ Acid etching 30 sec with activation (act as cleaner not for etching).
▪ Add bond & composite then cure together.
IF you do not know the type of composite:
▪ Sand blasting for micromechanical retention: AL2O3 ,50 μm, 2-3 bar -10sec.
▪ Acid etching 30 sec with activation (act as cleaner not for etching)
▪ Silane coupling agent:
o Let for 30 sec, then apply another layer and let it for 30 sec for complete evaporation.
▪ Add bond &composite then cure together.
Line of demarcation:
Avoid it by:
▪ Long bevel.
▪ Composite has the same refractive index of enamel (ENA hairy).
Manage it by:
▪ Remove line of demarcation by bur.
▪ Make steps of repair & beveling.
▪ Place dentin that blends with surface.
▪ Place enamel.

Porcelain repair with composite resin:
Replacing the restoration is the best solution, but intraoral repair can be a treatment option:
▪ Can save the dentist, technician and patient valuable time and money.
▪ Temporary solution when the replacement cannot be made immediately.
Causes of porcelain fracture:
▪ A high bite or patient’s occlusal dysfunctions, including refusal to wear a nightguard.
▪ Accidents.
▪ Repairs made during manufacturing in the laboratory that causes some alterations in its
strength and structure.
▪ Bubbles or cracks in the internal structure that were not evident to the technician.
Procedure:
1) Shade selection.
2) Surface Preparation:
▪ Isolate adjacent tissues and restorations with well-sealed rubber dam.
▪ Prepare the porcelain and/or metal with high-speed diamond bur and/or air abrasion.
o Air abrasion /sandblasting: with 50 μm alumina trioxide increases the bond strength.
o Remove the glaze and bevel (45 degree) the porcelain around the area to be repaired.
Bevel porcelain surface to increase the

bonding surface area.
3) Etching:
1. Application of porcelain etchant (9.5% hydrofluoric acid) warning:
on prepared porcelain and/or metal surface for 90 sec. ▪ Avoid application it on exposed
enamel and dentin (If enamel is
2. Suction acid from surface, then thoroughly rinse and dry
exposed, etch it by 37%
surface. phosphoric acid).
3. Apply phosphoric acid etch for 10 seconds to remove ▪ Hydrofluoric acid gives off a vapor
porcelain salts and debris formed by the hydrofluoric that irritates respiratory
etchant, then rinse and dry. passageways and on a chronic
basis can cause damage.
o Or agitate by moistened micro brush.
4. Porcelain will have a frosted appearance. Repeat step 3 if area does not appear frosted.
4) Silane application:
▪ Apply Silane and allow to evaporate for 60 sec. After one minute, air dry if needed.
▪ Silane coupling agents function partly by forming “chemical bridges” between two materials
(i.e., composite and porcelain).

5) Bonding:
▪ Apply the universal bond and agitate it by brush for 10 sec.
▪ Air thinning, porcelain should appear shiny.
▪ Curing for 20 sec.
6) composite layering:
▪ If metal is exposed, apply thin layer of opaquer.
Porcelain etchant & silane in market:

▪ Bisco porcelain etchant (9.5% hydrofluoric acid): 5 gm=360 LE.
▪ Ultra-dent porcelain etchant (9% hydrofluoric acid): 325 LE
▪ ENA etchant hydrofluoric acid 9,5%: 375 LE.
▪ CERKAMED POLAND YELLOW PORCELAIN ETCH 2ML
HYDROFLUORIC ACID 9,5%: 400LE
▪ Ultra-dent silane: 250 LE

▪ ENA silano: 300 LE

The oxygen inhibited layer (OIL):
 Definition:
▪ The sticky, resin-rich uncured layer left on the surface (10-20 micron according to composite
filler loading) due to the interference of oxygen in air with polymerization.
o Oxygen binds with free radicals (peroxy radicals which are much less reactive toward double
bond) results in:
• Efficiency of initiation is reduced.
• Inhibition of the polymerization.
 Effect:
▪ During composite placement:
o Composite in presence of oxygen not completely polymerized this help in bonding between
two layers (so avoid application of bond between composite layers as it acts as separator).
• Sometimes this layer is lost, if a correction is made with a diamond bur or the composite is
contaminated.
• This layer is easily recovered by using a primer-free bonding resin (resin modular) to moisten
the surface and blowing it with air to remove liquid excess.
▪ But in final layer it leads to:
o Discoloration.
o Decrease marginal adaptation.
o Decreased surface wear resistance & surface hardness.
 How to minimize:
▪ By using air block/barrier (mylar strip / glycerin):
o The final cure of the composite be completed through a Mylar strip (for interproximal
restorations) and in posterior cases the composite is already in contact with band.
o Or through an application of glycerin (KY gel) or (oxyguard) or a similar such material applied to
the surface (for more complex facial / palatal and occlusal surfaces).
• Glycerin: transparent & water soluble so easy removal by rinsing.
• When using glycerin, the final curing is completed through the glycerin. The glycerin is then
rinsed off prior to finishing and polishing. The result is a harder composite surface that is
easier to finish
• It can also form on the margins of indirect restorations that have been bonded with resin
cements, so it is advisable to also use glycerin on the margins of these restorations –
especially if you are not routinely finishing back the margins.
▪ Although this layer can be removed by finishing and polishing the restoration, it will typically
get in your bur or disc (clogging), thereby causing it to be inefficient or useless.
▪ Mylar strip was the most effective method in preventing OIL formation, but it is restricted only to flat profile.
▪ Glycerin applied before curing was the second most effective method but in posterior teeth it is restricted
to cases where occlusal surface cured in one step as in stamp technique (as it will rinsed with water that
affect bonding of any additional layer)
▪ Glycerin applied after initial curing (for 20 secs) has less effect than (glycerin before curing) but more effect
than curing in air.
▪ Finishing & polishing is a must and increase inhibition of oil formation. (some dentists depend only and
finishing &polishing without glycerin).

Vickers surface hardnesses (HV) of the four groups according to surface polishing and measurement
time
No polishing polishing
Group Immediately Immediately
Five days later. Five days later.
after curing. after curing.
Air. 46.1 (3.2) d 58.1 (3.8) b 112.2 (10.7) a 143.7 (8.2) a
Mylar strip 82.5 (2.8) a 94.8 (7.2) a 119.9 (17.2) a 145.9 (11.3) a
Glycerin 75.2 (3.5) b 89.6 (6.7) a 118.6 (14.8) a 147.9 (11.8) a
Air + glycerin 55.3 (4.6) c 63.7 (7.0) b 113.7 (11.7) a 142.9 (9.9) a
▪ Oxyguard. (kurary)
▪ Deox. (Ultradent)
▪ CERKAMED POLAND INOX GEL= 65 LE
▪ KLY LUBRICATING JELLY (from pharmacy 82 GM= 100 LE)
The Effect of Finishing and Polishing Time on Microleakage of

Composite Restorations:
▪ Composite resins require time to complete their polymerization. This process usually
reaches its maximum rate after 24 hours.
▪ On the other hand, immediately after restoration, water sorption results in hygroscopic
expansion of composite that reach its equilibrium at 7 days.
▪ So, delay in finishing and polishing (one day to one weak) will result in reducing the
.
marginal microleakage. Demo

Original article

Base and sub-base that can be used with composite:
 Indication of base under composite:
▪ Flowable composite:
o For better adaptation to irregularity.
o As stress breaking liner (low modulus of elasticity).
o Decrease post-operative sensitivity: can be cured High caries index patient.
sufficiently. o Sandwich technique.
▪ Glass ionomer (RMGI): o Or compomers for its quite
fluoride release and insolubility.
o High caries index patient.
ex: glass flow (Ivoclar), dyract
o In deep cavity with Dycal as subbase.
(DENTSPLY), twinky star (Voco).
o As stress breaking liner.
o Glass ionomer is better to bond to caries affected dentin than composite.
 How to use:
▪ Glass ionomer used as a base with composite in sandwich technique.
▪ Conventional glass ionomer:
o Fill all cavity with glass ionomer then let it for at least two days for final setting.
• 1 year is best: as all maturation is now completed.
This is true for all glass ionomer
• 3 months: it is good as most maturation is completed. types except that RMGI is less
• 1 month: is ok as significant maturation has occurred. sensitive than the conventional
• 1 week: is not bad as Ca salts are now replaced by Al salts. type.
▪ Resin modified glass ionomer (RMGI):
o Is the best as it has resin, so it bonds with composite vitrebond (1450 LE) / vitrebond
chemically beside micro-mechanical bond. plus (2432 LE) (3m espe): it is light
o We can apply composite in the same visit as it hardens curing glass ionomer it is the best to
immediately after light curing. be used as liner or base. but it is
o Ex: Fuji II by GC, Photac fil by 3m espe, RIVA light cure, expensive and technique sensitive
(mixing not capsulated)
IONOLUX from VOCO.
▪ Sandwich technique:
o Closed sandwich technique:
• As in cases of class 1 (even if it is class II, can restore it by composite to be class I)
o Open sandwich technique:
• As in cases of class II (deep margin elevation), especially in cases of:
- There is no cervical enamel.
- Difficult to achieve isolation.
 Subbase / liner:
▪ Thercal:
o Theracal LC is a light-cured, resin-modified calcium silicate. Its unique apatite stimulating ability
makes it ideal for direct and indirect pulp capping and as a protective base/liner.
▪ Dycal:
o Used as subbase (Dycal + glass ionomer + composite).
o Never used under composite directly:
• High solubility and degradation over time (causes gab = stress concentration).
• Acid etching dissolve it and jeopardizes its effect.

Glass ionomer
Advantages of using glass ionomer:
▪ Ability to release fluoride so can be used in high caries risk patients.
▪ Bond chemically to tooth.
▪ Less technique sensitivity than composite.
▪ Can be applied in a bulk rather than increments in composite.
Indication:
▪ Abrasion and erosion cavities.
▪ Restoration of deciduous teeth.
▪ Root caries.
▪ Class V restoration.
▪ Class III in cases of intact labial enamel.
▪ Sandwich technique: as in cases of deep marginal elevation.
▪ Build up before endodontic treatment.
▪ Core build up when at least three walls of tooth are remaining.
▪ Crown margin repair.
Highly viscous glass ionomer:
▪ They provide superior wear resistance and biocompatibility.
▪ They offer the highest mechanical properties compared to RMGI and other conventional
glass ionomer.
▪ Can be used in class I and class II cavity.
▪ Ex:- Fuji IX, Equia fil & Equia forte by GC or Ketac molar by 3m espe.
Resin modified glass ionomer (RMGI):
▪ It is glass ionomer with resin property so:
o Prolonged working time.
o Controlled setting time by polymerization (light curing).
o Can be finished and polished immediately.
o can be used in sandwich technique and apply composite above it immediately.
o Aesthetic appearance so can be used in class V and class III.
▪ Ex:- Fuji II by GC, Photac fil by 3m espe, RIVA light cure, IONOLUX from VOCO.
Application steps:
1- Isolate teeth prepare the cavity.
o Cotton roll isolation will serve the purpose (glass ionomer is sensitive to moisture that cause
dissolution of the formed matrix
2- Apply conditioner (poly acrylic acid 10-25%) for 10 -20 sec.
o The Conditioner removes the smear layer and increase the surface energy and so chemical
adhesion ex:- (Dentin conditioner by GC or Ketac conditioner by 3m)
o You may apply 37% phosphoric acid etch for 5 sec as conditioner.
o Increase etching time will demineralize the needed ions for chemical adhesion.
3- Wash thoroughly.
4- Remove excess water and keep moist (avoid over dryness).
o May apply CHX cotton for 1 min for disinfection and decrease sensitivity and increase bonding.
5- Activate the capsule and immediately mix in amalgamator.
o 6- 10 sec according to manufacture.
6- Place in capsule applicator (gun) and click trigger until paste is seen thorough the nozzle.

7- Apply glass ionomer in cavity in layering of no more than 2 mm into cavity and contour.
8- Apply varnish or bond on surface by bond applicator, to protect surface from syneresis and
imbibition.
o Varnish as (Equia nano coat, Fuji coat by GC, or ketac glaze by 3M)
Fuji II LC capsule Photac fil (3M espe) LC Riva LC capsule = 35 LE

45 LE capsule
10 reasons to prefer glass ionomer than composite in restoration of class III:

1- In case caries recurrence is anticipated as in high caries risk patients or when the enamel
margin has a white demineralized surface, then glass ionomer was proved to provide
better marginal resistance.
2- In case the gingival seat is in dentin or thin enamel, then it is easier to be wet and sealed
with the hydrophilic glass ionomer than a hydrophobic resin.
3- In case the neighbouring surface is involved with enamel caries, then glass ionomer was
proved to stop contact surface caries.
4- In case a palatal approach was used to excavate the lesion, then the aesthetic advantage
of resins is not required.
5- In case undermined enamel is preserved labially or gingivally, then only the low setting
shrinkage stress of glass ionomer won't cause its cracking.
6- In case the restoration is shaped with a celluloid matrix and marginal excess is
unavoidable, then glass ionomer is much easier to trim than resin.
7- In case the labial enamel is thin, then GI will better match the tooth translucency than
composite.
8- In case the restoration was inserted in bulk, then GI can fully set regardless thickness.
9- In case rubber dam was not used, then isolation cannot be usually maintained in this
location long enough to insert composite. Glass ionomer need less than a minute to insert
and protect against moisture.
10- In case the peripheral seal concept is applied with the partial caries excavation technique,
then the glass ionomer will have a more bacteriostatic advantage.
NOTES:
▪ After one year of maturation GI has wear resistance as composite.
▪ Glass ionomer does not dissolve in water but dissolves under 5.5 ph. (acidic medium)
▪ Composite is better than glass ionomer in:
o Tensile strength.
o Bond strength.
o Wear resistance.
o Colour matching usually not required in class III restorations unless it is showing labially.
• Such cases may also be restored in glass ionomer with a labial veneer with flowable or restorative
composite as an open sandwich restoration using self-etch bonding.
• Immediate veneering of light cured glass ionomer is possible, however it's preferable that the patient's
acceptance is gained to delay veneering as long as possible.

Case by DR: AMR EL DEEB:
▪ Preoperative view (facial)

▪ Decay was accessed from the palatal surface and labial undermined enamel was preserved for esthetics.
▪ Cavity preparation then matricing (space distribution).

▪ This enamel is highly susceptible to be cracked with the slightest excessive shrinkage stress of composite. So
RMGI is used in this case as It has a much lower shrinkage stress than that of composite, therefore less
susceptibility of the labial undermined enamel to be cracked. LC RMGI usually gives excellent color match
under labial undermined enamel as it has an opacity that is very close to that of natural dentin. It is bulk filled,
requires much less time for isolation and application and any excess can be easily trimmed unlike composite.
▪ Plastic wedges to be used instead of wooden one: as plastic wedge is compressible wedge that requires
minimal force for insertion to avoid breaking of the labial undermined enamel.

Deep marginal elevation (DME):
 DME VS DMA:
▪ DMA: deep margin acquisition (gingival modelling), it is to gain accessibility to deep margin by
removing soft tissue covering margin (make it below margin by 1mm).
o Papillectomy:
• By thermacut bur /GINGIBUR gingivectomy without coolant, the action is peeling of gingiva
without bleeding.
• Can be done also by:
- Dull round bur. (diamond bur &smooth it)
- Laser. - Electro surgery.
o HAKIM trench technique:
• Instead of removal all papilla, only make trench by thermacut bur adjacent to the operated
tooth.
• This trench act as sulcus for rubber dam inversion.
• Advantage here is maximum preservation of ID. papilla.
o Surgical crown lengthening:
• When papillectomy is not enough for margin acquisition, it is the time to make crown
lengthening.
• Flap + bone removal then suturing.
• Healing for 4 weeks.
o Three guide lines to make gingiva rebuild in the proximal triangle:
1) Very smooth composite restoration.
2) Maximum space between bone and contact area Is 3-5mm.
3) Remove only papilla not periosteum. (bone sounding test= probing anaesthetized tissue with a
periodontal probe to establish the level of the underlying alveolar bone)
• The space will be completely filled with papilla within maximum 2 years of follow up.
▪ DME (Deep Margin Elevation):
o Elevating gingival margin to level where it can be sealed with rubber dam.
o It's using one setting to seal the gingival portion of a deep cavity then using another setting to
restore the lost anatomy.
o Used Whenever it's difficult to achieve both goals using one setting.
 Technique:
▪ Prewedging is necessary: To know the needed part of gingiva to be removed.
▪ Deep margin acquisition if needed:
o Infiltration anesthesia in papilla (blanching) to decrease bleeding and pain.
o Papillectomy or HAKIM trench technique.
o Try wedge: if below the margin, acquisition is completed.
▪ Isolation:
o Use rubber dam &it is a must to use active clamp even in adjacent tooth.
o Then use wedge & Teflon.
o OR (may use Rubber dam split & use Teflon as 2nd isolation)
▪ Matrix:
1. Modified Tofflemire matrix:
o Decrease matrix height to 3 mm as maximum for easy placement subgingivally and sealing
margin without wedging.

o May use matrix in matrix (one vertical and one horizontal) if you can't access the margin.
2. Bioclear matrix (6.5 mm):

o It is better to be used in cases of DME to ensure complete curing from buccal, lingual & occlusal.
o It has great curvature so can be used to build proximal surface in one step.
3. Saddle matrix (2 or 3): it has great curvature & height.
4. Sectional matrix:
o Use two step technique by large sectional matrix.
o Or customize your band by cutting its periphery so can be placed more subgingival.
5. Double or triple bands: for band adaptation.
▪ Restoration:
o Place the sealing material usually in a thickness (2-3 mm) not less than 2mm to give it adequate
strength.
o This material must adapt easily and fast to dentin as glass ionomer cement or bulk flow
composite, because it's usually difficult to maintain isolation subgingivally long enough to place
composite and sometimes it's even impossible to apply a matrix and the material is inserted just
under retraction cord isolation to be later trimmed to the desired contour with a finishing bur.
o On the second stage -with the gingival seat elevated- it's now possible to secure the matrix,
wedge it and contour it for the restorative composite to be properly inserted.
o The tooth may be also prepared to receive an indirect restoration that terminates on the
elevated margin.
 Which material is better?
▪ Bulk flow composite, if you can maintain the isolation long enough to apply it or fast set highly
viscous glass ionomer.
▪ Snowplow technique (flowable + packable composite)
▪ Use selective etching technique as most margins is in enamel.
 Which is better conventional, or resin modified glass ionomer?
▪ The highly viscous is a conventional glass ionomer so it will wet the dentin much better
resulting in a better seal.
▪ It cures chemically so it will fully cure in such deep and humid area.
▪ It has a higher elastic modulus so it's more rigid and thus will better support the overlying
restoration in compression resulting in more longevity.

 Do you know what was the oldest technique to apply DME?
▪ The open sandwich glass ionomer/composite restoration, I guess.
▪ Use gingival dam or Teflon for isolation.
Double band (sectional +saddle)
RD inversion in DM cases.
Deep marginal elevation.

HAKIM TRENCH
DR: Ahmed Khairy
technique.

Bioclear Method
Deep Margin Acquisition and the Push-Pull Technique.
 In this technique there is no need for papillectomy any more.

 It depends on:
1- Widening gingival sulcus:
▪ insertion and removal of retraction cord (NO 3) for several times
(3-4 times).
▪ And each time the retraction cord is dipped in astringent (causes
retraction to gingiva and hemostasis)
2- Push and pull technique:
▪ Pull band mesially (toward adjacent tooth surface) then push it
distally & cervically.
▪ That make the band adapted to adjacent tooth and goes more
deeply in sulcus.
 Note: may trim bioclear band from periphery to reach more deeply
without any interference.
 Why to be caution with DME?

▪ It seems like, the biologic width can be potentially violated to a minor extent providing the
subgingival margin is highly polished and free of overhangs based on several case reports of
direct resin composite restorations. This might be possible only in two-step direct resin
composite restorations where a properly adapted matrix would highly minimize the risk of
overhangs. Patient consent is a must and they must be informed that there is still a potential
for failure.
▪ However, this is not possible with a DME for indirect adhesive restoration as when cemented,
excess resin cement needs to be completely removed and if the distance between the margin
and the alveolar bone is 2 mm or less, complete removal of all remnants of excess cement
that tend to stick to the outer surface of resin composite of the DME seems to be impossible
and chronic gingival inflammation would be the inevitable fate. And in such case surgical
crown lengthening is a must.
▪ Again, we still lack enough data. Extensive future research is required to answer many
questions before comprehensive conclusions and solid guidelines can be withdrawn and
given.

Resin infiltration (I-CON): 1850 LE
Micro-invasive treatment for carious white spot lesions (WSLs) aiming to prevent the progression of
the initial carious lesion into a cavitated one by occluding the lesion porosities with an unfilled low
viscosity light curing resin material with extremely high penetration coefficient.
 White spot lesion (WSL):
▪ May be carious or non-carious lesions.
▪ Non-carious: fluorosis, enamel hypoplasia or hypo calcification, erosion or after ortho TTT.
 Technique:
▪ Prepare your enamel surface by sandblasting or polish with disk.
▪ Application of 15 - 18 % HCl acid etchant (ICON-Etch) for 2 minutes to erode the relatively
impermeable hyper mineralized surface layer of the lesion exposing the lesion porosities.
o Application, rubbing by applicator tip, let it for 2 minutes then rinsing for 30 sec.
o May the case need 2nd application after rinsing 1st one.
▪ Application of a drying agent: 99 % ethanol (ICON-Dry) and let it for 30 sec.
▪ Visual inspection: if lesion is not accessible yet (insufficient result) so repeat etching step.
o Application of ICON dry gives you a preview of the result (if you got good esthetic with icon dry,
you are good to go with infiltration).
▪ Infiltration of the lesion porosities with an unfilled low viscosity light cured resin material with
extremely high penetration coefficient. (ICON-Infiltrant).
o Application, rubbing by applicator tip, let it for 3 minutes, excess removal by air & floss then
curing for 40 sec.
o May the case need 2nd application after curing 1st one.
▪ Polishing.
 Advantages:
▪ It creates a diffusion barrier not only on the surface but within the hard tooth structure thus
stabilizing and arresting the progression of the carious WSL.
▪ It provides mechanical support of the fragile enamel.
▪ Restore enamel translucency (masking of developmental or fluorosis white lesions).
 Why resin infiltration of carious WSLs?
▪ The traditional preventive measures aim to enhance remineralization of WSLs by application
of fluoride varnishes and improving the patient’s oral hygiene but unfortunately:
o In many cases especially with deeper WSLs those measures only slow down the progression of
carious lesions without arresting or reversing it.
o Lack of patient’s compliance may lead to progression of carious lesions and eventually lead to
enamel cavitation and invasive operative intervention.
o With remineralization although carious WSLs can become arrested and change its clinical
appearance from a chalky and rough active lesion to a bright and smooth inactive lesion, they
seldom disappear clinically.
 If the patient requests bleaching, is it advisable to do it before resin infiltration:
▪ It is advisable to do bleaching first as resin infiltration might interfere with the penetration of
the bleaching agent.
▪ The dentist should inform the patient that after bleaching the WSLs would look much whiter
and that subsequent resin infiltration would dull the bleaching result to an extent, but it is a
compromise to protect the fragile enamel.

 Can 37% phosphoric acid gel be used instead of 15% HCL gel?
▪ Better no. The penetration depth of 15% HCL etching is 58 μm more than twice that if the
37% phosphoric acid etching 25 μm.
▪ Therefore 15 % HCL acid gel has been demonstrated to be superior to 37% phosphoric acid
gel in removing the surface layer of natural enamel lesions when applied for 2 minutes.
 Requirement of the resin Infiltrant:
▪ Extremely high penetration coefficient >200cm/sec to penetrate to the depth of lesion.
▪ Solvent free (that’s why adhesives are not desirable).
 Would resin infiltration fade a WSL entirely?
▪ it may not always fade the white spot lesion entirely. However, this may improve over time.
Style Italiano case:
1. Rubber dam was placed to properly isolate the teeth, no anesthesia was necessary.
2. Enamel surfaces were slightly sandblasted.
3. Icon Etch (15% hydrochloric acid) was applied for 2 minutes and gently rubbed using the application tip.
4. The etchant was rinsed, teeth were air dried and the Icon etch was applied for a second time (2 minutes).
5. The etchant was rinsed once again for 30 seconds.

6. Ethanol (icon dry) was applied and then air blown. Ethanol has a refractive index close to that of resin, so it can
be really helpful to pre-visualize the final result.
7. Tegdma resin (Icon infiltrant) is applied for 3 minutes, gently rubbing the application tip. Excesses are removed
with a gentle air blow and floss, then a light curing procedure is performed for 40 seconds
8. The resin is applied a second time.

9. Then is cured again.
10. The result is quite good, but some spots are still visible, so the application of a composite layer was necessary.
11. A layer of resin composite is applied using a brush and light cured.
12. Finishing and polishing procedures are very fast and easy, just a silicone tip and an abrasive stripe.
 ICON Proximal treatment

▪ Young adults have an especially high risk of lesions in proximal surfaces of teeth.
▪ Icon proximal allows these lesions to be treated early and micro invasively, before it is too late
and the advancing caries makes an invasive intervention necessary.
1. Icon can be used to effectively arrest the progress of caries that x-rays show have not
advanced farther than the outer third of the dentine (E1-D1).
2. If x-rays show the lesion has advanced past the outer third of the dentine, treatment with
Icon is no longer indicated. In this case, traditional invasive therapy is required.
3. If initial lesions are detected on the neighboring tooth during an invasive treatment of a
cavity, Icon can be used to stop the lesion in a straightforward way.

Step by step – application of proximal Icon in the interdental space
▪ Check the necessity of x-ray images in advance, for example using fiber-optic
transillumination devices.
▪ Exact diagnosis with bitewing x-rays: early diagnosis of proximal lesions.
▪ Gentle tooth separation step by step:
o It is best to proceed slowly with the tooth separation.
o Guide the wedge into the interdental space until resistance is felt. The patient will experience this
as a light pressure.
o Hold the wedge in position for several seconds.
o Softly push the wedge further until the widest part of the wedge creates enough separation
between the teeth.
o Etching – Drying - Infiltration.
o Remove excess by dental floss.
o Curing.
 Documentation in patient records:
▪ Icon is not radiopaque.
▪ This is because certain filler materials are necessary to make it radiopaque. These materials
negatively affect the infiltrant’s flow properties and therefore its penetrative ability.
▪ In order to document the procedure properly, the patient card included in every package
should be marked and filed appropriately.

Fiber Reinforced Composite Restoration
Ribbond:
▪ The placement of fibers (Ribbond) as close as possible to the residual tooth
structure functions mainly to reduce the stresses and shrinkage within the
composite, bridges the cracks on dentin and mimic the shock absorbing
effect of the dentin-enamel complex.
Fiber Reinforced Flowable Composite:
▪ GC everX Flow is a short-fiber reinforced flowable composite indicated for
dentin replacement in bulk-filling and core build-up applications or in cases
of weakened/cracked tooth structure, together with a conventional
composite as enamel layer.
Advantages:
▪ Increased micro-tensile bond strength: when closely adapted and bonded against the cavity walls.
▪ Mitigating the harmful effect of c-factor (especially evident with deep and narrow Class I restorations):
o The increased micro-tensile bond strengths decrease the negative c-factor effects.
▪ Minimizes polymerization and decreases shrinkage and leakage:
o Because the Ribbond is closely adapted to the cavity walls, there is less volume of composite to
shrink and less polymerization shrinkage results in less leakage and less sensitivity.
▪ Bridging cracks on pulpal floor (commonly seen in floor of old amalgam restorations):
o Ribbond bridges the cracks by acting like staples across the cracks and holds the parts of the tooth
on both sides of the crack together.
▪ Relieves causes of symptoms of split tooth syndrome:
o Split tooth syndrome has been predictably successfully relieved when Ribbond has been used as a
buccal-lingual cross cusp splint under the occlusal surface to bridge cracks.
o The cross cusp Ribbond splint prevents the parts of the split tooth from moving.
▪ Increased fracture toughness.
▪ Stress distribution and energy absorption mechanism:
o Ribbond acts as a stress distribution and energy absorption mechanism. It minimizes the stress
concentrations by distributing forces over a greater area, which prevents crack formation and
propagation. It also absorbs the energy from repeated occlusal impacts.
▪ Fail-safe design:
o Studies demonstrate that if a crack starts in a Ribbond lined composite restoration, the crack is
redirected. If this crack leads to failure, the restoration/tooth complex fails safely and the tooth
can be retreated.
o In the case of standard composite restorations techniques; when the restoration/tooth complex
fails, it tends to fail catastrophically and the tooth must be extracted.
Procedure:
▪ The tooth is prepared for bonding and a bonding adhesive is applied.
▪ A flowable composite is placed in the bed of the preparation and is also placed against the interior
walls of the prepared tooth.
▪ Ribbond pieces are wetted with wetting resin (that contains no solvent or primers) and the Ribbond pieces
are pressed through the flowable composite against the tooth surfaces covering as much of the interior
tooth surfaces as possible. (Ribbond works best when applied directly to the dentin)
▪ The Ribbond pieces are cured and composite is incrementally placed into the preparation.
▪ To further reduce the risk of the tooth fracturing a piece of Ribbond is placed in the composite
approximately 1.5 mm below what will become the occlusal surface of the tooth.

Endo cores:
The goal is to retain as much remaining tooth structure as possible and create a core system that will help
distribute stresses and avoid weakening the remaining tooth.
▪ Remove GP 1.5- 2 mm into the canals.
▪ After bonding procedures (selective etching for enamel then universal bond).
▪ Place flowable composite.
▪ Then apply Ribbond fibers:
o Close adaptation of Ribbond to the underlying dentin is most desirable because this provides the
greatest reinforcing effects to the underlying tooth structure.
o 1st layer: 2mm wide Ribbond placed bucco-lingually and pushed down into each canal (creates a
torsional lock, stabilizing the core bucco-lingually and mesio-distally)
o 2nd circumferential layer: In cases of missing wall apply circumferential wrap of Ribbond (This
creates the walls of a fibre torsion box, prevents vertical crack propagation in the tooth)
o 3rd mesiodistal layer: may apply, mesiodistal layer if pulp chamber volume is significant.
▪ The core was filled with fibre reinforced composite (everXPosterior, GCA)
▪ 4th layer: in cases of direct restoration: A layer of Ribbond was then placed buccolingually from cusp
tip to cusp tip followed by a final occlusal layer of composite. This layer pulls cusps together decrease
damaging effect of compressive forces.

Indirect composite restoration:
 Steps for make indirect composite (Made on the cast):
▪ Apply the spacer (to make room for cement later) on all walls of the prepared tooth on
cast except finishing line.
▪ Apply flowable composite in very thin layer with high chroma (for good adaptation) then
light curing.
▪ Add body dentin colour ceramic composite all around the abutment + light curing.
▪ In case of posterior teeth, we put the fiberglass mesh on the body colour ceramic
composite before curing.
▪ Additional body dentin colour ceramic composite for making the primary anatomy of the
tooth
▪ Enamel shade ceramic composite as a final anatomy construction.
▪ Colouring by special stains for more details matching.
▪ Final flowable transparent layer with partial curing to get its shape then covering with gel
to complete the curing without oxygen.
▪ Remove the gel.
▪ Finishing the margins with carbide bur then polishing.
 Endo crown:
▪ Used in endo treated teeth, composite go inside canal by 1mm so take support from canal
dentinal structure.
▪ Best to be from ceramic, but we can make it by indirect composite especially in cases of
young patients (<18 years) used as temporary crown as bone and PDL still in growth.
Case: cementation of indirect composite restoration by self-made PICK & PRESS
INSTRUMENT (style Italiano case)
▪ As the tooth was root canal filled, the cusp coverage was indicated (the cusps were reduced by 1.5-2.0 mm).
▪ The old composite restoration was removed proximally from both sides, the demineralized tissue was cleaned,
and the gingival margin was elevated with composite resin.
▪ Then the preparation was finished, and an impression taken to be delivered to the laboratory (composite onlay)

▪ The tooth was sandblasted with 50 µm aluminum oxide particles and etched with 38% orthophosphoric acid
for 20 sec.
▪ The etching agent was then washed meticulously with water spray and delicately air dried.
▪ And the adhesive system was carefully placed in two layers, air dried and polymerized.
▪ To facilitate onlay pick up and correct sitting of the restoration, the self-made PICK & PRESS instrument was
created from an adhesive applicator stick.
▪ The polyvinyl siloxane adhesive was applied to the working end of the applicator, then a piece of
laboratory silicone was placed on it
▪ And before the silicone hardened, it was placed on the composite onlay seating on the cast. In this position it
was left for appropriate setting
▪ To create the occlusal print of the onlay
▪ Now the newly created silicone instrument can serve as a holder for easy inlay/onlay PICK UP & PRESS during
the cementation process.
▪ The inner surface of the indirect restoration was sand-blasted with 50 µm aluminum oxide particles, then
covered with silane and adhesive system and again placed into the PICK UP & PRESS INSTRUMENT.
Now the composite cement was placed on the whole inner surface of the indirect restoration.

▪ The onlay was picked up on the tooth and pressed with PICK & PRESS.
▪ The seating onlay only was left for initial removal of the composite cement excess.
▪ After initial removal of the excess, the PICK & PRESS instrument was adjusted with a scalpel on the two
proximal sides.
▪ In order to hold and press the onlay while allowing the proximal removal of the resin excess with interdental
floss.
▪ When all visible cement excess was removed, the glycerin gel was placed, then curing from all sides.
▪ small occlusal adjustments were carried out, in order to remove any premature interferences.

Bleaching
Types of stains:
External stains Intrinsic stains
▪ Smoking. ▪ Tetracycline.
▪ Smokeless tobacco. ▪ Aging discoloration.
▪ Chromogenic foodstuffs (coffee and tea), (beet, ▪ Discoloration due to loss of
raspberry, curry). vitality.
▪ Soda (causes chemical erosion). ▪ Enamel hypo-calcification.
▪ Regular use of chlorhexidine mouthwash. ▪ Enamel fluorosis.
▪ Bad oral hygiene (plaque and calculus).
▪ Cervical abrasion (erosion in cervical one third due
to thin enamel thickness).
▪ Amalgam filling in palatal surface of anterior teeth
in old patient.
 Mechanism of Bleaching (Science of bleaching):

▪ The main effective product in bleaching material is hydrogen peroxide H2O2 Which diffuse
through enamel and dentine as free radical (O-) that breakdown the double bond of stain
molecules into smaller, more hydrophilic, diffusible particles.
▪ As the tooth became dehydrated the small particles aim more hydrophilic media outside
the tooth.
▪ Bleaching materials which break down to give H2O2
o Carbamide Peroxide (home bleaching, chemical bleaching, over the counter products).
o Sodium Perborate (became history as it was used in internal bleaching disadvantage: cause
external cervical resorption).
▪ Prolonged application time of bleaching agent results in over dehydration and sensitivity.
Methods of Bleaching:
 Non vital bleaching / walking bleaching / internal bleaching.
 Vital bleaching:
▪ In office bleaching.
▪ Home bleaching.

Style Italiano Dental Bleaching Protocol:
1. Say hello and take the color:
▪ Take the shade at the beginning of appointment as soon as possible before teeth dehydration:
o Dehydration makes the teeth appear whiter than they really are: The air replaces the water
between the enamel rods, changing the refractive index that makes the enamel appear opaque
and white.
o Dehydration starts from the very first moment, we place the lip retractor and dry the saliva with
an air-water syringe.
o Rehydration takes time, usually more than 2 hours.
2. Choose the shade guide depending on value:
▪ Dental bleaching increases value has a little
effect on chromaticity (reduce yellowness) and
almost no effect on hue.
▪ VITA Bleached guide 3D-MASTER: it depends on
value, so it is more specific for bleaching.
3. Treat the upper arch first:
▪ Always bleach the upper arch first during the first
week, so patient can notice the difference
between upper and lower (before & after), that
motivate them to continue the treatment.
▪ This reduces the possibility of patients not
remembering their initial shade and concluding
that the bleaching is not working.
4. Use photography to help you:
▪ To take the picture use black Flexipalettes,
retractors and the most appropriate sample
from the shade guide.
▪ With one hand hold the camera and with the
other hold the tab. The assistant can show the patient how to hold the retractors and blow
air to remove saliva and with the other hand holds the black background as far as possible
from the teeth so as to obtain a pure black.
▪ It is important to use the same settings for the initial and the final pictures so as to compare
colour.
o The same camera (I use Nikon 7200 with a macro Nikor 105mm).
o Same flash power (with a Nikon point flash R1C1 power 1/2 and full power with a polarized filter)
o Same flash position (45 degrees with my point flashes R1C1).
o Same magnification ratio (1.8:1).
o Same exposition (f22, +/- 0).
o Same ISO (100).
▪ Using Smile Lite MDP (Mobile Dental Photography):
o This device allows you to adapt your
smartphone to a light system equipped
with three groups of LEDs (light emitting
diodes). The resultant pictures will
dramatically improve.

▪ We recommend the following type of photography to document bleaching:
o Polarized: this is ideal because it eliminates all the reflexes and enables us to appreciate colour
o Twin Flash 45 0 45: gives a good picture because it creates reflection only in transitional angles
o Ring flash: not ideal because it gives a lot of glare on the buccal surface.
o Diffusors: not ideal because reflections are too white and ‘kill’ the colour.
o Studio portrait: the least ideal to appreciate colour differences.
Internal / walking bleaching:
 Indication:
▪ Discoloration of pulp chamber origin.
▪ Dentin discoloration.
▪ Adequate root canal treatment.
 Contraindications:
▪ If a fiber post was cemented in the root canal and the pulp chamber was filled with composite
resin, removing the restorative material and post can compromise the amount of sound dentin
(aesthetic benefits vs. structural sacrifice).
▪ Discoloration caused by amalgam or other metallic materials (not bleachable).
▪ Significant dentin loss in the cervical portion (risk of fracture and leakage of bleaching agent).
▪ Extensive restorations.
▪ Visible cracks, especially with subgingival extension (risk of bleaching agent penetrating towards
periodontal ligaments).
▪ Young patients (<19 years old).
 Procedure:
▪ Record the shade of tooth in the beginning of appointment & take a picture.
▪ The quality and colour (shade) of any restoration present are assessed.
▪ Establish the expectations of the patient. Explain any esthetic limits before proceeding.
▪ Take periapical x-ray to assess:
o The quality of endo treatment (failed or questionable obturation to be retreated before
bleaching).
o The height of the alveolar crestal bone (any whitening material below alveolar crestal bone level
cause root resorption)
▪ Remove the restoration from the access cavity.
▪ Clean the pulp chamber from any remaining gutta percha, sealer or pulp horn.
▪ Gutta-percha should be removed to a level just below the gingival margin or 2 mm below canal
orifice /CEJ, solvents are used to dissolve remnants of the sealers
A periodontal probe is used to
determine the level of the epithelial
attachment from the incisal edge of
the tooth. This will serve as guide for
placement of the root canal barrier
▪ Seal the canal orifice to avoid any bleaching agent to go beyond the clinical crown causing root
resorption or affecting endodontic coronal seal.
o We can seal the canal by:
• Cement base (such as polycarboxylate, glass ionomer, zinc phosphate or cavit at least 2 mm thick).
• or by self-adhesive bond + flowable composite.

▪ In severe cases we can apply additional procedures such as:
o A thin layer of stained facial dentin is removed with a small round bar.
o Etching the internal dentin (placing acid etch inside chamber) to remove smear layer and open
the tubules will allow better penetration of the oxidizer.
▪ Apply bleaching material to the cavity (Leave 1.0 to 1.5mm of space to accommodate the
provisional restoration).
o Opalescence endo (ultra dent).
o Or mixing sodium perborate powder with 30% H2O2 to a consistency of wet sand.
▪ Apply glass ionomer as temporary restoration for good seal.
▪ Verify occlusal clearance in protrusive and laterotrusive movements. Premature occlusal
contact may fracture the provisional restoration resulting in leakage and loss of bleaching
material.
▪ The bleaching agent was replaced once a week, until the desired color change is achieved.
▪ Slightly over bleaching the tooth is recommended as some regression of whitening will
occur.
▪ Wait 8-10 days before restoring the tooth. This will allow the shade of the tooth to stabilize.
▪ Remove provisional restorative material and bleaching material to level of glass ionomer
sealing material. Rinse and clean access opening. Restore with adhesive dentistry
procedures.
 COMPLICATION
▪ External resorption: Internal bleaching occasionally induces external cervical root resorption.
Chemicals combine with heat are likely cause necrosis of the cementum, inflammation of the
periodontal ligament, and root resorption.
▪ Crown (Coronal) fracture: Increased brittleness of the crown part of the tooth, particularly when
heat is applied resulting in the tooth is more susceptible to fracture.
▪ Chemical burn: 30% hydrogen peroxide is caustic and will cause chemical burns and sloughing of
gingiva. Therefore, rubber dam is needed to protect the gum from chemical burn.
 LIMITATION
▪ Even though internal bleaching can produce satisfactory result in most cases, no all will achieve the
desirable result. Therefore, other options such as full porcelain crown, porcelain veneer will be the
alternative to whiten non-vital tooth!!

In-office bleaching:
 Material:
▪ Gel form.
▪ Powder and liquid form (powder and liquid is preferable than gel to avoid storage problem).
 Bleaching devices (Bleaching accelerators): optional choice.
▪ Most of the bleaching brands are chemically activated and
Bleaching with light accelerator
light accelerated, except for zoom brand is light activated.
makes the teeth lighter compared
▪ Bleaching devise may be:
to teeth treated without the light.
o LED devise:
o ZOOM devise: The device is working with its own bleaching kit only.
o Laser bleaching:
 Indication: When immediate results needed.
 Disadvantages:
▪ Increased sensitivity.
▪ Less lasting results compared with home bleaching.
 First visit (bleaching preparation):
▪ A diagnosis must confirm that the discolorations can be resolved by external bleaching. The patient
must be informed about the history, the procedures involved in the treatment, the expected
outcome of the procedure, and the potential for rediscoloration.
▪ Scaling and polishing should be done in visit prior to bleaching not in the same visit: as scaling causes
bleeding which hinders effect of the liquidam to do proper isolation of gum. Causing leakage of
bleaching gel which leads to chemical burn.
▪ Tray impression:
o Take impression for tray fabrication to be as carrier for desensitizing agent.
o Also, may be used for additional home bleaching to minimize any rebound, future maintenance
or in cases of stubborn stains.
 Bleaching visit:
▪ Initial shade:
o Take pictures in the beginning of the treatment with the tooth next to a shade guide to act as a
reference for the practitioner and the patient.
▪ Sunglasses: The patient and dental professionals should wear proper protective eyewear in cases of
light bleaching.
▪ The teeth should be cleaned again with rubber cups and pumice.
▪ Lip protection and cheek retraction:
o Sunblock cream may be applied to lip if it is exposed to potential ultraviolet emission.
o Place the lip and check retractor.
o Place cotton rolls in the vestibule.
▪ Gingival isolation:
o Apply liquidam to the gingival margin, to prevent leakage of bleaching material that causes
chemical burn to gingival tissue.
• Starting at one end of the arch, apply the liquid dam to the gingiva to build a strip about 3
mm wide by 1-1.5 mm thick.
• At embrasures, express the liquid dam through the opening, filling the space completely.
• Protect one extra tooth at each end of the arch beyond those that will be whitened.
• Be sure to extend the material at least half a millimeter onto the enamel and cover any
exposed root surfaces.

• Cure the liquid dam in sections (Initial curing for each tooth for 2 sec then move the light cure tip
forward and backward for 1-2 mins for complete curing to all teeth).
• If the liquid dam runs, cure after every two to three teeth.
o If a sheet rubber dam is used, the inversion of the rubber dam in the sulcus with an air syringe
followed by dental floss ligature is recommended.
▪ Application of bleaching gel:

o If the bleaching gel has been refrigerated, should be brought to room temperature.
o Mix whitening gel:
• Remove caps from both the
activator and base gel syringes.
Connect the two syringes
together by twisting one onto the
other until fully tightened.
• Tightly grasp the plungers of both
syringes. Mix whitening gel by
pressing the contents of the
lavender syringe into the clear
syringe. Reverse and repeat 25
times.
• Make sure gel is consistent throughout the syringe and continue mixing if necessary.
• Push the mixed gel into the gel base barrel, then unscrew the syringes from each other.
• Screw on a brush applicator tip.
o If powder & liquid:

• Add the liquid to powder in powder pot and immediately mix
using a brush applicator until gel is homogeneous.
• One pot should only be used for 2 applications or within 20
minutes of mixing.
o Apply gel:
• Divide the upper and lower arches into four treatment sites.
• Dry the teeth by wiping them with gauze or a cotton roll.
• Evenly apply a uniform thin layer (1mm) of the mixed gel over
labial surface of all four quadrants.
• Use only half of the gel in this application, saving the remaining
gel for the second application.
• Using a small paintbrush for application is easier.
• Make sure that the gel does not contact the patient’s gingiva, tongue, or lips.
• Check patient for sensitivity or discomfort. If sensitivity continues, use the desensitizer included in
the kit.
• Do not proceed if sensitivity continues.

▪ Activation of gel (according to manufactures):
o LED activation: 20 min per application.
o Zoom activation: 15 min per application.
o Laser activation:
• Biolase (diode laser with quadrant handpiece) 1min for each quadrant.
• Diode laser with single handpiece device tooth taking 30 sec.
• Place the whitening handpiece, with disposable clear cap attached, about 1mm from teeth without
contacting the gel.
• Repeat for all quadrants one more time (each quadrant will receive two doses).
o Allow gel to remain on teeth for a minimum of five minutes after last activation cycle.
▪ Second application.
o Follow manufacture instruction for each kit.
o Some kits may be applied for 3-4 application per session.
▪ Removal of gel and barrier:

o The gel should be removed with high suction 1st without water (To avoid gel splatter) then with a wet
gauze and copious amounts of water, then cleaned with pumice for a second time, and rinsed again to
ensure all remnants of the bleaching gel were removed.
▪ Post-bleaching shade and picture.
▪ Application of desensitizing agent and vit E if needed:
o The teeth should be polished, and a neutral pH sodium fluoride gel applied.
o The patient should be prepared to signal if a tingling sensation to the gingiva, mucosa, lips, or teeth is felt
or the temperature is perceived as too hot. As a precaution, vitamin E capsules, a powerful antioxidant,
should be ready at hand. In case of an emergency, these can be cut open and the oil inside the capsules
applied to the injured tissues with a cotton pellet.
 Post-bleaching instructions:
▪ Depending on the individual situation, results may vary.
▪ Frequent application is 2-3 times per year.
▪ Increased sensitivity of the teeth may be present for 2 to 3 days, so apply desensitizing agent.
▪ Avoid:
o Colored food for 48h up to 2 weeks.
o Avoid soda even if it is colorless.
o Colorless toothpaste.
o lipstick.
 Complications
▪ Sensitivity (use de-sensitization e.g after whitening mousse).
▪ Chemical burn (use vitamin E capsule immediately).
▪ Marginal leakage of old composite filling so replacement is necessary.

Home Bleaching:
 Indication:
▪ It is the most cost-effective method to bleach your teeth.
▪ We should use the at home approach as a first option (Only in some specific situations we
propose to bleach in office, for example before a wedding when the patient want immediate results).
▪ If patients do not want to undergo an in-office procedure.
▪ For maintenance after office bleaching.
 Materials:
▪ Custom-made bleaching trays.
o Fabricated in a dental laboratory.
o Available from a pharmacy, requiring only crude adaptation after softening in hot water.
▪ Bleaching gel or paste.
o Opalescence Go, Zoom from Philips or White Dental Beauty.
 Steps:
▪ Record the shade of teeth in the beginning of appointment & take a picture.
▪ Take alginate impression for tray fabrication.
o Pouring the impression for making casts or models.
o The buccal surface of model teeth can be blocked out to create a reservoir for the bleaching gel
(there are no differences in the rate of bleaching with or without reservoirs).
o 1 mm soft thermo-forming sheets are used to fabricate the tray.
• It’s very comfortable for the patient.
• There is no need to scallop the tray on each tooth. Only One or Two millimeter above the
cervical area of each tooth.
• Custom trays are checked for accuracy of fit, tissue adaptation, retention and occlusion and
the patient is shown how to insert the custom trays and to apply gel.
▪ The patient should place several drops of bleaching gel into the tray before every application.
▪ The most common bleaching agent for at-home bleaching is 10% to 22% carbamide
peroxide with an effective yield of 4% to 7.5% hydrogen peroxide.
o The 6% hydrogen peroxide for 30-60 min a day for 1-2 weeks.
o The 16% carbamide peroxide for 2-4 hours a day for 1-2 weeks.
o The 10% Carbamide peroxide for 8 hours a day, usually used during the night for 1-2 weeks.
o Carbamide peroxide 5% overnight for 4-8 weeks used with sensitive teeth.
▪ According to patient lifestyle we can choose the concentration that controls the
application time:
o For patients who don’t like sleeping with the tray and don’t have a lot of free time during the
day, use 6% hydrogen peroxide because it is the faster one.
o For patients working at home, hence having time to use the tray during the day, we suggest the
16% carbamide peroxide.

o For patients who have no problem using a soft thin tray during the night, we suggest the
carbamide peroxide 10% during all night.
o Carbamide peroxide 5% is the perfect option to use during the night for a prolonged period, up to
1 month and more, for patients who usually cannot use bleaching products because of sensitive
teeth.
▪ If any disturbance (e.g., thermal sensitivity, abnormal taste, or tissue irritation) occurs, the
patient should stop the procedure and seek advice from the dentist.
▪ Some dentists prefer nighttime bleaching regimes for their patients because they offer maximum
results with less bleaching material use, due to decreased salivary flow during sleep.
▪ The success of at-home bleaching mostly depends on the patient’s cooperation.
▪ Risks include the possibility of overuse of the bleaching agent.
▪ Results with at-home bleaching techniques tend to remain stable for 1 to 10 years.
After 1 week of bleaching at

home with 16% carbamide
peroxide, White Dental
Beauty per 2-4 hours a day.
 Notes:
▪ Demonstrate how to load the tray by expressing one continuous bead of gel approximately halfway
up (or slightly lower) from the incisal edge on the facial side of the tray from molar to molar. This
should use 1/3 to 1/2 of a syringe.
▪ Instruct patient to clean tray with a soft toothbrush and water after each use.
▪ For patients with known tooth sensitivity, pre-op and post-op treatment with UltraEZ desensitizing
gel, Opalescence sensitivity relief toothpaste, and/or Enamelast® fluoride varnish is recommended.
Depending on the severity of sensitivity, other treatment options are available.
▪ Follow up with patient treatment. The number of days required for complete treatment depends on
the type and severity of tooth stains. For example, tetracycline stains require more treatment time
than other types of stains.
▪ Because restorative materials will not whiten, we recommend whitening dark teeth before
restorative placement.
▪ Wait 7-10 days following bleaching procedures before placing restorations.
▪ Restorations should be adequately sealed, and all exposed sensitive dentin should be covered. If a
history of sensitivity exists, treat with appropriate restoration, dentin bonding agent, or temporarily
with dentin sealant.
▪ Hypocalcified areas (white spot lesions), which may not be visible to the naked eye, will whiten faster,
thereby becoming more obvious during bleaching. Continue bleaching treatment until the
unaffected tooth surface blends. Re-evaluate two weeks after bleaching treatment when tooth color
has stabilized.

Bleaching material in market:
 Internal bleaching material:
▪ Opalescence endo syringe (ultra-dent) = 450 LE.
o 35% hydrogen peroxide.
o Easy to place inside chamber.
o 3-5 days treatment
▪ ENA INTERNAL BLEACH = 400 LE.
o 12% HYDROGWN PEROXIDE.
o 2 ml syringe is enough for about 5 times.
 In-office bleaching material:

▪ Pola office plus (gel - 1 patient kit = 600 LE) / Pola office (powder & liquid - 1 patient kit = 600 LE)
o No bleaching light required: can be used with or without a bleaching light, or a standard heat emitting
curing light.
o Built-in desensitizer: No separate desensitizer is required. Pola Office+ has unique built-in desensitizing
properties that inhibit post-operative sensitivity.
o Pola office plus ch.ch by Simple delivery: No mixing is required. The dual barrel syringe system mixes as
you apply the gel directly to the tooth.
▪ Opalescence™ Boost™ (525 LE):

o Chemically activated, so no light is needed.
o Powerful 40% hydrogen peroxide gel.
o Contains PF (potassium nitrate and fluoride).
o Fresh chemical for each application.
o Precise delivery.
o Distinct Red Color: easy to see for complete removal.
o Two to three 20-minute applications.
o Thicker formula prevents the gel from running.
o No refrigeration required prior to mixing.
o formulated with a high-water content to keep the teeth hydrated during the whitening process.
▪ ENA white power refill (750 LE)

o 35% Hydrogen peroxide.
o Bicomponent syringe to activate only the necessary quantity for
the application.
o Ph neutral 7.3, less damages for enamel.
▪ WHITE SMILE POWER WHITENING YF (695 LE)

o POWER WHITENING YF with 40 % hydrogen peroxide (mixed 32 %) is suitable for medical
whitening of strongly discolored teeth.
o Application 3 x 15-20 minutes in one session.

o System:
• POWER WHITENING YF Gel in 2,5 ml-dual-chamber syringes
• GINGIVA PROTECTOR, light-curing, in 3 g syringes
• AFTER WHITENING MOUSSE for desensitizing and
remineralization with a fruity taste in 3 ml syringes
▪ WHITE SMILE light WHITENING YF (675 LE):
o Application time per session.
• 3 x 15 min (max. 3 x 20 min),
• NEU: Whitening Lamp XG: 3 x 10 Min (max. 3 x 15 Min)
 Home bleaching material:
▪ Opalescence™ PF (ultra-dent): (1.2 ml regular syringe = 125LE)
o Opalescence tooth whitening gel contains PF (potassium nitrate and fluoride).
o Formulated to prevent dehydration and shade relapse.
o Five concentrations for treatment flexibility (10%, 15%, 20%, 35%, and 45%.
o Three flavors: Mint, Melon, and Regular.
o Day or night wear.
o Sticky, viscous gel won’t migrate to soft tissues and ensures tray stays securely in place.
 Opalescence 10% gel 8-10 hours or overnight.

 Opalescence 15% gel 4-6 hours.
 Opalescence 20% gel 2-4 hours.
 Opalescence 35% gel for 30-60 minutes.
 Opalescence Quick 45% gel for 15-30 minutes.
▪ WHITESMILE HOME WHITEINING: (syringe = 245 LE)

o System
• HOME WHITENING Gel in 1,2 ml- or 3 ml-
syringes.
• AFTER WHITENING MOUSSE for
desensitizing and remineralization with a
fruity taste in 1,2 ml- or 3 ml-syringes.
• Tray sheets for production of customized
whitening trays.
• Light curing Blocker as spacer for laboratory
models.
o Available concentrations:
• 10 % CP (~ 3,5 % HP) for overnight application.
• 16 % CP (~ 5,6 % HP) for overnight or daytime application.
▪ ENA white light:

o 6% Hydrogen peroxide for home bleaching.
o Fluoride to protect the enamel.
o Package with personalized label.
o Pleasant freshness: mint flavor.

Bleaching accelerators in market:
 Zoom system:
▪ Advantages over than laser devise:
o Zoom reaches all teeth at the same time:
• This helps to ensure the most even reaction rate and better consistency of results.
Meanwhile, laser teeth whitening targets one tooth at a time.
o Zoom filters out infrared energy:
• The teeth aren’t exposed to as much heat as they are during laser whitening treatments.
Meanwhile, laser whitening does cause extended exposure to infrared emissions.
o Zoom whitens teeth faster:
• Zoom whitening actually produces results more quickly than laser teeth whitening.
▪ Drawbacks of zoom system:
o Sensitivity especially from yellow light zoom device. (now there are new generations with white
light = less sensitivity).
o Expensive.
o Works only with its zoom kit. (it can be uncoded to work with other system)
▪ Devises available in KANDIL company:
o Philips zoom advanced power:
o Philips zoom white speed led:
 Laser devise:
▪ Advantages over than zoom devise:
o Laser whitening can be easier to tolerate.
• Some patients find it difficult to tolerate three back-to-back sessions of Zoom whitening,
particularly if they have fairly sensitive teeth.
o Laser whitening can be more effectively used to target specific teeth.
• Laser whitening is applied to each individual tooth, making it valuable for patients who only
need to have one or two particularly stained teeth lightened.
▪ Biolase laser:
o Faster: more than twice as fast as other in-office systems. (less chair time)
o Brighter: more efficient and long-lasting results.
o Gentle: less comfort to patient and less sensitivity.
o Note: Dark laser bleaching gel preferable (diode laser is better absorbed in
darker gel).
▪ Woodpecker LX16 Plus Dental Laser Machine (125000 LE)
o Come with it bleaching contra.

 LED accelerators:
▪ White smile flash whitening lamp (40500 LE).
▪ CRYSTAL TEETH / BLEACHING DEVICE (25000).
▪ COXO C-BRIGHT Teeth whitening accelerators (7000 LE).
 Light curing unit with bleaching tip:

▪ Woodpecker led F with bleaching tip.
Bleaching tips:
▪ In cases of old restorations:
o If it is good restoration (optimum seal) with darker shade, you can replace it after bleaching with
lighter shade.
o Wait 7-10 days following bleaching procedures before placing restorations.
o Defected restoration: remove it and place temporary restoration, then replace it after bleaching.
▪ Cracked tooth:
o The crack must be blocked before bleaching to avoid sensitivity.
o We can block it by:
• Application of universal bond.
• Or widening by bur then restoration with flowable composite.
▪ Darker shades:
o The bleaching result of darker teeth is more obvious than the bleaching of lighter teeth.
▪ D shade has the worst bleaching result compared with other shades.
▪ In patient with sensitive teeth:
o Give him analgesics (brufen tab) before the visit to avoid pain.
o Desensitizing agent to be applied before and after treatment.

Notes
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Anterior composite matricing
Anterior composite
mastering

Anterior composite mastering
INTRODUCTION:
There are three basic requirements in restoring anterior teeth (function, shade and shape).
Function:
 Phonetics:
▪ Whistling as in cases of class III & class VI (air will pass between two teeth during speech
causes whistling).
 Occlusion:
▪ Broad incisal edge cannot incise food properly.
 Contact:
▪ has effect on embrasure size, phonetics and aesthetic.
 Para functional habit:
▪ change your treatment plan from composite to crown.
Shade:
A. Shade analysis: (light – material)
Light.
 Diffuse reflection:
1- diffuse reflection 2- smooth reflection
▪ Occurs due to presence of depression like that in
natural tooth, so your anatomy must stimulate
that of tooth to give similar reflection.
 Refracted light:
▪ The difference between the speed of light in a
vacuum and the speed of light in a medium is
called the index of refraction.
o Nature enamel: 1.62.
o Composite: variable.
o ENA HRI: 1.62
 Index of reflection: if not similar in composite and tooth,
line of demarcation will appear.
▪ ENA HRI composite has the similar index of enamel, so can be
used in the same thickness of enamel with invisible margin.
▪ However, if you haven't Ena composite:
o Make long bevel to avoid line of demarcation.
o Utilizing layering technique & reduced thickness of
enamel to control enamel value.

 Opacity & translucency:
▪ Opacity: it is the quality of a material that does not allow light to
pass through it.
▪ Transparency: It is the property of transmitting light without
appreciable scattering so that bodies lying beyond are seen clearly.
▪ Translucency: refers to a state of something that is not completely
clear or transparent but clear enough to allow light to pass through.
o Dentin is more opaque and has more chroma than enamel.
o Dentino-enamel junction: In histological cuts, it looks extremely
translucent, with very opaque dentin underneath and more
translucent enamel above.
 Fluorescence:
▪ Dentin is visibly more fluorescent than enamel due to its
higher organic composition.
o Note the dentin-enamel junction zone which looks even
more fluorescent than the circumpolar dentin. These
effects need to be considered when layering.
Material:
 Know your material more: Shade selection depends on the material you use, as there is no
standardization between manufactures regarding nomenclature, shading, or degree of
translucency/opacity.
Traditional composite:
 Composite has shades A, B, C, D they differ in value and each shade differs in Chroma as A1,
A2, A3…etc.
• A: reddish orange. (the most common)
• B: yellowish orange.
• C: brownish grey
• D: brown (note: in patients with D shade, bleaching has no benefit)
1- Hue: The degree of mixture of the three primary colors; in simple language, the name of the color, for example,
red, yellow, or blue. (dentin)
2- Chroma: The degree of color saturation; pure colors have a high chromaticity and weak colors have a low
chromaticity. (dentin)
3- Value: The degree of color brightness; the whiter the color is, the more Value it has, and the darker the color is,
the less Value it has (enamel)
 Note:
▪ Working with an A shade, the user can achieve some final color changes with stratification tricks:
o Mixing composites with light-cured stains.
o placing a middle layer that will act as a screen.
o Playing with the enamel thickness to increase or decrease the Value, and in this way being able
to achieve any color.
• Shade C is easily obtained by increasing the enamel thickness to lower the Value.
▪ May use A1(for enamel) & A2 – A3 -A4 (for dentin)

It is difficult to appreciate color differences in the The four VITA shades clearly evidence differences in
four VITA shades, A, B, C, and D, when tabs of hue when tabs of maximal chromatic expression are
minimal chromatic expression are compared. compared.
 The Five Basic Colors of Teeth:

▪ There are five color shades that form a natural tooth; the combination of these colors enables
production of an incredibly extensive chromatic range.
1. Yellow /Orange: Dentin (Cervical and middle thirds).
2. white: Enamel and internal enamel characteristics (Mamelons, incisal halo, occlusal and facial
surfaces).
3. Blue / gray: Free enamel opalescence that is found in incisal edge and interproximal enamel
(dentin free area).
4. Amber: Opalescence, counter opalescence, and various enamel and dentin characteristics
(incisal halo, incisal edge, and facial surfaces (characteristics).

Universal composite:
1- Transparent shade (glaze composite):
▪ It is very transparent (like water).
▪ Used after polishing to make composite shining as glaze layer on crown.
2- Opalescence:
▪ The material appears yellowish-red under transmitted light
conditions and blue under incident or scattered light
perpendicular to the transmitted light.
▪ Used as a line between two enamel layers in incisal edge of young teeth.
o Ex: OBN – trans opal (IPS impress direct (flowable – sculptable))
3- Translucent shade:
▪ Somewhat opaque (like water tinted by drop of milk).
▪ Used in between mamelons, or as a middle layer between two enamel layers in incisal edge to
avoid thickness of enamel (gray appearance).
o Palatal enamel layer 0.5 mm then translucent layer 0.5 mm then labial layer 1mm.
o Ex: amelogen plus – trans 30 (IPS impress direct)
4- Enamel shade:
▪ More opaque than translucent (like water tinted by 2 drops of milk).
▪ Used to replace enamel.
5- Dentin shade:
▪ More & more opaque (like half water + half milk)
▪ It is the bulk of restoration that dominates the chromatic nature of teeth.
6- Opaque shade (bleaching composite):
▪ The most opaque (like milk)
▪ Used to mask any discoloration. (it is flowable, just cover stain)
▪ May used in make incisal hallowing, demineralization effect (Or use white stain).
o Ex: ultra-blend.
7- Characterization tints:
▪ Kit of different colors from Ivoclar or Bisco used to mimic natural shape.
8- Body shade = universal shade (3M espe):
▪ Used in the area that you can't decide it is enamel or dentin (as in middle third).
▪ More translucent than dentin & less translucent than enamel.
▪ May used as monochromatic approach.
9- Mimicking effect = intermediate opacity:
▪ To mimic dentin or enamel shade (in-between) so it is useful in cases of composite veneering as it
covers dentin shade and somewhat similar to enamel.
o Tetric N ceram Flow.
o Brilliant ever glow coltene.

Shadeless composite:
 OMNICHROMA composite (from Tokuyama company):
▪ Gives a single shade of composite that’s clinically proven to match the color of any tooth from A1
to D4 in just one application.
A3 A3.5 A4 B1 B2 B3 B4 C1 C2 C3 C4 D2 A2 A1
D3 D4
▪ Features and benefits:

o No need to shade match ever again, just one syringe saves the time and cost of +20 shade
matches!
o High compressive and flexural strength
o High polishability and luster
o Low polymerization shrinkage
o Wear- and acid-resistant
o OMNICHROMA BLOCKER masks stains and the oral cavity in large Class III and IV preparations.
▪ Evaluators’ Comments:
o “The transition from opaque-white to tooth shade blending after curing is amazing.”
o “Creamy consistency, stacks well and handles beautifully.”
o “Easy to pack. Did not stick to instruments or pull away from the tooth during placement.”
o “90% of the time, a perfect shade. Other times, the value was neutral or slightly translucent.”
o “This concept could be a real game changer for everyday dental restorations.”
o “Not well suited for extreme white (bleach) shades.”
o “Somewhat opaque after curing, and it needs to be more radiopaque.”
o It matches the neighboring tooth structure not the neighboring tooth, So in cases of build up
tooth (massive loss of tooth structure) less matching.

Recommendation for anterior composite
ENA HRI (MICERIUM):
 ENA HRI nano-hybrid composite produces incredibly natural looking composite restorations.
Only ENA HRi matches a natural tooth's optical properties to produce invisible restorations
with invisible margins (the same refractive index of enamel 1.62).
 HRI enamel - Just like human enamel:
▪ A thicker HRi enamel increases the opalescent effect
o Just like human enamel, thicker layers of HRi increase in opalescence. This allows you to restore
missing enamel by simply replacing it with an equal amount of HRi - with no visible margins, no
need for significant bevels, and no graying effect.
 HRi dentin - Just like human dentin:

▪ HRi has a fluorescent dentin.
o HRi dentin shades are highly fluorescent and designed to work with HRi enamel shades for
desired results. One or two dentin shades are all that is needed to get the desire results. In
nature, the dentin mass transmits its hue and chroma through an enamel mass, which
completely surrounds the underlying dentin. This is exactly how a tooth is restored with HRi.
 HRi - ENAMEL ONLY Technique:

▪ Restored with only 1 HRi enamel shade:
o HRi Enamel is ideal as for all restorations that require replacement of only the enamel layer of
the patient's tooth structure.
o The HRi enamel system uses a simplified value-based shading system that mimics natural
enamel, which is achromatic (has no hue/colour) and varies only in value.
 HRi - BASIC Technique:
▪ Restored with only 1 HRi enamel & 1 HRi dentin shade:
o Because of HRi's unique optical properties, by using only one to two dentin shades and one
enamel shade, you can achieve highly esthetic results in anterior and posterior restorations.
 HRi kit:
▪ Three universal enamel: only 3 enamel shades, and these are related to the patient's age group.
o Universal E1 (low value =dark, old age).
Enamel shade 5 gm = 650 LE
o Universal E2 (medium value, middle age) Dentin shade 2.5 gm = 350 LE.
o Universal E3 (high value, for younger patients or bleaching Composite opalescent = 700 LE
shades) Composite stain 2 gm = 475 LE
▪ Nine universal dentin: Ena flow 1 gm = 125 LE
o Universal D0 / D0.5 / D1 (bleaching shades)
o UD2 / UD3 / UD3.5 / UD4 / UD5 / UD6.
▪ Three intensive enamel: White (IW), White Spot (IWS), Milky (IM)
▪ Opalescence: OBN (opal-enamel Blue Natural) – OA (opalescent enamel Amber)

Estelite Sigma Quick (tokuyma):
 ESTELITE® SIGMA QUICK utilizes Tokuyama's patented innovative initiator system "Radical
Amplified Photopolymerization Technology" (RAP), to offer reduced curing time and
excellent stability to ambient light while maintaining the superior esthetic and physical
properties of Estelite Sigma.
▪ Quick curing time 10 sec with a halogen light (≥400mW/cm2)
▪ Extended working time - 90 sec. under ambient light.
 One of the best composites.
▪ Outstanding polishability & High gloss retention over time.
▪ High wear resistance. Syringe 3.8 gm = 820 LE
▪ Wide shade matching range (chameleon effect).
▪ The composite blends exceptionally well with the surrounding tooth structure.
▪ Available in 20 shades: A1, A2, A3, A3.5, A4, A5, B1, B2, B3, B4, C1, C2, C3, OA1, OA2, OA3, OPA2
(opalescent), BW (bleach white), WE (white enamel), and CE (clear enamel).
GC essential universal:
 GC essential kit:
▪ Three dentin shades: Light dentin (LD) - Medium dentin (MD) - Dark dentin (DD)
▪ Two enamel shades: Light enamel (LE) - Dark enamel (DE).
▪ Universal (U): for small & posterior restorations.
▪ Masking liner (ML): with an injectable viscosity to block discolorations in deep cavities.
▪ Opalescence modifier (OM) – Brown modifier (BM) – red brown modifier (RBM).
 Easy in layering and shade selection.
 Duo-layering concept (combination of one dentin and one enamel):
▪ In anterior:
Junior / bleach shade. Adult
LD + LE MD + DE
Young senior
MD + LE DD + DE
▪ In posterior:
o Posterior duo: DD + LE. (but in deep cavity, (MD) + (DD) to avoid excessive chroma or translucency
o Posterior mono: U (universal shade)
 Biomimetic approach: (the seven shades of Essentia are based on different formulations)
▪ Dentins & Universal: are based on a micro-hybrid composition. They display an optimal light
scattering effect and offer a soft handling.
▪ Enamels: an innovative composition with a mix of ultra-fine glass fillers and high performance
prepolymerised fillers. They display an excellent polishability and gloss retention, as well as perfect
translucency and a small amount of opalescence.
o Traditional composite where enamel and dentin have the same structure, it is recommended to create
an intermediate layer to reproduce the specific change in light direction which is observed at the dentin/
enamel interface of natural teeth.
o With Essentia, this is no longer necessary as dentins and enamels are based on different
formulations and already emulate the light behavior observed in a natural tooth.

IPS direct composite (Ivoclar Vivadent):
▪ Sculptable consistency available in 1 x 3-g syringe.
o Dentin: A (1-2-3-3.5-4-IVA5-IVA6) / B (1-2) / C (3) / D (2) / Bleach L Dentin / Bleach XL Dentin.
o Enamel: A (1-2-3-3.5-4) / B (1-2-3-4) / C (1-2-3) / D (2-3) / Bleach L Enamel | Bleach XL Enamel.
o Translucent: Trans 20 | Trans 30 | Trans Opal.
▪ Flowable consistency available in 1 x 1.8-g syringe (including 5 tips):
o Effect: Trans 30 | Trans Opal | Bleach XL.
o Opaque.
▪ IPS Empress Direct Color available in 1 x 1-g syringe (including 5 tips):
o white | honey | blue | violet | ochre | brown | grey.
Covering opacity Light refection
Z350 XT (3M):
▪ Body: A (1-2-3-3.5-4-6) / B (1-2-3-5) / C (1-2-3) / D (2-3) / WB / XWB.
▪ Dentin: A (1-2-3-4) / B (3) / C (4) / WD.
▪ Enamel: A (1-2-3) / B (1-2) / D (2) / WE / XWE.
▪ Translucent: clear – blue – gray – amber.
▪ For bleached teeth:
• White Dentin, Body and Enamel (WD, WB, WE),
• Extra White Body and Enamel (XWB and XWE)
▪ For cervical restorations: A6 body and B5 body
Kerr harmonize:
▪ Enamel shades: A (1-2-3-3.5-4)E / B (1-2-3-4)E / C (1-2-3-4)E / D(2-3-4)E / XL.
▪ Dentine shades: A (1-2-3-3.5-4)D / B (3)D / C (4)D / XL2.
▪ Translucent shades: TA (amber) – TB (blue) - TC (Clear) – TSC (super-clear) - TG (gray).
Charisma diamond:
▪ Universal shades: A (1-2-3-3.5-4) / B (1-2-3) / C (2-3) / D (3).
▪ Opaque dentine shades: OL (Opaque Light) - OM (Opaque Medium) - OD (Opaque Dark).
▪ Incisal shades: CL (Clear Light) - AM (Amber) - CO (Clear Opal) - YO (Yellow Opal).
▪ Bleach shades: BL (Bleach Light) - BXL (Bleach Light Extra) - OB (Opaque Bleach).
Composite based on value: easy in cases of shade selection.

▪ Ena Hri (only three enamel shades).
▪ GC (two enamel shades).
▪ VOCO Amaris.
Composite based on chroma: enamel has different coolers, so it is somewhat difficult in shade selection.
▪ 3M.
▪ KERR.
▪ IVOCLAR VIVADENT.

Hints:
▪ The 1st step to success in mastering anterior composite is to restrict yourself to one system, so
you can understand it and its shade.
▪ You can make your system by mixing other system together (GC enamel + ENA dentin …etc.)
▪ Ena Hri & GC (somewhat expensive) are highly recommended.
▪ 3M composite shade is slightly opaquer than other systems.
Monoshade
▪ Used in cases of Class III and class V & posterior. (safe time)
▪ Composite used:
o GC universal. (expensive)
o Charisma diamond A2.
o 3M Z350XT body shade A2. (the cheapest)
Enamel (OUT composite)

 Enamel composite properties:
▪ High opalescence.
▪ Refractive index equal to that of natural enamel.
▪ High translucency.
 Maximum thickness of enamel composite is 1mm:
▪ Enamel composite should be only half or less than half of the natural enamel thickness, in most
situations.
▪ If more than 1mm = gray appearance (lower the value) and decrease opalescence.
o Glass effect (lose brightness as they increase in thickness)
The thick enamel composite lowers the Value of the restoration

and makes the margin visible. It also produces a gray and
unnatural appearance.
▪ Ideal thickness is 0.8 mm, so make it 1mm or less as enamel layer reduced during finishing.
▪ Increase dentin in expense of enamel.
▪ ENA Hri is the only composite that can be used in thickness like that of natural enamel without
the need for long bevel due to its refractive index is like that of enamel.
An anterior restoration has been fabricated from

a 0.8-mm layer of an enamel composite with a
high refractive index 1.62 (Enamel Plus Hri, UE1,
Micerium). No bevels were prepared.
Different thicknesses of Enamel plus HRi change

in shade in the same manner as Natural Enamel
would in the same thickness

▪ Enamel thickness decreased with age and so value.
o Young: increase in enamel thickness (high value)
o Old: decrease in enamel thickness due to enamel wear so mostly dentin (low value, high
chromatic)
High value Medium value Low value
Aging
 Halo effect:
▪ In natural teeth, the halo effect is caused by the reflection of red-yellow wavelengths of the
internal lingual-incisal surface of enamel.
▪ The red-yellow light hits the surface at a low incidence angle and therefore does not
transilluminate. Instead, it reflects or scatters off the buccal–lingual–incisal surface.
▪ The scattering halo effect will occur in natural teeth when there is a buccal-facing lingual–incisal
surface of enamel at a right angle.
▪ How to create it in composite:
o Traditionally, by placing a more opaque or “milk like” composite shade at the incisal border
(dentin roll). But, through wear or occlusal adjustment this artificial halo disappears.
o Ideally this effect should be created by the proper angulation of the incisal border of the
restoration, which should be close to 40 degrees.

Dentin (IN layer composite)
 Maximum thickness of dentin is 3mm:
▪ If more =dull appearance. (change from translucent to opaque).
▪ In cases of increase depth of cavity more than 3mm (as in cervical area):
o Use darker shade of dentin (1mm D4 then 3mm D3) or may use A3.5 below dentin. This makes
dentin in cervical darker than middle.
o The larger / more cervical is the cavity the more dentin thickness, the more dentin shades:
• Incisal (small cavity) = one dentin shade.
• Middle (medium cavity) = two.
• Cervical (large) = three (dentin A3 +dentin A2 +dentin A1 =A1 tooth)
 Dentin closer to the pulp is more chromatic than the surface dentin ex:
▪ In an A2 tooth, the dentin near the pulp would likely be shade A3.
 Stratification allows us to generate natural colors and shades that are not commercially
available.
▪ If we stratify a tooth with an A4 dentin as the deep layer, A3 dentin as the middle layer, and A1 as
the superficial dentin, we will obtain A1.5 base Chroma.
Using the overlapping dentin technique, we can create 12 different colors

from the A spectrum, without the need for complex composite systems and
with fewer syringes. With these 12 colors is possible to match 95% of the
teeth we would potentially need to restore.
A (X) = A (X) + A (X+1) + A (X+2)

A (X.5) = A (X) + A (X+2) + A (X+3)
 There are significant differences in the opacity of the dentin composites available from
various composite manufacturers.
Different brands of composite

resin, shown in the same
thickness of A3 dentin, under
direct light. The differences in
Chroma and Hue are obvious.

B. Shade selection:
 Digital shade selection: vita easy shade.
35,000LE from
GET shop.
Shade guide:
 Kit shade guide (guide that come with composite kit – plastic) or vita classic shade guide
(porcelain): formed from different material so different refractive index (inaccurate shade
selection).
1500 LE
 Customized shade guide:

▪ It is made from the same composite system you use (restrict yourself to one system, so you can
understand it and its shade).
o It costs, time consuming and limit your choice to specific type of composite.
▪ Steps:
▪ Make impression to readymade shade guide (vita classic).
▪ Then place composite in this impression by layering. (the ideal thickness is 2.5 mm in cervical and 1
mm in incisal).
▪ Adhere to it any hand by flowable composite.
▪ Cure it and then finish &polish your shade.
▪ Example: customized essential shade guide (layered DD/LE U LD/LE MD/LE MD/DE DD/DE
tabs).
 Composite button technique.

▪ If you use different systems of composite, it will be benefit from economic view to use composite
buttons rather than customized shade.
▪ Button thickness 1mm X 1mm.
▪ Complete curing 30 sec (as composite color is slightly darker after curing).
o Dentin shade is selected from the cervical third.
o Body shade from center / body of tooth.
o Enamel shade from incisal third.

Shade selection:
Chroma (Dentin).
value (Enamel).
Incisal edge opalescence.
Intensive and characterization.
Chroma:
 1st determine dentin shade (Chroma):
▪ Place two composite buttons from different chroma in-between middle & cervical 1/3, then full
cure it (30 sec). or use customized shade guide
▪ Ask your assistant as another opinion.
▪ For more accurate selection take a photo:
o Take a photo under cold light flash (mobile flash is warm light give somewhat red photo).
o Edit it in PowerPoint program or light photo app (mobile), editin may be by:
• Decreasing brightness & increasing contrast.
• Increase saturation.
Saturation
Customized shade guide
Value:
 2nd determine enamel shade (value):
▪ Place composite button on incisal edge (not more than 1mm).
▪ Then take a photo (ISO 100) and edit it (white & black) or decrease contrast to zero.
▪ If you are not sure, make composite patch instead of button (appear blending)

Polar eye:
 Using a cross polarizing device (filter for flash & filter for lens):
▪ The result is a photo that has absolutely no glare or reflection … a photo that allows for much
more objective assessment of shade and translucency.
Cross polarization: is a two-step filtering process using two linear polarizer filters—one
on the flash oriented either horizontally or vertically, and one on the lens oriented 90
degrees off the axis of the flash filter. This causes the light illuminating the teeth to be
filtered for one direction of light wave; then the reflected light is organized in the
contrasting direction as it passes through the filter/lens combo and is recorded by the
DSLR sensor.
Important notes in shade selection:

 Position of shade tab: The area of tab to be compared with natural
tooth is middle / body area.
 The best position is to be placed beneath the tooth in
horizontal position.
 If placed in reversed vertical position: you make the

area to be compared is the most translucent area (incisal
edge).
 If placed in vertical position: you make the area to be

compared is the opaquest area (cervical third).
 If placed adjacent to the tooth, it will make shadow on

it so appear darker.

 Teeth should be clean. If not, do prophylaxis.
 Teeth and shade guide should be wet to simulate the oral environment as dehydration will
cause the shade to be too whitish.
 Shade matching should be carried in natural daylight especially afternoon so switch off the
light of the dental unit.
 Imply the 5-second rule. .
 No lipstick or bright-colored clothes.
 Use a neutral patient towel (blue or grey, never yellow nor pink).
 Patient’s back reclined 45º.
 Observe the shade at an arm-length distance.
 Patient’s corner of the mouth at the level of dentist’s eye.
Shade map:
 you should draw your tooth and add what you will do in it (shade of each part & stain) OR
write on the photo.
 This help you during the procedure as the tooth dehydrated and you will be confused each
shade to be used during the procedure.
▪ Immediately after a tooth is isolated from moisture, tooth begin to dehydrate, and
effects are visible after only 3 minutes. This decreases its refractive index and blocks
the passage of light (enamel and dentin obtain an opaque white color)
▪ Maximum tooth dehydration is appreciated after 30 to 45 minutes, and complete
rehydration of the tissues can take between 24 and 48 hours.
▪ Wait from 48 hours to 7 days for complete rehydration then decide if you used the
correct shade or not.

Shape and texture detection:
 The shade is affected by depression and elevation.
 The most important requirement from patient view is tooth shape.
%8
%8
%9
54%shape
21%shade
shape shade bevel build up finishing and polishing
Primary tooth anatomy:

 Primary tooth anatomy defines the geometric shape or outline of the tooth and usually falls
into three categories: square, triangular, and oval.
 This is determined by the angle lines.
square triangular oval
square oval triangular

Transitional line angles:
 There are three transitional line angles in maxillary anterior teeth.
▪ Represent the area of transition between the two proximal surfaces and incisal surface with the
facial surface.
▪ Altering the distance between the two proximal line angles gives the illusion of making the tooth
appear wider or narrower. (this is important in cases of diastema closure)
o The closer the line, the narrower the tooth appears. (important in cases of diastema cases)
▪ The proximal transitional line angles also influence the size of the facial embrasures.
▪ We can locate it from white and black photos.
Point angles:
 Point angles are the junctions of the two proximal transitional
line angles with the incisal facial line angle.
 The point angles determine the size of the incisal embrasures,
wherein esthetically oriented maxillary anterior teeth grow larger
away from the midline.
Contact area:
 The most apical point of the restoration should be 5 mm or less
from the crest of the bone to avoid black triangle formation. (by
bone sounding we can measure the distance).
Facial embrasures:
 The volume of the facial embrasure is determined by the
location of the proximal transitional line angles.
▪ The closer the transitional line angles are to each other in a tooth,
the greater the embrasure space.
▪ This embrasure space can be most accurately and clinically
evaluated by the incisal view using a mouth mirror.
Incisal embrasures
 The volume of the incisal embrasure space is determined by the
location of the point angles between two adjacent teeth.
▪ female (rounded incisal angle): The larger the distance the point
angles are between two adjacent teeth, the greater the incisal
embrasure.
▪ male (sharp incisal angle): the point angles are closer together, so decrease incisal embrasure.
▪ Type of matrix:
o The less incisal embrasure, the more straight the profile. (Egyptian unica band)
o The more incisal embrasure, the more rounded profile. (sectional band)

Three facial planes:
 This morphologic characteristic depicts the three facial planes of
maxillary anterior teeth and can be evaluated best by viewing from
the sides (M or D) of the tooth rather than straight on.
 Gingival plane: is important for emergence profile to avoid biological
problems.
 Incisal plane: important for incisal edge position.
▪ A common error with anterior composite resins is over contouring the
incisal third (bulky), which results in:
o An appearance that is too flat.
o May also impinge onto the lower lip.
o Phonetics: especially V&F letters.
Secondary tooth anatomy (macrotexture):
 Secondary tooth anatomy is the result of normal tooth development and refers to the facial
depressions and undulations commonly found in maxillary anterior teeth.
 Vertical macrotexture: the proximal/middle lobes.
▪ These vertical grooves are usually more open in incisal and will narrow each time we walk to the
cervical of the tooth, giving the "V" shape to this depression.
▪ There are usually two vertical grooves, of which the distal is usually longer than the mesial.
▪ Done by low-rotation fine-grained diamond drill. (ex: perio komet bur)
 Horizontal macrotexture: is more evident in the cervical third and in the transition with the
middle third of the tooth.
▪ It consists of 2 to 3 small, very smooth horizontal grooves that lie between the angle lines.
▪ Done by fine grain spherical diamond drills in low rotation. (ex: rose head bur)

Tertiary anatomy (microtexture):
 This commonly refers to perikymata and various forms of surface stippling usually present in
younger teeth.
 This is commonly lost in older teeth or those that are in function longer due to frictional
forces that erode this morphology over time.
Surface anatomy identification:

 There are two methods for the texture identification:
▪ The silver powders.
▪ Articulating paper.
 It is helpful in anatomy coping.

Notes
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Class IV & Class III&V
Class IV &
Class III &V

Anterior preparation
In class IV:
1. Long Skirting bevel = scalloped bevel:
▪ Long bevel > 1.5 mm (2mm).
▪ Depth =0.5-1mm
▪ Drawn by pencil then by finishing bur angled 45 degree.
2. Beveling the bevel:
▪ By coarse disk (blue, TOR VM) beveling (1mm) the end of your bevel to make infinity margin.
In multiple surface restoration (class III + class IV + class V):

1. Starburst bevel:
▪ Every star has different depth, length, and width.
▪ Make composite interlock with tooth.
▪ Drawn by pencil then use finishing bur.
▪ Then increase depth of each star.
2. Beveling the bevel.
Importance of bevel.
 Invisible transition between tooth and resin, no demarcation line (esthetics).
 Improve adaptation so avoid gabs, composite can’t adapt to line but area.
 Increase enamel surface area (retention).
 Expose more fresh enamel surface so increase surface energy of enamel (retention).
Notes:
 If enamel is very translucent, make longer and deeper bevel.
 If the tooth is more opaque, make bevels less pronounced.
 Bevel equals missed structure: If ½ tooth is missed so the last half is bevelled.
 Class V:
▪ The gingival margin is chamfer or shoulder (no bevel), to avoid inflammation of gingiva.
 Palatal margin is chamfer or shoulder: (no bevel) just roundation so can support the palatal
shell.

Steps:
 Rose head diamond burs (high speed) for removing enamel caries.
 Excavation for dentin caries.
▪ It is better to use low speed burs (blue or green) for dentin preparation.
▪ Excavate until excavator can't remove any more or you can hear the normal sound of dentin on
probing.
 Toilet cavity to remove any dentin ships.
 Caries indicator for remaining caries.
 Finishing cavity:
▪ Diamond burs or high-speed white stone.
▪ Make smooth, round cavosurface angle, remove undermined enamel except
intact labial surface, but if the labial surface is included remove undermined
enamel and make long bevel.
▪ Air abrasion is the best (no smear layer)
▪ If filling will not be placed in the same visit, make finishing if cavity in the visit of filling to provide
fresh enamel and dentin.
▪ Use only diamond stone (blue or red) not yellow, under copious coolant to avoid:
o Burning dentin even in non-vital tooth.
o In class 4 lead to micro crakes & demarcation line in enamel affect aesthetic.
 Disinfect the cavity by chlorohexidine before bonding:
o In cases if bleeding, toilet cavity by chlorhexidine or glycine for disinfection.
o CHX Increases surface energy so increases bonding.
o Decrease post-operative sensitivity.
Tooth preparation for Class IV (long indefinite bevel)
. .

Waxing up
Intra oral / direct mock up.
 Steps:
▪ Prior to any tooth preparation, directly apply composite on tooth without etching or bonding to
reshape tooth.
▪ Prior to curing, instruct your patient to occlude in centric
then do lateral extrusions to mold the palatal surface of
the soft mock-up to conform the exciting occlusion.
▪ Remove any excess and re-adapt composite labially and
palatal then cure it.
▪ Then finishing your restoration especially, the margins.
▪ Check length, width, shade & function.
▪ Take index: by placing rubber base impression between
upper &lower teeth, make patient support impression
palatal by his tongue then bite gently on it.
 Time consuming.
 Intra oral is more superior than extra oral in two basic things:
▪ Confirmation of match between the expected form and facial context of the patient as well as
patient acceptance.
▪ Proper centric and eccentric adjustment.
Extra oral (on model):
 More easy and so more popular.
 Can be achieved by:
▪ Modelling wax: Snow white L (for lab waxing up).
▪ Expired composite or any non-sticky inexpensive one.
 Palatal index (palatal stent or silicon index).
▪ Addition silicon is more superior than condensation silicon.
▪ For the palatal and incisal edge only.
 May be one step or two step procedure.
▪ Two step procedure: preferred to record interdental spaces exactly.
o 1st adapt a piece of addition silicon palatal and exert some pressure, so that it flows enough
labially then add a complementary increment of addition silicon for rigidity extending over 4 or 6
anterior.
o Ensure that it only registers the palatal surface and incisal edge of mockup not extending to labial
surface.
o Trim your index:
• By removing excess labially (by scalpel).
• Let only 2mm of gingival part and support it by one tooth
RT& LT at least and maximum from canine to canine.
• Readjust interdental impression by plastic instrument.
• May cut incisal part also if you prefer.

Composite building for class IV.
1. Palatal shell:
 Build palatal shell guided by palatal index.
▪ To avoid over buildup of composite, may scratch the palatal index with explorer along palatal
chamfer finish line.
▪ By Thin layer of enamel shade 0.3 -0.5 mm (may use A1 as enamel).
o Roll composite as a ball then the composite is patted on index until the scratched line.
• May Apply snowplow technique on palatal margin for more adaptation.
• Or use bulk flow (SDR), give better adaptation than packable composite.
▪ After curing, remove excess composite from margin by scalpel.
▪ Put some dentin composite on palatal shell to support it against matrix.
▪ Remove index.
 May use modified celluloid crown to make palatal shell.
2. Proximal wall:
 Using sectional matrix (longitudinal), fix it in position by wedge.
▪ Bioclear matrix band (A system).
▪ TOR VM IS better than Palodent (highly contoured so give semicircular shape for
anterior )
 By dentin shade:
▪ As if we used enamel it will be more than 1mm (gray appearance).
▪ But if you can control the thickness of enamel, use it.
3. Building anatomy:
 Build anatomy by dentin shade from inner side to outer side.
 Dentin level to cover 2/3 bevel = 1st bevel level.
▪ Dentin level determines thickness of enamel. If ended at DEJ, more enamel
thickness (gray appearance).
▪ The Misura Instrument (LM Arte by Style Italiano) was used to get the right
amount of dentine mass.
▪ Dentin should be burnished over the bevel until it disappears (blended) by
brush.
▪ The dentin should be convex to follow DEJ.
 By Fine tipped instrument (hollenback#6 or LM Arte Fissura instrument)
create the mamelons (mesial, middle, distal lobes) in a finger-like
projection style.
▪ These mamelons don't reach the incisal edge.
▪ A separation of 0.5-1mm mainly is needed depending on each case.
 Curing for 40 secs (dentin shade).
4. Incisal halo:
 Enamel shade (T shades): As they are translucent; allow light to pass for some extent, this step
was done in the Palatal Index step.
 Dentin shade (O shades) roll: on the incisal edge to block-out the light transmission thereby
simulating the natural opal. (Thickness: from 0.5-1mm thickness)

▪ Spaghetti Technique: Its rolling composite into spaghetti-shape by either finger rolling or using the
side of the Modified probe, to be adapted on the incisal edge (Outlining the edge).
Halo effect.
Spaghetti technique.
 Translucent shade:
▪ May be blue translucent / opalescence or clear transparent or gray transparent according to case.
▪ A little amount applied on palatal shell, between the mamelons and the incisal edge.
▪ This transparent shade will account for opal effect halo.
▪ Opalescence composite placed as a line in incisal edge of young teeth (ex: OBN from ENA)
o Some use blue stain and lighten it by flowable composite but this hampers the passage of light so
the result will be an unnatural effect.
o Many manufacturers claim that their enamels have natural
opalescence, but scientific and clinical data indicate that
these statements do not correspond with reality.
o It is essential to use highly translucent colors to simulate the
opalescent effects.
5. Stains:
 Intensive (dark- patches or spots-obvious in-patient mouth) or just characterization (light-
lines-obvious in dehydrated tooth).
▪ As in cases of fluorosis (white stains) or enamel cracks (ochre).
▪ Put drop of stain on your gloves then apply it by endo spreader on composite.
 Note: If you forget to put stain, by bur make place for it then etch & bond, then stain, and after
that add enamel layer.
6. Enamel layer:
 Place translucent enamel as a roll in incisal part to give opalescence effect.
 Translucency of incisal 1/3 determined by space left for enamel and opalescence effect.
 Maximum thickness of enamel composite is
1mm: if you find that enamel layer will be
more than 1mm, use ENA enamel or use
translucent enamel as intermediate layer
between enamel and dentin.
 Enamel should be Placed as one increment to avoid lamination appearance.
 Cover 2nd bevel, adapt it by painting brush.
 Light curing for 20 secs.

 May use Condensa instrument (LM Arte by Styleitaliano) combined with brushes to create a
primary surface macro anatomy and the form of the tooth.
7. Final curing:
 Apply oxyguard or (liquid glycerin) on filling for air blocking = oxygen inhibiting layer.
 Then final curing 40 secs.
 Washing (air and water)
 Finishing & polishing.
Class IV
. .
.
Demo
Vanini's stratification technique (layers):

 Depends on:
▪ Palatal index for building palatal shell:
o That will house the dentinal body and serve as a reference during the stratification phases.
o A thin (0.5-mm) layer of medium-value enamel is constructed with the aid of a thin spatula, and
natural bristle brushes.
o Once this layer is thin and uniform, it must be cured for at least 20 seconds.
▪ Sectional matrix for building proximal wall.

▪ Correction:
o When it is not possible to achieve a highly accurate shape during modeling, a correction is
made with a coarse (80-µm) diamond bur used at low speed and without water.
o The restoration will become covered with white powder while the bur is operating. The entire
surface should be moistened with a natural bristle brush soaked in modeling fluid.
o When the fluid contacts the powder, it develops the same refraction index, causing the
powder to disappear optically.
o Chemically, the restoration becomes clean, but it is essential to remove excess liquid with
plenty of air. In addition, this process recovers the oxygen -inhibited layer previously lost
during the correction.
o No polymerization is needed after the liquid excess is removed with air.
▪ Building dentinal core that has some bases:

o A high chromaticity cores.
o Chromatic desaturation from cervical to incisal and from palatal to facial.
o Placement of multiple layers to gain depth and in this way avoid monochromatic structures.
o Control of contraction and polymerization through multilayer application.
o Each dentin shade should occupy at least one third of the volume of entire restoration.
o The 1st dentin layer:
• It should be the highest chroma
- In A2 tooth, the 1st layer is A4.
• Should be placed in an oblique direction (thicker cervically
and thinner where it approaches the middle 1/3).
o The next dentin composite:

• It is a lighter shade (A3).
• This layer is also placed obliquely, covering all the
previously applied dentin, occupying approximately 60%
to 65% of the total volume, and reaching two-thirds of
the cervical -incisal length.
o The last dentin composite:

• Placed corresponds to the selected base color (A2),
stratified in the same way as the other layers.
• It should cover both previous dentins, but it .is important
to respect the space of the opalescent masses (incisal
and proximal gaps).
- Should be kept 0.5 – 1mm away from incisal edge.
• Approximately 90% to 95% of the final volume of the tooth should be formed with this
dentin.
• A specially designed spatula (Misura, LM-Arte, LM instruments) helps to calculate the
thickness of enamel.

▪ The opalescent masses are placed on the incisal edge (space left for it).
o Irregularities must be avoided in this layer.
o Mamelons should be covered just slightly or not at all.
▪ Final layer is enamel:

o It must be thicker in incisal area (except in opalescence zone) and thinner in cervical.
o It must be as smooth, uniform and clean as possible.
Simplified technique:
 The first step is to create a palatal wall and an enamel shell. (no mamelons)
 Using only two dentin shades (A(X) + A (X+2))
▪ A high-Chroma dentin (A4) is placed obliquely so that it occupies 60% of the volume.
▪ The base dentin (A2) is placed to fill the remaining 40% of the total dentin dimension.
▪ The contours of the mamelons are designed in this layer.
 The final layer (enamel composite):

▪ For this technique, it is necessary to use an optically efficient mass (Empress Direct enamel
(Ivoclar), or Enamel Plus HRi) to obtain opalescent effects and high Value without effects.
The incisal edge shows subtle opalescent

characteristics, both blue and amber,
without the use of any kind of opalescent
masses. These effects were achieved
through proper control of thickness and
the use of optically efficient enamel
composites.

Other stratification techniques:
Newton Fahl's technique. Single-shade technique. This Reverse technique. Whiter dentin
This technique consists of technique is recommended composites are used in the
using a chromatic enamel for provisional restorations, innermost portion for masking, and
(Vita) or body on the some posterior restorations, chromatic dentin or body
margin zone and an and cases where esthetics is composites are used near the
achromatic enamel (non- not essential. surface to increase the chromaticity.
Vita) on the incisal portion The mamelons can be personalized
of the restoration. Few as well. This technique is indicated to
dentin composites are opacify dark features of teeth.
required.

Class III
Palatal or labial approach:
 Palatal approach is preferred, as the main concern is to preserve enamel even if it is
undermined enamel.
 Indication of labial approach:
▪ The carious lesion is positioned facially (labial surface is carious).
▪ The teeth are irregularly aligned, making lingual access undesirable.
▪ An extensive carious lesion extends onto the facial surface
Matrix system:
 Many types of matrix band can be used in class III:
▪ Sectional band.
▪ Bioclear A system.
▪ Unica band.
▪ Celluloid strip:
o ex: Hawe transparent stop strip. (flat profile)
o For more control on celluloid band cut it to 2 - 2.5 cm.
Case with sectional band:
Place concave side of band facing the open area of cavity (concave is palatal in cases of palatal approach):
▪ for better view, more control on composite application and able to see neighbor tooth.
Class III with celluloid band.
▪ Celluloid band is useful in cases of misaligned teeth that hinders using sectional band.
▪ The contact opened by bur to place the celluloid.

Application technique:
 Snowplow technique.
 Injection molding technique.
▪ Injection molding technique may be done in class
III by bioclear band or modified celluloid crown.
▪ But in cases of modified celluloid crown, use it in
back-to-back class III to avoid open contact.

Layering technique:
 Monochromatic shade.
Finishing margin for more adaptation.
 By finishing strips (green &yellow).
▪ The stripe should be pulled in two different directions that resemble the letter S. This leads to
good contact between two anterior teeth.
▪ If otherwise this step is not followed, an open contact will result.
Class V
Tips & tricks:
 Common problem with class V is detachment / debonding:
▪ Most clinicians attempt to seal the cervical margin as quickly as they can, usually by layering a very
big amount of composite thus dramatically increasing shrinkage and marginal debonding.
 Tips:
▪ Place impregnate retraction cord 1st (control bleeding and for G.M acquisition).
▪ Preparation:
o Butt joint gingival margin.
o Bevel Incisal margin: indefinite margin
• If class V restricted to cervical 1/3, extend bevel to the middle 1/3.
• If it extends to half of tooth, bevel all tooth except 1-2 mm incisal (to maintain incisal
characteristics ex: opalescence.)
▪ RD isolation: with active clamp or dental floss.
▪ Composite procedures:
o Selective etching: if gingival margin in cementum, no etching.
o Bonding: with universal bond containing MDP.
o Snowplow technique on gingival margin.
o After final layer of composite: place drop of flowable composite on cervical margin especially
then on facial composite to close any micro gab. (excess flowable will be removed with
finishing)
▪ Close gab technique:
o In order to reduce polymerization
shrinkage, composite is layered in
progressively smaller increments,
from the coronal margin towards
the cervical, up to leaving a small gap (about 1 mm).
o Closing gap is filled last, and virtually creates no contraction thanks to its reduced thickness.

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Diastema & Veneering
Diastema &
veneering

Diastema closure
Rules for diastema closure & veneering:
 Rule no 1: central dominants.
▪ In facial esthetic during smiling the two centrals dominate smile followed by eye color.
▪ From facial view:
o Lateral incisor 65% of central.
o Canine 85% of lateral. (only mesial side of canine will be seen in facial view)
 Rule no 2: width to length ratio.
▪ Width/length of face = width/length of tooth.
▪ The central incisors width must be 78% of length, for high esthetic result.
o Maximum 85%, minimum 75%.
 Rule no 3: bilaterally symmetry.
▪ Two centrals must share in Diastema closure.
 Rule no 4: golden proportion.
▪ Golden proportion When viewed from the facial, the width of each anterior tooth is 60% of the
width of the adjacent tooth (mathematical ratio being 1.6:1:0.6).
o The ratio between central and lateral and canine (mesial viewed part) is 1.6: 1: 0.6.
Red proportion:
▪ It is simpler and more flexible than the golden proportion. (more common)
▪ The successive width proportion when viewed from the facial aspect should remain constant as
we move posteriorly form midline. This offers great flexibility to match tooth properties with
facial proportions. (each tooth becomes smaller by a fixed percentage when we move distally).
Diastema closure:
 According to technique:
▪ Direct: direct mockup or direct free hand (bioclear method).
▪ Indirect: waxing up & silicon index.
 According to size:
▪ Small (1mm or less): can use enamel composite.
▪ For moderate to large diastema (1 to 2.5 mm):
o Dentin composite to block the show thorough effect caused by the darkness of mouth.
o Enamel composite to establish the facial and incisal contour.
▪ If the diastema exceeds 2.5 mm:
o Orthodontic treatment is necessary in this case, closing by composite or veneer alone will
break the width to length proportion.
o But if the patient refused ortho TTT:
• So, we may make the four anteriors share in
diastema closure, For optical illusion use proximal
transitional line to make incisors appear narrower.
• After waxing up, if the case esthetically is nonacceptable, not close the diastema
completely.

Practical notes:
 Case: patient come with 2 mm diastema:
▪ Bilateral symmetry: increase width for each central by 1mm.
▪ Width / length ratio: if it is still in average or not.
 If proportion of tooth is ideal (width/length), so to close diastema (width increase) you
should increase length.
 The normal smile curve follows contour of lower lip, centrals and canine touch curve and the
lateral is shorter by 0.5 -0.7 mm.
▪ Ask your patient to smile, if upper teeth touch lower lip during smiling (normal smile curve) so you
only can increase length by gingivectomy or crown lengthening especially in cases of gummy smile.
 Use diagnostic wax up & mockup:
▪ In cases of the width and length proportion will be changed, so it is neceassry to see if it is esetically
acceptable or not.
▪ Mockup is helpful for patient and dentist to the final result.
o Make impression of waxing up then fill it with temporary crown material (protemp) and apply
it to patient teeth without bonding.
 Buccal corridor is found normally but not to large (aged appearance).
Common problems with diastema closure:
1. Asymmetrical width. 5. Cervical ledge.
2. Inappropriate width: length ratio. 6. Poor emergence profile.
3. Incorrect midline position. 7. Poor contact area.
4. Incorrect midline angle. 8. Residual black triangle.
Steps:
 Impression & waxing up on cast / or direct mockup.
▪ It is important especially in cases of you will change width / length ratio to be greater than average.
 Isolation is important for:
▪ Moisture control.
▪ Rubber dam suppresses the papilla to reduce black triangle formation post operatively.
 Air abrasion / diamond bur to remove biofilm:
▪ For increasing the surface energy and so the bonding.
 Etching:
▪ It must be extended to middle of the labial and palatal surface, the composite will be limited to one
third of tooth, but to ensure there is no applied composite over non-etched area.
▪ It is only enamel to be etched (no exposed dentin), so over dryness is not a problem.
 Palatal shell: built by the aid of palatal index in cases of large diastema.
 Matricing: .
▪ Use bioclear D system or vertical sectional matrix to build proximal wall.

 Cervical over molding:
▪ for more natural look, better emergence profile and to avoid black triangle.
▪ Bioclear band is the best but you can made it by other bands like celluloid band.
▪ May modify palatal index by making a way for celluloid strips,
then carefully tuck the strips into gingival sulcus.
 Make the composite extend 2mm or more on tooth surface
and ends with indefinite margin to avoid demarcation line.
 Manage each tooth individually.

D system (4): More cervical curvature, so used for space closure (diastema)
▪ Diastema Closure matrices are for creating a new and exaggerated emergence profile.
▪ These matrices are for closing diastema larger than 1mm and for large black triangles.
▪ Trimming: trim your bioclear band according to the size of diastema.
o 2mm > space > 1mm make trimming for D groups.
o 2mm < space < 4mm make trimming for D204.
ID curvature
DC201 0.9 MM INCISOR MESIAL:
▪ For mesial diastema closure up to 2 mm.
DC202 0.9 MM INCISOR distal:

▪ For distal diastema closure up to 2 mm.
DC203 0.9 MM SMALL INCISOR:

▪ for space closure on lower incisors.
DC204 ▪ 1.8 Extreme diastema closure:

MM ▪ for space closure on spaces larger than 2
mm. (XL)
Diastema closure using bioclear method:
▪ Measure diastema space using bioclear smile gauge.

▪ Make Roughness to remove biofilm and so increase enamel surface energy (increase bonding)
then etching.
▪ Use 2 bioclear band (M&D from bioclear D system) in back-to-back position.
▪ Apply bond on one tooth (Ivoclar bond brush to reach inaccessible area) then air dryness /
thinning and curing.
▪ Apply flowable composite in cervical portion & cure it.
▪ Then use injection over molding technique (labial &palatal).

▪ Final curing with glycerin. .
▪ Then finish your restoration & remove its band.
▪ Recalibrate and start the 2nd tooth.
▪ Apply flowable composite in cervical portion & cure it.
▪ Now it is the time of wedging to create contact.
o May build the two teeth together by using wedge after building cervical portion of both teeth.
Composite guide for matrix band (one visit) instead of palatal index method.
Delayed wedging after cervical over molding
The Front Wing Technique

 Advantages:
▪ Skipping the wax-up (but not skip DSD: it is mandatory).
▪ Giving the user the chance of building and selecting the emergency profile and contour of one or
multiple diastemas.
▪ The chance of working with single shade or multi shade approach.
▪ Tight contacts are easier to get.
▪ Ideal cervical fit.
▪ Aesthetics of the restoration.
A simplified DSD was made in order to identify how
much material to add and where. Facial midline (solid
line) was consistently shifted from the dental midline
(dotted line), making this diastema closure even more
difficult. According to the project, it was decided to
close the distema of 11 at the expense of the mesial
area and lengthen 1.5mm the incisal edge, and the diastema of 21 at the expense of 21 distal and
22 mesial with an incisal lengthening on 21.

▪ Maximum retraction is achieved with active clamp. The rubber dam retracts very efficiently the papilla
as well, making the whole mesial area visible up to the desired emergence profile point of departure.
This area is critical and is where most mistakes happen.
▪ Acid etching of the enamel. In this kind of extensive restorations, it is common to end up with composite
in areas where it might not be expected to have restorative material: the risk of this happening is big,
and it is preferred to etch beyond the limits, sometimes much further than needed.
▪ In this case, all the buccal and proximal surfaces were etched.
▪ Bonding application is made with a flat brush in order to have high precision, especially in the extremely
narrow areas in the mesio-cervical region.
▪ The key is to model free hand the buccal part of the diastema, making this shape as efficient and
precise as possible.
▪ Achieving an appropriate contour is easy when the only thing we need to focus on is the shape.
▪ Once the buccal part is done, the palatal and the precision of the restoration are very far from ideal, but
this has an easy solution.
▪ Application of an addition of the first hand-free buccal layer in order to optimize the shape. After
modeling, mechanical trimming can be done in order to optimize the shape, it is mandatory when doing
that you don’t touch the already bonded enamel, but composite only.
▪ Now it is time to focus on the sealing of the restoration and on the achievement of a tight contact, by
placing an anatomical matrix.
▪ A really small drop of flowable resin is placed and NOT cured yet. This helps the wettability of the
following composite increment.
▪ An increment of composite is placed on the palatal side, displacing all the flowable resin towards the
buccal one. It is mandatory to keep condensing until there’s excess material flowing on the buccal. For
the experienced operator, this step is not necessary, just condensing the composite mass until excess is
found is more than enough.
▪ After polymerization, the matrix is pulled out. It is very easy to obtain tight contacts and good contours.
▪ The incisal edge was built with a dual layering technique.

Composite veneers:
Indication of veneering:
1. Broken and chipped teeth.
2. Mild alignment: patient refuses ortho treatment (just recontouring)
3. Palatal version of teeth: by increasing the tooth thickness.
4. Revered smile line: increase the tooth length (DSD in this case is important).
5. Post orthodontic: almost destroyed labial surface (loss of gloss, white patches or caries) or we
need slight recontouring.
6. Heavily stained teeth: amount of preparation, thickness, shade, opacity of composite is very
critical.
7. Spacing and diastema. (DSD in this case is important.)
8. Gummy smile (re-contour the level of gum then use restoration to change the dimension of
teeth - DSD in this case is important).
Composite veneers VS porcelain veneer:
 Indicated rather than porcelain veneers in cases of:
▪ Young patient.
▪ Prepless veneer cases: if the patient prefers nothing is ground off his natural teeth.
o E-max can’t be used in fabricating prepless veneers: As it has low edge strength, which will lead
to marginal chipping causing rough surface, plaque accumulation and gingival inflammation.
▪ Single visit veneer cases.
▪ Economic cases: composite is cheaper.
▪ Lower anterior veneer: composite veneers behave much better functionally.
▪ In asymmetrical cases: composite or crown are indicated.
▪ multiple restorations and limitation in bonding surface of tooth structure.
 Porcelain veneer is indicated in cases of:
▪ Elongation of upper anterior: composite more susceptible to fracture.
▪ Severe discoloration cases: porcelain can mask the discoloration rather than composite.
▪ Bad oral hygiene (composite discoloration tendency): the composite veneer is more inferior than
porcelain veneer in color stability and glazing.
▪ Heavy hand cleaner patient: result in worn up discolored composite.
Preparation (according to case):
 Prepless veneer:
▪ If the patient prefers nothing is ground off his natural teeth.
▪ Increase the incidence of over contouring: plaque accumulation and gingival inflammation.
▪ In cases of buccal corridors: using prepless veneers on premolars decrease the buccal corridors.
 Preparation:
▪ Finish line:
o Equigingival or supragingival is preferred to avoid gingival inflammation.
o Subgingival may be used in case of:
• Caries / restoration on the margin (margin should be on enamel).
• High lip line (Gummy smile).
o Chamfer gingival margin (no beveling).
▪ Proximal reduction:
o No need for opening the contact, so we usually stop just labial to the contact area.

o Except in cases of: Diastema/spacing or class III caries/restoration. (We stop lingual to contact
area).
▪ Depth:
o Ideal depth ranges from 0.3 to 0.5 mm, but we can increase the depth to 3/4 thickness of
enamel according to the extent of discoloration.
o A quarter round bur may be used to provide 0.5 mm depth, that allow for the labial thickness
of composite required to mask most discoloration without significant over contouring.
Material:
 A1 Z350 (3M): nano pure composite but it is somewhat opaque.
 A1 Tetric N Ceram.
 Intermediate opacity composite:
▪ Tetric N Ceram Flow.
▪ Brilliant ever glow Colten.
 OR bleaching composite:
▪ Ivoclar B1-B2-B3 + light cure Ivoclar (Blue X): Due to different type of initiator so different
wavelength for curing.
Matricing:
 Celluloid band.
 Unica band: (Dental town)
▪ It is the best way to adapt composite in cervical and interproximal area and to produce over-hang
free highly polished margins in those critical areas.
o Style Italiano Unica band:
.
• Contoured band so can be used to build contact area.
Style italiano Unica

o Egyptian Unica = modified Tofflemire band:
• Non-contoured so not used to build contact but used only in: .
- Class V.
- Labial veneer.
• Modification:
- Cut about 1mm from concave side of band. Make convex one (smooth side)
to rest on cervical part of tooth. (video by Dr ahmed Saad)
- Or make U shape at concave side. (pics by DR IBRAHIM ABD EL MONEM)
Egyptian Unica

Hints:
 If non-prepared enamel = virgin enamel:
▪ Make slight roughness to remove biofilm & etching for 60 sec.
▪ Agitation of etchant gel by bond applicator brush.
 Use Unica band or two sectional band for proximal wall.
 Use snowplow technique in cervical part.
▪ Initial set for flowable in cervical part to avoid its escaping.
 May use only flowable composite.
 Use articulating paper for anatomy copy.
Flow injection technique / Injection moulding technique

 It is a technique used for veneering anterior teeth by injection flowable composite through
clear silicon matrix.
Material used:
 Flowable composite:
▪ Tetric N flow BL shade composite.
▪ G-aenial universal flow BW.
 Clear silicon impression.
▪ Transil F (clear additional silicon from IVOCLAR vivadent).
▪ Memosil 2 (kulzer).
▪ EXACLEAR (GC).
▪ DENU trans SIL: (275 LE from prime dental store)
Steps:
 Lab steps:
▪ Take impression of teeth then pour it to make cast.
▪ Waxing up is done (manual or digital waxing up)
▪ Immerse waxed cast in water for 5 minutes to facilitate removal from impression.
▪ Clean waxed cast & non-perforated tray by alcohol.
o Non perforated tray for transparency and ease of removal.
▪ Apply (Transil f) in tray & on waxed teeth then take the impression.
o When taking the impression, take care not to press too hard on the silicone, so that all of the
incisal edges are covered by sufficiently thick layer (for stability of the stent and avoid
deformation or deforming of silicon key).
o The index should extend two teeth mesial and distal for stability of silicon key inside mouth and
for accurate reproduction of aesthetic details.

▪ Make incisal hole in each tooth position by diamond bur & ensure the hole is wide enough for
flowable tip.
o May make 2 holes (mesial and distal one) this help in eliminating air trapping and reduces the
amount of excess.
▪ Clean the silicon matrix by alcohol for more shinning.
 Clinic steps:
▪ Separate neighboring teeth by teflon.
▪ Etching & bonding steps.
▪ Place clear silicon key.
▪ Inject flowable composite through holes.
o Little overflow is needed to ensure that there are no voids remained.
o Beginning with positioning the tip near the cervical margin then withdraw incisally through the
vent hole.
▪ Curing is done through the silicon key (40 sec facially & 40 sec Occluso gingivally).
▪ Finishing the restoration: remove gingival excess by the scalpel & fine needle bur.
▪ Night guard is recommended especially in cases of bruxism to avoid composite chipping.
. . .
Demo
Demo
Demo

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Finishing & polishing
Finishing &
polishing

Finishing & polishing armamentarium
Contouring & Finishing burs:
 Carbide tungsten burs (multiblade bur):
▪ They are available in different degree of abrasiveness.
o More blades (32) = less cutting = fine.
o Less blades (8) = more cutting = rough.
▪ Involve a cutting mechanism to remove material.
o Ideally suited to finish composite.
o Not used with ceramics.
▪ VERDANT bur from DANDENTAL = 60 LE
 Diamond stone burs:
▪ They are available in different grit sizes.
▪ Involve a milling operation to remove material.
o Used to finish composite.
o Ideally suited to finish ceramics.
 White stone burs:

▪ White Stones are designed for contouring and finishing of Enamel,
Composites and porcelains.
Intensive composhape set
Proximal and subgingival finishing

with instrument FG 4062.
Finishing of occlusal filling

surfaces with instrument FG
4255.
Finishing of the filling margin

(1000 LE, each bur 90 LE
Finishing of central fissures


Komet burs (finishing styles)
 Finishing Style is a set of 6 burs:
▪ 1 and 2 are for posteriors.
▪ The 3, 4 and 5 are for anteriors.
▪ The last bur is for corrections.
Step 1: Low speed multi-blade round bur for occlusal adjustments. This bur
may also be used for secondary anatomy development in anteriors.
Step 2: High speed multi-blade point bur, to finish, smoothen and remove
excess from margins
Step 3: High speed medium grit diamond football bur, for palatal finishing and
occlusion adjustment in anteriors.
Step 4: Low speed flame diamond bur for finishing, smoothening and shape
configuration in anteriors. This bur provides extra control during finishing and
is suggested to use with very low speed and without water.
Step 5: Perio komet 831 bur: Available in Alex dent (131 LE)
1- for finishing excess composite without removing from enamel.
2- carry out 90% of finishing work, including definition of shape and
primary and secondary anatomy.
3- removing excess composite after ortho.
Step 6: Correction bur (0,5mm calibrated)

Interproximal Finishing & Polishing Strips:
 Hints:
▪ Used in 45 directions below contact are.
▪ Has smooth part to pass contact.
▪ May be used to decrease tight contact (make separation 1st to avoid opening contact).
Diamond grip strip (INTENSIV):
 It is metal to avoid being cut as in celluloid one.
 Strips are diamond-coated to provide precision finishing and polishing for restorations in
proximal areas.
 Contain two working areas of different grit sizes (a coarser grit for stripping and removing
material, and a finer grit for polishing) so you can finish and polish with only one strip.
Finishing &polishing discs:

 Disks are used to define proximal areas and transition angles, in the areas where the bur is not
able to reach.
 These instruments also are probably the most comfortable and accurate for defining the incisal
and proximal shapes.
 Four grits are available: coarse, medium, fine, and superfine.
 We recommend the medium grit for removing excess and the fine grit for subtle modifications.
Stem discs (TOR VM):
 TOR VM polishing discs (40 PCS = 160 LE):
▪ Blue discs: for gross reduction & beveling the bevel.
▪ Green discs: for contouring.
▪ Yellow discs: for finishing.
▪ White discs: for polishing.
Opti disc (Kerr):

 Polyester disks coated with aluminum oxide abrasive particles.
 Opti Discs are translucent for enhanced working surface
visibility, with color coded ring:
▪ Extra-coarse: for contouring.
▪ Coarse / medium: for finishing.
▪ Fine: for polishing.
▪ Extra fine: for high gloss polish.
 kit (120 disc + standard mandrel + short mandrel + optishine brush):1400 LE.

Rubber tips:
 These are used to eliminate the grooves that the bur and the disk leave.
 They have two main functions:
▪ When they are used firmly, a smooth abrasion results on the composite surface.
▪ when they are used delicately, they are able to prepolish.
 The finishing stage is improved with this kind of instrument.
 The correct speeds are 10,000 rpm for finishing and 5,000 rpm for polishing.
 Examples:
▪ Kenda polishing kit. (190 LE)
▪ Microdont.
▪ Idontoflex Kerr (diamond abrasives)
▪ Opti step Kerr (one step)
▪ Toboom.
Idontoflex Opti step
Soft-Lex spiral finishing &polishing wheel (3m)

 The Spiral Wheels easily adapt to all tooth surfaces and are useful for both posterior and
anterior teeth.
▪ Unique shape is flexible and adapts to all surfaces so it's easier to work intraorally, especially on
posterior teeth.
▪ Two-step system makes it quick to achieve a life-like luster
▪ All surfaces can be used since abrasive particles are embedded throughout; top, bottom and edge,
making it effective from any angle.
▪ The brown wheel used first (finishing wheel), then white wheel (polishing wheel).

Brushes:
Opti shine (Kerr). 100 LE
 The concave shape of the brush is efficient on all tooth surfaces, as well as on
less accessible surfaces like interproximal spaces and occlusal fissures.
 The polishing effect is created by polishing particles embedded in the bristles
(silicon carbide).
Astrobrush (Ivoclar).
 The abrasive medium silicon carbide is integrated into the special fibers of the Astrobrush
polishers. As the bristles wear down, fresh abrasive medium is released on the surface.
 Astrobrush is supplied in three different shapes:
▪ Regular/ large Cup: for large posterior restoration surfaces and for removing stains.
▪ Small Cup: This shape is suited for polishing anterior and cervical restorations, occlusal surfaces
and for removing stains near the gingiva in confined areas.
▪ Point: for polishing occlusal fissures and proximal areas.
Hair goat brush & Felt wheel:

 Used to achieve extra-gloss.
 Natural goat-hair brush = shiny G (Micerium): 37 LE
▪ When a goat-hair brush rotary instrument is combined with 3- and 1-µm diamond pastes for the
initial shine stage, the result is a high gloss.
▪ The hardness of the brush permits the surface to be polished at high speed and deep zones to be
polished at low speed.
▪ These brushes generate significant heat; they can be used at 1,000 rpm with a gentle touch and
without water and at 10,000 rpm under abundant water spray.
 Soft felt disk = Shiny F (Micerium): 8 LE
▪ A felt wheel, which is a very soft material, is used with a 1-µm
aluminum oxide paste to achieve a very high gloss.
▪ These wheels generate significant heat. They can be used at
1,000 rpm with a gentle touch and without water and at 20,000
rpm under abundant water spray.
ENA MINI CUP IMPREGNATED BRUSH FOR POLISHING

 Impregnated Brush for Posterior composite polishing (115 LE).
Nylon brush:
 Cheap brush (1 LE) for single use.

Polishing paste:
Diamond polishing paste:
 Not only for composite but also with porcelains, enamel, gold and amalgam (clinic or lab).
 Used before aluminum polishing paste or alone.
 Differs according to grit size: (6 -micron, 3 -micron, 1 -micron…).
 Start from larger to fine size.
 Examples:
▪ Ena shiny (shiny A = 3- micron & shiny B = 1 -micron): 1 Gram = 100 LE.
▪ Diashine.
▪ Diamond polishing paste (Ultradent): 225 LE
▪ Intensive unigloss (one step)
▪ Microdont. (medium 6µ, fine 3µ, extra fine 1µ): 200 LE
Aluminum polishing paste:

 Examples:
▪ Enamelize paste (550 LE)
▪ Ena shiny C. (2.5 Gm = 50 LE)
▪ Prisma gloss (fine / extra fine): one system 1300LE from Dentsply.

Anterior composite finishing workflow
Finishing:
1. Excess removal: First use yellow (super fine 30 um) or red coded (fine 50 um) finishing burs on
low speed with water to remove any excess of composite.
▪ Use finishing with water to avoid debonding that resulted from overheating.
▪ May use Perio Komet bur 831 =style Italiano bur.
2. Labial planes:
▪ By pencil divide the tooth in three planes (cervical – middle –incisal)
▪ Cervical &incisal made at 45 degree.
▪ And middle somewhat straight.
o Made by finishing bur or Perio Komet 831.
3. Surface texture and microtexture:

▪ Transitional line angle: Made by marking it by sharp pencil according to adjacent.
o Start from transitional point angle then go cervically, keep away from mesial and distal surface of
tooth by 1-2 mm = the maximum is 2mm (wider cervically)
o Made by disk or perio komet bur on low speed with water and not remove the pencil line (the
limit = end)
o we may get help with red and yellow diamond polishing strips.
▪ Incisal characterizations:
o Round incisal edge by disk or Komet bur.
o Make the proximal lobes shorter as in many young teeth.
o Mark some incisal lobes division (mamelons) and develop them with the tip of the bur or disc.
o If they need to be really sharp, we can help ourselves with the red diamond strip.

 The edge of disc:
▪ Use the edge of a small, thin, stiff disc to establish gross proximal contouring.
o This should be done gently, rotating the disc from 90 degrees toward the facial at a
very slow speed.
▪ Use the edge of a very thin disc to adjust incisal edges.
o Adjust out any interferences that could contribute to wear or loss of the restoration.
 The face of disc:
▪ Use the face of flexible disc for gross contouring.
▪ Use it at three distinct planes that are gently blended together.
▪ To avoid flat spots, keep the disc moving in gentle circular motions.
 Outermost 1mm of disc:
▪ Use the outermost 1mm of disc at 90 degree to the surface to place
developmental grooves.
▪ Use a gentle sliding motion along the groove length.
▪ A more textured look is achieved by intermittently touching the surface.
▪ Secondary anatomy:
o According to adjacent (use articulating paper to determine location of depression = not stained).
o mark it by sharp pencil: we mark some vestibular weaves which must be sharper in the cervical
and wider in the incisal, but always very smooth.
o There are usually two vertical grooves, of which the distal is usually longer than the mesial.
o Use rose head on low speed to make depression (two grooves parallel to transitional line), then
by the disk eliminate the steps.
o Or perio komet bur / or single flame-shaped fine diamond bur.
• We must pass the bur from mesial to distal, applying more pressure when approaching the
center of the groove and releasing int he surroundings.
▪ Tertiary anatomy =perikymata:

o Mark by sharp pencil as wavy lines run mesiodistal (note that the closer and parallel the grooves
are, the more natural they look).
• Yellow coded Finishing bur on low speed.
• Or perio bur komet 831 on low speed. (with the bur tip)

Polishing:
1. Pre-polish (initial gloss):
▪ To remove roughness and for smoothing the macro & micro texture.
▪ By rubber cups as: Kenda polishing kit. (or Microdont – Opti step Kerr – Toboom)
o Kenda 3 step polishing system: used with water.
• White (coarse grit): for contouring.
• Green (medium grit): for finishing.
• Pink (fine grit): for polishing.
2. Final gloss (by impregnated brush with or without polishing paste)

▪ Opti shine (Kerr) or Astrobrush (Ivoclar).
o Used with or without paste at low speed.
o It is silica impregnated but the silica removed after multiple usage so use spiral wheel better.
▪ Soft Lex spiral wheel (3M):
o Use brown wheel 1st (finish) then white one (polish).
3. Extra gloss (DR: Ahmed Saad protocol):

▪ Goat hair brush:
o Used with diamond paste 1-3 micron
• With polishing paste and water.
• Then with paste only.
• Then use brush only.
▪ Soft felt wheel:
o Used with aluminum oxide paste ex: Prisma gloss.
• Start with low speed (without water & with intermitted action) then increase speed (with
water)
• May use bur on low speed surrounded with cotton instead of felt wheel.

ENA shiny system (style Italiano protocol)
1. Shiny A (diamond paste):
▪ Apply a 3-micron diamond paste (Shiny A, Micerium, Italy).
▪ We spread the paste with the goat hairbrush without rotation.
▪ Then we start at 3,000 rpm with no water, doing really slight touches otherwise
extreme heating can happen and ruin something more than the restoration.
▪ And then at 15,000 rpm with water.
2. Shiny B (diamond paste):
▪ we repeat exactly the same steps but this time with a 1-micron diamond paste
(shiny B, Micerium, Italy)
3. Shiny C (aluminum oxide paste):
▪ For the high gloss polishing, we switch to the felt wheel and apply a 1-micron
aluminum oxide paste, repeating the spreading, 3,000 rpm with no water and
15,000 rpm with water.
finishing and polishing is completed!

 A quick and effective way to verify the anatomy and ensure
that all scratches are removed is with the use of edible silver
glitter (available at most cake-decorating establishments).
Apply the glitter with a makeup brush. Silver glitter will
quickly show areas that need additional smoothing or
blending of the surface texture for a restoration that
appears natural.
If you cannot achieve finishing and polishing protocol.
 Bond as a glazing layer!!
▪ Applying bond to composite surface providing smoother and shiny surface with closing any
microcracks.
▪ Avoid using it as possible:
o Bond is hydrophilic so more subjected to staining & increase surface degradation.
o Hema in bond give bond yellowish color that affect shade of composite.
o low wear resistance: so, gives temporary luster.
 Simple & cheap finishing and polishing kit.
▪ Yellow coded diamond finishing bur.
▪ Kenda polisher rubber cups.
▪ Polishing paste & Nylon brush.
▪ Low speed bur surrounded by cotton.
Anterior composite finishing videos
Style Italiano DR: Ahmed Saad.

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References:
Many sources but as I remember:
Part 1: rubber dam sources.
▪ STYLE ITALIANO (rubber dam inversion)
▪ Coltene handbook of basic dental dam procedures.
▪ Dr. N. Blaine Cook rubber dam handout (Helpful Hints for Rubber Dam Isolation).
▪ SUMMITS’ FUNDAMENTALS OF OPERATIVE DENTISTRY A Contemporary Approach, 4th Edition.
▪ Ivory brochure (ivory clamps).
Part 2: composite sources.
▪ Layers.
▪ Style Italiano website.
▪ Esthetic dentistry - a clinical approach to techniques and materials (3e).
▪ Esthetic & restorative dentistry material selection & technique, second edition.
▪ Looking for the ideal adhesive – a review (science direct).
▪ Introducing the Clark Class I and II Restoration.
▪ Journal of dental biomechanics (shrinkage stresses generated during resin-composite
applications: a review).
▪ Influence of the oxygen-inhibited layer on bonding performance of dental adhesive systems:
surface free energy perspectives.
▪ The American journal of esthetic dentistry (deep marginal elevation).
▪ Intracoronal Whitening of Endodontically Treated Teeth.
▪ Pocket dentistry: bleaching procedures.
▪ Give life to your composite restoration by de David.
▪ Mastering more than anterior composites (Ivoclar Vivadent)
▪ Dental advisor website.
▪ NCBI website.
▪ Photo initiators in dentistry: a review.
▪ Contact point. Methods of restoration.
▪ David Clarck (injection modeling technique).
▪ Roberto Ramos (flow injection technique).
Many thanks to all doctors who share their knowledge:
▪ AHMED SAAD. ▪ AMR EL DEEB.
▪ AHMED ALHAKIM. ▪ KHALED NOUR.
▪ IHAB IBRAHIM. ▪ ABD ELRAHMAN TAWFIK.
▪ MOHAMED SHALABY. ▪ AHMED KHAIRY.
Dental carts website for prices.


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ALL IN ONE

MASTERING RUBBER DAM &

BY: AHMED HESHAM ABO BAKR

)‫ وإن يك خطأ فمن قبلي والشيطان‬،‫(فإن يك صوابا فمن عند هللا‬

ALL IN ONE 2 AHMED HESHAM

ALL IN ONE 3 AHMED HESHAM

ALL IN ONE 4 AHMED HESHAM

Coltene rubber dam

ALL IN ONE 5 AHMED HESHAM

 Rubber dam stamp:

2. Ivory-design (Heraeus Kulzer) rubber dam punch:

▪ IVORY (Alex dent)

4 – molar & Clamped premolar

3- Premolars & Upper canine

2 – upper incisor & Lower canine

ALL IN ONE 7 AHMED HESHAM

When placed both look identical from occlusal view.

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Clamp holder with undercut as a mean clamp holder without undercut

 Balls forceps modification:

o Or remove inner half of ball completely & reduce outer half.

 Notched forceps modification:

ALL IN ONE 9 AHMED HESHAM

 Articulated / foldable frame:

ALL IN ONE 10 AHMED HESHAM

 Tissue retraction clamp = active clamp:

 Soft clamp (resin clamp):

Hole for forceps Jaw

Serration Central wing

Anterior wing Beaks

ALL IN ONE 11 AHMED HESHAM

 26 clamp: (joker clamp)

 212 clamp: (butter fly clamp =double arch)

 44 clamp (= Brinker B4)

 W8A clamp: (joker clamp)

ALL IN ONE 12 AHMED HESHAM

 12A & 13A clamp:

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▪ Universal premolar, vary in size.

 Molar clamp: (200 – 201 – 202 – 203 – 204 – 205)

▪ 200 clamp: for lower molar with broad fringe.

 Anterior clamp: (210 – 211 – 212)

▪ For labial cavities on anterior.

ALL IN ONE 15 AHMED HESHAM

206 (passive) B4 W2A

206 KSK 206 IVORY W2A KSK

210 (6) IVORY 212 KSK 44 KSK B4 Brinker

ALL IN ONE 16 AHMED HESHAM

Make your clamps kit:

ALL IN ONE 17 AHMED HESHAM

Pic: by ahmed kutainy.

liquidam / Opaldam / flowable composite:

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▪ More area = more visibility.

o Cases of contact reconstruction.

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 Custom made holes:

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 Bow technique: with wingless clamp:

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