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Recent Advances In Restorative Dentistry

By
Hisham Abdelwahab Mostafa
Professor Of Operative Dentistry
Faculty Of Dentistry, Ainshams University

Important Notice
Copy&/or modification of all or part of the
following text is prohibited by law
Contents
- The recent concept in restorative dentistry
- Aspects in which restorative dentistry is modernized
- Recent advances in diagnosis and treatment planning
Computerized Radiography:
Radiovesiography
Wave length dependent fiber optic transillumination
Argon laser fluorescence
Computerized occlusal analysis
Electrical Caries Monitor ECM
Caries detection dyes
New concepts in treatment planning
Prevention, Minimal intervention vs drill and fill, ART,
Ultraconservative preparation, ozone therapy.
- Recent advances in cavity preparation
Recent classification of cavities based on site and size Si/Sta
Use of air abrasion technique
Use of lasers in tooth preparation
Use of ultrasonics in tooth preparation
Stepwise excavation
Chemomechanical caries removal (Caridex&Carisolv)
Management of smear layer(Concept of hybridization)
- Recent advances in restorative materials and adhesives
Gallium based silver alloy
Bonded amalgam restorations (Amalgam bond)
Novel adhesive systems
Packable and flowable composites
Microhybrid non shrinking composites
Glass ionomers, Compomers, Giomers and Smart restoration
Ormocers and Ceromers
Tooth colored inlays:
-Fabricated (direct, indirect)
-Machine ground (CAD/CAM, Celay)
-Ready made inserts
(size matching: sonic-sys, cerana)
(non-size matching: megafil beta quartz inserts)
- Recent advances in manipulation techniques and equipments
Ultrasonic condensation
Incremental packing, c-factor, decoupling technique

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Guided polymerization:
Soft start polymerization ( stepped, ramped and pulse delay)
High intensity QTH polymerization(Turbo curing), PAC and LED:
Recent technology in Hand pieces and rotary instruments:

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Recent Concept Of Restorative Dentistry

Since the days of Greene Vandiman Black (1896), the concept of


undergoing restorative therapy remained unchanged for many decades. It
involved all measures by which the dentist can prepare the decayed hard
tooth tissue to receive a restoration which maintains the tooth integrity,
restores function, esthetics and preserves the health of the masticatory
system. Later on, as early as the sixties, the scope of operative dentistry
was then extended to involve all lesions affecting the hard tooth tissues,
not only the carious involvement of a tooth but also other defects
including fracture, erosion, abrasion, attrition, discoloration as well as the
developmental and acquired defects(Anderson etal,1991).
The modern concept for restorative dentistry is based on
conservation and has concentrated on the importance of prevention of
diseases affecting hard tooth tissue and preservation of the sound tooth
structure either by taking the measures to preserve the integrity of teeth
from being affected or by undergoing treatment protocols which involve
the minimum intervention just necessary to restore the tooth as an active
member in the masticatory apparatus and to ensure its future
performance. Thus, restorative dentistry encompasses the prevention,
diagnosis, interception, treatment and prognosis of defects of the hard
tooth structure ( Albrektsson etal, 2001). Consequently, we believe that the
era and the ultimate objectives of restorative therapy is currently
changing. Thus it was not unexpected to find out a dramatic change and
shift from the classical believes founded as early as GV Black more than
100 years ago.

The recent advances in restorative dentistry has got four


main principal files:
To point out the aspects in which the restorative dentistry is
modernized, one should look upon the recent advances and modifications
encountered in the following views:
1. Diagnosis and treatment planning.
2. Cavity design and tooth preparation.
3. Recent advances in restorative materials and adhesives.
4. Recent advances in manipulation techniques, tools and
equipments.

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The procedure of recognition of disease and its extent for achieving the
plan of treatment is termed diagnosis. Apart from the traditional methods
for patient examination and diagnosis, the new restorative dentistry is
currently dependent on many recent methods and techniques that not only
help in reaching to a prompt diagnosis for the case but also facilitate the
plan of treatment and helps in explaining it to the patient to participate
positively in the process of decision making to proceed during the steps
for treatment.
Computerized Radiography:
According to many investigators (Richardson,1981 and Jackson,etal,1985),
the digitized radiography proved to be superior than the traditional
radiograph in disclosing the defects affecting the hard tooth tissue,
undoubtedly, caries is of primary concern in this respect.

When large number of records are to be analyzed, the digitizer offers


advantages in terms of speed and preparation of data for computer
analysis. The computerized digital sensitivity allows for the use of up to
1024 gray levels, thus it enables the operator to distinguish the earliest
changes that could affect the hard tissues especially in areas of low

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contrast. This would be usefull in particular in detection of incipient
caries at the inter-proximal areas.
Recent technological developments have produced a new generation
of software with computer aided image analysis making it possible to
drive a variety of objective measurements from approximal enamel
radioluscencies corresponding to natural lesions depicted in clinical bite
wing radiographs which were regularly employed for the purpose of
detecting early proximal decay. Moreover, the ability of the digital
radiograph to generate a scale plot of the lesion boundary as well as the
estimate for the depth of penetration of the lesion enables the operator to
accurately estimate the progression of decay and by follow ups, he can
judge the regression or the arrest of the carious procedure (Pitts,1984).
Furthermore, the ability to perform an accurate radiograph while
minimizing the exposure time and omitting the procedure of film
processing adds to the benefits of the technique in addition to the
possibility of repeating the shots and save only of the best quality of them
as a record. The filing system incorporated helps the operator to bring
back the desired image in the touch of a button.
On the other hand, numerous barriers still need to be overcome in
the use of computers in dental radiography mostly in the part of its
software. In many instances, the alteration of an image to remove artifacts
or scratches needs to be documented and can not be relied on as an
evidence in the legal sense (Pickens,1986).
The high cost of the computerized radiograph does not encourage
many of the practitioners. However, some of the equipments are
introduced with a reasonable price so that a transition from traditional to
computerized radiography is currently taking place.( Hess,1986)

Radiovesiography:
The radiovesiograph is a multi-component system advocated by Dr
Francis Mouyen in 1989 ( Mouyen etal,1999). It enables the operator to
capture colored images from the patient mouth via an intra oral camera
and the transfer of this image to the computer to be saved there so that
many options and applications could be carried out by that image. The
image can be zoomed, rotated, cut or edited in the same manner as
pictures captured from the computer scanner. Further manipulation of the
image is possible, it includes enhancement, contrast stretching and
reversing. The appearance of the image on the computer monitor and the
possibility of file reopen enable the operator to share the process of
decision making during planning of treatment of the case, taking in
consideration the possibility of informing the patient about the existing
condition and explaining the steps of treatment to be proceeded. On the
other hand, alarming the patient from the unfavorable consequences that

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could occur if such treatment is neglected . Again, as digital radiography
could be an adjunct to the same equipment, a sensor for radiography can
be attached instead of the intra-oral camera for radiographic purposes
(Snow, 2002). The sensor can be cold sterilized and for infection control,
disposable latex sheaths are used to cover it when it is in use inside the
mouth.
The newer versions of intra-oral cameras are very light in weight (less
than 50 Grams) and the illumination for image capture is no longer a
fiber-optic which is affected by aging but it became light emitting diodes
which give adequate white illumination to comply with darkness inside
the mouth. The focusing of the camera lens is automatic and the image
could be transferred either to pc or to any other video compatible system.
Some devices include a defogging feature to prevent the effect of intra-
oral humidity from altering the image quality. Moreover, there is a
capability of freezing the images up to four images at the same timing.

Wave length dependent fiber optic transillumination :


Apart from the conventional fiber optic trans-illumination,
Vaarkamp etal, in 1997 (Vaarkamp etal,1997.) advocated a technique by
which the occlusal surface is imaged by a charged coupled device
camera(CCD) which utilizes the light in the blue and red portions of the
light spectrum during imaging. The average mineral loss of the tooth
structure can be determined via analyzing the recorded image and
assessment of the optical thickness difference of the tooth structure since
there is a marked difference between the light transmitted through carious
and non carious sites. This method can provide an assessment of the
mineral loss of the suspected tooth to provide a quantitative diagnosis. A

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high intensity light is shone through the tooth and the transilluminated
image of the tooth is captured by the above mentioned intra oral camera,
then it is displayed on the computer screen for diagnosis.

Argon laser fluorescence :


This technique is used to quantify the mineral loss in carious lesions.
The lesion is subjected to argon laser and will emit fluorescence which is
different in healthy sites compared to the demineralized carious sites.
(Emami etal,1996.). More recently in February 2000, a newer device was
introduced , it works on the fluorescing nature of bacteria and its
metabolic by-products. This fluorescence is detected into a meaningful
numerical figure that can be used not only to diagnose caries but also to
measure the level of cariogenic bacterial activity(Shi etal , 2000 and
Featherstone , 2000).

Computerized occlusal analysis :


The problems of occlusion constitute a major issue in the
establishment of dental disorders. Occlusion analysis and simulation of
occlusion of a patient, remained the day dream of the dental profession.
It constituted a great difficulty to analyze the problems arising from
occlusal origins due to the complex nature of the human occlusal system.
The search for the most atraumatic dental occlusion is an increasingly
growing demand especially in the fields of restorative and reconstructive
dentistry. However, in 1988, Dr William Maness (Maness,1988.) working
in Tufts introduced his automated computerized sensor for analysis of the
dental occlusion. The idea is to register the patient occlusion on a thin

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patented 60 microns thickness disposable sensor to record instantaneously
the patient bite in terms of location, timing and force of every tooth in
contact. This record is transferred to a computing system which can make
an actual simulation of the patient occlusion on a monitor assuming the
different situations possible during centric, eccentric and functional
movements. Thus, providing both qualitative and quantitative assessment
of occlusion instead of the former messy only qualitative carbon marks
and presenting this in a moving show. The movie can be replayed in
frame by frame manner to study the occlusion. The system was termed T-
Scan and has got many advantages as being simple to operate, dynamic
viewing of occlusion, timed analysis of force during various positions of
teeth contact and the possibility of permanent documentation and
monitoring of the occlusal condition after carrying on the various
treatment protocols. The T-Scan not only presented a valuable method for
clinical evaluation and understanding of the occlusal problems but also it
offered an important tool for teaching purposes as explained by Dr
Maness, the inventor of the system. (Maness,1988).

Dr William Maness

Computerized sensor for registration of occlusion

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Electrical Caries Monitor ECM :
The existing clinical methods for caries diagnosis are unable to
discriminate between lesions with or without a remineralized surface
layer. The idea is that the electrical conductivity of a tooth changes with
demineralization, even when the surface remains macroscopically intact.
A major advantage of the ECM is to present reliable objective reading .
Thus, it becomes suitable for early detection of lesions and to monitor
lesion progression or recession, arrest or remineralization.(Ashley P, 1997).
The ECM measures the electrical resistance of a site on the tooth ; high
measurements indicating well mineralized tissue and low values are
indicative of demineralized tissue. Electrical resistance measurements
have demonstrated accuracy in detecting occlusal caries (Albrektsson etal,
2001)
Ricketts etal .( Ricketts etal, 1995), reported the benefits of utilizing the
ECM in diagnosis of early occlusal and cervical carious lesions. Baysan
etal, (Baysan etal,2000) recently in 2000, showed the definite correlation
between ECM readings and th clinical findings during caries assessment
as texture, hardness, size, cavitation. The researchers concluded that the
ECM is a valuable method to detect incipient lesions. One of the
marketed appliances is the ECM III, Lode diagnostics BV, Groningen,
Netherlands.

Caries detection dyes :


Caries detection dies evolved in an attempt to solve the conflict of
differentiating between affected and infected dentin and whether all
doubtful dentin has to be eliminated or remineralization is possible.
Fusayama in 1980, came out with a dye indicator which was 1% basic
fuchsin in propylene glycol in order to replace the policy of drill and fill
by a more conservative approach. More recently, Husoda and Fusayama
(Husoda and Fusayama, 1984) proposed a tooth substance saving technique

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in a more biological look and summarized the conservative technique in
two man steps, the first was to use the caries detection dye and the second
was stepwise excavation to remove only the infected irreversibly
denaturated dentin and leave the deeper non infected reversibly denatured
remineralizable dentin.

New concepts in treatment planning :


Planning the treatment for restorative therapy is getting a more
biological model than the drill and fill old surgical model. The old model
included tooth preparation to remove the defect and include it in a
suitable design that can accommodate and retain the final restoration. On
the other hand, the non surgical biological model is based on the medical
therapy by controlling the causative factor and eliminating the reservoirs
of the pathogenic micro-organisms. Even the intervention policy is
currently changing to present a new ultraconservative approach with
minimal intervention (Mount,2000) and atraumatic restorative techniques
.ART (Frencken and Holmgren,1999). Recent modalities of treatment
included prevention of caries by fluoridation, diet control, oral hygiene
measures and immunization based on molecular biology. Another
alternative is the conservative management of suspected lesions by
fissure sealing, enameloplasty and preventive resin restoration. More
recently, an effective and powerful method was employed which is the
ozone therapy.
Ozone is known to be a powerful antimicrobial agent. Studies have
shown that exposure of carious dentin to O3 for 10 or 20 seconds has
caused a substantial reduction in the level of cariogenic organisms. It can
penetrate the bacteria and kill them in their protected niches. It can alter
the bacterial metabolic activities that inhibit the process of
remineralization and thus allow clinical reversal of the lesions in both
root caries and occlusal surface lesions.( Baysan and Lynch 1999, 2001and
Baysan etal in 2000). Ozone was first suggested to disinfect water because
of its ability to inactivate microorganisms. Currently, it is used in
dentistry by utilizing a special delivery system known as (Healzone). The

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portable apparatus includes a source of oxidizing gas and a dental hand
piece for delivering the gas/water to the target tooth. A cup attached to
the hand piece is provided for receiving the gas and exposing a selected
area of the tooth to the gas action. The tightly fitting cup includes a
resilient edge for sealing the margins to prevent escape of the gas. The
procedure should be followed by rinse and suction (Ebensberger etal, 2002)
to eliminate gas residues since some reports indicated that excessive
exposure to ozone may result in complications as eye, lung or
subcutaneous emphysema.

Healozone Ozone Delivery System

Hand piece with cup for ozone delivery

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Recent classification of cavities based on site and size
Si/Sta:
The traditional Black,s classification which served for identification
and standardization of cavities for many years is currently debated for
inefficiency in specifying the size and extent of the lesion. Mount and
Hume in 1998,( Mount and Hume, 1998.), proposed a new classification that
is based on site and size and was termed Si/Sta classification. It includes
site1 for pits and fissures and enamel defects on the occlusal surfaces of
posterior teeth and smooth surfaces on anterior teeth. Site 2 involves
approximal enamel immediately below the contact areas with adjacent
teeth. Site 3 refers to the cervical one third of the crown or exposed root.
The four sizes are size 1 , which indicates minimal dentin involvement,
size 2 indicates moderate dentin involvement , size 3 designates
involvement beyond moderate and the restoration is designed to support
the remaining tooth, while in size 4, there is an extensive involvement
and bulk loss of the tooth structure and hence, a more radical form of
restoration will be designed.

Use of air abrasion technique:


The technology of air abrasion came as early as 1940. It was an
alternative to the slow speed belt driven hand piece used at that time for
the removal of tooth structure. At that time, Black in 1945, published a
detailed method for cavity preparation using a stream of gasborne
aluminum oxide abrasive particles to wear away and abrade the tooth
structure. Eakle etal, in 1994 (Eakle etal,1994) and Goldstein and Parkins,
in 1995,(Goldstein and Parkins, 1995) have demonstrated the importance of
employing the air-brasive technique to match with the needs for a
conservative approach in removing carious dentin and conditioning the
adherend dentinal surfaces. The usual range of size of the abrasive
particles utilized in the air abrasive technique is25- 50 microns while the
pressure used to apply the particles ranged between 80-160 psi.
The present outcome in the field of air abrasion is the Kinetic cavity
preparation using KCP2000. The apparatus involves minute abrasive
particles which are too small to be seen by the naked eye carried to the
target tooth by a stream of air gently and precisely acting to remove away
the decayed tooth structure. It allows the removal of such decayed part of
the tissue without the removal of the healthy tooth substance
unnecessarily. The resultant prepared surface was found to be ideal for

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adhesive dentistry and the application of bonded restorations. It is a
precise, gentle, time saving , painless as it reduces thermo-genesis and
omits the vibration of the ordinary rotary tools. It is recommended for
treatment of children, pregnant women and other medically compromised
patients.

Newly introduced Kavo Air abrasion system

Use of lasers in tooth preparation:


Laser is an acronym of light amplification by stimulated emission of
radiation. The laser optical chamber is a resonator which comprises two
mirrors, one is totally reflective to increase the excitement of the atoms
by the reflection of radiation while the other is partially transmissive to
emit the laser beam proper. The laser is named according to the excitation
medium, accordingly, various types of lasers are available, among which
the Nd-Yag (Neodymium Ytterium/Alluminum/Garnet is most suitable
for tooth preparation. The produced laser beam is then passed through a
lens and the resultant radiant energy can be focused to a very small sized
spot to yield the various uses of laser as cutting, vaporizing, coagulation
or conditioning effects. The use of laser technology in cavity preparation
was faced with many complications such as the difficulty in the
localization of its effect and the enormous temperature rise
(Elmortada,1995). However, the innovation of a hydrokinetic laser to
employ a combination of laser energy and water spray can be utilized to
rapidly remove the enamel, dentin as well as the decayed tooth ( Biolase
technology incorporation). The employment of pulsed laser and the recent
technology of micro and nano seconds have yielded a hope in achieving
the objective of utilizing only the required laser energy to effect the
procedure needed and avoid the unfavorable squeal of pulp affection
( McDonald etal, 2002).

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Special Handpiece for laser application from Kavo

Use of ultrasonics in tooth preparation:


Generally, ultrasound is generated by either magnetostriction or by
piezo electricity. Ultrasonics are usually utilized in dentistry for
elimination of calculus deposits, however, drill inserts of various forms
and sizes can be attached instead for cavity preparation. The sonicsys was
introduced to the dental profession in the international exhibition held in
Koln 1997. It consists of metallic inserts coated by diamond from one
side to assure that no damage would occur if the tip contacts the
neighboring tooth. It complies with the requirements of the minimal
invasive technique of preparation. It has the advantage of providing a
standard preparation to accommodate standard prefabricated inlays. There
are three sizes of tips for preparing standard proximal cavities (sonicsys
approx) and there is another smaller tip for ultra small proximal
preparation( sonicsys micro).Each size of preparation has a corresponding
prefabricated inlay that is exactly fitting its size of the preparation.

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Various tips for ultrasonic preparation of the tooth structure

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Ultrasonic equipment used to attach preparation tips

Stepwise excavation:
The carious process passes by periods of activity in which there is
increased rate of demineralization and proteolysis with resultant tooth
destruction and other periods of rest in which recovery takes place and
there is reparative mechanism causing remineralization by deposition of
sclerotic dentin. In cases of acute caries, the activity of the lesion is
enhanced due to increase of the rate of acid production while in chronic
decay, there is an enhanced reparative mechanism due to decrease of
virulence of the microorganisms, less production of acid and greater tooth
resistance. In many instances, during management of deep carious lesions
by complete one step eradication, the pulp is often approximated and may
be involved by minute undetected or frank exposures. The idea of
stepwise excavation is to perform peripheral dentin excavation first to
change the ecology of the lesion and arrest the spread of decay so that
repair can take place. This should be followed by removal of the central
cariogenic biomass and the superficial necrotic dentin in a separate
session as late as 2-4 months. Doing this, many pulps could be saved
from injury and the removal of the minimum amount of tooth structure as
a part of ART is achieved.( Bjorndal and Larsen, 2000 and Ricketts,2001).
The maximum outcome of the stepwise excavation procedure can be
established in combination with caries detection dyes which are able to
distinguish the infected from the affected dentin such as acid red dye
( fuchsin dye) or the more recent blue dye ( Quadrant CariTest) . Thus,
what is removed would be only the amount of dentin necessary to be
removed. Numerous researches indicated the benefits of stepwise
excavation which includes; reduced risk of pulp exposure, decreased CFU
counts, an alteration of the typical cariogenic microbiota, and an increase
of remineralization and repair evidenced by the formation of hard less
penetrable sclerotic dentin which adds to the quality and protective
capacity of the remaining dentin bridge (Leksell etal,1996,Bjorndal and
Thylstrup, 1998, and Banerjee etal, 2000).

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Chemomechanical caries removal (Caridex&Carisolv) :
The ART involves the removal of only the infected carious dentin and
remineralization of the reparable only affected dentin. Mchanical removal
of decay using hand excavators or rotary tools would not satisfy the
objectives. The original chemomechanical agent for caries removal was
based on N-Monochloro-DL-2aminobutyrate (NMAB) and is currently
marketed under the name Caridex. (Watson and Kidd, 1986 and Romand-
Roeloffs etal, 1991). The system acts by altering the secondary and /or
quaternary structure of collagen in carious dentin by chlorination of the
collagen. The hydrogen bonding in the collagen is disrupted rendering it
more friable and easier to remove by scrapping the carious fragments
away. Studies have shown that the system is efficient in eradication of
more than 90% of carious dentin in 98% of cases (Albrektsson etal, 2001).
The advantage of the Caridex system is that it provides painless and
efficient removal of carious dentin and thus preferred than conventional
mechanical removal which requires the administration of local
anaesthesia. However, it was reported that it is a time consuming
technique which precluded its universal adaptation.
More recently, a new gel Carisolv was introduced from ( Medi-
Team Incorporation, Gothenburg, Sweden). It is a combination of 0.5%
sodium hypochlorite and 0.1 M amino acids ( glutamine, leucine and
lycine). It comes in the form of two gels, one is transparent, and the other
is red. The two gels are mixed together or brought out from the tube
mixer supplied and applied into the cavity. The carisolv works on the
tooth substance to remove the decay evidenced by a cloudy vapor coming
after action. The application of gel takes 5-8 minutes in an average case
to remove the decay. The procedure is ceased when no cloud comes out
on gel application then, the supplied scrappers are used to eradicate the
softened dentin. The material selectively acts on denaturated collagen,
that is the collagen which has lost its cross striations by the action of the
cariogenic organisms and is considered as being irreparable or not liable
to the process of remineralization. By applying the carisolv, only dentin
decayed beyond repair is removed which matches the objectives of ART.

The carisolv gels in tube with the supplied kit of instruments

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Management of smear layer(Concept of hybridization):
The state of art in the management of smear layer is to totally
remove it using phosphoric acid etching as a part of the total etch
procedure before application of adhesives to both enamel and dentin.
Whether total etch in a separate step or self etching adhesives are
better employed remains a controversial issue. The etching time suitable
for total removal of the smear unit ranges from 10-60 seconds with most
of the recommendations favoring the 30 seconds. This is of quite
importance to assure adequate etching effect on enamel at the same time
.(Nakabayashi and Pashley, 1998)

Open tubules after dentin etching Collagen network at the intertubular


With Phosphoric acid. Partial removal area after etching Mag. X 36600
Of peritubular cuff. Mag. X 18300

The success of adhesion to dentin and the adequate protection of the


pulpodentinal complex after tubular patency as a result of dentin etching
is achieved via the formation of the 1-5 microns thickness hybrid layer
which is formed by resin infiltration of tubules and encapsulation of the
collagen fibrils at the intertubular areas after application of the resin
adhesive and its polymerization.

Hybridization with resin lateral branching. Mag. X 9100

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There are two requisites necessary for hybridization to occur. The first
is the preparation of dentin substrate by removal of the smear layer and
the smear plugs provided that no denaturation or deformity or collapse of
collagen occurs. The second requisite is the use of a suitable resin
monomer that can easily impregnate and wet the dentin to infiltrate into
the tubules and encapsulate the collagen fibrils projections. The process
of resin impregnation is critical in the success of hybridization.
( Nakabayashi, 1996 and Nakabayashi and Pashley, 1998).
On the other hand, the presence of a non resin impregnated zone of
dentin i.e. intertubular dentinal collagen non infiltrated with resin is
termed hybridoid layer. The hybridoid presence is thought to adversely
affect the bond, however, later studies have shown that this zone is later
on remineralized( Akimoto etal, 2001).

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The search for an ideal restorative material is still going on. None of
the available restoratives is free from either biologic, esthetic or
mechanical limitations (Sturdevant ,2002). The evolution of new materials is
very rapid and the competition in the market is too high. I would say that
there is a weekly outcome in the field of restoratives to the dental
profession. Some materials proved superiority while others just survived
for short periods of time. All I can say is that the search is still going on.

Gallium based silver alloy:


The vigorous attack on the toxicity of mercury with amalgam alloys
in the last two decades has urged the producers to find out an alternative.
Currently, many dentists do not use amalgams either convinced with the
hazards of mercury, or obeying their patients. Others went for replacing
old amalgam restorations with composites. However, soon dentists
discovered that this was an unwise decision. (Flanders, 1992, Psarras
etal,1992 and Lutz, 1996)
The Gallium based alloy is developed as a part of a program
supported by the American Dental Association. It is a direct filling
material which contains no mercury. It comes in the form of a
powder(60.1% silver, 28.05% tin, 11.8% copper and platinum 0.05%)
and a liquid ( gallium 61.98%, indium 24.99%, tin 12.98% and bisthmus
0.05%). The product suffers from some limitations especially excessive
corrosion and decreased workability (Navarro etal, 1996).
The melting point of gallium is about 29oc., thus, it is recommended to
slightly preheat the mixing device before trituration to assure melting of
gallium and enhance its wettabiliy. Some reports indicated that gallium is
not free from toxicity but its vaporization at room temperature is much
less compared to mercury.

Gallium based dental alloy

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Bonded amalgam restorations (Amalgam bond):
This is a resin adhesive used with amalgam restoration after etching of
enamel and conditioning of dentin. Its chemical composition is essentially
4 META (Methacryloxy chloride trimellitic dianhydride) . This is
particularly useful in extensive cavities in premolars to decrease
microleakage and to limit the tendency of tooth fracture. The possibility
of bonding a resin composite to the facial aspects of amalgam restoration
makes the system applicable to increase esthetic qualities by covering the
surface of amalgam restoration. Some products are supplied with an
oxyguard to counteract the oxygen inhibition of polymerization at the
margins (Al-Moayad etal, 1993 and Saiku etal, 1993).

The 4 META (Amalgam bonding) kit

Novel adhesive systems:


Bondodontics is becoming a subject of its own. The successful
bonding of restorative materials to tooth tissues is the prime achievement
in the modern restorative dentistry. Both chemical and micromechanical
bonding to tooth structure could be well established. The bonding to
enamel structure does not face the same obstacles met with dentin due to
different architectures and mineral content. The acid etching invented by
Bunocore (Buonocore, 1955) is still the key stone in the production of a
strong and stable bond with enamel.
The novel dentin adhesive systems started with the 5th. generation
One bottle adhesive (Prime and bond, Dentsply, Syntac single
component, 3M-Espe & Excite , Ivoclar, Vivadent). It was produced to
standardize and simplify the procedure of bonding by incorporating both
the primer and adhesive in a single bottle where the processes of resin
impregnation and adhesive bonding are combined together. Still a total
etch procedure should be carried out before application of the adhesive

22
(Swift etal, 1997). However, to ensure adequate resin impregnation and
hybridization, more than one application was recommended. The research
continued to eliminate the need for acid etching before application of the
dentin bonding agent until a bonding agent with self etching qualities
containing phosphate ester was produced under the name of (Prompt L
Pop, Espe) to constitute a single bottle self etching primer/adhesive
6th. generation bonding system (Perdigao etal, 2000).
The self etching system proved to produce a strong adhesive bond to
both enamel and dentin together with an excellent marginal seal and
possess a very simplified unique 2 steps application which are the
application for 15 seconds followed by gentle spread with air stream. The
simplicity and superior results has urged many clinicians to utilize the
material.(Breschi etal, 1999, Nunes etal, 1999 and Frey, 2000). The self etching
primer adhesive systems were blamed for the incorporation of smear
layer within the hybrid layer if the primer is not agitated during
application and that its highly acidic monomers incorporated to penetrate
smear layer to underlying dentin can cause hypersensitivity and can
interfere with polymerization of auto-polymerizable resins since this high
acidity deactivates the more basic amines incorporated as catalysts in auto
or dual cured resins. Moreover, as the newer generations of adhesives are
becoming more hydrophilic, the adhesive may absorb water from
underlying dentin(dentin perfusion) which can cause an interference with
the overlying composite polymerization (Tay and Pashley, 2003, Ahmad, 2003,
Ozok etal, 2004 and Tay etal, 2003).

5th. Generation single bottle adhesives 6th Generation single bottle.


Total Etch Technique Self etching primer

23
More recently, in 2002, a 7th generation of adhesives has erupted .
The system is quite similar to the 6th generation but a desensitizing agent
was added to overcome the problem of hypersensitivity (Freedman and
Leinfelder, 2002). An example of this generation is the recently introduced i
bond.. The material is claimed to decrease hypersensitivity in addition to
the similar other properties compared to the 6th generation adhesives.
(Dunn, 2003 and Van Meerbeek etal, 2003).

i Bond ( Heraeous, Kulzer) 7th. Generation adhesive system

Another development in adhesive systems is the evolution of the


bioactive adhesive. This was performed by the incorporation of an
antibacterial monomer (MDPB:12-Methacryloyloxydodecyl pyridinium
Bromide) to a self etching adhesive system to give it a bactericidal effect.
This will enable the use of the system with minimal intervention and in
root caries to produce a modified sealed restoration and gives hope for
success in direct pulp capping with an adhesive.(Imazato etal, 2000).

Schematic diagram showing the effect of bioactive adhesive

24
Packable and flowable composites:
The invention of a condensable composite satisfied the operators due
to their excellent handling characteristics. They are non sticky and
moldable and easily released from the hand instruments, thus, less they
are time saving and less frustrating. The material possess advanced
physical and mechanical properties (Suzuk , 2001). However, the marginal
adaptation of such materials suffers from a shortcoming and there is a
possibility of interfacial debonding due to lack of adequate flexibility.
Shrinkage during polymerization can break the established interfacial
bond. The application of a flowable composite prior to the placement of
packable composite will provide a stress breaking effect to prevent this
debonding.(Miranden etal, 1999). The flowable composite usually has low
viscosity due to decrease of its filler content.

Flowable and packable composite combination from Vivadent

Flowable composite from Bisco

25
Microhybrid non shrinking composites:
The search for a universal composite to be suitable for use in both
anterior and posterior regions has emerged a consensus that hybrid
composites which has got high filler loadings up to 90% by weight of
both microfined silica , borosilicate glass and quartz are suitable for use
as anterior and posterior restorations. They possess excellent mechanical
properties due to high filler content, polishable and has got high wear
resistance and adequate translucency to produce the desired esthetics.
Numerous products are available in the market with different shades.
Each manufacturer claims superiority of his product. The incorporation of
non shrinking monopolymer systems has added to the high performance
of the materials by decreasing the resultant shrinkage of polymerization
which is reflected to better bonding and reduced marginal gap formation.
(Davidson, 2001).

Filtek Z250 & P 60 newer forms of microhybrid composite.

Glass ionomers, Compomers, Giomers and Smart


restoration:
The need for a fluoride releasing restorative that can directly bond to
tooth structure led to the development of glass ionomer restoration. The
material has a coefficient of thermal expansion close to that of the tooth
structure and due to its desirable characteristics, has a wide variety of
applications including restoration of cervical and root defects, core
construction in addition to its use as a restorative in permanent and

26
primary teeth and when its anticariogenic potential is required (Powis etal,
1982 and Thornton eal, 1986).
Due to the cement nature of the material, it suffers from disintegration
in the mouth and susceptible to hydration and /or dehydration. Moreover,
it is a technique sensitive material during manipulation and its properties
are markedly affected with imperfect handling (Teo,1986, Walls etal, 1988
and Knibbs,1988). This has led to the incorporation of resin polymers to the
structure of polyalkenoates to develop the compomers (Antonucci and
Stansbury, 1989 and Mitra,1991).
Compomers possess better handling characteristics, more
translucent, less disintegrable and has got a better marginal adaptation
compared to glass ionomers. Moreover, the pattern of fluoride release has
been found to be equivalent to that of the original glass ionomers.
Furthermore, the possibility of light polymerization adds to the
advantages of the material (Elbadrawi, and McComb, 1998).
Giomers are another addition to the glass ionomer technology by the
incorporation of pre-reacted glass ionomer filler to the powder of the
glass ionomer. This was performed to obtain enhanced mechanical
properties. However, unlike the compomers it was noticed that this
category of glass ionomers significantly release less fluoride compared to
conventional glass ionomers (Yap etal, 2002).
The attempts for combining composite resin and glass ionomer has
led to the development of ion-releasing polyacid modified composite
known as smart restoration (Van Dijken, 2002). The smart restoration
elutes fluoride, calcium and hydroxyl ions when pH value drops in the
oral cavity. Consequently, the material may be able to reduce plaque
formation, remineralize the tooth structure, inhibit caries and neutralize
acids (Heintze, 1999)

Glass ionomer capsules (Ionofil molar) Compomer restorative (Dyract)


Voco, Cuxhaven,Germany. Dentsply, USA.

27
Ormocers and Ceromers:
The ormocer stands for an organically modified ceramic composite
restoration. The restorative material is considered a new material that
substitutes the organic fraction of resin composites (Bis GMA & UDMA)
with another component which possesses an inorganic component of
modified silicon dioxide in an organic methacrylate group forming a
highly cross-linked matrix. The physical properties of ormocer
restorative is improved, but the marginal approximation is compromised
and can be decreased by utilizing a flowable composite liner better than
one bottle adhesive system.(Manhart etal,2000)
The ceromer is a ceramic optimized polymeric composite restoration
or fiber reinforced ceramic polymeric restoration ( Targis/Vectris) where
ceramic fillers are incorporated to substitute the quartz fillers. They got
an improved wear resistance and excellent esthetic qualities. The material
is available in LC direct restoration or LC followed by heat curing
fabricated inlays which are cured in a special furnace and cemented in
place with an adhesive resin cement supplied in different viscosities. The
material possesses enhanced mechanical properties, excellent esthetics.
Its marginal quality is optimized by utilizing a flowable composite and/or
a resin cement. Undoubtedly, the inlay form can compensate for the
polymerization shrinkage and is able to attain and maintain better
relations with neighboring and opposing teeth (Fahl and Casellini, 1997).

Ormocer restoration(Admira, Voco) Ceromer restoration with supplied resin


cement(Variolink,Vivadent)

Tooth colored inlays:


This category of restorations was developed to compensate for the
polymerization contraction in case of direct restorations with in-situ
polymerization and to enhance the mechanical properties by more
completed polymerization or by using ready made blocks with high

28
physical properties ground to produce the desired inlay. Undoubtedly,
direct, indirect or machinary inlays are able to produce better anatomical
landmarks, occlusal and proximal contact relationships with better
accuracy compared to the direct restorations.(Wassel etal, 1995). Apart from
the material of construction of the inlay, three types of tooth colored
inlays are currently available.; Fabricated inlays, either by direct or
indirect technique, machine ground inlays and Ready made inlays
(inserts). Repeatedly, the inlays are inserted into the corresponding
preparations and luted with adhesive bonding systems and/or flowable
composite or with a dual cure adhesive resin cement The ceramic inlays
should be etched with hydrofluoric acid and sialanated before insertion.
(Craig and Powers, 2002).
Direct inlays can be fabricated from composite resin, ceromers or
ceramic. The prepared inlay cavity is lubricated, the material is packed
incrementally, the increments of composite or ceromer are light cured
until the preparation is filled to the margins. The inlay is removed to
receive secondary polymerization by light, or by light and heat in a
special polymerization apparatus for 8minutes at 110oc.. Alternatively,
the indirect inlays can be constructed in the same way after an accurate
impression of the preparation and the inlay is constructed on a die in the
lab. The ceramic inlays are fabricated similarly as all ceramic full
coverage crown (Lutz, 1996, Burke etal, 1996 and Goracci and Andreasi
Bassi,1999).

Fabricated ceromer inlay

Machine ground inlays(CAD/CAM Cerec & Celay copy milling):


CAD/CAM stands for computer aided design and computer aided
manufacturing. The system was introduced by Mormann and Brandistini
in 1988. The prepared cavity is captured by a miniatured camera and
transferred to a computer linked to a milling machine. The software
program in the computer gives data to the machine so that when an order
of fabrication is given, the milling machine will provide the ingot of the
restoration in about 10-15 minutes time. Then, the occlusal anatomy of

29
the restoration is adjusted with manual grinding and finally the inlay is
polished and cemented in place. The main advantage of the system is to
provide the inlay in clinic in one session.(Christensen, 2001). The ceramic
blocks for making the restoration are mainly constructed from feldspathic
porcelain produced by Vita company. However, there is a newer version
for use with Cerec III CAD/CAM (Dicor MCG) which is a glass ceramic
with fluoromica crystals in a glass matrix. It has high wear resistance and
possess more flexural strength. In Cerec III system, the milling machine
is able to construct not only an inlay or onlay with all fine details of
occlusal anatomy, but also can fabricate venners , crowns and full
bridges. Moreover, the milling machine should not be placed aside of the
dental unit but can be stationed away in a separate room and connected
with or without a cable(remote radio control) to the computer unit.
The Celay copy milling technique fabricates the ceramic inlay
after constructing a pattern from composite resin or similar material on a
die. Then, a grinding machine similar to that which duplicates house keys
takes part in producing the restoration from the ceramic ingot. It is
important to note that as long as the ceramic blocks (ingots) do have the
same color, the produced restoration will always suffer from imperfect
esthetics.

CAD/CAM grinding machine Cerec Some inlays produced by Cerec 3


With ceramic block in place. most advanced CAD/CAM technology.

Celay key like grinding machine pattern and inlay produced

30
Ready made inlays (inserts):
This group of inlays come as prefabricated inlays in different sizes.
They are used to restore cavities in posterior teeth, however, the rest of
preparation should be restored with packable and/or flowable composite.
The inserts have the advantage of standardizing the preparation, desirable
mechanical properties, efficient control of the polymerization contraction
and a reduction in time of the procedure.
Sonic Sys approx & sonic sys micro.
These are ready made size matching prefabricated ceramic inserts for
the proximal box cavity supplied in three different sizes produced by
Vivadent company corresponding to the ultrasonic tips of the Sonic sys
produced by Kavo. The inserts fit exactly the prepared proximal box
cavity and restores the proximal contact with the neighboring tooth to
produce the desired embrasures. The occlusal part of the preparation can
be restored with packable and flowable composites if necessary. In case
of small proximal cavities, a smaller size insert is available ( Sonic sys
micro) while he occlusal part of the preparation may be restored with
flowable composite or cavifils which are produced in compules of either
0.25 or 0.50grams. The fitting surface of ceramic inserts is usually
silanated to increase the wettability by the remainder composite
restoration.

Sonic sys approx

Cerana inserts.
The cerana inserts are tapered cylindrical ready made size matching
ceramic pieces of different sizes. After cavity preparation, the proximal
part of class II preparation is drilled with the supplied corresponding
cylindrical diamond point, then, the insert is fitted in place via the plastic
tweezer supplied not to disturb the silanated fitting surface of the insert.
Another insert is selected to fit another preparation at the occlusal surface
and so on , the remaining parts of the occlusal preparation are either fitted
with smaller inserts in between the previously inserted inserts or with
flowable composite. The occlusal anatomy is finally adjusted after
removal of the inserts handles with abrasive stones. Finally, polishing is
performed for the final restoration.

31
Cerana inserts

B-quatz ceramic inserts (Mega-fil)


These are the first type of ready made inserts to be utilized. It is
composed of a non size matching inserts. It comes in a pack of different
sizes. The operator selects suitable size inserts to fit the preparation, then,
the remaining part of the cavity is restored with a composite resin
material. It was introduced to overcome the problem of polymerization
shrinkage and waste of time during incremental packing. Moreover, the
wear resistance and strength properties of the final restoration is markedly
upgraded with the beta quartz inserts since it s formed of silica based
glass heated to specific temperature to produce a microcrystalline
translucent ceramic which is very close to the hardness of the tooth
structure.

Glass ceramic inserts Megafils Megafil inserted in prepared cavity

32
The clinical performance of the final restoration is greatly dependent
on its technique of manipulation, instrumentation and tools utilized,
knowledge of the operator about the recent developments and concepts,
in addition to the employment of the most updated equipments. The
introduction of new materials to the field of restorative dentistry is
usually accompanied by a recent technology in insertion and
manipulation in an attempt to optimize the clinical utilization and the
functional performance of the restorations.

Ultrasonic condensation:
The ultrasonic condensation of amalgam restoration has increased the
hazards of mercury vapor in clinics since the procedure entails a process
of thermo-genesis ( Haley, 2003). On the other hand, ultrasonic packing of
conventional or condensable composites was found to increase its flow
and adaptation to cavity walls and margins, in addition to enhancement of
polymerization due to thermo-genesis encountered (Mohsen MMA and
Gilbert L, 1991). Various forms and sizes of ultrasonic tips are currently
available for ultrasonic condensation of composites. They are routinely
supplied with the newer forms of ultrasonic equipments.

Incremental packing, c-factor, decoupling technique:


Bulk packing of composite resin in case of chemically activated
composites was found to give satisfactory marginal sal and good physical
properties. This was explained on basis of slower conversion which may
give rise to a less stressful polymerization shrinkage. Moreover, the
incorporation of oxygen and porosities may act as shrinkage absorber
(Fusayama , 1992). On the contrary, in case of light polymerization of
composite resin, irrelative of the curing depth, the polymerization
shrinkage is known to be mass dependent. This necessitates the approach
of layering technique to decrease the effect of polymerization shrinkage,
enhance marginal adaptation and esthetic behavior of the restoration
( Neiva etal, 1998).
The increment configuration during placement of light cured
composite is of great importance to control polymerization shrinkage of
the restoration. C-Factor is the ratio of the free and bonded surface of the
increment. It determines the amount of stress relief by flow of the
material at the free surface. Thus, the horizontal layering of the
increments is contented for the vertical or oblique layering since it was
deduced that the minimization of the c-factor as much as possible is the
key stone to the success in controlling the shrinkage pull at the margin of

33
the restoration., hence, it is advisable to separate between walls during
polymerization as much as possible ( Peutzfeldt and Asmussen, 2002). Some
authors recommend the use of a gingival auto-polymerizing increment in
class II cavities to separate the initial increment from the body during
polymerization, decoupling technique was advocated by Wilson etal in
2000, but it was debated for creating a new interface which may decrease
the outcome of mechanical properties of the restoration.

Guided polymerization:
In photo-activated composite, unlike the chemical, shrinkage vectors
travel towards the light source . This is explained on basis of the high
intensity of light at the surface which causes a rapid start of
polymerization that pulls the rest of the polymerizing chains towards the
site of initial polymerization.(Victor and Lyjan, 1994 and Yoshikawa etal, 2001).
Manufacturers have introduced various shapes of curing tips to be utilized
to guide the polymerization contraction, while in the critical gingival
margin, the use of a light reflection wedge will be helpful to concentrate
the light on the gingival area of the restoration to achieve such guidance
effect.( Lutz etal, 1986 and Victor and Lyjan, 1994). The technique was termed
three sited polymerization where curing is performed for buccal, lingual
and gingival to effect concentration of light at the proximal cavity.
( Pereira etal, 2002). Guiding polymerization by the three sited technique
proved an improvement in the adaptation of class II cavities when
compared with the conventional curing. However, Loesche in 1999
attributed the improvement in case of three sited polymerization to the
reduction of light intensity rather than to guided polymerization

Curing using light reflecting wedge

34
Soft start polymerization:
Slowing down the initial intensity of polymerization by soft start
polymerization at a lower intensity 180 mw/cm2 for 10 seconds followed
by full intensity polymerization at 800 mw/cm2 will cause a slow down in
the conversion of double bonds of the resin monomer. Two steps of
polymerization are carried out by this technique (stepped
polymerization). Another method to apply the soft start polymerization
is the ramped curing in which the irradiance is gradually increased from
a low value to maximum intensity over a 10 seconds period after which it
remains constant for the duration of exposure. The third method to apply
soft start is the pulse delay in which there is an application of 10 seconds
conventional curing followed by an interruption of curing for one or two
minutes before completion with the same light intensity. Slowing down
the initial polymerization results in a decreased pull at the margins of the
restoration. The full intensity polymerization follows to complete the
conversion to the maximum to attain the desired mechanical properties.
Goracci and Casa de Martiniz,1993, explained the effect of reducing the
intensity of light source to slow down the speed of conversion and to
prevent the rapid increase of viscosity ( Trommsdorff effect ) which is
likely to occur by massive emission of light intensity. Thus, it is possible
by utilizing low intensity initial polymerization to obtain a slow and
gradual conversion at the beginning which facilitates flow of the resin
composite.
Pulse delay controls the process of polymerization for sake of
decreasing the contraction and improving the adaptation, yet, attaining
adequate mechanical properties for the restoration. The given time
probably allows for securing the established bond while the material is
adequately flowy. This will prevent the forceful pull of the material from
the bonded margins prematurely ( Yap etal, 2002). Moreover, the pulse
delay polymerization may be in favor of attaining high mechanical
properties by more cross linking of the pendant chains occurring as a
result of the presence of a ceased polymerization period ( Ruggeberg etal,
1999 and Sahafi etal, 2001).

35
Elipar trilight curing apparatus for soft start polymerization

High intensity polymerization (Turbo curing), PAC and


LED:
It is well documented that the ultimate properties of direct light
polymerization tooth colored restoratives are not attained except when
adequate curing is performed.( Oberholzer etal, 2003).Undoubtedly, the
inefficiency of curing results in diminished physical and mechanical
properties of the restoration as a result of incomplete conversion and
delayed hardening of the material. The result will be a decreased depth of
curing, lack of strength, diminished hardness and wear resistance,
insufficient bonding and loss of adaptation with subsequent failure of
restoration due to inadequate retention, gross leakage and or recurrent
decay as well as the inability to withstand the functional stresses which
may end in fracture and excessive wear and loss of anatomical landmarks
of the restoration ( Eldewani etal , 1997).
In order to avoid the possibility of inadequate curing, the
manufacturers produced high intensity quartz tungsten halogen lamps
curing devices providing very high intensity of curing that exceeds 1000
mw/cm2. The devices were given the name turbo appliances. Other
manufacturers launched other types of high performance appliances
which utilizes a high energy, high pressure ionized gas in the presence of
an electrical current to create an intensely bright, very high temperature
light source that provides laser like curing speeds. Plasma arc curing
(PAC) devices are able to perform rapid 5-10 seconds polymerization of
composites having activators which absorb light in the range of 430-500
nm , a range which almost matches with the absorption curve of the
camphoroquinone photo-activator present in most types of commercial
composites. The power density of PAC devices was found to be at least

36
1196mw/cm2 , that is almost double that of conventional QTH appliances
giving about 600mw/cm2.

Turbo curing apparatus Optilux 501 from Kerr

Apollo plasma arc curing apparatus from DMD

Two types of the current LED devices for composite curing

The most recent innovation in curing appliances in current use is the


LED appliances. Light emitting diodes curing devices produce a high
intensity of curing light but in a very narrow zone of wave lengths of light
spectrum with peaks around 440-470 nanometers. Depending on the
brand, this is ideal to be absorbed by the most common photo-initiator
(camphoroquinone) which has an absorption peak of 468 nm, but is less
effective for other photo-initiators that have peaks below 440 nm, such as
phenyl-propanedione. The problem is that camphoroquinone is yellow in
color and in some composites particularly translucent shades it cannot be
used. Thus, clinical research associates recently published a listing of

37
products that may not polymerize with LED appliances. Some companies
shifted the emission spectrum of their LED appliances to suit a variety of
photo-initiators by combining two different diodes with a wide range of
spectral emission to allow the curing of all the materials(second
generation LED appliances).
The advantages of LED devices are; the less power necessary to
operate the unit because of their unfiltered narrow emission spectrum.
Consequently, they may be powered with rechargeable batteries, making
them available in light weight, cordless units. The diodes have a potential
lifetime of several thousand hours instead of the range of a hundred with
halogen systems. Ninety nine percent of the original energy of emitted
from QTH lamps is a useless energy that must be filtered out. Noisy fans
are required to help eliminate this unwanted heat, but, the LED devices
have very little wasted energy and require minimum cooling.(Leonard etal,
2002 and Soh etal, 2003)

Recent technology in rotary tools and hand pieces:


In addition to the improvement in material of construction of the
rotary cutting tools in order to improve the cutting efficiency and prolong
life of the tool which may be endangered from repeated sterilization,
Standardizing operative procedures is an objective of modern dentistry.
Manufacturers have produced efficient tools designed to perform certain
step or function. Burs are designed to prepare a conservative minimally
extended cavity for composite restorations in posterior teeth having
rounded ends to conform to the internal line angles of the required
preparation. Others are designed to remove caries with minimum
vibration. Other designs are made suitable for removal of old amalgam
restorations. A newly designed rotary cutting tool is also supplied to cut
and shear off full coverage crowns.

New designs of rotary tools to perform certain functions

38
Modern models of high and conventional speeds hand pieces are
fabricated with a more advanced technology. The body is constructed
from titanium alloy which prevents rust and provide light weight and
stability and to withstand repeated autoclaving. An anti-retraction
technology is also supplied to prevent regurgitation of fluids for infection
control purposes. Moreover, the fiber-optic illumination supplied comes
out from a compacted glass nozzle which does not hinder the passage of
light by repeated autoclaving. Ceramic ball bearings are also incorporated
to prevent wear and damage of the internal rotating parts by the extensive
use or repeated sterilization. The air/water spray coolant is designed in a
triple way burst for effective control of the generated heat and clearance.

New model of titanium hand piece

Maintenance of the hand pieces is also given great attention since the
performance of the hand piece affects the quality of work. It is becoming
very simple to just fitting the hand piece in its place in the Assisstina
machine to be effectively cleaned and then lubricated with the specified
cleaner and lubricant.

Assistina machine for cleaning and lubrication of hand pieces

39
The most recent outcome is the Neulite technology introduced by
Bien Air in which a single fiber-optic module can be plugged with either
a rotary high speed or conventional contra-angle hand piece, meanwhile,
the same module can be plugged with a high efficiency light curing tip to
be utilized for polymerization of various resin restoratives.

Neulite technology of plug and cure

Technology is still going on, the future perspectives in restorative


dentistry is very promising. Thanks to the recent advancements which
have introduced a true revolution in the field of restorative dentistry
which has enabled the dental clinicians to perform better and to present
high quality service for their patients.

40
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