OPERATIVE 2007 Indications for glass ionomer cements (choose all that apply): a. Crown margin repairs b.

Class IV restorations c. Class III restorations d. Non-stress bearing areas e. Core build ups with less than 3 sound walls remaining f. Core buildups with more than 3 sound walls remaining Answer: a, c, d, and f In addition to the ones listed above, indications include: Class V in adults, Class I and II in primary, temporary or caries control restorations, crown margin repairs, cement base under amalgam, resin, ceramics, direct and indirect gold. Contraindications for glass ionomer cements would be placement in high stress areas: cusp replacement, Class IV and Class II, core build-ups with less than 3 walls.

Match the constituents of amalgam with the properties they contribute to the mix? ____ Silver A. activates reaction with other alloy particles to produce different phases ____Tin B. decreases oxidation of the other elements ____Copper C. decreases setting time, increases setting expansion and strength ____Mercury D. reduces corrosion ____Zinc E. decreases surface tension, reduces creep and marginal breakdown ____Palladium F. increases setting time, decreases expansion and strength ____Indium G. ties up tin reducing gamma-2 formation Answer is: C Silver A. activates reaction with other alloy particles to produce different phases F Tin B. decreases oxidation of the other elements

G Copper C. decreases setting time, increases setting expansion and strength A Mercury D. reduces corrosion B Zinc E. decreases surface tension, reduces creep and marginal breakdown D Palladium F. increases setting time, decreases expansion and strength E Indium G. ties up tin reducing gamma-2 formation Basic constituents: Silver (Ag) 40-70%---decreases setting time, increases setting expansion and increases strength Tin (Sn) 25-27%---decreases expansion and strength and increases setting time (influences amalgam in opposite manner to Silver. Copper (Cu) 9-30%---ties up tin reducing gamma-2 formation, increases strength, reduces tarnish and corrosion, reduces creep. Mercury (Hg) 3% max---activates reaction with other alloy particles to produce different phases. Other Constituents: Zinc (Zn) 1%---used in manufacturing, decreases oxidation of other elements. Palladium (Pd) 1%---reduces corrosion Indium (In) 1%---decreases surface tension, reduces creep and marginal breakdown and increases strength--Must be used in admixed alloys. References: Martinez, MC, Rivera, JM, Rodriguez, Colon LI, & De Jesus NR, Applications of Engineering Mechanics in Medicine, University of Puerto Rico, Mayaguez. September, 2003, pp B2-5.

Which of the following are advantages of the visible light curing systems compared to the old ultraviolet light curing systems? A. A greater depth of resin can be cured by visible light B. The resin can be polymerized through enamel, which is particularly advantageous in class III restorations. C. Generally the intensity of visible lights remains relatively constant until the bulb fails completely. D.

All of the above Visible light curing systems have virtually replaced the UV light systems. Also, visible light curing systems are much more widely used than the chemically activated ones (self cured). An advantage of light curing systems as a whole is that the dentist has complete control over the working time and is not confined to the built-in curing cycle of the self-cure. This is particularly beneficial when large restorations are placed. To deal with problems of incomplete curing with VLC due to the thickness of restorations and filler particles scattering light, manufacturers have developed composite resins that are dual cured which combines self curing and visible light-curing. Another polymerization method is staged curing which is a two-staged cure. However, VLC composites are still the most popular today. Visible light cured composites are single component pastes, and the polymerization process is activated by an external energy source. The alpha-diketone initiator ( usually camphor quinine) absorbs energy from a visible (474 nm-blue light) light source. The ketone absorbs energy and reacts with an amine (added to the system to enhance the effect of the light-sensitive catalyst) to produce free radicals. Answer is: D

Drawbacks attributed to the use of calcium hydroxide as a pulp capping agent include which of the following: 1. Dissolution with acid etching 2. Degradation under leaky restorations 3. Interfacial failure during amalgam condensation 4. Long term success steadily drops to less than 10% after 10 years a. 1 and 3 b. 2 and 4 c. 1,2 and 3 d. 1,2,3 and 4 e. 4 only

Answer: C. 1,2 and 3. The most significant drawback of calcium hydroxide is that acids cause dissolution, the material degrades under restorations and it does not provide a strong base for restorations. However, clinical trials demonstrate favorable long term success when used as a pulp capping material. Therefore, the use of Ca(OH)2 should be limited to as small an area as possible. Lightactivated forms have been developed which eliminates most of the problems, and a glass ionomer lining material can be placed over the Ca(OH)2 as well. The glass ionomer then provides acid resistance and the ability to support condensation pressures. Finally, the advantages of fluoride release and adhesion to tooth structure help the long term prognosis of the Ca(OH)2 / glass ionomer combination Tetracycline staining always occurs at a young age. Long term bleaching effects from peroxide solutions take effect by decreasing the translucency of the enamel, preventing the effects of dentinal stain from shining through the enamel. a. Both statements are true. b. The first statement is true, the second is false. c. The first statement is false, the second is true. d. Both statements are false Answer: d. Both statements are false. Tetracycline staining most frequently occurs at an early age. It is caused by ingestion of the drug concomitant with development of the dentition, However, studies indicate that permanent teeth in adults also can experience a graying discoloration as a result of long-term exposure to minocycline, a tetracycline analog. Sturdevants Art and Science of Operative Dentistry, 4th ed. p. 606 Mosby, 2002. The mechanism of action of bleaching teeth with peroxide is considered to be oxidation of organic pigments. Which of the following statements is/are true about the soft start polymerization technique? 1. Less polymerization stress is associated with the use of this technique. 2. It works with all types and brands of curing lights. 3. Can involve use of stepped, ramped or pulse delayed light curing methods. 4. A stepped cure involves increasing the intensity every 10 seconds for one minute. A. 1, 3

B. 1, 2, 3 C. 3 only D. 1, 2, 3, 4 Answer: A Soft start polymerization involves a slow increase or delay in irradiance. A slower rate of shrinkage and reduction in stress are the desired advantages. Some curing lights have a soft start curing program build into them. There are three methods for soft start polymerization: Stepped - Short, low initial burst for 10 seconds, then full intensity for the remainder of the curing time. Ramped Gradual increase from an initial low level. Pulse delayed Short, low level burst. Delay for polishing. Full intensity. Match the following components with their function in the setting reaction of composite restorations. One answer per component. a. Organosilane ____ Lowers viscosity, polymer conversion, cross-linking and b. Benzophenone shrinkage. c. TEGDMA ____ Increases strength and abrasion resistance. d. Glass ____ UV absorber. e. Metal oxides ____ Serves as an inhibitor to the setting f. Camphorquinone reaction. g. butylated hydroxytoluene ____ Initiator of the reaction by absorbing blue light at 400-500nm. ____ Bifunctional molecule that combines filler particles with the resin matrix. ____ Provides shading and opacity. Answer:

c Lowers viscosity, polymer conversion, crosslinking and shrinkage. d Increases strength and abrasion resistance.

b UV absorber. g Serves as an inhibitor to the setting f Initiator of the reaction by absorbing blue light at 400-500nm. a Bifunctional molecule that combines filler particles with the resin matrix. e Provides shading and opacity. The setting reaction for resin restorative composites involves free radical polymerization. The following stages occur during the setting reaction: Initiation Production of reactive free radicals. This is accomplished with a peroxide-amine system and exposure to blue visible light or a diketone-amine system. (Benzoyl peroxide + Aromatic tertiery amine + blue visible light) free radicals or (A diketone such as camphorquinone + Aliphatic amine + blue visible light) free radicals Propagation Molecules link together forming chains and cross-linking begins. Termination Material stiffens. Not all double bonds react. The "degree of conversion" varies from 35% at the air inhibited layer to 80% in the bulk. Inhibition Inhibitors terminate the reaction. Composites are composed of the following components: Resin matrix monomer Bis-GMA which is an oligomer and is very viscous. Diluents are added to lower the viscosity and increase polymer conversion, crosslinking and shrinkage. Diluents may be UDMA, EGDMA or TEGDMA. Shrinkage is about 2-7%. initiator - Camphorquinone. Absorbs blue light at 400-500nm. activator - Tertiery amine. inhibitor - Heat, light, butylated hydroxytoluene, atmospheric oxygen, phydroquinone.

pigments - Metal oxides. Titanium and aluminum oxide. Provide shading and opacity. Inorganic filler - Glass, quartz, colloidal silica. Increase mechanical properties including strength, abrasion resistance, esthetics and handling. Coupling agent - Organosilane. Combines filler particles with resin matrix. It is a bifunctional molecule. UV absorbers Benzophenone. What is the proper sequence of events that occur during the setting reaction of glass ionomer cements? a. Release of Ca++, Al+++, Fl- ions and silica-based hydrogel forms around glass particles. b. The polycarboxylates ionically crosslink the poly anion chain and cause the cement to harden. c. Powder and liquid are mixed together. d. A slow hydration of both the silica-based hydrogel and the polycarboxylates occurs which results in a further improvement in the cement's physical properties. e. H+ ions are released from ionization of polyacrylic acid in water. H+ ions attack the glass particle. f. Ca++ and Al+++ ions migrate from the silica hydrogel into the aqueous cement phase where, as the pH increases, they precipitate out as polysalts (polycarboxylates). 1. c, a, e, f, d, b 2. c, e, a, f, b, d 3. c, a, f, e, d, b 4. c, e, a, f, d, b Answer: 2 It is an acid-base reaction between the glass powder and the polyacid liquid. When the powder and liquid are mixed, the fluoroaluminosilicate glass is attacked by hydrogen ions (H+) from the polyalkenoic acid, releasing Al+++,

Ca++, Na+ and Fl- ions. A layer of silica gel is slowly formed on the surface of unreacted powder, with the progressive loss of metallic ions. When the free calcium and aluminum ions reach saturation in the silica gel, they diffuse into the liquid and crosslink with two or three ionized carboxyl groups (COO-) of the polyacid to form a gel. As the crosslinking increases through aluminum ions and the gel is sufficiently hydrated, the crosslinked polyacrylate salt begins to precipitate until the cement is hard. The powder is ion-leachable calcium aluminoflurosilicate glass. Modern powders are composed of silica dioxide (41.9%), aluminum oxide (28.6%), calcium fluoride (15.7%), and possibly aluminum phosphate (12%), aluminum fluoride (8%) and sodium fluoride (9%). The liquid is an aqueous solution of polymers and copolymers of acrylic acid (polyacrylic acid). In addition itaconic acid is present and promotes reactivity between the glass and the liquid. It also prevents gelation of the liquid which can result from hydrogen bonding between two polyacrylic acid chains. Polymaleic acid may also be present. It causes the cement to harden and lose its moisture sensitivity faster. Because polymaleic acid contains more carboxyl groups it leads to more rapid polycarboxylate crosslinking. Tartaric acid is a reaction-controlling additive. It extends working time and promotes a snap set by facilitating ion extraction from the glass particles. It then complexes with the ions, preventing them from cross-linking the polymer chain until the chain becomes more linear when crosslinking can occur more readily. Tartaric acid also strengthens and hardens the cement and improves the manipulative characteristics of glass ionomer cements. Setting reaction is as follows: Phase 1

1. Powder and liquid is mixed together. 2. Hydrogen ions (H+) are released from ionization of polyacrylic acid in water. 3. Hydrogen ions (H+) attack the glass particle. 4. Ca++, Al+++ and Fl- ions are released and silica-based hydrogel forms around glass particles. Phase 2 5. Ca++ and Al+++ ions migrate from the silica hydrogel into the aqueous cement phase

where, as the pH increases, they precipitate out as polysalts (specifically as polycarboxylates). 6. The polycarboxylates ionically crosslink the poly anion chain and cause the cement to harden. Calcium polycarboxylates form first. They form over the first 5 minutes, while the stronger aluminum polycarboxylates form over the next 24 hours. Phase 3 7. A slow hydration of both the silica-based hydrogel and the polycarboxylates occurs which results in a further improvement in the cement's physical properties. This phase may continue for several months. Two important clinical results of this reaction are that the physical properties of the glass-ionomer cements take a relatively long time to fully develop because of the cement's long setting reaction and that the cement is sensitive to moisture contamination and to dessication because the glass particles are covered with the hydrogel. Reaction broken down into stages: i) Decomposition: Acid attacks gel particles releasing metal ions. ii) Migration: Ions migrate into aqueous cement matrix. Cement has a shiny, glossy appearance. iii) Gelation: Metal ions gel the polyacid. Calcium polyacrylate is the primary component. Cement is rigid and relatively opaque. iv) Post-set hardening: Ions become bound to the polyacid chain (crosslinking). Aluminum polyacrylate becomes the dominant component. v) Maturation: Increased crosslinking, decrease in "loosely" bound water, increase in "tightly" bound water. Leads to improved physical properties, increased resistance to acid attack and dessication and increased translucency. This can continue for several months.

The total etch technique generally yields higher bond strengths than the selfetch technique. Clearfil SE Bond is an example of a total etch adhesive system. a. Both statements are true. b. The first statement is true. The second statement is false.

c. The first statement is false. The second statement is true. d. Both statements are false. Answer: b

Adhesives can be broken down into three groups: Etch and rinse (total etch), selfetch and glass ionomer adhesives. The etch-and-rinse approach involves three steps: Application of conditioner or acid etchant, followed by primer or adhesion-promoting agent and then the actual bonding agent or adhesive resin. The simplified two-step version combines the second and third step but still follows a separate etch-and-rinse phase. This technique is still the most effective approach to achieve an efficient and stable bond to enamel. Selective dissolution of hydroxyapatite crystals through acid etching with 30 or 40% phosphoric acid gel is followed by polymerization of the resin that is absorbed by capillary attraction within the created etch pits, enveloping individually exposed hydroxyapatite crystals. In dentin, this phosphoric acid treatment exposes a

microporous network of collagen with elimination of most or all hydroxyapatite. The bonding mechanism of etch-and-rinse adhesives to dentin is primarily diffusion-based and depends upon hybridization or infiltration of resin within the exposed collagen fibril scaffold. True chemical bonding is unlikely. The most critical step in the etch-and-rinse approach is application of the primer. If an acetone-based primer is used the wet-bonding technique is necessary. For wateror ethanol-based adhesives gentle air-drying of acid-etched dentin (and enamel) followed by dry-bonding is used. With the two-step etch-and-rinse adhesives, the primer and adhesive resin are combined into one solution. In the conventional three-step systems, the primer ensures efficient wetting of the exposed collagen fibrils, displaces residual surface moisture, transforms a hydrophobic tissue state into a hydrophobic one and carries monomers into the interfibrillar channels. The adhesive resin fills the pores between the collagen fibrils, forms resin tags that seal the opened dentinal tubules, initiates and advances the polymerization reaction, stabilizes the hybrid layer and resin tags and provides sufficient methacrylate double bonds for copolymerization with the restorative resin. The self-etch approach is more user friendly and less technique sensitive. They do not require a separate etch-and-rinse step. This technique involves two- or one-step application procedures. These adhesives can be divided into strong, intermediary strong and mild self-etch adhesives. Low-pH self-etch adhesives have often been shown to have low bond strengths, especially to dentin. Mild self-etching agents leave residual hydroxyapatite still attached to the collagen. Sufficient surface porosity is created to obtain micromechanical interlocking. The preservation of hydroxyapatite within the submicron hybrid layer may serve as a receptor for additional chemical bonding. The weakest property of mild self-etch agents is their bond to enamel. Intermediary-strong adhesives typically produce a dentinal hybrid layer with a complete demineralized top layer and a partially demineralized base. The deepest region of the hybrid layer still contains hydroxyapatite. Better micromechanical interlocking is achieved in enamel as well as dentin. The residual hydroxyapatite at the hybrid layer base may still allow chemical intermolecular interaction. The strong self-etch adhesives work similarly to etch-and-rinse adhesives. They have been shown to have low bond strength values, especially to dentin. The one-step self-etch adhesives are userfriendly but they have lower bond strength values than multistep self-etch adhesives and etch-and-rinse adhesives. Adhesives we use today: 4th generation adhesives Pretreatment of dentin with conditioners and/or primers. They generally come with 30 to 40% phosphoric acid gels and are referred to as three-step etch-and-rinse adhesives. The final step involves the

application of an unfilled or semifilled low-viscosity adhesive resin that copolymerizes with the primed dentin surface layer and simultaneously offers bonding receptors for copolymerization with the composite. Ex. All-bond 2, Optibond FL, Permaquik and Scotchbond Multi-Purpose. 5th generation adhesives These adhesives utilize a separate etch-and-rinse (total-etch) phase followed by a combined primer-adhesive resin solution. Bonds strengths are often a little less than 4th generation adhesives. Ex. Prime & Bond, Single Bond or Scotchbond 1. 6th generation adhesives Self-etch adhesives. Omit the separate conditioning phase and are composed of two different solutions. These include adhesives with self-etching primers and those that combine the conditioner, primer and adhesive but require mixing. This generation contains two-step self-etch adhesives and one-step, two-step component self-etch adhesives. These adhesives use the smear layer on the enamel and dentin as a bonding substrate. Again bond strengths are generally lower than that of 4th and 5th generation adhesives. Ex. (two-step self-etch adhesives) AdheSE, Clearfil SE Bond, Clearfil Protect Bond, Optibond Solo plus Self-Etch and Tyrian SPE One-Step Plus. (Onestep, two-component self-etch adhesives) Adper Prompt L-Pop, One-Up Bond F and Xeno III. 7th generation adhesives Single component one-step self-etch adhesives. Truely one-bottle systems. Conditioner, primer and adhesive all in one bottle pre-mixed. Prone to phase separation and formation of droplets within their adhesive layers. Consistently lower bond strengths than 4th and 5th generation adhesives. Ex. Clearfil S Bond, G-Bond, i-Bond and Xeno IV.

Packable composites have less polymerization shrinkage than hybrid composites. Packable composites can be bulk cured in increments of 4-5mm. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. Answer: d Packable composites were specifically designed for posterior use. These materials have increased viscosity to give them a consistency more similar to dental amalgam. Claims of enhanced clinical performance, reduced polymerization shrinkage and enhanced wear resistance have been made. Properties such as flexural strength, fracture toughness and polymerization shrinkage of packable composites are comparable, but not superior to those of other hybrid or reinforced microfilled resin composites currently available. Manufacturers have claimed that these materials can be bulk filled in increments of 5mm or greater. Research has clearly demonstrated that this is not true. Adequate polymerization of composites can only be accomplished with increments of 2mm or less. These materials may have a heavier consistency and a "drier" feel to them.

What is true about composites? a. Microfilled are the most indicated composites for a for a cl. IV restoration b. Microfilled composites have 0.04 m filler particles c. Hybrid composites have 0.04 m and 1-4 m particle fillers d. Hybrid have increased polishability compared with microfilled e. Esthet-X is an example of a nanofilled f. b,c,d,e g. All of the above answer: f Microfilled composites: 0.04 m 0.2 m microfine filler particles o High coefficient of thermal expansion due to lower filler content; much higher volume % of polymer, higher shrinkage o CTE= 55- 68 x 10-6 0 C o Contain silica with a very high surface area o 25% by volume or 38% by weight silica o Low tensile strength reduced stiffness and increased rate of crack propagation (diametral tensile strength= 30-55 Mpa) o High water sorption- 26- 30 g/mm3 o High polymerization shrinkage 2-3% o Modulus of elasticity in compression= 2.6- 4.8 GPa o Increased polishability due to smaller filler size rather than volume o

Indications: areas of high polishability, with no occlusal contacts. Ex. labial veneers with no incisal edge extension, Class V erosion lesion (enamel margins) improved esthetics; not recommended for Class 4 restorations but when a highly polished restoration is needed, a hybrid material may be used as a substructure that can be veneered with a microfilled composite. o Contraindications: restoration with occlusal forces, high caries, cementum margins. o Ex. A 110, Durafill VS, Renamel Microfill, and Matrixx Anterior Microfill, Heliomolar. Hybrids : 0.04 m to 1-4 m particle fillers o Blends the properties of macro and micro fillers strength of macrofills with polishability of microfills making smaller particles of uniform size and increasing the loading volume. o Contain irregularly shaped glass (borosilicate glass; lithium or barium aluminium silicate; strontium or zinc glass), quartz or zirconia particles of uniform diameter. o 60- 70% filler by volume o 77% - 84% filler by weight o Contain mostly fine particles (0.4 3 m) and some microfine particles (0.04 0.2 m) o CTE= 25- 38 x 10-6 0 C o Modulus of elasticity in compression= 5.5- 8.3 GPa o water sorption- 5 - 17 g/mm3 o Microhybrids or nano filled composites: less than 1m average particle size: ex. Esthet-X o Increased compressive strength o Decreased polymerization shrinkage- (0.7 1.4%)

o Increased hardness o Increased wear resistance o Indications: posteriors, Class III/IV with occlusal contacts o Ex. Point-4, Tetric Ceram, Venus, Z 100 Nanofilled/ Nanohybrid: 2-20 nm silica; 0.6 nm zirconi-silica nanoclusters o nanofill and nanohybrid composite resins include: Filtek Supreme, Simile, Esthet-X Improved, and TPH. Enamel, dentin, amalgam, composites: o Knoop Hardness: o Composites (22-80 Kg/mm2 ) o Enamel (343 kg/mm2 ) o Amalgam (110 kg/mm2 ) o Polymerization shrinkage stresses comp-tooth up t0 13MPa o Polymerization reaction 24h o % double bonds that react: 35- 80% o Activation of initiator camphorquinone @ 470 nm o Accelerator: organic amine o CTE enamel= 11.4 x 10-6 0 C o CTE dentin= 8.3 x 10-6 0 C o Modulus of elasticity in compression: o

Amalgam 62 GPa o Dentin 19 GPa o 83 Gpa enamel Match each statement on the left with the type of amalgam on the right that is most appropriate. ___ Easier to achieve contact in a class A. Admixed amalgam, high Cu II cavity. ___ Dispersalloy. B. Spherical amalgam, highCu ___ Easier to seal margins if condensed C. Low copper amalgam well. ___ Valiant. ___ The mercury content is higher. ___ Has increased tarnish, corrosion, and creep. ___ Requires more force on condensation. ___ Needs more time in the triturator. ___ Easier to achieve contact in a class II cavity.

___ Easier to achieve contact in a class II cavity. A. Admixed amalgam, high-Cu ___ Dispersalloy. A. Admixed amalgam, high-Cu ___ Easier to seal margins if condensed well. B. Spherical amalgam, highCu ___ Valiant. B. Spherical amalgam, high-Cu ___ The mercury content is higher. A. Admixed amalgam, high-Cu ___ Has increased tarnish, corrosion, and creep. C. Low copper amalgam ___ Requires more force on condensation. A. Admixed amalgam, high-Cu ___ Needs more time in the triturator. B. Spherical amalgam, high-Cu In general, admixed amalgams (containing both spherical and lathe cut particles) require less time in the triturator (8-10s), and more readily achieve good contacts in class II cavity preparations. They have a slightly higher mercury content than spherical amalgams because the particles do not pack together as

closely when the setting reaction is taking place. Brands include Dispersalloy, Contour, Valiant PhD and Megalloy. In contrast, spherical amalgams require more time in the triturator (10-12s), require less force on condensation, and exhibit better marginal closure when condensed well. They have a slightly lower mercury content due to the more intimate packing of particles in the final alloy. Examples include Tytin and Valiant. All amalgam alloys on the US market to day are considered high copper alloys and contain 13-30% copper. Adding this to the alloy significantly decreases the gamma-two phase (Sn7-8Hg ) in the final product; as this material has the highest corrosion rate, static creep and tarnish, the resultant physical properties are improved. Which of the following are true about compomers? Choose all that apply. a. They are also known as polyacid-modified glass ionomers. b. Like composite resins, darker shades tend to cure less effectively with visible light as the depth from the surface is increased. c. Once in place, they take up water in situ, which activates the glass ionomer-type reaction and causes the release of fluoride. d. Water uptake causes further strengthening of the material as it activates the glass ionomer-type reaction. e. Water uptake tends to cause discoloration of the material. f. Compomers are indicated for class I, II and V cavity preparations, as pit and fissure sealants, and as orthodontic band cements. g. These materials are especially useful in permanent teeth. A. a, b, c, d, e. B. b, c, e, f. C. b, d, e, f, g.

D. a, b, c, e, f, g. E. All of the above. F. None of the above. Answer: B. b, c, e, f. Compomers are also known as polyacid-modified resin composites, although the former name doesnt describe the materials as accurately as the latter. The material contains no water, and when placed, is initially cured with visible light. After the initial set, water is absorbed in vivo which activates the glass ionomertype reaction, leading to the release of ions and fluoride in clinically significant amounts. Like composite resins, darker shades tend to cure less effectively as depth of material is increased, so incremental placement is indicated. While water absorption is a distinctive feature and leads to fluoride release, it also weakens the compressive and flexural strengths of the material, making their physical properties inferior to traditional resin composites. Obviously, as water is absorbed, pigments can be taken up as well, leading to discoloration. These materials have performed well in primary teeth and tend to have good handling properties. They have also performed adequately as pit and fissure sealants, as a cement for orthodontic bands, and in class I, II and V cavity preparations. Reference: Nicholson JW. Polyacid-modified composite resins (compomers) and their use in clinical dentistry. Dental Materials. June 2006. 19; Epub ahead of print. Which of the following are true concerning resin-modified glass ionomers? A. They were developed to address the limitations of traditional glass ionomers including technique sensitivity, moisture sensitivity, short working time, and inferior esthetic properties. B. They still contain ion-leachable fluoroaluminosilicate glass, but also contain resin monomers and may be light activated via camphoroquinone; this improves the working and setting properties as well as the final esthetics. C. Because they contain composite resins and release fluoride, dentists should abandon traditional composite resins and traditional glass ionomers.

D. All of the above. E. A and B only. Answer: E. A and B only. Resin-modified glass ionomers were developed to address the limitations of traditional glass ionomers including technique sensitivity, moisture sensitivity, short working time, and inferior esthetic properties. They still contain ion-leachable fluoroaluminosilicate glass, but also contain resin monomers and may be light activated via camphoroquinone; this improves the working and setting properties as well as the final esthetics. They can be utilized as direct restorative materials, but are commonly employed as cements/luting agents (ie: Fuji series). They differ from polyacid-modified composite resins (compomers) because the initial setting reaction is the glass ionomer reaction (SLOWLY), which allows for increased working time. When the clinician is ready, he/she activates the photoinitiator to polymerize the resin groups and speed the final setting. In general, they are easier to use than conventional glass ionomers, their physical properties are better than conventional glass ionomers (including compressive/tensile/flexural strengths, fracture toughness, wear resistance, fatigue resistance, bond strengths to enamel/dentin/resin-based restorative materials, marginal adaptation, and microleakage), they are less water sensitive, and they have comparable fluoride release to traditional glass ionomers. Physical properties do remain inferior to composite resins.

Which of the following are true concerning bleaching? A. Vital bleaching is generally a safe procedure. B. Nonvital bleaching may be completed in the office or between visits. C. Walking bleach refers to patients who wear bleaching trays while traveling from place to place (ie: during their commute). D. All of the above. E. A and B only. Answer: E. A and B only. Vital bleaching is generally a safe procedure. It can be completed between visits by providing trays and bleach to the patient. The dentist can also perform the service in-office, usually with access to stronger bleaching agents in these cases isolation of the soft tissues is key (rubber dam) as many of the stronger agents can cause damage. Regardless of the technique, the end point is generally the same whiter teeth. The decision about which technique to use should be made depending on how much time, inconvenience and expense the patient is willing to tolerate. The most common complaint from patients is sensitivity. Nonvital bleaching is indicated in endodontically treated teeth that have become discolored. The dentist should make sure that no residual gutta percha or sealer remains in the pulp chamber. The dentist should place a barrier between the root canal filling and the pulp chamber (usually a glass ionomer material) between the CEJ and a point about 2mm apical to this; doing so has been shown to prevent external root resorption believed to occur due to seepage of bleaching agents through the cervical area of the tooth. Sodium perborate is the agent of choice as superoxol has fallen out of favor. When a bleaching agent is placed in the tooth and the patient reappointed about a week later for changing/removal of the solution, the term Walking Bleach applies not when patients bleach with trays while moving from place to place. Bleaching of any kind has been shown to interfere with normal dentinal bonding be sure to schedule the patient for such procedures at least 7-14d after completion of tooth whitening. Reference: Summit JB, Robbins JW, Schwartz RS. Fundamentals of operative dentistry: a contemporary approach. 2nd Ed. Quintessence Publishing Co, Inc. 2001.

Light-emitting diode curing lights emit light over a range of wavelengths while quartz-tungsten-halogen lights produce light at a very narrow spectral range. A. True. B. False.

Answer: B. False. Just the opposite is true: light-emitting diode or LED curing lights produce light over a narrow spectral range. If you use this light in your clinical practice, you must make sure the unit you purchase produces the right wavelength of light to activate your photoinitiators. For camphoroquinone-based materials, =470nm should be the main focus. LED lights are appealing to the dentist because they produce less heat than QTH, have good longevity, and have relatively constant bulb output in terms of power density. Quartz-tungsten-halogen or QTH curing lights are both affordable and effective, but have some drawbacks relative to LEDs. They do produce heat which can have ramifications in the dental pulp, and their bulbs emit diminishing power intensity light over time; consequently, a radiometer should be present in the office and used at least weekly to ensure that light output is adequate for curing VLC materials. Both QTH and LED lights have been shown to be clinically effective. OPERATIVE- MATERIALS 2008 By incorporating cross cuts into the head design of burs, the cutting efficiency is increased. The cut surface is much rougher however. a. The first statement is true, the second one false b. The first statement is false, the second one true c. Both statements are false d. Both statements are true. T he answer is d. Both statements are true

When running in slow to medium speeds, cross-cut burs are more efficient. The cross cut reduces the total length of the bur blade that is actively cutting at any one time. They increase the cutting pressure and the perpendicular pressure holding the blade edge against the tooth. The cross cut produces ridges that are not removed and therefore the cut surface is rougher. Roberson,TM, Heymann, HO, Swift,EJ, JR>; Sturdevants Art & Science of Operative Dentistry; Mosby; St. Louis, MO; 2002; pp. 334-336. 3. Dental Amalgam can be classified by: a. Alloy particle geometry and size b. Amount of platinum included c. Copper content d. Hydrogen Scavenger content The answer is a and c. Amalgam can be classified by the size and geometry of the amount of copper within a dental amalgam. Lathe cut Spherical Admix High copper content amalgam has at least 12% copper in corrosion, by eliminating the gamma 2 phase (Hg-Sn). 4. What are some of the advantages of RMGI over conventional GI? a. More rapid early development of strength b. Resistance to moisture attack earlier c. Improved mechanical properties d. All of the above e. None of the above The answer is d. All of the above RMGI are easier to use than GI because of improved material mechanical properties: compressive strength, tensile and flexural strengths, wear resistance, better bond strengths to enamel and dentin, lower marginal leakage. They are used in high caries risk patients, ART, in areas where esthetics are concerned, Summit,JB, Robbins,JW, et al: Fundamentals of Operative Dentistry; Quintessence Publishing, Co.; Chicago, IL; 2004; pp. 246-247. 5.

The setting reaction in a GI is acid-base type of reaction. What reacts as acid and what reacts as base? a. Water b. Fluoroaluminosilicate glass c. Polyalkenoic acid d. Hydrofluoric acid e. HEMA f. A and B g. C and E h. B and C i. B and D The answer is H. The fluoroaluminosilicate glass is attacked by hydrogen ions from the polyalkenoic acid releasing calcium, aluminum, sodium and fluoride ions. A silica gel forms around the unreacted glass and when the aluminum and calcium ions reach saturation in the gel, they start to react with two or three COO- of the polyacid to form a gel. As more of these cross link, they precipitate out until the cement is hard. OPERATIVE 2006

1. Which of the following properties of a packable posterior resin composite are superior to those of other conventional restorative hybrids?

1) Wear 2) Flexural modulus 3) Flexural strength 4) Fracture toughness

5) Polymerization shrinkage

A) 1, 4 B) 2, 3, 4 C) 5 only D) All of the above E) None of the above

Answer: E

Although claims by manufacturers may lead you to believe otherwise, extensive clinical research has shown that in packable composites, the above properties are comparable to, but not superior to, similar properties in currently available hybrid resin composites.

In these packable materials, the filler type, size, and/or particle distribution differ from those of conventional restorative hybrid and microfilled resin composite materials in order to increase viscosity and impart a consistency that more closely mimics that of dental amalgam.

Of particular concern with these materials is the claim by some manufacturers that these materials can be bulk-cured in increments of 5 mm or greater. This is not the case; adequate polymerization of the resin composite can be accomplished only in increments of 2 mm or less.

The only significant difference with the packable composites is the handling characteristics, which are a matter of personal preference. If used properly, they can be expected to produce results that are comparable to other resin composites used in the posterior.

Summit & Robbins Fundamentals of Operative Dentistry, 3rd ed. (2006) p. 326. 3. Which of the following statements is FALSE concerning resin-modified glass ionomer cements?

A) Most mechanical properties are superior to those of conventional glass ionomers B) Fluoride release is equal to or greater than that of conventional glass ionomers C) Preferred over resin composite in root caries lesions because of less microleakage D) Bond strength to dentin is generally lower than that of conventional glass ionomers E) Offer better esthetics than conventional glass ionomers

Answer: D

Mechanical properties of RMGI such as compressive, tensile, and flexural strengths; fracture toughness; wear resistance; fatigue resistance; bond strengths to enamel, dentin, and other resin-based restorative materials; marginal adaptation; and microleakage are reported to be better than those of conventional glass ionomer cements. They appear to be less sensitive to water, are radiopaque, and offer better esthetic possibilities than do conventional GIs.

The fluoride release of current RMGI cements is reported to be equal to or greater than that of conventional GI cements, and the fluoride-releasing property may even be rechargeable.

Because of their inferior physical and chemical properties as compared to resin composites, the primary indications for the RMGI materials are restorations for patients at high risk for caries and in areas where esthetics is not a primary concern.

Summit & Robbins Fundamentals of Operative Dentistry, 3rd ed. (2006) pp. 246-247.

4. What properties will be improved by the application of an unfilled resin surface sealant after finishing of a resin composite restoration?

1) Marginal integrity 2) Microleakage 3) Wear 4) Marginal staining 5) Hardness

A) 1, 2, 4 B) 2, 4 C) 1, 5 D) 1, 2, 3, 4 E) All of the above

Answer: D

Finishing procedures are destructive to the resin composite restoration and have been shown to adversely affect wear. In addition, the composite surface that was closest to the light tip during curing, and therefore has the best mechanical properties, is removed during the finishing procedures. Finishing procedures can also exacerbate the marginal gaps following polymerization.

For these reasons, the occlusal surface and all accessible restoration margins should be rebonded with an unfilled VLC resin (surface sealant). The lower the viscosity of the rebonding resin, the more effective it will be in penetrating interfacial gaps and microcracks. Rebonding has been shown to improve and prolong marginal integrity, reduce microleakage, reduce marginal staining, and reduce wear.

Summit & Robbins Fundamentals of Operative Dentistry, 3rd ed. (2006) p. 328. 6. Sectional matrix systems such as Palodent are often used in the placement of Class 2 resin composite restorations. All of the following are advantages of these systems EXCEPT:

A) The metal band is typically stiffer and less malleable than a conventional matrix band, allowing for heavy burnishing into the contact area B) Provides wedging to ensure good interproximal contact C) Provides better proximal contours for posterior resin composite restorations than traditional matrices

D) Simplifies matrix placement for single proximal surface restorations compared to a circumferential band E) Are available in different sizes and shapes to accommodate many clinical situations

Answer: A

B, C, D and E all represent advantages of most sectional matrix systems (e.g. Palodent, Composi-Tight).

The matrix should be burnished gently against the adjacent proximal contact. The sectional matrices in these systems are typically made of dead soft metal. Heavy burnishing will cause grooves to be formed in the matrix that will be replicated in the restoration. This makes for a rough, irregular contact that can tear and shred floss when the patient performs oral hygiene measures, so only light burnishing should be used.

After the sectional matrix and wooden wedge are placed, the ring is placed using the rubber dam forceps so that the vertical points of the ring are positioned in the facial and lingual embrasures adjacent to the box preparation. The ring holds the ends of the sectional matrix tightly against the tooth and exerts a continuous separating force between the teeth. If left in place for a long period of time, excess separation can occur, resulting in an overly tight contact.

Summit & Robbins Fundamentals of Operative Dentistry, 3rd ed. (2006) p. 312-313. 9. Which pre-fabricated post material has the highest modulus of elasticity?

A) Titanium B) Quartz fiber C) Glass fiber D) Zirconia

Answer: D

Zirconia (ceramic) posts have a very high modulus of elasticity, and are therefore very rigid. They have high flexural strength, but because they do not flex, they may transmit more stress to the root and increase the risk of catastrophic failure (unrestorable root fracture). In addition, because of their rigidity, it can be difficult to remove a cemented zirconia post from a failed restoration.

Glass fiber and quartz fiber-reinforced posts have a MOE similar to dentin, and are therefore less likely to cause catastrophic failure. However, if they are too flexible, they may lead to microcracks and/or microleakage at the core/tooth interface. When using these post systems, it is absolutely critical to have at least a 2 mm ferrule circumferentially to lend strength to the restoration.

Akkayan B, Gulmez T. Resistance to fracture of endodontically treated teeth restored with different post systems. J Pros Dent 2002;87:431-437. Fernandes AS, Shetty S, Coutinho I. Factors determining post selection: A literature review. J Pros Dent 2003;90:556-562.

11. Which two of the flowing statements are true?

A. Self-cured glass ionomer sealants have superior retention compared to resin-based sealants. B. Self-cured glass ionomer sealants have inferior retention compared to resinbased sealants C. Self-cured glass ionomer sealants have equal retention compared to resinbased sealants D. Self-cured glass ionomer sealants have superior sealing ability compared to resin-based sealants. E. Self-cured glass ionomer sealants have inferior sealing ability compared to resin-based sealants. F. Self-cured glass ionomer sealants have equal sealing ability retention compared to resin-based sealants.

Answer: B and E

This is true for resin-modified glass ionomer sealants as well. The retention and marginal seal of light-cured, resin-based sealants has been shown to be superior to that of glass ionomer sealants in many studies.

It has also been shown that placing sealants with a rubber dam significantly increases sealant retention and marginal seal.

References: Forss H, Saarni UM, & Seppa L. Comparison of glass-ionomer and resin-based fissure sealants: a 2[-year clinical trial. Community Dent Oral Epidemiol. 1994 Feb; 22(1): 21-4.

Kilpatrick NM, Murray JJ, & McCabe JF. A clinical comparison of a light cured glass ionomer sealant restoration with a composite sealant restoration. J Dent. 1996 Nov; 24(6): 399-405.

Forss H & Halme E. Retention of a glass ionomer cement and a resin-based fissure sealant and effect on carious outcome after 7 years. Community Dent Oral Epidemiol. 1998 Feb;26(1): 21-5.

Ganss C, Kilmek J & Gleim A. One year clinical evaluation of the retention and quality of two fluoride releasing sealants. Clin Oral Investig. 199 Dec;3(4): 188-93. 13. Which of the following statements regarding bonding systems are true?

1. When using a total-etch bonding system, preparing enamel prior to bonding results in better adhesion than bonding to unprepared enamel. 2. When using a total-etch bonding system, preparing enamel prior to bonding does not result in better adhesion than bonding to unprepared enamel. 3. When using a self-etching bonding system, preparing enamel prior to bonding results in better adhesion than bonding to unprepared enamel. 4. When using a self-etching bonding system, preparing enamel prior to bonding does not result in better adhesion than bonding to unprepared enamel.

A. 1 and 3 B. 1 and 4 C. 2 and 3 D. 2 and 4

Answer: C

Many studies have shown that when using a total-etch bonding system (etching followed by primer and adhesive), preparing enamel provides no advantage in adhesion.

In contrast, preparing enamel does permit better adhesion to occur when using a self-etching bonding system.

References: Gray GP et al. Factors associated with shear bond strength of composite resin to human enamel. Eur J Prosthodont Restor Dent. 1996 Dec;4(4): 163-8.

Strydom C. Self-etching adhesives: review of adhesion to tooth structure part I. SADJ. 2004 Nov; 59(10): 413-19.

Brackett WM et al. Eighteen-month clinical performance of a self-etching primer in unprepared class V resin restorations. Oper Dent. 2005 Jul-Aug; 30(4): 424-9.

Shook LW et al. Effect of surface roughness of cavity preparations on the microleakage of Class V resin composite restorations. Oper Dent. 2003 NovDec;28(6): 779-85.

14. Compared to conventional glass ionomers, compomers have a prolonged duration of fluoride release (longer-lasting effect). After recharging the materials with topical fluoride, resin-modified glass ionomers have a longer

duration of fluoride release (longer-lasting effect) than conventional glass ionomers.

A. Both statements are true B. Both statements are false C. First statement is true, second statements is false D. First statements is false, second statements is true

Answer: D

All fluoride-releasing materials release most of their fluoride within the first 24 hours. The fluoride release decreases sharply the second day and then tends to gradually diminish over 3 weeks or so. After 2-3 weeks, GIs and RMGIs tend to sustain a long-term, low-level fluoride release. Compomers lose their fluoridereleasing ability much more rapidly.

Following re-charging with topical fluoride, RMGIs release the greatest amount of fluoride for the longest amount of time. This is a relative benefit, because after 24 hours the amount of fluoride released is low for all materials. To achieve the desired benefit of recharging glass ionomers with fluoride, the materials should be recharged with fluoride sources such as toothpaste, mouth rinse, or topical fluoride solutions daily.

Some manufacturers recommend sealing the surface or placing a protective coating on the surface of glass ionomers after placement. This may improve esthetics, but it drastically reduces the products fluoride releasing and recharging ability until the applied coating is abraded away at which point the material behaves as any other glass ionomer.

It has been shown that restorations with larger surface area releases more fluoride. Placing adhesive or a barrier in the prepared tooth under a fluoridereleasing material prevents the tooth from benefiting from fluoride uptake.

References Delbem et al. Fluoride Release/Recharge from Restorative Materials Effect of Fluoride Gels and Time. Operative Dentistry 2005;30(6): 690-5.

Summit JB, Robbins JW & Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach, 2nd ed. Quintessence Publishing Co, Inc. Chicago. 2001: 378-9.

15. Which of the following does not describe an advantage of LED curing lights compared to halogen curing lights?

A. Temperature increase to tooth is less with an LED light. B. The LED diodes last longer than halogen bulbs. C. The spectrum of visible light emitted with the LED is narrower and concentrated closer around the wavelength necessary to cure most modern dental materials. D. Equal depth of cure and hardness values can be obtained in less time with the LED lights. E. LED lights are more energy efficient than halogen lights

Answer: D

-Temperature increase as measured in enamel during irradiation: Halogen = 15oC LED = 9-10oC Plasma ranged from 15-60oC -LED diodes have a life span approximately 1000 times longer than the typical halogen bulb. -Spectrum: Halogen (with filter) = 400-500nm LED = 450-490nm Plasma with 470nm filter = 450-490nm

Plasma and halogen lights emit a broad spectrum on light. Filters are required to limit the spectrum to the desired wavelengths. LED lights require NO FILTER. They naturally emit light in the 450-490nm wavelengths. This is great for camphorquinone, but could be a potential problem if using a material whose photoinitiator requires wavelengths of light outside of this spectrum. Camphorquinone is the most widely used photoinitiator in dental materials. The most efficient wavelength to initiate this is 470nm.

-Energy efficiency: LED lights are much more energy efficient, allowing them to run on battery power. This enables easy transportation between operatories if desired. ISO light intensity standards were developed for halogen bulbs in dentistry. The acceptable intensity for wavelengths between 400-515 is

between 300-1000mW/cm2. Plasma lights far exceed this intensity and LED lights are less intense than this range. These ranges were developed for halogen bulbs, though, so this does not indicate inability to adequately cure composites for LED lights. -Depth of cure: LED lights have been proven to be able to adequately cure composite to depths of 2mm. Depths greater than this are not recommended for any light source. Although some manufacturers advertise ability to cure faster with LED lights, studies have shown that at least equal amounts of time are required for both LED and halogen bulbs to achieve adequate depth of cure and hardness. Studies have also shown that when compared to LED lights, halogen bulbs are able to achieve greater hardness in composite depths >2mm, though this practice is not recommended.

References: Soh MS, Yap AUJ, Siow KS. The Effectiveness of Cure of LED and Halogen Curing Lights at Varying Cavity Depths. Oper Dent. 2003;28(6): 707-15. Nomoto R, McCabe JF, Hirano S. Comparison of Halogen, Plasma, and LED Curing Units. Oper Dent. 2004;29(3): 287-94. Summit JB, Robbins JW & Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach, 3rd ed. Quintessence Publishing Co, Inc. Chicago. 2006: 283-4,324-26.

16. During a routine exam, you notice a discoloration in the distal pit of tooth #3. After air-drying the tooth and using good lighting and magnification, you diagnose the tooth as having a small carious lesion. To confirm your suspicion, you probe the area with an explorer and get a small stick. What is the best treatment recommended for this tooth?

A. Put a watch on the lesion, not treating until a radiolucency is observed on a bitewing radiograph. B. Apply a sealant C. Place a preventive resin restoration D. Place a class I amalgam restoration

Answer: C

Preventive Resin Restorations (PRRs) limit the preparation to pits and fissures that are carious. Once all of the carious tooth structure is removed, no further preparation is performed.

Advantages of a PRR: -Conserve tooth structure no preparation beyond carious activity -Esthetics better than occlusal amalgam -Minimal wear the prep should be such that most of the occlusal force remains on natural tooth structure, not on the restorative material -Good longevity PRRs have been shown to last over 10 years and can equal or exceed the performance of an amalgam restoration

In this case, caries was definitely diagnosed. The carious tooth structure should be removed rather than simply placing a sealant over the tooth. Based on clinical judgment, remineralization may be performed IF the lesion is not cavitated. Some will argue, though, that the stick of the explorer just cavitated the lesion even if it wasnt before. This is why caries diagnosis should be done visually.

To properly place a PRR, rubber dam isolation should be used. The preparation eliminates demineralized dentin, unsupported enamel, and associated demineralized enamel. If the preparation is restricted to a narrow opening of a fissure, a sealant material or a flowable composite can be placed. If more tooth structure is removed, a filled composite should be placed, and the occlusal surface sealed with a sealant.

References: Simonsen RJ. Preventive resin restorations and sealants in light of current evidence. Dent Clin North Am. 2005 Oct;49(4): 815-23.

Strassler HE, Porter J, Serio CL. Contemporary treatment of incipient caries and the rationale for conservative operative techniques. Dent Clin North Am. 2005 Oct;49(4) 867-87.

Summit JB, Robbins JW & Schwartz RS. Fundamentals of Operative Dentistry: A Contemporary Approach, 3rd ed. Quintessence Publishing Co, Inc. Chicago. 2006: 303-5.

19. Which of the following is/are false regarding self etching?

A) It may reduce post-op sensitivity. B) In lab studies, it has shown an increased bond strength when compared to total etch. C) It slowly removes the smear layer without exposing the dentinal tubules. D) It etches enamel E) B and C

Answer: E

In lab studies, self etched adhesives have shown low bond strength due to the formation of a very thing adhesive layer. A multicoat approach is recommended. Self etching adhesives do not remove the smear layer but rather it incorporates it into the interface. It theory, it may reduce post-op sensitivity since the smear layer in maintained. Limited clinical data is available for self etching adhesive.

Sturdevants Art and Science of Operative Dentistry, Fourth Edition, page 241.

20. When comparing self cured composite initiators to light cured initiators (photoinitiators) which is the following is false?

A) The most common light cured composite initiator is benzoyl peroxideamine. B) Photo initiators normally require a coinitiator for efficient polymerization to occur. C) The photoinitiator absorbs light whereas the coinitiator does not. D) One of the main advantages of self cure composite is the depth of cure.

Answer: A

Benzoyl peroxide-amine is the common polymerization initiator found in self cured composite. A photoinitiator is a molecule that can absorb light and, as a result, either directly or indirectly, generate a reactive species that can then initiate polymerization. The most common light cure initiator is Camphorquinone. Camphorquinone is an example of a photoinitiator that requires a coinitiator for an efficient polymerization process to occur. A coinitiator is a separate compound that does not absorb light but interacts with an activated photoinitiator to produce a reactive species. In the case of a dental composite restorative containing CQ, a tertiary amine photoreductant is used as the coinitiator to provide the reactive radicals that begin polymerization.

Journal of Esthetic Dentistry; Hamilton; 2000; Jeffrey W Stansbury; 22. Which of the following dental adhesive monomers is considered to be the most cytotoxic?

A) Bis-GMA B) TEGDMA C) UDMA D) HEMA

Answer: A A study done at the University of Michigan ranked the toxicity of several dental monomers found in some of the most common dental adhesive systems. Bis-GMA > UDMA > TEGDMA >>> HEMA (least toxic) after 24- and 72-hour exposure. - Bis-GMA Benzalkonium chloride Optibond Solo

- UDMA Urethane dimethacrylate Prime & Bond NT - TEGDMA Triethylene glycol dimethacrylate - Permaquick PQ1 - HEMA 2 Hydroxyethyl methacrylate One Bond, Optibond Solo 23. The following statements regarding glass ionomer are true except:

A) Glass ionomer is very well suited for patients with oral diseases that accelerate the pathogenic activities associated with caries. B) Glass ionomers maintain a constant release of fluoride. C) It's the only restorative material that bonds chemically to tooth structure. D) The main reason for replacing a glass ionomer restoration is usually esthetics.

Answer: B

Generally, the fluoride release is relatively high during the first few days but that rate of release falls overtime. As a consequence they need to be recharged.

Sturdevants Art and Science of Operative Dentistry, Fourth Edition, pages 210-1. 26. Which of the following effects would be expected when decreasing the filler content in a composite resin?

A) decreased modulus of elasticity B) decreased fluidity

C) decreased wear resistance D) increased water sorption E) none of the above F) A and C only

Answer: F

Almost all important properties of composites are improved by using higher level of fillers. The only practical problem is that, as the filler level is increased, the fluidity decreases.

Sturdevants Art and Science of Operative Dentistry, Fourth Edition, page 194. 29. Which of the following lists materials from least fluoride release to the greatest?

A) compomer, fluoride releasing composite, glass ionomer, resinmodified glass ionomer B) glass ionomer, compomer, resin-modified glass ionomer, fluoride releasing composite C) fluoride releasing composite, compomer, resin-modified glass ionomer, glass ionomer D) fluoride releasing composite, compomer, glass-ionomer, resin modified glass ionomer Answer: C 30. Which of the following statements about polyacid-modified composite resins is/are correct? 1) are also known as giomers

2) have better wear resistance compared to resin composites 3) are indicated for use in class I and II restorations in pediatric cases 4) are indicated in class V restorations a) b) c) d) e) 2 and 4 1 and 3 3 and 4 2, 3 and 4 All are correct

Answer: C Giomers are distinguished by the fact that, while they are resin-based, they contain pre-reacted glass-ionomer (PRG) particles. The particles are made of fluorosilicate glass that has been reacted with polyacrylic acid prior to being incorporated into the resin. The pre-reaction can involve only the surface of the glass particles (called surface pre-reacted glass ionomer or S-PRG) or almost the entire particle (termed fully pre-reacted glass ionomer or F-PRG). Giomers are similar to compomers and resin composites in being light activated and requiring the use of a bonding agent to adhere to tooth structure. Polyacid-modified composite resin or compomer: compomers have lower mechanical properties than hybrid-resin composites. Compomer materials were introduced as an alternative to resin-modified glass ionomers. Their ease in placement and polishing, and fluoride release made them an attractive alternative. Compomers have better mechanical properties and esthetics than resin-modified glass-ionomer restorative materials, however, they release less fluoride and provide no chemical bond to tooth structure. Compared with hybrid-resin composites, compomers have inferior mechanical properties that may lead to accelerated wear and ledging in restorations receiving direct contact.1 Marketing by some manufacturers and a least one clinical study suggest that compomer materials will provide reliable restorations in stress-bearing areas.2 However, due to the increased potential for wear in direct-contact restorations as found in this study, compomers should be limited to areas of

lower stress such as Class V3, or III4 or perhaps lower life expectancy, such as pediatric Class I or II restorations.5 Compomer undergoes greater wear than resin composite. Etch and bond required. 31. A resin-modified glass ionomer does not have an acid-base reaction. They have better physical properties than conventional glass-ionomers but not composite resins.

A) Both statements are true B) First statement is true, second one is false C) Both statements are false D) First statement is false, second one is true

Answer: D

A true resin-modified glass ionomer cement is defined as a twopart system characterized by an acid-base reaction critical to its cure, diffusion-based adhesion between the tooth surface and the cement, and continuing fluoride release. Resin-modified glass-ionomers are easier to use than conventional glass-ionomer cements. The supplementary light polymerization allows a longer working time, rapid hardening on command, and a more rapid early development of strength and resistance against aqueous attack than are found with conventional glass-ionomer cements. Mechanical properties such as compressive, tensile, and flexural strengths; fracture toughness; wear resistance; fatigue resistance;

bond strengths to enamel dentin and other resin-based restorative materials; marginal adaptation; and microleakage are reported to be better than those of conventional glass-ionomer cements. The fluoride release of resin-modified glass-ionomer cements is reported to be equal to or higher than conventional glass-ionomer cements Physical properties are still inferior to resin composites Example of resin-modified glass-ionomer is Fuji II LC and Vitremer 32. The physical properties of calcium hydroxide make it suitable for use under stress-bearing areas of restorations. True or False? Answer: False Cavity liners are placed with minimal thickness usually less than 0.5mm. Ca(OH)2 can be used as a liner because of its pulpal compatibility and stimulation of reparative dentin when in direct contact with the pulp. Conventional formulations of calcium hydroxide liners have demonstrated poor physical properties. They have high solubility which can lead to softening under a restoration. Visible-light activated Ca(OH)2 liners are questionable. Due to the unfavorable physical properties, use should be limited to the smallest area to aid formation of reparative dentin. Summit, Robbins, Schwartz. Fundamentals of Operative Dentistry: a contemporary approach. 2nd Ed. Chicago: Quintessence Publishing Co, 2001 33. What form of mercury is released in urine? A) methyl B) ethyl

C) organic D) inorganic E) C and D Answer: E Powers J, Sakaguchi R,eds. Craigs Restorative Dental Materials. 12th ed.St. Louis: Mosby, 2006.

The forms of mercury that are most toxic are organic forms: methyl, ethyl, vapor. The least toxic is inorganic. Good ventilation is necessary to clear mercury vapors. Levels can return to normal in 10-20 minutes. Charcoal filters reduce levels by 25%. Kingman A, Albertini T, Brown LJ. Mercury concentrations in urine and whole blood associated with amalgam exposure in a US military population. J Dent Res. 1998 Mar;77(3):461-71 The release of mercury is greatly increased during mastication and tooth brushing. Most of the vapor inhaled enters the blood through the lungs while a small amounts are ingested an absorbed through intestine. Most of mercury from amalgams is excreted in feces and urine. Urine lab tests measure the total and inorganic mercury levels and the organic level is measured by the difference of the two. 34. Micro-hybrids which are also known as nano-hybrids have particle sizes that are larger than microfill and smaller than hybrid. Micro-hybrids can be comparable in strength and hardness to hybrid composites.

A) Both statements are true

B) First statement is true, second one is false C) Both statements are false D) First statement is false, second one is true Answer: A

Microfills were developed to provide better esthetics and polishability.13 These tiny particles of silica are only 0.04 microns in diameter and are literally born in fire through a pyrolytic process.2 The large surface area of these filler particles demands much more resin matrix to wet the surface. This creates extremely high viscosity that limits the percentage filler content possible. In order to maximize filler loading and minimize viscosity, the use of prepolymerized resin and microfiller is used. The heavily filled polymerized resin is ground into 30-65 micron particles and mixed with more resin and microfiller to provide a composite that is filled 30 to 50% by volume. A smoother surface can be produced due to the smaller size of the silica particles.2 However, mechanical properties such as strength and stiffness are generally inferior to larger quartz or glass filled composites because of the lower filler content, which often limits their use to non-stress-bearing areas.13 Also, microfills are typically radiolucent which also limits their application to anterior areas. However, some manufacturers have introduced the reinforced microfill. These composites generally have a higher percentage of filler content than traditional microfills and have been marketed for posterior use. https://decs.nhgl.med.navy.mil/3QTR05/PRODUCTEVALUATIONS/composi tesynopsis.htm Comparable in hardness and strength to other popular hybrid resin composites, not better. https://decs.nhgl.med.navy.mil/DIS61/sec12.htm

 Hybrid resin composites contain a blend of submicron (0.04 micro) and small-particle (1-4 micron) fillers. The combination of medium and small filler particles allows the highest levels of filler loading among resin composites and a corresponding improvement in physical properties. They can be polished to a fairly high luster, but not to the extent of microfill. Often material of choice for class 3 and 4 restorations Micro-hybrids average particle size less than 1 micron (esthet-x, Point 4) aka nano-hybrids.

Summit et al. Fundamentals of Operative Dentistry: a contemporary approach. 3rd Ed. Chicago: Quintessence, 2006

35. Light cured composites are more time consuming to place but have more complete polymerization than auto-cured composites. Dual-cure and autocured composites have are comparable to light-cured in physical properties.

A) Both statements are true B) First statement is true, second one is false C) Both statements are false D) First statement is false, second one is true

Answer: B

Auto-cured resin composites are sometimes recommended for posterior restorations because an auto-cured composite tends to induce less polymerization stress than does a comparable bulk of light-cured composite. This is due in part to greater porosity being incorporated in to the auto-cured resin composite as a result of mixing. The incorporated oxygen inhibits the set of resin

immediately adjacent to the voids and decreases the ratio of bonded to unbonded surface area.

Auto-cured: -not so commonly used. -can be placed in bulk, saving time compared to the incremental insertion technique used with visible light cured materials. -Tend to incorporate voids as a result of mixing -Increased porosity means decreased tensile strength and surface smoothness -Tend to have accelerated wear -Mixing interrupts the polymerization process and may compromise the size and configuration of the final polymer molecules

Resin-modified glass-ionomer: dual cured original acid-base reaction is supplemented by light polymerization. Not used for load bearing areas

Light cured composite: More time consuming More complete polymerization Superior mechanical properties and better color stability Incremental build-up technique needed Performed better in clinical trials over 1 and 3 years

Summit et al. Fundamentals of Operative Dentistry: a contemporary approach. 3rd Ed. Chicago: Quintessence, 2006 39. When bonding amalgam it is condensed into viscous filled resin. During this process fingers of resin are incorporated into the amalgam, which unfortunately leads to its decrease in strength.

A) both statements are true B) both statements are false C) statement one is true, two is false D) statement two is true, one is false

Answer: C

It is best when the amalgam is condensed into a viscous non-set filled resin. This resin should be chemically cured since it is difficult to get light to penetrate metal. The fingers that are incorporated into the amalgam provide the attachment of the amalgam to the resin. There is enough research to support bonded amalgams being as successful as pin retained amalgams.

Summit and Robbins, 3rd ed 2006, pg 365-7 43. The use of a spherical amalgam alloy such as Tytin can present problems with developing adequate proximal contacts. What technique(s) can be employed to improve contacts?

A) A smaller condenser would allow the force to be greater per unit area, thus the amalgam will be condensed better. B) Admixed (Dispersalloy) alloys are more easily condensed with less pressure, and will be condensed into a contact area more easily. C) If Tytin is the only amalgam available, a smaller condenser, and lateral condensation will improve contact formation. D) A, B, and C are all ways to improve success in achieving a good proximal contact.

Answer: D When condensing amalgam the smaller the nib of the condenser, the more force per unit are can be applied. When using spherical alloys care must be taken not to use too small a nib, or the material may roll out of the way and you will push right through it. It has been suggested that spherical alloys are less condensable. They require less force to condense, but are less adaptable to cavity walls so direction of condensation is important. Admix alloys require more force to condense. They adapt much better to cavity walls than spherical, and it is easier to obtain a good contact when using admix.

Summit and Robbins, 3rd ed, 2006, pages 374-376

44. Hybrid resin composites are more resistant to attrition than microfilled resin composites. They also have a higher resistance to wear than microfilled materials. A) Both statements are true B) Both statements are false C) Statement one is true, statement two is false

D) Statement one is false, statement two is true

Answer: C

Microfills are more resistant to abrasion because of their smoother surfaces, decreased interparticle spacing, and lowered coefficient of friction. Because of their relatively low filler content they are more subject to attrition are marginal breakdown especially adjacent to occlusal contact areas. Hybrids are more heavily filled and thus are more resistant to attrition. Because of their large particle size they tend to have higher abrasion wear. Loss of filler particles leads to three body wear and increased stress transfer from the particles to the resin matrix which leads to cracks.

Summit and Robbins 3rd ed 2006, page 296 Operative 2005

1. Differences between a packable composite and a hybrid The differences between a packable composite and a hybrid one are:

a) packable composites are less viscous than hybrid composites b) the inorganic filler material of hybrid composites is approximately 80 % by weight c) the hybrid composites inorganic fillers have an average particle size of 0.4 to 1 m d) the packables have a smoother surface texture in the finished restoration e) b and c

Answer: e [Resin]Composite. In an effort to improve the physical characteristics of unfilled acrylic resins, Bowen of the National Bureau of Standards (now called NIST) developed a polymeric dental restorative material reinforced with silica particles. The introduction of this filled resin material in 1962 became the basis for the restorations that are generically termed composites. Composites are presently the most popular tooth-colored materials, having completely replaced silicate cement and acrylic resin. Basically, composite restorative materials consist of a continuous polymeric or resin matrix in which an inorganic filler is dispersed. This inorganic filler phase significantly enhances the physical properties of the composite (as compared to previous tooth-colored materials) by increasing the strength of the restorative material and reducing the linear coefficient of thermal expansion. Composites possess linear coefficients of thermal expansion that are one half to one third the value typically found for unfilled acrylic resins and therefore nearer to that of tooth structure. For a composite to have good mechanical properties, a strong bond must exist between the organic resin matrix and the inorganic filler. This bond is achieved by coating the filler particles with a silane coupling agent, which not only increases the strength of the composite but also reduces its solubility and water absorption. Composites are usually divided into 3 types based on the size, amount, and composition of the inorganic filler: 1) conventional composites; 2) microfill composites, and 3) hybrid composites. However, more recent changes in composite composition have resulted in several other hybrid type categories, including flowable and packable composites. Conventional composites. Conventional composites generally contain approximately 75 % to 80 % inorganic filler by weight. The average particle size of conventional composites in the 1980s was approximately 8 m. Because of the relatively large size and extreme hardness of the filler particles, conventional

composites typically exhibit a rough surface texture. The resin matrix wears at a faster rate than the filler particles, further roughening the surface. Unfortunately, this type of surface texture causes the restoration to be more susceptible to discoloration from extrinsic staining. Conventional composites have a higher amount of initial wear at occlusal contact areas than do the microfill or hybrid types. The composition of the inorganic filler in conventional composites also affects the degree of surface roughness. A soft or friable glass such as strontium or barium yields a smoother surface than those with a quartz filler. Also, when strontium or barium glasses are incorporated in sufficient amounts, the composite is made radiopaque. This is an important characteristic because caries around or under a composite restoration can be more easily interpreted when viewing a radiograph. It should be noted that most conventional composites currently have been supplanted by hybrid composites. Microfill composites. In the late 1970s the microfill, or polishable, composites were introduced. These materials were designed to replace the rough surface characteristic of conventional composites with a smooth, lustrous surface similar to tooth enamel. Instead of containing the large filler particles typical of the conventional composites, the microfill composites contain colloidal silica particles whose average diameter ranges from 0.01 to 0.04 m. The restoration with this small particle size results in a smooth, polished surface in the finished restoration that is less receptive to plaque or extrinsic staining. However, because of the greater surface area per unit volume of these micro fine particles, the microfill composites cannot be as heavily filled. Typically, microfill composites have an inorganic filler content of approximately 35 % to 60 % by weight. Because these materials contain considerable less filler than do conventional or hybrid composites, some of their physical and mechanical characteristics are somewhat inferior. Nonetheless, microfill composites are clinically very wear resistant. [Generalized wear, in other words, they wear in the whole occlusal surface, versus just on the cusp which then would be abrasion wear]. Also, their low modulus of elasticity may allow microfill composite restorations to flex during tooth flexure, thus better protecting the bonding interface. This feature may not have any effect on material selection for Class V restorations in general,

but it may make microfill composites an appropriate choice for restoring Class V cervical lesions or defects where cervical flexure can be significant (e.g., bruxism, clenchers, stressful occlusion). Hybrid composites. In an effort to combine the favorable physical and mechanical properties characteristic of conventional composites with the smooth surface typical of the microfill composites, the hybrid composites were developed. These materials generally have an inorganic filler content of approximately 75 % to 85 % by weight. The filler is typically a mixture of a micro filler and small filler particles that results in a considerably smaller average particle size (0.4 to 1 m) than that of conventional composites. Because of the relatively high content of inorganic fillers, the physical and mechanical characteristics are generally superior to those of conventional composites. Also, the presence of sub-micrometersized microfiller particles interspersed among the larger particles provides a smooth patina-like surface texture in the finished restoration. Hybrid composites currently are the predominant direct esthetic restorative materials used. They have almost universal clinical applicability and are the primary materials referred to as composites throughout this book. Flowable composites. Flowable composites have lower filler content and consequently inferior physical properties, such as lower wear resistance and strength, when compared to more heavily filled composites. Even though manufacturers promote widespread usage of these products, they appear to be more appropriate for use in some small Class I restorations, as pi-and-fissure sealants, as marginal repair materials, or, more infrequently, as the first increment placed as a liner under hybrid or packable composites. While their ease of use, favorable wettability, and handling properties are popular features, clinical indications for their use are limited. Packable composites. Packable composites are designed to be inherently more viscous to afford a feel upon insertion, similar to that of amalgam. Because of increased viscosity and resistance to packing, some lateral displacement of the matrix band is possible. Currently, there are no long-term clinical studies to equate [substantiate] packable composites promoted benefits with improved clinical results when compared to hybrid composites. Their development is an attempt to accomplish two goals: 1) easier restoration of a proximal contact, and

2) similarity to the handling properties of amalgam. They do not completely accomplish either.

Glass Ionomer Conventional Glass Ionomers were developed first by Wilson and Kent in 1972. Like their predecessors, silicate cements, the original glass ionomer restorative materials were powder/liquid systems. Glass ionomers enjoy the same favorable characteristics of silicate cements they release fluoride into the surrounding tooth structure, yielding a potential anticariogenic effect, and possess a favorable coefficient of thermal expansion. Unlike the silicate cements that have a phosphoric acid liquid, glass ionomers use polyacrylic acid, which renders the final restorative material less soluble. [Bond to tooth structure] Although conventional glass ionomers are relatively technique-sensitive regarding mixing and insertion procedures, they may be good materials for restoration of root-surface caries because of their inherent potential anticariogenic quality and adhesion to dentin. Similarly, glass ionomers may be indicated for other anterior restorations in patients exhibiting high caries activity. Because of their low resistance to wear and relatively low strength when compared to composite or amalgam, glass ionomers are not recommended for the restoration of occlusal areas of posterior teeth. Glass-ionomer cements also have been widely advocated for permanent cementation of crowns. Like other cements, conventional glass-ionomer systems require hand mixing of a powder and liquid with a spatula. However, some glass ionomers are available in encapsulated forms that are mixed by trituration. The capsule containing the mixed material is subsequently placed in an injection syringe for easy insertion into the tooth preparation. While fluoride-releasing materials have received much publicity and been very popular, one systematic review of numerous research articles on glass ionomers concluded that there was no conclusive evidence for or against a treatment effect of inhibition of secondary caries by the glass ionomer restorations.

Resin-Modified Glass Ionomers. In an effort to improve the physical properties and esthetic qualities of conventional glass ionomer cements, resin-modified glass ionomer (RMGI) materials have been developed. RMGIs are probably best described as glass ionomers to which resin has been added. An acid-base setting reaction is present, similar to that of conventional glass-ionomer cements. This is the primary feature that distinguishes these materials from compomers. Additionally, the resin component affords the potential for light-curing, autocuring, or both. RMGIs are easier to use and possess better strength, wear resistance, [appears to be less than conventional GIs], and esthetics than conventional glass ionomers. However, their physical properties are generally inferior to those of composites, and their indications for clinical use are limited. Because they have the potential advantage of sustained fluoride release, they may be best indicated for Class V restorations in adults who are at high risk for caries and for Classes I and II restorations in primary teeth that will not require long-term service. Compomers. (Polyacid-Modified Composites [Resins]). Compomers are best described as composites to which some glass-ionomers components have been added. Primarily light-cured, they are very easy to use and have gained popularity because of their superb handling properties. Overall, their physical properties are superior to traditional glass ionomers and RMGIs but inferior to those of composites. Their indications for clinical use, therefore, are limited. Although compomers are capable of releasing fluoride, the release is not sustained at a constant rate and anticariogenicity is questionable.

IMPORTANY PROPERTIES There are considerations regarding various properties of composites that must be understood if a successful composite restoration is to be done. These properties generally require that specific techniques be incorporated into the restorative procedure, either in the tooth preparation or the application of the material. The various property factors are presented here: Linear Coefficient of Thermal Expansion. The LCTE is the rate of dimensional change of a material per unit change in temperature. The closer the LCTE of the

material is to the LCTE of enamel, the less chance there is for creating voids or opening at the junction of the material and the tooth when temperature changes occur. The LCTE of improved composites is approximately 3 times that of tooth structure, that for hybrid glass ionomer is 1.5 to 2 times that of tooth structure [CAPT Cook told me is not 1.5 times, but just about the same that of tooth structure]. Bonding a composite to etched tooth structure reduces the potential negative effects due to the difference between the LCTE of tooth structure and that of the material. Water Absorption. It is the amount of water that a material absorbs over time per unit of surface area or volume. When a restorative material absorbs water, its properties change, and therefore its effectiveness as a restorative material is usually diminished. All of the available tooth-colored materials exhibit some water absorption. Materials with higher filler contents exhibit lower water absorption values. Wear Resistance. It refers to a materials ability to resist surface loss as a result of abrasive contact with opposing tooth structure, restorative material, food boli, and such items as toothbrush bristles and toothpicks. The filler particle size, shape, and content affect the potential wear of composites and other toothcolored restorative materials. The location of the restoration in the dental arch and occlusal contact relationships also affect the potential wear of these materials. Wear resistance of composite materials is generally good. While not yet as resistant as amalgam, the difference is becoming smaller. A composite restoration offers stable occlusal relationship potential in most clinical conditions, particularly if the occlusal contacts are shared with those on natural tooth structure. [Generalized versus localized wear, attrition wear and abrasion wear are important concepts that we have to know. Generalized is occlusal wear, versus localized which would be only on a cusp of a molar, attrition due to bruxism and abrasion due to tooth brushing, for example). It depends on the filler of the material how the resin composite can withstand these forces. Consult with CAPT Cook]

Surface Texture. It is the smoothness of the surface of the restorative material. Restorations in close approximation to gingival tissues require surface smoothness for optimal gingival health. The size and composition of the filler particles primarily determine the smoothness of a restoration, as does the materials ability to be finished and polished. While microfill composites offer the smoothest restorative surface, hybrid composites also provide surface textures that are both esthetic and compatible with soft tissues. Radiopacity. Esthetic restorative materials must be sufficiently radiopaque, so that the radilucent image of recurrent caries around or under a restoration can be more easily seen in a radiograph. Most composites contain radiopaque fillers, such as barium glass, to make the material radiopaque. Modulus of Elasticity. It is the stiffness of a material. A material having a higher modulus is more rigid; conversely, a material with a lower modulus is more flexible. A microfill composite material with greater flexibility may perform better in certain Class V restorations than a more rigid hybrid composite. This is particularly true for Class V restorations in teeth experiencing heavy occlusal forces, where stress concentrations exist in the cervical area. Such stress can cause tooth flexure that can disrupt the bonding interface. Using a more flexible material such as a microfill composite allows the restorations to bend with the tooth, thereby better protecting the bonding interface. However, as noted, the elastic modulus of the material may be less significant with current bonding systems unless significant occlusal stress form bruxism, clenching, or other forms of stressful occlusion is present. Stress-breaking liners that possess a lower elastic modulus also can be used to better protect the bonding interface. Solubility. Solubility is the loss in weight per unit surface area or volume due to dissolution or disintegration of a material in oral fluids, over time, at a given temperature. Composite materials do not demonstrate any clinically relevant solubility.

Source: Roberson, Theodore M., et al. Sturdevants Art and Science of Operative Dentistry. 4th Ed. 2002. Mosby, USA. Pp: 202, 477, 47 479

Cook, B, CAPT. Restorative Dentistry Syllabus. NPDS, 2005. Consult with CAPT B. Cook.

2. Interface of a resin bonded amalgam Answer the following question with True or False. Macroshear bond strengths for joining amalgam to dentin are relatively low (2 to 6 MPa). Although good bonding occurs to tooth structure, micromechanical bonding at the interface of the amalgam with the bonding system is poor.

Answer: True

Amalgam Bonding Systems. Amalgam bonding systems may be used to seal underlying tooth structure and bond amalgam to enamel and dentin. They require dual characteristics to achieve optimal wetting. Amalgam is strongly hydrophobic, where as enamel and dentin are hydrophilic. Therefore, the bonding system must be modified with a wetting agent (comonomer) that has the capacity to wet hydrophobic or hydrophilic surfaces. Typical dentin bonding systems may be used, but a special 4-methyloxy ethyl trimelitic anhydride (4-META)-based systems are used frequently. This monomer molecule contains both hydrophobic and hydrophilic ends. Macroshear bond strengths for joining amalgam to dentin are relatively low (2 to 6 MPa). Although good bonding occurs to tooth structure, micromechanical bonding at the interface of the amalgam with the bonding system is poor. Most de-bonding occurs by fracture along this interface. Since no chemical bonding occurs at this interface, it is important to develop micromechanical bonding. To accomplish this, the bonding system is applied in much thicker layers (10 to 50 m), so that amalgam being condensed against the resin adhesive layer will force fluid components of the amalgam to squeeze into the unset bonding adhesive layer and produce

micromechanical laminations of the two materials. Thicker bonding agent films can be produced by adding thickening agents to the unset bonding materials or by applying many (5 to 8) applications of bonding material. The primary advantages for amalgam bonding agents in most clinical situations are the dentin sealing and improved resistance form, but the increase in retention form is not significant. Adhesion of amalgam to tooth structure is not necessary in clinical circumstances when satisfactory retention and resistance forms of tooth preparation already exist. Primary indication for amalgam bonding is when weakened tooth structure remains and bonding may improve the overall resistance form of the restored tooth. If sealing amalgam preparations is the sole purpose for bonding, then an alternative is the use of dentin sealers. The earliest version of such a system (Gluma 2, Bayer Dental Products) was actually the primer component of a dentin bonding system. Since the introduction of that product, several others have been developed that are essentially primer monomers and/or polymers dissolved in solvent that penetrate the surfaces of the preparation and dry or are cured as a polymer film. The action of this film is very similar to that of varnish, except the film has much better wetting characteristics and produces a completely impervious layer. The film actually covers enamel as well as dentin but it is still characterized as a dentin sealer. Because the same material may be used over open dentin tubules on exposed root surfaces to eliminate fluid flow and desensitized dentin, dentin sealers are also known as dentin desensitizers. However, an expansive list of other products also may be called dentin desensitizers, but they are not routinely used to seal dentin under amalgam restorations. Bonding systems used below insulating restorations, such as composite, do not utilize traditional liners and bases except when the tooth excavation is extremely close to the pulp (RDT <0.5 mm). In that case, a traditional Ca(OH)2 liner is used for pulpal medication, to stimulate reparative dentin. Roberson, p. 185-186

3. Bis GMA, Tegma, UGMA, HEMA, etc. Which are more cytotoxic? Which is the most cytotoxic of the following dentin bonding liquid acrylic monomers? a) Bis-GMA b) TEGDMA c) BPA d) HEMA e) UDM f) All of the above Answer: d (HEMA)

Dentin Bonding Systems. Dentin bonding systems involve an unfilled (or lightly filled), liquid acrylic monomer mixture placed onto an acid-etched and primed dentin surface. The bonding primer depends on hydrophilic monomers, such as 2-hydroxylethyl methacrylate (2-HEMA or HEMA), to easily wet hydrophilic dentin surfaces that contain some moisture. Although primer and/or bonding agent may flow into dentinal tubules, the bond strength is primarily achieved by micromechanical bonding to the intertubular dentin (between tubules) along the cut dentin surface. P. 182 The key ingredient for priming in many dentin bonding systems is hydroxylethyl methacrylate (HEMA). This molecule is an analog to methyl methacrylate, except that the pendent methyl ester is replaced by an ethoxy ester group to make it hydrophilic. Importantly, it is relatively volatile and has some tendency to produce mild sensitivity. Dentists and assistants should be aware that it is very mobile, can diffuse through rubber gloves, and will cause skin dryness and cracking in many individuals. Therefore, during the use of primers and bonding agents, high-volume evacuation should be used to minimize HEMA vapor contact. P. 183 The properties of sealants are essentially those of the resin matrix component of composite materials. There is no evidence that water absorption, chemical degradation, or other events observed with composites, detract from the

longevity of these materials. However, there has been a controversy concerning the BIS-GMA monomers in sealants. In 1994, a single report suggested that BIS-GMA (produced from bisphenol-A and glycidyl methacrylate reaction) could be decomposed into its constituents releasing bisphenol-A (BPA). BPA is known to be an estrogenic material. Further investigation revealed a number of scientific problems with this report, such as the misidentification of TEGMA as BPA. However, to avoid political controversy over the safety of these materials, manufacturers quickly switched to alternative monomers that did not include BPA as a precursor. Another problem with the original report was that measured levels of monomer released from sealants seemed unusually high. Unfortunately, it was not noted during the sampling procedure that the air-inhibited superficial layer of resin had not been removed by wiping with a cotton roll before sampling the sealants. This small layer is generally wiped away or quickly lost during the first few chewing strokes. This material is not representative of the actual cured sealant material below. Even so, sealants are not totally innocuous. Some of the dilutant monomer (TEDGMA) remains unreacted (residual monomer) and slowly diffused out of the sealant. However, both the small amount and the very long time period of release suggest that only minimal health risk would ever be involved.

Historical Development. Early attempts at esthetic filling materials that predated acrylic resins and composites were based on silicate cements. These cements resulted from reactions of phosphoric acid with acid soluble glass particles to form a silica gel matrix containing residual glass particles. Solubility problems with these materials led to the introduction of unfilled acrylic systems based on polymethyl methacrylate (PMMA). Methyl methacrylate (MMA) monomer contracted excessively during polymerization, permitting subsequent marginal leakage. Also, PMMA was not strong enough to support occlusal loads. Therefore, reinforcing ceramic fillers, principally containing silica, were added to the composition. Retrospectively, the original PMMA materials now are called unfilled acrylics. (If the amount of filler or filler-like phase added to a resin matrix is small, the overall composition is

considered unfilled. Therefore, 1 % to 2 % filler-modified sealant compositions are still classified as unfilled.) MMA-based matrices were supplanted by Bis-GMA (alternatively called BisGMA). BIS-GMA is a difunctional monomer originally produced as the reaction product of bisphenol-A and glycidyl methacrylate. Several analogues of that structure have been investigated (modified BIS-GMA). Another very similar difunctional molecule used in composites is urethane di-methacrylate (UDMA). UDMA replaces the bisphenol-A backbone with a linear isocyanate one. Both BIS-GMA and UDMA are extremely viscous. For practical reasons, they are diluted with another difunctional monomer with an aliphatic backbone, TEGDMA, of much lower viscosity. To gain the full advantage of a composite formulation, it is very important to provide interfacial bonding between the phases. In modern composites, silica particles are pre-coded with monomolecular films of silane coupling agents. These molecules are difunctional. One end is capable of bonding to hydroxyl groups, which exist along the surface of the silica particles, and the other end is capable of copolymerizing with double bonds of monomers in the matrix phase. Coupling agents work best with silica particles. Therefore all composites have been based on silica-containing fillers.

Source: Roberson, Theodore M., et al. Sturdevants Art and Science of Operative Dentistry. 4th Ed. 2002. Mosby, USA. Chapter 4. pp182-192

4. Bonding agents and non-prepped surfaces Answer with True of False Bonding agents work better in non-prepared surfaces (enamel rods) than in dentinal tubules (prepared surfaces) due to the moist (wet) dentinal surface.

Answer: True

Bonding Systems. In Dentistry, the agents producing adhesive dental joints are referred to as bonding systems and generally have been classified on the basis of the primary adherend. Enamel Bonding Systems. Enamel Bonding Systems (or dental bonding systems that also produce enamel bonding) most often consist of an unfilled (or lightly filled) liquid acrylic monomer mixture placed onto acid etched enamel. The monomer flows into interstices between and within enamel rods. Enamel bonding depends on resin tags becoming interlocked with the surface irregularities created by etching. Resin tags that form between enamel rod peripheries are called macrotags. A much finer network of thousands of smaller tags form across the end of each rod where individual hydroxyapatite crystals have been dissolved, leaving crypts outlined by residual organic material. These fine tags are called microtags. Macrotags and microtags are the basis for enamel micromechanical bonding. Microtags are probably more important because of their large number and great surface area of contact. During the 1970s and 1980s, before these details were known, bonding studies concentrated more on the length of the macrotags and the patterns of etching (Type I = core etching, Type II = periphery etching, Type III = mixed patterns). Macrotag length is unimportant because fracture occurs in the neck of the tag. Most macrotags are only 2 to 5 m in length. Rod etching patterns also are generally not important to the resulting bond strength. The bonding system copolymerizes with the matrix phase of the composite, producing strong chemical bonding. The macroshear bond strength for the joint is 18 to 22 MPa and is affected by both the film thickness of the bonding system and the shear strength of adjacent enamel rods. The theoretic upper limit for joint strength is probably approximately 50 MPa. The current bond strengths of approximately 20 MPa appear to be acceptable clinically. More than 20 years of clinical monitoring has not revealed any significant degradation of the mechanical bonds due to fatigue.

[CAPT Cook mentioned we should use etching gel 15 to 20 seconds in enamel and just 10 seconds on dentin] Source: Roberson, Theodore M., et al. Sturdevants Art and Science of Operative Dentistry. 4th Ed. 2002. Mosby, USA. P. 181 5. Retention of a Class III composite In order to have better retention in a Class III composite restoration, the dentist should: a) finish the peripheral surface of the restoration in a butt-joint preparation b) place retention groves in the axial walls c) bevel the peripheral surface of the preparation when replacing an existing defective restoration d) b and c e) a, c, and d f) none of the above Answer: d

Beveled Conventional Class III Tooth Preparation. The beveled conventional tooth preparation for composite restorations is indicated primarily for replacing an existing defective restoration in the crown portion of the tooth. However, it also may be used when restoring a large carious lesion for which the need for increased retention and/or resistance form is anticipated. P. 506 Modified Class III Tooth Preparation. A modified tooth preparation is the most used type of Class III tooth preparation. It is indicated for small and moderate lesions or faults and is designed to be as conservative as possible. Usually no groove (or cove) retention form is indicated because the retention of the material in the tooth in the tooth will result from the

bond created between the composite material and the etched peripheral enamel. Thus, the preparation design appears to be scooped or concave. P 512 Larger preparations that are extended into dentin may require additional beveling or flaring of the accessible enamel walls to enhance retention. Bevel these enamel margins with a flame-shaped or round diamond instrument. Prepare the bevel by creating a 45 angle to the external surface and to a width of 0.25 to 0.5 mm. Recall that if the gingival floor has been extended gingivally to a position where the remaining enamel thickness is minimal or nonexistent, the bevel is omitted from this area to preserve the remaining enamel margin. Likewise, a bevel on the lingual enamel margin of a maxillary incisor may be precluded because of the presence of occlusal contact, for reasons previously noted. Thus, final tooth preparation steps for a modified tooth preparation are, when indicated: 1) removal of infected dentin, (2) pulp protection, (3) bevel placement on accessible enamel margins, and (4) final procedures of cleaning and inspecting. P. 514

Source: Roberson, Theodore M., et al. Sturdevants Art and Science of Operative Dentistry. 4th Ed. 2002. Mosby, USA. Pp. 506, 512, 514

(All the quotes in [these kind of brackets] are the corrections that CAPT Cook made Important, by the way!

Operative 2003 1. Indirect composite materials have physical characteristics that include which of the following?

1. Some of the polymerization shrinkage occurs outside of the mouth, but the most of the polymerization occurs inside the tooth upon delivery. 2. One potential advantage is a slightly higher degree of polymerization is attained. 3. Laboratory processing may employ heat and pressure. 4. These resins have greater color stability than light-activated resins. 5. Bond failures and induced stresses are reduced a. b. c. d. e. 1, 2, 3 1, 2, 3, 4 2, 3, 4, 5 2, 4, 5 all of the above

The polymerization shrinkage occurs outside of the mouth, not in the tooth, which improves the physical properties and resistance to wear. The polymerization shrinkage does not occur in the tooth. This reduces induced stresses and bond failures. This will theoretically reduce the potential for leakage. These resins are also repairable in the mouth and are not as abrasive to opposing tooth structure as ceramic inlays.

Laboratory processing may employ heat (140 C) and pressure (0.6 MPa for 10 minutes). This polymerization under heat and pressure is used for a homogeneous microfilled resin that is claimed to have a higher filler content, less porosity and greater color stability than light-activated resins. In addition, a slightly higher degree of polymerization (degree of conversion) is attained.

The following are additional physical properties of laboratory composites: Flexural strength is high-90-150 MPa Flexural modulus is variable-4.7-15 GPa Compressive strength is 210-280 MPa Handling characteristics and properties: Advantages-best anatomy and contacts, lower wear Disadvantages-lab cost, special equipment, requires resin cement

1. Is incorrect as noted above. The polymerization occurs completely outside of the mouth. The correct answer is c. (2, 3, 4, 5.)

Extra notes to recall about all composites (direct) regarding repair: A restoration that has just been cured and polished may have up to 50%of unreacted methacrylate groups to copolymerize with the newly added material. As the restoration ages, fewer and fewer unreacted methacrylate groups resin, and greater cross-linking reduces the ability for fresh monomer to penetrate into the matrix. Then strength of the bond between the original material and the added composite resin decreases in direct proportion to the time that has elapsed between the original polymerization and the addition of new composite. In addition, it should be noted that the polishing step would expose filler particles that are free from silane coating, which will inhibit a chemical bond to the new composite. The strength of the repair composite is less than of the original material.

References:

Anusavice K: Philips Science of Dental Materials, 10th Ed. WB Saunders, 1996. Craig RG and Powers JM: Restorative Dental Materials, 11th Ed. Mosby, 2002. 2. The following statements are problems with bonding agents and solutions in various environments or clinical situations. Choose which of these combinations are correct.

1. Problem: Debonding of a composite core build-up occurred during removal of an impression. Solution: Compatible composite core material should be used. Certain self-cured composite cores are incompatible with certain light cured bonding agents. Choose a dual cured bonding agent or used a light cured composite core material. 2. Problem: A dentist etched tooth structure prior to using a 6th generation bonding agent. Solution: Sixth generation bonding agents bond effectively to enamel and dentin without prior etching with phosphoric acid. The additional etching could result in over etching of dentin and may lead to nanoleakage. 3. Problem: After etching, a dentist over dried the tooth. Solution: Most modern bonding agents bond best to a moist tooth surface. Dentin should be rehydrated by applying a moist cotton pellet until the dentin surface glistens before applying the primer of the bonding agent. 4. Problem: A ceramic restorative surface has fractured on your patient with a 3-unit anterior FPDPFM, exposing only the fractured porcelain. Solution: The fractured surface should be isolated, prepared and then micro-etched with 50 um aluminum oxide particles; it is then treated with 5-9% hydrofluoric acid for 4 minutes; ; it is then treated with silane to wet the surface and act as a chemical coupling agent; then the bonding system is applied and light cured; and finally, the composite material is applied incrementally and light cured.

5. Problem: A dentist uses a standard unfilled bonding agent to bond a laboratory composite restoration. Solution: Bonding requires agents for both the tooth structure and the undersurfaces of the indirect restoration.

a. b. c. d. e.

1. is correct 1 and 2 are correct 1, 2, and 3 are correct 1, 2, 3, and 4 are correct all of the above

Correct answer is e. all of the above.

Answers for # 1-4 contain self-explanatory responses. Answer for #5 can be best explained as follows: Resin composite cements are used to fill the space between the laboratory composite and the tooth surface. Bonding to the indirect composite surface is difficult. The goal is to swell the outer surfaces of the resin matrix and allow new monomers from the bonding agent to penetrate spaces among existing polymer chains. At the time of curing, the new polymer chains become micromechanically intertwined with the existing polymer chains, producing relatively strong bonding. Bonding can be enhanced by micro etching with aluminum oxide (50um) etching with hydrofluoric acid, or treating with primers. Sandblasting roughens the surface. Etching removes smear layers and partially dissolves glass filler particles. Primers provide good wetting and potential chemical bonding to exposed glass filler particle surfaces. Commercial primers foe laboratory composites contain silane, unfilled resin monomers, or silane-monomer combinations. Bonding composite cements to laboratory composites can produce bond strengths in the range of 20-35 MPa. The formation of an optimally bonded interface has the following: 1) the surface of the substrate be clean; 2) the adhesive wets the substrate well and has a low contact angle;

3) adapts to the substrate to produce intimate approximation of the materials without entrapped air or other intervening materials; 4) the interface include the sufficient physical, chemical and or mechanical strength to resist intraoral forces of debonding; and 5) the adhesive be well cured in the environment or conditions for which they are to be used. References: Craig RG and Powers JM: Restorative Dental Materials, 11th Ed. Mosby, 2002.

3. Regarding environment and biocompatibility (toxicity), which one of the following is not true?

1. The term biocompatible is defined in Dorlands Illustrated Medical Dictionary as being harmonious with life and not having toxic or injurious effects on biologic function. 2. Biocompatibility is measured on the basis of localized cytotoxicity. 3. Naturally occurring mercury can be found in large cold water fish with concentrations that often exceed FDA limits. 4. Ten percent of the female population is allergic to nickel, compared with only about 1% of the male population. 5. Berylliosis is a disease resulting from contact dermatitis of some RPD alloys. a. b. c. d. e. 1. 2. 3. 4. 5.

1. Is a true statement. 2. Is true. Biocompatibility is measured on the basis of localized cytotoxicity (such as pulp and mucosal response), systemic responses, allergenicity, and carcinogenicity.

3. Is true. Methylated mercury accumulates in the food chain and is derived from areas of undersea volcanic acidity and hydrothermal waters. Virtually 100% of methyl mercury is absorbed in the gut. Thus, conversion of elemental mercury to methyl mercury would greatly increase absorption via the gastrointestinal route. All of the mercury in seafood is methyl mercury and all is absorbed. The average contribution of one seafood meal per week to blood mercury levels of methyl mercury is many times that of the aberage contribution of elemental mercury from the presence of 8-10 amalgam restorations in the mouth. 4. Is true. Ten percent of the female population if allergic to nickel, compared with only about 1% of the male population. This disparity is attributed to the greater exposure of females to nickel. Almost all gold plated jewelry is made with a nickel undercoat beneath the gold plating Only about 30% of those patients with a known nickel allergy develop a reaction to an intraoral nickel-chromium dental alloy. 5. Is false. Berylliosis is an inflammatory lung disease resulting from the inhalation of beryllium dust or fumes. Beryllium containing alloy should be ground with adequate ventilation. The correct answer is e. (5 is a false statement).

References: Anusavice K: Philips Science of Dental Materials, 10th Ed. WB Saunders, 1996.

5. Glass Ionomer differ from a compomer (polyacid modified resin)in which ways.

1. 2. 3. 4.

Compomers contain both composite and glass inomer Glass ionomer releases less fluoride than compomers Glass inomers use polyacrylic acid Compomers have improved physical properties over glass ionomers

Answers: a. b. c. d. 2, 3, and 4 2 and 4 1 and 2 1, 3, and 4

The answer is D.

Answer 2 is not correct. Conventional glass ionomers release fluoride into the surrounding tooth at a greater amount that compomers. This gives them a higher anticariogenic effect. Glass ionomer have low wear resistance, and relatively low strength compared to composite or amalgam. Compomers have improved strength and wear resistance with the combination of composite and glass ionomer.

Roberson T.M., Heymann H.O., and Swift E.J. Studervants Art & Science of Operative Dentistry, Fourth Edition, Mosby Inc. 477-478.

6. Which of the following statement(s) distinguishes a flowable composite from a regular composite.

1. Flowable composite have equal filler content but just smaller particles when compared to regular composites. 2. Flowable composite have lower filler content 3. Flowable composites have favorable wettability 4. Flowable composite have lower wear resistance and increased strength. A. 1, 3, and 4 B. 1 and 4 C. 2 and 3 D. 3 and 4

Answer 1. is incorrect since flowable composite achieves its ability to flow by decreasing the amount of filler particles.

Answer 4. is not correct since flowable composite has decreased strength.

Flowable composites have lower filler content which make it have inferior physical properties such as lower wear resistance and decreased strength. It does have increased wettability. Indications are limited to Class 1 restorations, pit and fissure sealants, cavity liners and margin repair materials.

The answer is C.

Roberson T.M., Heymann H.O., and Swift E.J. Studervants Art & Science of Operative Dentistry, Fourth Edition, Mosby Inc. 477-478.

13. Which of the following statement(s) on the mercury hazard is(are) false? 1. Mercury in the environment is bioaccumulative. 2. Mercury in the form of dental amalgam is very stable, but when incinerated mercury may be released to the environment. 3. Amalgam sludge is the mixture of liquid and solid material collected within vacuum pump filters or other amalgam capture devices. 4. Mercury can be recovered from amalgam waste through a distillation process and reuse in new products. 5. ADA recommends recycling as a best management practice for dental offices. a) b) c) d) e) 1 2 3 All of the above None of the above

Answer: (e) Majority (87%) of mercury released to the environment comes from combustion of fuel and waste. Dentistry contributes less than 1%. Mercury is present in numerous chemical forms. Methylated mercury compounds and Elemental mercury are toxic. Elemental or inorganic forms can be transformed into organic forms by biological systems. Some mercury released into the air eventually collects in waterways and then enters the food chain. Amalgam in environment is bioaccumulative, which means that it can build up in fish and cause health problems in any animals that eat fish. Dental Amalgam is a solid intermetallic compound, quite different from elemental, cationic and organic mercury. Dental amalgam is very stable.

REF: ADA BMP, 2003. 15. What makes a glass ionomer a true glass ionomer?

1. It must have an acid-base reaction (i.e. metal + acid= salt). You must mix materials together to have a true glass ionomer.

2. Calcium ions are gradually replaced by Aluminum ions to produce a more cross linked, more mechanically stronger material.

3. Glass ionomers are materials consisting of ion-cross linked polymer matrices surrounding glass-reinforcing filler particles.

4. Fluoride is an integral part of the matrix formation.

5. Polyacrylic acid may be freeze dried-(anhydrous) and combined with aluminosilicate powder.

6. Water is a key ingredient for the setting reaction.

A. B. C. D. E.

All the above are true none are true 1,2,4 are true 1,2,3,5,6 are true 4,5,6 are true

Answer is D

SOURCE: CAPT Cooks lecture on Glass Ionomers, page 5,6. SOURCE: STURDEVANTS ART AND SCIENCE OF OPERATIVE DENTISTRY 4TH EDITION. Page 207-211. It must have an acid-base reaction (i.e. metal + acid= salt). You must mix materials together to have a true glass ionomer. Calcium initially and the later aluminum replaces the hydrogen ions on the carboxyl groups resulting in the post set hardening stage. Glass ionomers are materials consisting of ion-cross linked polymer matrices surrounding glass-reinforcing filler particles. Fluoride is NOT an integral part of the matrix formation, therefore it is available for release without compromising the structural integrity of the restoration. Polyacrylic acid may be freeze dried and combined with aluminosilicate powder. The freeze dried form is called anhydrous, there also is a semi-hydrous form available. Water is a key ingredient for the setting reaction, it is critical for the reaction to occur. The water hydrates the salts and allows them to crosslink. Too much water results in an opaque weakened restoration, if water is lost during setting crazing will occur.

16. Which of the following advantages for the curing lights are true?

1. Quartz-Tungsten-halogen curing lites- 90% of the light produced is suitable for curing. Output ranges from 400-800 mW/cm2. 2. Plasma arc curing units-PAC- curing times can be as low as 3-10 seconds. This produces a much more rapid polymerization resulting in decreased polymerization stresses and stronger bond strengths. 3. Laser curing lights-curing times can be as low as 3-10 seconds. 4. Light emitting diode (LED) lights-Allows one to generate the appropriate wavelength in a narrow spectrum and curing cycle. 5. Stepped cure lights-may allow the newly formed polymer network to stress-relax and eliminate strains before completion of the curing cycle. a. 1,2,3 are true b. 2,3,4 are true c. All the above are true d. All the above are false e. 3,4,5 are true

The answer is E. The quartz bulbs only produce 0.5% of light suitable for curing. Most is converted into heat. UV and infrared filters eliminate unnecessary light . Output is in the range of 400-800 mW/cm2. Curing times for Lasers and PAC lights are advertised as 3-10 seconds. The fast cure can however cause INCREASED polymerization stress and DECREASED bond strengths. LEDs are advertised as allowing one to generate the appropriate wavelength and curing cycle for the

many products on the market. Camphoroquinone is the photoinitiator most used in composites. Stepped cure lights (Elipar 1997) used 100 mW/cm2 for 10 seconds, then 600 mW/cm2 for 30 seconds this shows some promise in decreasing polymerization stresses. SOURCE: STURDEVANTS ART AND SCIENCE OF OPERATIVE DENTISTRY 4TH EDITION. page 198-202. 21: Primers have excellent ability to wet a surface when they form a high contact angle. A liquid with a relatively low surface tension coefficient will have improved surface wetting properties.

a. b. c. d.

The first statement is true, the second is false. The first statement is false, the second is true Both statements are true Both statements are false.

A: b The contact angle is a measurement formed by the balance of energies between the liquid and solid. A higher contact angle means more bubble-like and hence poorer wetability.

Surface tension is measured in terms of force (dynes) per centimeter of the surface of liquid. The higher the surface tension, the less the wetability. Some examples at 20 C follow:

1-benzene 29 dynes 2-water 72.8

3-mercury 465

These values are influenced by temperature and purity. Higher temperatures and impurities, especially detergents, decrease surface tension. Just remember:

HIGH SURFACE TENSION OR HIGH CONTACT ANGLE = POOR WETABILITY. Restorative Dental Materials,11th ed. Craig and Powers

OPERATIVE 2002 1. Dentin Bonding and proximity to the pulp:

What is the average number of dentinal tubules at the pulp? a. 10,000 - 20,000/mm2 b. 30,000 - 50,000/mm2 c. 40,000 - 50,000/mm2 d. 45,000 65,000/mm2 e. 50,000 70,000/mm2

The correct answer is d. 45,000 65,000/mm2

Components in an Adhesive System: 1.) Conditioner a. Dissolves or removes smear layer b. Demineralizes dentin surface exposing fibers c. Conditioning Agents i. Strong acids total etch technique ii. Weak acids (maleic, oxalic) primarily smear layer removal iii. EDTA attacks calcium exposing organic portion of dentin (collagen) iv. Glutaraldehyde stabilizes collagen constituents

2.) Primer a. Contains bi-functional molecule b. Forms chemical and micromechanical bond to dentin, copolymerizes with restorative bonding resin c. Typical chemical used as primers: i. HEMA ii. PMDM iii. NPG-GMA

iv. 4-META v. PENTA

3.) Bonding Resin a. Unfilled or minimally filled resin of low viscosity b. Polymerizes with hydrophobic portion of bi-functional molecule of primer c. Example: Bis-GMA, UDMA

4.) Proximity to Pulp a. Shallow dentin fewer tubules of smaller diameter therefore greater surface area b. Deep dentin more tubules of greater diameter (more fluid flow), also high hydraulic conductance and its high intrinsic wetness, which may lead to dilution of the hydrophilic monomers

Tubular Density 1.) 15,000 20,000/mm2 at DEJ 2.) 45,000 65,000/mm2 at the pulp

Summary

Tubules are larger and more numerous toward the pulp. Tubules are smaller and fewer toward the DEJ. Therefore, dentin surface area is much larger toward the DEJ.

5.) The interaction of the dentin + primer + bonding agent + composite = Hybrid Layer

2. Microfills vs. hybrids

What is the most preferred restorative material to fabricate chairside labial veneers with no incisal edge extension? 1. 2. 3. 4. Glass ionomer Microfill resin composite Hybrid resin composite Resin reinforced glass ionomer

The correct answer is: 2. Microfill resin composite Microfills: (0.04m o o o o o o High coefficient of thermal expansion due to lower filler content Low tensile strength reduced stiffness and increased rate of crack propagation High water sorption High polymerization shrinkage More fatigue fracture Increased polishability due to smaller filler size rather than volume

o Indications: areas of high polishability, with no occlusal contacts. Ex. labial veneers with no incisal edge extension, Class V erosion lesion (enamel margins) improved esthetics; not recommended for Class 4 restorations but when a highly polished restoration is needed, a hybrid material may be used as a substructure that can be veneered with a microfilled composite. o Contraindications: restoration with occlusal forces, high caries, cementum margins. Hybrids : (0.04m to 1-4m o Blends the properties of macro and micro fillers strength of macrofills with polishability of microfills making smaller particles of uniform size and increasing the loading volume. o Increased compressive strength o Increased CTE o Decreased polymerization shrinkage o Increased hardness o Increased wear resistance o Indications: posteriors, Class III/IV with occlusal contacts Ref: Fundamentals of Operative Dentistry by Schwarz

3. All of the following are true regarding flowable composites when compared to microfills and hybrids except?

a. The particle size is decreased b. The filler amount is decreased c. The CTE (coefficient of thermal expansion) is higher d. The wear rate is higher e. The surface roughness is higher

Answer: a. The particle size is decreased.

Ref: Wakefield CW & Kofford KR, Advances in restorative materials, Dental Clinics of North America. Vol 45 (1) Jan 2001 pg. 14

FLOWABLE COMPOSITES

Since 1995, a new type of composite described as flowable has become popular. Practitioners, always attentive and susceptible to marketing claims of faster, better, easier, have succumbed to marketing claims made by almost every dental restorative manufacturer. To make a composite of low viscosity, or flowable, two processes must be accomplished: (1) The particle size is increased, and (2) the filler amount is decreased. Compared with microfills and hybrids, flowables are less sticky and are advertised to have exceptional handling properties. Most of these flowable composites are significantly less filled than microfills. Manufacturers claim that this class of composites may be used in restoration of all tooth surfaces, all classes of restorations, direct veneers, and core buildups. When compared with microfills and hybrids, the CTE, wear rate, and surface roughness all would be

significantly higher for flowables, whereas the physical properties would be drastically inferior. This represents a classic situation in which clinicians who limit their information on materials to that obtained from companies are led astray. Scientific information must be sought out to select the proper restorative. Flowable composites do have some valuable clinical applications. They are excellent as definitive restoratives in extremely small micropreparations or as wear-resistant occlusal sealants. Restoration of deep grooves when using air abrasion or small burs is accomplished nicely with flowable composite. When using bis-acryl composite material for fixed prosthodontic provisional restorations, flowable composites are good for margin or void repair. Controversy exists regarding which material is best in direct composite restorations to use as a liner to decrease the potential destructive effects of stress and gap formation resulting from composite polymerization contraction. As discussed earlier, adhesives that are filled or have a greater film thickness may serve this purpose as a shock absorber to alleviate the negative effects of stress. Flowables, with a higher CTE, greater flex, and lower filler percentage, may add additional relief to stress. Subsequent generations of this type of composite may show vast improvement and have a major impact in quality clinical practice. 5. When compared to high-copper admixed amalgam alloys, high-copper spherical alloys

a. b. c. d. e.

Have a higher copper content Show an increased propensity for microleakage Require more Hg to wet the alloy particles Have lower initial compressive strength Have longer working time

The correct answer is b.

Dental amalgam alloy consists principally of silver in the form of lathe -cut particles, spherical particles, or as an admixture, a combination of both. In

1896, Dr. G.V. Black publicized an amalgam formula that specified 68.5% silver, 25.5% tin, 5% gold, and 1%. Recent amalgam alloys differ only slightly and copper was added to react with tin. This practically eliminates the weak mercury-tin phase called gamma-2. This decreases creep and dimensional changes. It also improves compressive strength. Co mpared to admixed alloys, high-copper spherical alloys have higher 1-hour compressive strength, has relatively the same copper content and require less mercury to wet the alloy particles. The lathe-cut particles are rough and irregular in shape, but the spheres are smooth and essentially regular in shape. Therefore, less mercury is required to wet the spherical alloy particles. The result is less working time for spherical alloys. It has been reported in several studies that spherical particle alloys as a group showed an increased propensity for microleakage. Studies also show Spherical unicompositional, high-copper amalgam exhibits more dimensional change upon setting compared to admixed alloys. Increased mix plasticity increased condensation force, forces directed next to and toward cavity walls, and burnishing all decreased microleakage.

Taken from Charbeneau GT, Principles and Practice of Operative Dentistry, Third edition 1988 Lea & Febiger, and Mahler DB The amalgam -tooth interface, Operative Dentistry, 21; 230-236 and Craig (1996) Restorative Dental Materials, Mosby pg. 218

6. Which of the following physical properties contribute to the choice of a microfil to restore an abfraction lesion?

a. A low Youngs modulus of elasticity b. A high coefficient of thermal expansion c. A low polymerization shrinkage d. A low wear resistance

e. A low water sorption

The correct answer is: a: A low Youngs modulus of elasticity

Abfraction lesions can be defined as the pathologic loss of hard tooth substance caused by biomechanical loading forces. These cervical lesions are explained by fatigue due to flexure of the enamel and dentin at the point of loading. These lesions are typically wedge-shaped with sharp line angles, but occlusal abfractions have been observed as circular invaginations. Abfraction is a regressive process caused by occlusal loading, creating tensile and compressive forces, which in turn cause microfracture, fatigue, flexure, and deformation of the tooth structure. The thought behind the use of microfils is that their low Youngs modulus of elasticity would allow for flexure of the restoration with the tooth. Although microfils have a high coefficient of thermal expansion and low wear resistance, these are not the properties that make them advantageous in abfraction lesions. Microfils have a higher polymerization shrinkage than hybrids. They also have a higher water sorption.

Taken from: Owens BM, Gallien GS (1995). Noncarious dental abfraction lesions in an aging population. Compend Contin Educ Dent 16(6):552-61. 7. Core Materials Of the following core materials, which would be the material of choice, in a tooth that is subjected to heavy occlusal forces?

a. b. c. d. e.

Amalgam Resin Composite Glass Ionomer Cast Metal Resin Modified Glass Ionomer

The answer is D.

Resin Composite: Advantages: - Time efficient - Economical Disadvantages: - Polymerization shrinkage - Microleakage - Water sorption - Coefficient of thermal expansion - Low modulus of elasticity - Interaction with luting agent

Cast Posts: Advantages: - Better fit - More rigid - More uniform cement thickness Disadvantages: - Time consuming - 2 appointments - increased cost - decreased fx resistance

Glass Ionomers: Advantages: - Chemical Bond to dentin, enamel and cementum Disadvantages: - Low bond strength - Low compressive

strength - Fl release - Minimal polymerization shrinkage

Amalgam: Advantages: - High compressive strength - Ease of placement Disadvantages: - Color show -through - Must wait to prep

8. Treating pits and fissures in conjunction with restoring amalgam and composite.

In order to restore carious occlusal pits not involving the oblique ridge of tooth #3, which of the following restorations would you consider: a. b. c. d. Glass ionomer Amalgam GV Black design Composite with a sealant None of the above

The correct answer is c. Composite with a sealant

Changes in restorative techniques and the development of newer restorative materials have allowed for the use of more conservative cavity preparations. A 10-year study evaluated bonded and sealed composite restorations placed directly over frank cavitated lesions extending into dentin vs. sealed conservative amalgam restorations and conventional unsealed amalgam restorations. The results indicated that both types of sealed restorations exhibited superior clinical performance and longevity compared with unsealed restorations. Also, the bonded and sealed composite restorations placed over the frank cavitated lesions arrested the clinical progress of the

lesions for 10 years. The sealed restorations were superior to the unsealed restorations in conserving sound tooth structure, protecting margins, preventing recurrent caries and prolonging the clinical survival of the restorations. The preventive resin, which is composite resin and a pit and fissure sealant, is an acceptable alternative to restoration of an entire occlusal surface when only isolated pits and fissures with caries are present. Glass ionomer is lacking compressive strength and is not indicated for occlusal restorations. Taken from: Fairhurst et al: Ultraconservative and cariostatic sealed restorations: Results at year 10. JADA, 1998:55-66 Casamassimo et al: Pediatric Dentistry: Infancy through adolescence. 2nd ed.1994, Saunders. 11. Common chemicals used as dentin primers include:

a. HEMA (Hydroxyethylmethacrylate) b. NPG-GMA (N-phenylglycine + glycidyl methacrylate) c. UDMA (Urethanedimethacrylate) d. All of the above e. a and b only

The correct answer is: e: a and b only

UDMA (and Bis-GMA) is a bonding resin. Current available dentin bonding agents use resin systems that are based on a bifunctional molecule that acts as a primer. This molecule has:

HYDROPHILIC PORTION displaces water to gain intimate contact allowing penetration/interpenetration of the molecule into the moist surface to react/intermingle with the organic and inorganic components of the dentin. HYDROPHOBIC PORTION contains methacrylate groups that allow bonding to the restorative resin.

Taken from: Cochran, MA: Resin adhesives in dentistry. 18. Indirect Posterior Composites: Advantages:

Of the following, which is not an advantage of Indirect Posterior Composites? 1. Lab Characterization 2. Esthetic 3. Decreases Opposing tooth wear 4. Decreased degree of conversion 5. Reparable with composite

The correct answer is 4.

- Lab Characterization - Reparable with composite - Esthetic

- Decreases Opposing tooth wear - Increases Physical properties compared to hybrid composites

19. Advantages/disadvantages of posterior composites compared to amalgam. The advantages of a posterior composite restoration vs. an amalgam restoration includes all of the following except: a. Esthetics b. Conservation of tooth structure c. Polymerization shrinkage d. Low thermal conductivity The correct answer is c. Polymerization shrinkage.

Advantages: 1. Esthetics - 98% of composite restorations still provided an excellent color match at 2 years. 2. Conservation of tooth structure shallower since retention is through bonding to tooth rather than mechanical undercuts; narrower which allows less occlusal contact on restoration and reduces wear; rounded line angles; no extension for prevention. 3. Adhesion to tooth structure bonding offers the potential to seal the margins and reinforce remaining tooth structure against fracture. 4. Low thermal conductivity insulating effect that helps to reduce postoperative temperature sensitivity. 5. Elimination of galvanic currents - resin composite does not contain metal and so will not initiate or conduct galvanic currents. Disadvantages: 1. Polymerization shrinkage during polymerization, composite may pull away from the least retentive cavity margins (usually the gingival margins), resulting in gap formation.

2. Secondary caries marginal degradation (due to the difference of CTE of composite and tooth) has been demonstrated to increase with time, the risk of secondary caries increases with time. 3. Postoperative sensitivity possibly due to polymerization shrinkage leading to gap formation allowing bacterial penetration and fluid flow under the restoration. 4. Decreased wear resistance composites undergo wear by 2 different mechanisms - abrasion (generalized wear across entire occlusal surface) and attrition (loss of material that occurs as a result of direct contact with opposing tooth surfaces in the occlusal contact areas of the restoration). The best wear characteristics for posterior use are generally exhibited by heavily filled composite (>60% by volume) with a mean filler particle size between 1-3m. Current composites have acceptable wear characteristics oat 3 years. 5. Water sorption hydrolytic breakdown of margins. 6. Technique sensitivity there is little room for error. 7. Questionable durability - amalgam shows significantly better clinical longevity as a posterior restorative material then resin composite. Ref: Schwartz, Summit and Robbins: Fundamentals of operative dentistry A contemporary approach. Quintessence1996. 20. What are the effects of increasing filler loading on the physical properties of resin composite restorative materials?

1. Decreased coefficient of thermal expansion 2. Increased modulus of elasticity 3. Increased polymerization shrinkage 4. Decreased water sorption 5. Increased wear resistance

A. 1, 2, 3 B. 1, 3, 4 C. 1, 2, 3, 5

D. 1, 2, 4, 5 E. All of the above

Answer: D, 1, 2, 4, 5

Ref: Fundamentals of Operative Dentistry by Schwartz (Quintessence). Wakefield CW & Kofford KR. Advances in restorative materials. Dental Clinics of North America. Vol 45 (1) Jan 2001 Operative lecture handout by CDR Blaine Cook, 2001

Microfill Composites Conventional composites had relatively large, irregular filler particles (average particle size of 8 12 microns with particles as large as 30 microns or larger.) Polishability was poor because the resin matrix wore away during finishing exposing the large filler particles. Microfilled resins were developed to overcome the polishability problem. However, other physical properties were compromised in the process.

Compared to the large particle composites, the submicron filler particles of the microfills have more surface area to be wetted by the resin matrix causing the composite to be too viscous when loaded to the same volume % as conventional composite. To attain a usable material, filler loading was reduced. The result was a material with high polishability at the expense of decreased strength and increased polymerization shrinkage and thermal expansion.

Hybrid Composites - The hybrids emerged as manufacturers attempted to blend the properties of macro and micro fillers to make a material with the strength of macrofills and the polishability of the microfills. The physical properties of composite materials continue to improve as manufactures learn to make smaller particles of uniform size

and how to increase the loading volume while maintaining favorable handling characteristics. Presently the most common class of all purpose resins are the small particle blend composites.

Hybrids are a combination microfill and larger filler particles. The main disadvantage of this group, as determined by larger particle size, is the difficulty in long-term maintenance of a high polish. The advantages of hybrids are strength; high percent fill (75% to 80% by weight); and a wide array of shades of varying opacity, translucency, dentin replacement, and incisal edge restoratives that rival microfills. The higher the filler amount, the lower the CTE is, which leads to minimal marginal stress and microleakage when compared with microfills.

Basic Principles of Resin Composites 1. Almost all important properties of resin composites are improved by using higher filler levels. 2. The properties of the materials appear to be proportional to the volume % of the filler in the resin matrix. Weight % is often reported because it is easy to measure. However, it can be misleading because dense fillers may have a higher weight % than lighter fillers and still have the same volume %. 3. Surface roughness (polishability) is a factor of filler size rather than volume. The size of the largest particles is more important than the average particle size. The smaller the particle size, the smoother the surface. 4. There is no one perfect all-around composite resin material. For the time being, we are forced to make compromises (example: We give up strength to get polishability.) In a clinical situation, the doctor must decide what properties are most important to the success of that restoration, and then select a material that maximizes those properties. 5. Today, long-term studies can mean 6 months. Dont be in too big of a hurry to buy the latest and the greatest. Let someone else do the testing at their expense on their own patients.

6. Currently, the small particle blend composites with ultrafine particle size are probably the best all-around resin composite with the dense-filled being material of choice for posterior stress-bearing applications.