Composite Restoration Steps

Week 1 Review Questions

• A Class V filling happens at the gingival margin
• A Class II cavity extends between two molars
• The edge of a matrix band placed at the occlusal surface has a larger circumference
• The T band matrix system is designed for restorations of primary molars
• Post-op instructions after an amalgam restoration should include noting how long the anesthetic will last, not drinking anything hot, and waiting 24 hours before chewing anything hard

Composite Restoration

• Composite resins have become the material of choice for dentists and patients.
• This is because of their esthetic qualities and new advances in their strength.
• Class III and IV carious lesions are restored with composite
• Class IV lesions involve the proximal surface and incisal edge of anterior teeth
• Open through the lingual surface, if possible, to reduce the restoration size from the facial aspect
• If decay is subgingival, tissue retraction R.D clamp may be used to access the caries under the gingiva

Class V Restorations

• These are classified as a smooth surface restoration
• They occur in the gingival third of the facial or lingual surfaces of any tooth.
• Class V restorations can occur on root surfaces near the cemento-enamel junction (CEJ).
• Class V restorations are prepared with a smooth outline and without angles
• The location of the lesion dictates the material that will be used
• If moisture is an issue and it is a posterior tooth, amalgam may be chosen.
• Proximity to the gingiva could require retraction to keep the area dry
• A cervical R.D clamp may be used to retract the gingival area

Application of Composite Resins

• Polymerization is the process by which a material changes from a pliable state into a hardened restoration
• Polymerization happens via self-curing (auto-cured) or light-curing

Anterior Matrix Systems

• A clear plastic strip (matrix) is used with anterior composite resin or glass ionomer restorations
• Composite resins (CR) have inorganic filler particles that would be scratched or marked by stainless steel
• Newer bonding materials can interfere with stainless steel bands affecting polymerization
• A clear matrix is also referred to as a celluloid or mylar strip
• A retainer is not necessary for a clear matrix

Liners/Bases

• Dycal and glass ionomer liners are commonly used under composite resins
• Both dycal and GI are available in self and light-cured forms
• Varnish and ZOE should never be placed under a composite resin
• These interfere with bonding and setting of the resin (polymerization)
• The eugenol in the liquid will affect the setting of the resin material

Etching

• Etchant is critical on both enamel and dentin surfaces for a better chemical bond between the tooth and resin
• Maleic acid and phosphoric acid are types of acid etchants
• Etch creates micropores in enamel and dentin
• It also removes the smear layer from dentin in preparation for bonding
• A major factor in the success of bonding is removing the smear layer
• This allows the bond to adhere to the tags created in the dentin
• Etching times vary from product to product
• Read the manufacturer's instructions for proper use
• Anywhere from 15 to 20 seconds is normal
• Etch must be thoroughly rinsed from the tooth surface and dried

Bonding Process

• Enamel bonding occurs with pit & fissure sealants (PFS), ortho brackets, and resin-bonded bridges
• Most of these are attached directly to the intact enamel surface
• A sealant, resin cement, or restorative material is placed on the etched surface, flowing in and around the enamel tags
• The material hardens in this location to form a mechanical bond with enamel
• Dentin consists of a range of organic substances, making it different from enamel, making bonding difficult
• Smear layer removal is a major factor in the success of bonding to dentin
• Removal of the smear layer debris, composed of fluids and tooth components, should be addressed following cavity prep
• A slight amount of moisture must be maintained on the dentin to prevent desiccation
• Bonding may or may not be light cured

Placement of Composite Restoration

• Placed in increments no larger than 2mm
• The first increment is placed in the proximal box, which is the prep's deepest interproximal area
• The plastic matrix strip is held tight against the cavity prep to hold the composite resin (CR)

Purpose of Plastic Strip and Wedge

• Placed before etching and bonding, the matrix helps protect adjacent teeth from these materials
• After placing the composite resin before light curing, the matrix is pulled tightly to reconstruct the tooth's natural contour
• Clear plastic allows penetration of light from the curing light
• The wedge prevents overhang and holds the matrix in place

Plastic/Teflon vs Metal PFI

• Advantages to using plastic or Teflon instruments include the fact that they will not discolor or contaminate the composite restoration
• Composite resin material will not cling to the instrument

Steps in Finishing the Composite Restoration

1. Reduction of the material is completed with a white stone or finishing diamond
2. Fine finishing is completed with carbide finishing burs and diamond burs
3. The composite restoration is polished with medium discs then superfine discs
4. Finishing strips assist in polishing the interproximal surfaces
5. Polishing paste is used with a rubber cup

Procedural Steps for CRs

• Review the day sheet to ensure all steps are fully prepared
• Examine the CONTOUR of the prepped site
• Pay attention to the OUTLINE of the prep
• Contour the mylar strip
• Slide the mylar interproximally to ensure the gingival edge of the matrix extends beyond the prep
• Use thumb and index finger to pull the band over the prepped tooth on the facial and lingual aspects
• Position the wedge within the gingival embrasure
• Ensure that the material is flush with the tooth, providing tighter contact
• After it is filled, light cure, and then the matrix is removed
• Check articulation and contact, and give post-op instructions
• Inform client about how long anesthetic will remain
• Tell them that tooth color will improve as the tooth hydrates
• Explain they don't need to avoid chewing in that area.
• Retrieve chart to update medical history and explain procedure

During a composite procedure, the dental team should:

• Position the bracket tray, and pass explorer and mirror
• Adjust lighting, dry teeth, and have client bite on articulating paper to determine occlusal relationship
• Polish the tooth with slurry of pumice and water; use rubber cup on slow speed prophy angle
• Use natural light when possible to choose shade; involve the client
• Pass gauze and topical anesthetic on Q-tip to administer anesthesia
• Punch and place rubber dam
• Open the cavity preparation
• Prepare the outline/resistance form of cavity prep
• Remove caries and place the retention form
• Mix GI liner and transfer the applicator to the dentist, and have gauze available to wipe the applicator

Following cavity preparation:

• Pass the matrix trip interproximally approx 1 mm below the cervical wall
• Select size of wedge and secure it in holder or cotton pliers
• Pass wedge which keeps material flush with tooth and forces teeth apart for a tighter contact
• Ensure area is dry, and assess isolation
• Prepare and pass etching agent (gel or liquid) allowing it to sit for 10-30 seconds
• Thoroughly rinse for at least 30 seconds, evacuate, and blot dry
• Replace with mylar strip and wedge if needed, and maintain a clear field
• Pass curing light or activate for 20-30 seconds
• Note that not all operators will cure the bonding agent.
• Dispense just before using the adhesive.
• Retrieve curing light and pass filling material and PFI, keeping gauze handy to wipe the PFI
• Pass the matrix strip holder, if using.
• Pass the explorer to test hardness and receive the curing light

Finishing & Polishing

• Remove matrix strip holder, strip, and wedge
• Pass cotton pliers for removal of the wedge and strip
• Remove the rubber dam after isolating the teeth
• Pass a sharp, pointed instrument to remove excess flash
• Receive scaler, place the diamond finishing bur in high speed handpiece
• There are two different kinds of burs; diamond finishing burs are not available in the clinic.
• Ready the HVE for removal of excess materials
• Prepare required cups, stones, or disks on mandrels and place in slow handpiece
• Prepare composite polishing paste and cups as needed.
• A superfine disc is needed for CR and should be kept moist

Correct Order for Composite Restoration

1. Slow speed with pumice
2. Shade Selection
3. Anesthetic
4. Highspeed with round bur
5. Etch, then rinse and dry (then bond is placed)
6. Curing light
7. Explorer to check for hardness
8. Sickle scaler removes excess flash
9. Finishing strip to smooth interproximal for flossing

This covers essential steps in composite restorations, including etching, flash removal, polishing, and matrix strip removal. It also addresses shade selection and the importance of etching in bonding.