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Dental Direct and indirect esthetic materials restorative materials

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Midterm exam
15/11/2011 Tuesday 12.15 pm Location: 10H3,4, N2

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Direct placement restorative materials
Esthetic materials are those materials that are tooth colored. Direct placement materials, are placed directly by the clinician in prepared teeth without the need for extra-oral construction of the restoration

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Replacement of amalgam

Re-contouring a pig shaped lateral
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Uses

Maybe used for cosmetic purposes

Out of necessity

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Direct restorative materials
Composite Glass ionomer cements (GIC) Resin modified-GIC Compomers

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Composite resin
Composite: mixture of two or more components. Major components:
Resin matrix Fillers Coupling agents (silane), join filler and matrix Pigments

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Components
Resin matrix:
bis-GMA (bisphenol A-glycidyl methacrylate). UDMA (Urethane dimethacrylate) These resins are made of oligomers (organic molecules) and low molecular weight monomers

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Fillers: silica, quartz, glasses composed of barium, strontium etc. Why add fillers:
Add strength Increase wear resistance Reduce polymerization shrinkage

Size of filler? Ratio or weight of filler to resin matrix? Coupling agent: silane, binds filler to matrix and reduces wear. Pigments: to produce different colors and shades.
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Varity of filler size, A, Macrofilled. B, Microfilled. C, Hybrid
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Polymerization
Monomers join polymers Initiators and activators cause the reaction to begin. Side chains on polymers cross-link to form stronger material

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Polymerization
1.

Chemical cure (self-cure): 2-paste system:
Base: composite and benzoyl peroxide as initiator Catalyst: composite and tertiary amine activator Require manual mixing which may lead to air bubbles incorporation.

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Polymerization
2.

Light cure: blue light (400-500 nm) is used to harden the composite. These light curable composites contain components that start to react once subjected to the light:
1. 2.

Diketone Organic amines

Depth of cure? Depends on color and location of restoration

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Polymerization
3.

Dual cure: 2-paste system containing both types of initiators and activators. Advantage: light starts the polymerization rxn and the chemical reaction continues in areas were light can’t reach them.

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Classification of composites
1. 2. 3. 4. 5. 6. 7. 8. 9.

Macrofilled Microfilled Small-particle composite Hybrid Flowable Pit and fissure sealant Packable composite Smart composite Core build up composite

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Macrofilled composites
First generation Filler particle size 10-100 µm Difficult to polish Stronger than composites with smaller particles

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Microfilled composites
Filler particle size 0.04 µm in diameter Volume of filler is 35-50% (smaller
compared to other composites due to the larger volume of several small particles as opposed to one large particle of the same weight)

Lower physical properties

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Small particle composite
Particle size 1-5 µm Used to be used for posterior restorations but have been replaced by hybrid composite

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Hybrid composite
Mixture of macro and microfillers (75-80% by weight) Microhybrid composite: contains 2 particle sizes, small 0.5-3 µm and microfine fillers 0.04 µm Hybrids have high polishability and strength so they can be used for anterior and posterior restorations

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Flowable composites
Low-viscosity, light cured Can be lightly filled (40%), or more heavily filled (70%) Particle size 0.07-1 µm Delivered into cavity using a syringe

Used for PRR Pit and fissure sealing Liners (cushion stress
caused by polymerization shrinkage of overlying composite)

Weaker and wear more compared to hybrids

Class V

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Pit and fissure sealants
Range from no filler to more heavily filled composites similar to flowable composites Low viscosity Preventive material

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Packable composites
Highly viscous Heavily filled Stiff and strong Posterior restorations (as a substitute for amalgam) Shrink less due to higher filler content

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Smart composites
Combat caries by having the ability to release fluoride, calcium, hydroxyl ions when acidity increases Effectiveness has not yet been proven

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Core buildup composites
Heavily filled Replace lost tooth structure in teeth needing crowns Colored to distinguish then from natural tooth structure

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Provisional restorative composites
Replace acrylic resin in constructing provisional onlays, crowns and bridges More expensive than acrylic, but wear less, and shrink less, and produce less heat when polymerized. Easier to repair with flowable composite However, they are more brittle than acrylic
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Physical properties
Biocompatibility
Polished composites are tolerated by soft tissue. Bonding agents protect pulp by sealing tubules Larger filler composites are stronger in tension and compression Lower filler content increases wear. Composites wear more than amalgams Composite shrink away from cavity walls Minimized by incremental placement. Can cause postoperative sensitivity, & pressure on tooth 27

Strength Wear Polymerization shrinkage

Shrinkage outcomes

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Thermal conductivity

Low thermal conductivity, close to that of natural tooth structure

Coefficient of thermal Greater than tooth structure, causes expansion (CTE) debonding & leakage. Filler content CTE Elastic modulus Determined by amount of filler. Filler increases stiffness. Important in selection for anterior & posterior restorations Water sorption resin content water sorption Radiopacity Barium, strontium radiopacity. Quartz (radiolucent) used as filler in anterior composites to improve shade
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Clinical handling of composites
Composite is used for all sorts of restorative procedures from class I to class IV. Selection criteria:
Esthetic demands: ability to match tooth color and achieve high polishability. Microfills and microhybrids are suited Strength demands: in posterior teeth and stress bearing areas, hybrids are more suited
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Shade guide: Some practitioners apply a
portion of composite on tooth surface and cure it to observe the appropriate shade. The tabs in the shade guide should be moist and held adjacent to the tooth and observed under different lights Shelf life: follow manufacturer instructions but as a general rule, avoid heat and light. Average shelf life 2-3 years.

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Dispensing and cross-contamination: composites are usually dispensed in syringes. Disposable small containers are used to avoid cross-contamination. Once composite is dispensed, it should be covered with a light-protected container

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Isolation

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Single paste, light activated composite Instruments for placing composite Syringe for injecting composite

Self-cure 2 paste composite, and bonding agent bottle
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Matrix strips/ bands: Mylar strip is used in class III,
IV. Metal matrix bands are used for class II cavities (curing is from an occlusal direction then after the band is removed, light is directed from facial and lingual aspects). Clear crown forms are used for build up restorations. A wedge is also used to seal gingivally.

Incremental placement: 2 mm thick is recommended:
To minimize polymerization shrinkage Allow curing light to properly penetrate and cure

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Etching and bonding:
Etching is achieved using phosphoric acid ( 34-37%). After etching, tooth surface is washed and gently dried, etched enamel will appear frosty white. Bonding agent is applied in a thin layer and light-cured according to manufacturer instructions. (remember micromechanical retention).

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Etching and bonding

Etching

Bonding and light curing

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Acid etched enamel

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Resin to resin bonding: proper isolation, no contamination is necessary for proper bonding of successive composite layers. The surface layer is a thin layer of unpolymerized composite (airinhibited), is removed by polishing

Enamel etching

Bonding agent Composite (bonds chemically to bonding agent) 2nd layer of composite, etc.

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Contaminants: After etching and bonding, dentine
surface should be kept contaminant free. Otherwise reetching for 10-15 seconds is necessary. Eugenol containing cements should be avoided. Bonding agent can be used to prevent sticking of composite to instrument during filling.

Light-curing:
Should be held as closely as possible to composite 20-40 seconds for thin layers Thicker layers, darker shades, deeper locations require more time

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Finishing and polishing: sandpaper discs, fine, ultra-fine diamonds. For gingival or interproximal areas, scalpel knife, abrasive strips and needle-shaped diamond burs are used. Polishing pasts can also be used. Surface sealers: unfilled resin maybe added after cleaning and etching the surface. It is thought to be useful to reseal margins opened by polymerization shrinkage, or surface porosities.
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Light curing units
Halogen light bulbs are used as a light source. Light delivery probe or tip is glass or glass encased in metal or plastic casing. Should be covered in a disposable cover
Cordless curing units Plugged into an electric outlet

High intensity light units: curing time
Plasma arc curing units (PAC) Argon laser units

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Precautions for light curing
1.

Inadequate light output: monthly check on light
source, to examine output (using radiometers), any scratches on light probes or darkening due to disinfection.

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Premature set of composites: caused by operatory
light which should be moved away during placement of composite.

3.

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Eye protection: light-shielding protective device, glasses for patient. Heat generation: may cause pulp irritation in deep
cavities (1 mm or less of dentine).
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Light curing unit, protective glasses and shield

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Compomers
Composites modified with polyacid (polyacid-modified resin). The resin contains MMA and polycarboxylic acid. Light activation chemicals are included and also fluoride containing glasses. Fluoride release is small compared to conventional GIC due to resin binding the glass fillers after light activation. Setting rxn occurs in 2 stages Same as light-cured composite Acid-base rxn Bonding to tooth structure occurs as in composites

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Indirect esthetic materials
Inlays Onlays Veneers PFM All-ceramic Crowns with composite resin facing Indirect composites
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Indirect composite restorations
Veneers: can be porcelain or composite. Veneers are used to treat staining, close diastemas, lighten teeth color, reshape crooked teeth.

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Indirect composites:
inlays, onlays, veneers. Preparation is done in the clinic, followed by an impression and construction of the restoration on a die, then cementation in the preparation. With resin cements and bonding agent.

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Laboratory processed composites
Procedure:
Preparation is performed by dentist Impression and bite registration Restoration construction Cementation

Shrinkage occurs outside the cavity, therefore less stress is created as opposed to direct restorations
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Restorative materials used:
Conventional composite Fiber reinforced composite. Fiber source is carbon Kevlar, glass fiber, polyethylene ( to improve strength). Particle-reinforced composite: heavily filled (70-80% by weight) with ceramic particles to improve wear resistance.

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Indirect chair-side technique
Tooth preparation Alginate impression Poured in fast setting die stone or PVS die material (sets in 2 minutes) Composite restoration is made and light cured Adjustment and cementation

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Shade taking

Patient 1. Hue 2. Chroma 3. value Dentist Assistant

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Vita shade guide and shade selection

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Guidelines for taking the shade:
Group effort by dentist, assistant and patient Should be taken before preparation Taken before rubber dam placement Teeth should be clean, free of stains and moist Two different lights should be used (Metamerism): dental offices usually have fluorescent light (blue), or incandescent light (yellow). Natural light is a good source except in morning or late afternoon (more yellow and orange, and less green and blue)

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Continue,
A neutral background should be used (e.g. blue apron) Female patients should be asked to remove lipstick, and colorful clothes should be covered Several tabs are held close to patients teeth and kept moist. Separate shades for cervical part of the tooth might be necessary.

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Characterizing the shade
Surface texture (affects light scatter from tooth) and luster (the degree to which the surface appears shiny) should be noted. These two properties affect how the tooth reflects light and scatter it. The amount of translucency (especially near the incisal edge) should also be noted.
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Continue,
Any surface characteristics should be replicated if the patient demands that the restoration matches existing teeth. A photograph of the patients teeth and adjacent shade guide tab maybe helpful.

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Reference
Dental materials, clinical applications for dental assistants and dental hygienists Chapter 6

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