Presented by Dr.

Vian Sabah

Composite Fillings

* Composites have been used for more than 40 years as direct filling materials for restoring damaged teeth. * Composite is the general term used for a compound comprising at least two different phases (e.g. monomers and fillers). * All composites have one characteristic in common; during curing, they all form a matrix into which glass, quartz or porcelain filler particles are embedded.

An ideal composite consists of the following four qualities:

(1) mirror natural tooth structure in color and translucency. (2) strength to withstand function in stressbearing areas for the long-term. (3) seamless or undetectable margins from restoration to tooth for the long-term. (4) achieve the appropriate contour and polish and maintain it for the long-term.

Composition - Phases
* matrix... Organic phase

* filler.
* coupling agent..............

Inorganic phase
Interfacial phase

* the initiator-accelerator of polymerization.

A dispersed phase or filler phase : glass ,quartz , silicon dioxide Matrix phase : of BIS_GMA , urethane dimethacrylate The two phases are united by coupling agent usually epoxy silane

Types of composite Restorations

Composites are usually divided into three types based primarily on the size, amount, and composition of the inorganic filler:

(1) conventional composites. (2) microfill composite. (3) hybrid composites. However, more recent changes in composite composition have resulted in several other hybrid type categories, include in flowable and packable composites

Filler Size and Type Classification

* Macrofill: 5 to 75 mm Small: 1 - 5 mm Medium: 5 - 10 mm Large: 10 - 20 mm * Microfill: < 0.05 mm

* Hybrid: combined microfill and macrofill

particles * Nanofillers

1. Macrofilled resins or conventional resins:

* contained inorganic particles like quartz and borosilicate glass 5 100 microns * Can not take high polished. It is virtually impossible to polish macrofilled composites after trimming. * The (only) best way to attain a short-term smooth surface is by polymerizing the composite under a strip of cellophane. * Mainly used for posterior teeth

2. Microfilled resins:
* contain small particles measuring .02 to .04 microns. * It seemed as though the solution had been found with the use of pyrogenic SiO2 as a filler material. * Can take high polish. * More abrasion resistant than macrofilled. * Can not bear mechanical loading like macrofilled. * Used for anterior teeth.

3. Hybrid resins
* contain a mixture of macrofilled and microfilled particles. * They have the advantage of combining in one material the optimum physical properties of glass macrofillers with the excellent polishing properties of pyrogenic hydrated silica microfillers. * Hybrid composites are therefore ideal for use as universal composites.

Flowable composites:
* It is often difficult to work with medium to high viscosity composites in very small cavities. * With medium viscosity composites it is difficult to apply and adapt small portions without producing gaps and with condensable composites it is virtually impossible. * The main areas of application for flowable composites are in minimally invasive Class III cavities, Class I and II cavities without masticatory loads, pit and fissure sealing as well as extended pit and fissure sealing and Class V cavities.

The relative ease of flow allows these materials to be used in difficult-to-access areas and repairs of amalgam, crown, porcelain or composite restorations

Packable composites:
* Packable composites were especially developed for use in the posterior region. contain a slightly higher proportion of filler material or use specialized filler technology. * The packable property of these materials facilitates contouring the a proximal contact area when using standard metal matrices. * These composites do not stick as readily to the instrument and exhibit excellent positional stability, which facilitates contouring the occlusal surface.

Linear Coefficient of Thermal Expansion

(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 openings at the junction of the material and the tooth when temperature changes occur.

** The LCTE of improved composites is approximately three times that of tooth structure.

** Microfills much higher than hybrids.

** Increasing filler content decreases the difference.

** Values of Linear Coefficient of Thermal Expansion for composite resins available ranged from 27 to 41 x 10-6/0C.

Clinical procedure
1. Prophylaxis: * clean the tooth with flour or pumice and water in order to removed the acquired pellicle * Wash away all the pumice or prophylaxis paste

2. shade selection: * Select the shade quickly and early during the visit before the clinicians eyes become tired. * One can make a trial cure on the paper pad or unetched tooth surface and compare the shade of the cured composite directly with the tooth.

3. Tooth isolation: * Isolate the teeth with rubber dam * Invert edges of the rubber dam to ensure maximum gingival retraction

4. protection of dentine: Protect all exposed dentine with calcium hydroxide preparation, e.g. Dycal or light-cured glass ionomer cement

5. Etching of enamel: * Brush to place the gel * Etch for 15 seconds * Gel is better than liquid * Note it takes longer time to etch fluorosed and deciduous teeth.

Acid etch technique

* It cleanses the enamel surface of any deposits or acquired pellicle * It increases the enamel surface area available for bonding * It produces micropores into which resins interlocks * It exposes a more reactive surface layer (area with higher surface energy)

6. Washing: * Wash away all traces of the acid for 30 seconds using a gentle stream of water. * Dry the tooth using an oil-free air stream. * Frosty white (matt) appearance * A chalky white appearance is indicative of over etching which results in low bond strength between the resin and enamel

7. Application of resins: * Add enamel bonding agent * Use Mylar matrix strip or cellulose acetate crown form * Cure the resin bonding agent * Each incremental layer should not be more than 2 mm thick

* The light source should be about 1 mm from the resin but not touching it. * Allow an exposure time of 20 30 seconds for each increment. * Protect the eyes with eye goggles or light shield to filter wave length 450-500 nm.

8. matricing: * Use either Mylar strip or cellulose acetate strip * Cellulose acetate crown form * Finish the restoration with flexible abrasive discs

Finishing discs

Gold knife/scalpel

Finishing strips

Finishing burs

Composite polishing pastes with prophy cup or felt discs

Scanning electron micrograph of polished surface

Indications for the use of composite resins:

1- Restoration of cavities on anterior teeth 2- Cervical lesions 3- Hypo plastic lesion 4- Restoration of conical lateral incisors 5- Semi permanent restoration of fractured incisors. 6- Labial veneering of fluorosed teeth 7- fissure sealants and preventive resin restorations 8- diastema closure 9- periodontal splinting 10- class II cavities (heavy filled hybrid) 11- orthodontic brackets 12- Anterior tooth replacements

Changing from amalgam to composite

DIASTEMA CLOSURE

Peg-shaped laterals

Contraindications
* Uncontrolled bruxism * Excessively wide`preparations * Inability to bond to tooth structure * Poor operating field isolation

Polymerization shrinkage

Composites shrink away from cavity walls May lead to breaking marginal seal leading to sensitivity and recurrent cries May pull at tooth structure and lead to cracks and sensitivity Depends on type of resin and amount of resin Bond between composite and dentine is weaker than between enamel and composite

How to overcome these problems?

Incremental placement of composite (increment no more than 2 mm) Slow curing or soft start curing method to allow relaxation of stresses Using highly filled composites when possible Developing improved dentine bonding systems

Stress from polymerization shrinkage is influent by

* restorative technique * modulus of resin elasticity * polymerization rate * cavity configuration or C-factor.
C-factor is

ratio between bonded and unbonded surfaces an increase in this ratio results in increased polymerization stress

To minimize the stress from polymerization shrinkage

* improving placement technique * improving material and composite formulation * curing methods

1- improving placement techniques

The incremental technique polymerizing with resin-based composite layers less than 2-millimeters thick achieve good marginal quality prevent distortion of the cavity wall ensure complete polymerization of the resin-based composite

 Horizontal technique
occlusogingival layering generally used for small restorations increases the C-factor.

 Oblique technique
wedge-shaped composite increments prevent distortion of cavity walls and reduce the C-factor polymerization first through the cavity walls and then from the occlusal surface direct vectors of polymerization toward the adhesive surface (indirect polymerization technique)

Figure 1. Schematic representation of wedge-shaped composite increments (1-6) used to build up the enamel proximal surface. F: Facial aspect. L: Lingual aspect.

 Successive cusp buildup technique

the first composite increment is applied to a single dentin surface without contacting the opposing cavity walls And then wedge-shaped composite increments Each cusp then is built up separately to minimize the C-factor in 3-D cavity preparations

Figure 2. Schematic representation of the flowable composite increment (1) and wedge-shaped increments (2-7) used to build up dentin;two increments (8 and 9) are used to build up enamel using the successive cusp buildup technique. F: Facial aspect. L: Lingual aspect.

2- improving material and composite formulation

RESIN-BASED COMPOSITE CLASSIFICATION AND PHYSICAL PRPERTIES.
COMPOSITE TYPE AVERAGE PARTICLE SIZE (MICROMETERS) FILLER PERCENTAGE (VOLUME %) PHYSICAL PROPERTIES
Wear Resistance Fracture Toughness polish ability

Microfill Hybrid Microhybrid Packable Flowable

0.04-0.01 1-3 0.4-0.8 0.7-20 0.04-1

35-50 70-77 56-66 48-65 44-54

E F-G+ E P-G+ P

F E E P-E+ P

E G G P F-G+

E: Excellent G: good F: fair P:poor + Varying among the same type of resin-based composite

CLINICAL INDICATIONS OF RESIN-BASED COMPOSITES.

COMPOSITE TYPE Microfill CLINICAL INDICATIONS
Enamel replacement in Class III, IV and V restorations Minimal correction of tooth form and localized discoloration Posterior resin-based composite restoration Class V restoration Dentin build-up in Class III and IV restoration Posterior and anterior direct composite restoration Veneer Correction of tooth form and discoloration Posterior resin-based composite restoration Pit and fissure restoration Liner in Class I, II and V restoration (dentin)

Hybrid

Microhybrid

Packable
Flowable

3- curing methods
* soft-start polymerization
This may reduce the stress buildup by supplying extended time for stress relaxation before reaching the gel phase. This can be accomplished by using a soft-start curing technique in which the curing begins with a low intensity and finishes with a high intensity

The Injection-Molded Technique for Strong, Esthetic Class II Restorations

This technique involves the use of a redesigned cavity preparation, a translucent matrix system, and the proper combination of paste and flowable composites to create strong and esthetic restorations .

With this shallower preparation, the composite can be injected in one phase instead of increments, which saves time and, more importantly, eliminates the risk of gapping between layers.

The Injection-Molded Technique for Strong, Esthetic Class II Restorations

Translucent Matrix System These matrices make it possible to perform buccal lingual curing, and also facilitate single-load filling.

Balanced Use of Paste and Flowable Composites

snowplow technique, in which the flowable is placed first and not cured separately, followed with a paste composite injected into the flowable, which is then squeegeed out of the sides of the restoration. These researchers have found that this technique can improve adaptation and also lessen the chance of marginal leakage, versus separate layers of flowable.

The Injection-Molded Technique

Before beginning the technique, if a significant amount of dentin is present, that dentin is either covered with glass ionomer or dentin bonding agents. The injection-molded composite dentistry technique calls for first applying a bonding resin to both the previously treated dentin and freshly etched enamel inside the matrix, then injecting a flowable composite into the pool of bonding resin, and then finally injecting the paste composite

The resin-flowable-paste mass is polymerized together in a single light-cure.

V3 Sectional Matrix System

The key to the V3 Sectional Matrix System is the Ni-Ti V3 Ring, which exerts optimal force to produce ideal tooth separation for predictably tight contacts. The rings V-shaped tines accommodate the wedge in the embrasure and provide a stable grip, preventing the ring from collapsing into large cavities

Perforated Bands and untracontacts

Cervical Matrix 360

for faster Class V restorations easy build, quicker finishing Reaches every tooth with ease Excellent seal on gingival margin High quality esthetics and mirror finish Clear matrices for easy curing Rotatable handle and three grip positions for easy access and application angles Flexible matrix conforms to tooth contour Prevents voids and air-inhibited layer

Properties
Water absorption
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
Wear resistance refers to a material's 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 tooth-colored restorative materials. The location of the restoration in the dental arch and occlusal contact relationships also affect the potential wear of these materials

Surface Texture
Surface texture is the smoothness of the surface of the restorative material. The size and composition of the filler particles primarily determine the smoothness of a restoration, as does the material's ability to be finished and polished.

Modulus of Elasticity Modulus of elasticity 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.

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.

Radiopacity

helps to detect caries around and underneath composite fillings. Should be as radiopaque as enamel

Most composites contain radiopaque fillers such as : Barium glass ,to make the material radiopaque

Thank you