Week 3 Composite Restorations DENTD 1532 PDF

Composite Restorations Kyung Choi DMD 12/20/2024 DENTD 1532 1  Fair Usage Disclaimer This presentation may contain copyrighted material (“Material”), the use of which may not have been specifically authorized by the copyright owner. Midwestern...

Composite Restorations Kyung Choi DMD 12/20/2024 DENTD 1532 1  Fair Usage Disclaimer This presentation may contain copyrighted material (“Material”), the use of which may not have been specifically authorized by the copyright owner. Midwestern University is making the Material available through this presentation solely and strictly for illustrative purposes, including criticism, comment, and teaching, with the objective of advancing dental education. This use of the Material constitutes a “fair use” of any such copyrighted Material as provided for in Section 107 of the United States Copy Right Law. In accordance with Title 17 U.S.C. § 107, the Material is distributed without profit to those who have research and/or educational interests. Reproduction or dissemination of the Material, including this presentation, in any format or medium is prohibited. All rights reserved. 2  Learning Objectives 1. Discuss the indications, contraindications, advantages, and disadvantages of composite restorations. 2. Evaluate the predictors of composite success. 3. Appraise the process of shade selection for composite restorations. 4. Justify the importance of occlusion checks in composite restorations. 5. Discuss the rational for tooth isolation when using composites. 6. Assess the steps involved in tooth preparation for composite restorations. 7. Discuss the etching technique used in composite restorations. 8. Explain the role and use of desensitizers in composite restorations. 9. Analyze the C-Factor and its impact on composite restorations. 10. Discuss the process and importance of light curing in composite restorations. 11. Apply the steps involved in finishing and polishing composite restorations. 12. Provide post-operative instructions for patients following composite restoration procedures. 13. Apply CDMI composite restoration protocol. 3  Composite Introduced in 1960s It’s called “composite” because it’s made by combining different materials: Like resin and tiny glass or quartz particles→ Together, these materials create a strong, durable, and tooth- like material that’s great for dental restorations First material that bonds to tooth structure Widespread use in dentistry, most direct restorations have transitioned to this material 4  Advantages and Disadvantages (Compared to Amalgam) Advantages Disadvantages Great esthetics Polymerization shrinkage Conservative tooth preparation: no bulk and Technique sensitivity: isolation, bonding, no need for mechanical retention incremental layering Easier, less complex tooth preparation: Limited wear resistance → Limited longevity: adhesive bonding area with heavy occlusal forces Decreased microleakage: stronger seal Possible marginal stain: bond failure through chemical bonding Provides insulation: non-metallic material More costly 5  Indications 1. Sealants 2. Preventive Resins Restorations (PRR) 3. Direct restorations 4. Bonding other materials: orthodontic Class I, II, III, IV, V cavities attachments, periodontal splints Esthetic dentistry (direct veneers, diastema closure) 6  Other Indications 1. Large restorations as foundations for crowns →Core build-up to restore lost tooth structure 2. Interim restorations Crown indicated but final treatment needs to be delayed (e.g., fractured tooth due to trauma, young patients) Due to cost or ability to come to appointments 7  Contraindications An area that cannot be properly isolated →Dry filed is essential to prevent contamination of saliva, blood, or moisture Large restorations with heavy occlusal stresses →Prone to material fatigue or fracture Proximal boxes (Class II) that extend onto the root surface →Challenging, no matter what material is used Deep gingival margins where light cannot penetrate easily 8 Clinical indications and prognosis are always case specific More predictable, better Less predictable, worse prognosis prognosis Primary caries Secondary caries: weakened tooth structure, compromised bonding surfaces Smaller preparations Larger preparations: increase stress Margins on the enamel: Margins on the cementum: strong bond weak bond Well isolated field Contaminated field 9 Manufacturer’s Instructions Dry working field Proper working technique 10 The success of a composite restoration is predicted on 3 things 1. Remaining 2. Patient’s 3. Operator’s tooth caries risk technique structure More natural tooth High caries risk Proper preparation, = = bonding protocols, Stronger restoration Shorter lifespan of the material handling, restoration and placement directly impacts success. 11  Outline Remove isolation (Dental Dam) 12  Shade Selection A1-A4: Natural, typical tooth colors B1-B4: Warmer, yellower tone C1-C3: More neutral or gray undertone D2-D3: Red or brownish-gray undertone BL-L, BL-XL: For bleached teeth (Light, Extra Light) T: Translucent shade which mimics the natural light interaction of the tooth (e.g., incisal edge) *The higher the number, the darker the color 13  Shade Selection As soon as patient is seated in the chair (before teeth get dehydrated) Natural light if possible (operatory light should not be used) Wait 1-2 weeks after bleaching until the color to stabilize Much more critical in anterior teeth Spectrophotometer (color matching device) can be used as confirmation 14  Shade Selection Operator’s eyes are the standard of care Color mapping: The tooth is not monochromatic; therefore, it would be a good idea to do a color mapping, especially when working on a cosmetic case Get patient’s approval and document Color mapping 15  Occlusion Check (Pre) Centric and eccentric movements Does your patient have anterior or canine guidance? Proportional and focused on the location Anterior guidance Canine guidance and extension of the lesion-restorations Restorations we place should not negatively alter occlusion →Restorations should preserve the patient’s natural occlusion by Centric Eccentric understanding their existing bite and minimizing any change or disruptions 16  Isolation Technique for composite placement requires an isolated field, free of saliva and blood Longevity of composites: linked to placement conditions (this variable is under your control) An isolated field is best gained with a dental dam Minimum extension 1 tooth posterior, 2 teeth anterior (need free access to prepping and restoring) 17  Isolation Which restoration will have a longer lifespan? At CDMI, a dental dam is required for EVERY direct restoration 18  Tooth Preparation Principles for an ideal prep: Sound dentin 1. Large enough to allow access to damaged structure Affected dentin 2. Prep includes the removal of caries, Infected dentin existing restorations, liners, bases Affected dentin refers to dentin that is compromised but not necessarily infected or decayed. 3. If prep is close to pulp It might be softened but still -May leave LITTLE affected dentin to relatively intact. prevent pulpal exposure -Apply liner (Theracal, Vitrebond) to Liner protect the pulp, stimulate healing, and promote the long-term health of the tooth Pulp 19  Tooth Preparation Principles for an ideal prep: 4. Needs to have convenience form: the shape of a prep that allows to easily access and observe the cavity, making it easier to prepare and restore.( →The minimum isthmus width of 1 mm, allowing the fit of the smallest condenser, is an example of convenience form 5. Additional retention features such as grooves are not necessary in posterior composites: Retention is provided by bonding 20  Etching techniques At CDMI, we use Selective Enamel Etch Technique (based on evidence) for POSTERIOR composites 21 (Selective Enamel Etch Technique) Etch ENAMEL only. Self-Etch Bonding Steps Indication: To minimize dentin sensitivity when restoring deep preparations. Example: Class I occlusal preparation on #19 which extends to dentin 22  Etch both ENAMEL AND DENTIN. Total Etch Bonding Steps Indication: Bonding restorations (Enamel and Dentin) where preparations are primarily in enamel, with minimal dentin involvement. Example: Composite restorations for anterior veneers 23  Knowledge Test 1 Case 1 #8, 9 diastema closure with composite No preparation needed, bonding limited to enamel QUESTION: Self-Etch Bonding Steps or Total Etch Bonding Steps? ANSWER: Total Etch Bonding Steps (etch both enamel and dentin) 24  Knowledge Test 2 Case 2 Deep class II cavity on tooth #5 Preparation involves both enamel and dentin QUESTION: Self-Etch Bonding Steps or Total Etch Bonding Steps? ANSWER: Self-Etch Bonding Steps (Etch enamel only) 25 (Selective Enamel Etch Technique) Self-Etch Bonding Steps Selective Enamel Etch Technique (Etch enamel only) You have this guide in the shared drawer at SIM 26  Self-Etch Bonding Steps (Selective Enamel Etch Technique) Etch enamel only with 37% phosphoric acid for 10-15 seconds Rinse thoroughly and dry 27 Desensitizing Agent GLUMA desensitizing agent 28  Why use a desensitizer? 1. To reduce post-op sensitivity/pain 2. To “suspend” and neutralize collagen fibers and prevent their degradation and debonding the bonding agent → Helps increase the longevity of the restoration 3. To disinfect the medium (prepped tooth) 29  GLUMA Type: Dentin desensitizer Primary Use: -It is primarily used to manage dentin hypersensitivity by sealing exposed dentinal tubules, preventing fluid flow, and reducing pain after restorative procedures -Often used before bonding procedures to ensure minimal post-operative sensitivity How it works: It works by using glutaraldehyde and hydroxyethylmethacrylate (HEMA) to form a protective layer over the dentin GLUMA = GLUtaraldehyde + HEMA Sealing dentinal tubules with GLUMA 30  GLUMA Scrub Gluma Desensitizer into dentin (deep cavity/cervical lesion) in one 30-second coat. Air-dry the surface carefully until the liquid film has disappeared and the surface is no longer shiny. Rinse with plenty of water under suction. Gently air dry. CAREFUL! GLUMA is a highly reactive chemical Will burn soft tissue Flush immediately if in contact 31  Primer Used to increase the strength of the bond Clearfil SE Protect PRIMER contains functional monomers like MDP, which chemically bond to hydroxyapatite in the tooth structure, enhancing bond strength and durability 32  Primer Scrub Self-Etch Primer (Clearfil SE Protect Primer) to both dry enamel and dentin. Leave undisturbed for 20 seconds. Then gently air dry for 4 seconds. 33 Bonding Agent 34  Bonding Agent Apply Self-Etch Bond agent (Clearfil SE Protect Bond) on all surfaces and leave for 20 seconds. Distribute evenly with mild air flow- no pooling. Cure for 10 seconds with curing light. 35  Composite placement Goals Restore anatomy to the natural form Harmonious with the rest of the mouth Restore occlusion Esthetic results Restoration margins sealed Polished surface 36  C-Factor (Configuration Factor) It is the ratio of bonded walls to unbonded (Free) walls Bonded Walls C-Factor = Unbonded (Free) Walls It highlights how bonded surfaces increase polymerization shrinkage stress More bonded walls = Higher polymerization shrinkage stress Polymerization shrinkage stress can cause: Bond failure Microleakage Postoperative sensitivity Fracture of tooth structure or restoration A lower C-Factor is preferable 37 C-Factor (Configuration Factor) What is C-Factor of class I prep? PULPAL FLOOR (WALL) Occlusal view of class I prep 38  C-Factor (Configuration Factor) What is C-Factor of class I prep? Bonded Walls: 5 Unbonded Walls: 1 1. Mesial 1. Occlusal surface 2. Distal 3. Buccal 4. Lingual 5. Pulpal Bonded Walls 5 C-Factor = = =5 Unbonded (Free) Walls 1 Occlusal view of Class I prep 39  C-Factor (Configuration Factor) Examples of C-Factor in Different Preparations/Restorations Class IV Class III Class II Class V and Class I Class IV Class II & III Class I & V 1:4 4:2 5:1 Gingival wall (1)/MIFL (4) MDBL (4)/MO (2) IAGF (4)/ML (2) Bonded Walls Lowest C-Factor = Unbonded (Free) Walls Highest 40 C-Factor (Configuration Factor): How can we reduce? Use incremental/layering technique when placing composite Unbonded surfaces in each increment allow relief of polymerization shrinkage stress This minimizes the risk of stress concentration at the adhesive interface 41 Composite placement: Incremental/Layering technique Why incremental/layering technique? Composite cures effectively up to a depth of 6mm, requiring layering to avoid incomplete polymerization Bulk-fill technique: Is not recommended since there are not enough clinical trials to support its success At CDMI: We layer composite with 1.5-2.0 mm increments, each cusp at a time yet Layering reduces masticatory stress on the restoration 42 Composite placement: Incremental/Layering technique Excessive handing can cause air entrapment, Avoid leading to inhibited polymerization, grainy over-manipulation of appearance, weakened material strength composite Clean instruments with alcohol gauze between layers to ensure smooth Instrument care composite application -“Enamel layer” is the final occlusal segment and it should replicate natural anatomy Enamel layer - Place instrument against unprepared cusp consideration inclines to match proper inclinations and contours -It should respect occlusal relationships which can 43 minimize adjustments later Incremental/Layering Technique 44  Composite instruments #18 Ball Burnisher: used to adapt composite to the cavity walls CVHL 1/26 or Hollenback: used to place, remove, and refine composite (develop anatomy) CIGFT 36 or Goldstein: used to place or remove composite 45  Composite instruments Ivoclar OptraSculpt Instrument handle with disposable tips in different shapes Allows for composite condensing without pullback from previous layer or cavity walls Tips do not stick or leave prints on composite There is no need to wipe with alcohol gauze in between uses-saves time 46  Handling composite resin Composite is light cured It will begin setting (hardening) when exposed to light, so it should be protected from light as much as possible Do not dispense composite until you are ready to use it 'Bleed' the composite with the dispensing gun before use to remove any partially polymerized composite Keep the cover on the composite compule when not in use 47  Handling composite resin To prevent the premature setting/hardening of composite: In clinic: Change the overhead light setting to light cure mode In SIM: Cover the headlight of your loupes with the orange shield 48 Curing Light Do not see the light directly (will cause retinal injury), look through the orange filter only 49  Light curing (Polymerization) During light curing some shrinkage is to be expected → Research indicates that linear shrinkage can range between 2-5% Factors that ensure proper polymerization and reduce shrinkage: Adequate light intensity (minimum 400 mW/cm²) Sufficient exposure time (20 sec per increment) Proper positioning of the light tip (as close to the material as possible) Optimal design of the curing light tip (shape, size) 50  Light curing (Polymerization) Factors that can be controlled Factors more difficult to be controlled Adequate light intensity Location and orientation of restoration (minimum 400 mW/cm²) (anterior vs. posterior) Sufficient exposure time Material/structures that partially block light (20 sec per increment) (adjacent teeth creating shadows when working on a Class II proximal box) Proper positioning of the light tip Darker composite shades (less light (as close to the material as possible) penetration due to higher opacity and pigment density) Optimal design of the curing light tip Ability to maintain a 90o angle while curing (shape, size) (subgingival restorations) 51  Light curing (Polymerization) Light must reach the entirety of material, at the right intensity, and for the full amount of time Cure each composite increment ≤ 2mm for 20 seconds Light is placed as close as possible to the composite Orient curing light tip towards all tooth surfaces 52  Light curing (Polymerization) Working time is limited… Work efficiently Time is ticking! Be familiar with the goals, dental anatomy, and the patient’s unique traits Have instruments and materials ready Know the procedure steps If composite hardens before light curing, you need to remove the increment completely as it is not fully cured 53  Occlusion check (Post) Remove dental dam: Make sure there is no deficiency before removing the dental dam! Move side to side Tap! Tap! Check occlusion with an articulating paper (12-40 µm): make sure tooth is dry before checking Check centric and excursive contacts Keep in mind that patient may have distorted proprioception (sensory change) due to anesthetic: Inform the patient that Tap! Tap! their bite might feel off after the anesthetic Move back and forth wears off and that a follow-up may be needed 54  Finishing-check list Is there proper contour, line angle,abd anatomy? Is margin integrity good? Excess? Deficiency? “Flash”-mild excess composite or boning agent beyond the margins Is the surface texture smooth without any irregularities? Is bonding intact? 55  Finishing What if you find deficiencies in the composite restoration after the occlusion check and need to add more composite? Place the dental dam back! Place the dental dam back! Finishing has started already, and composite has been touched with Composite has not been touched a bur and water spray with a bur and water spray MUST abrade the surface with a bur Can add to the existing or air-abrasion and then follow the composite since the oxygen bonding protocol over again prior to inhibiting layer is still on the placement of the composite The oxygen inhibition layer helps improve the bond strength between composite layers without the need for etching or bonding 56  Finishing-instruments Begin with hand instruments (scaler, scalpel) especially in the interproximal areas Remove excess composite with burs: use multi-fluted carbide or super fine diamond burs at lower speed (15,000 RPM with water) SIM Spend enough time to take care of irregular surface at this stage before moving onto polishing →you must “earn” polishing Football Carbide 57  Polishing-benefits Less roughness and scratches means: ✓ Good marginal integrity ✓ Less plaque accumulation ✓ Less gingival irritation ✓ Less secondary caries ✓ More color stability ✓ Easier for patient to clean ✓ Superior esthetic appearance 58  Polishing-instruments and materials These are not for creating anatomy, only for polishing Use in the right sequence (FINE → SUPERFINE) Use the right shape for the right tooth surface (e.g., Polishing strips for interproximal areas, and polishing points for occlusal surfaces) Constant shifting motion Slow-speed with water Moderate to light pressure (too much pressure will flatten the anatomy and wear off acrylic teeth in SIM) 59 Polishing-instruments and materials Polishing strips Sof-Lex Discs Shofu Discs FINE SUPERFINE Discs 60  Polishing-instruments and materials Enhance Polishing System Polishing rubber wheels Polishing brushes Polishing paste: water-soluble, aluminum oxide paste 61  Restoration failure Any one of these steps can cause restoration failure We should control variables as much as possible to maximize the chance of success and ensure restoration longevity 62  Post-op instructions CDMI Direct Restorations (Fillings) Post-treatment Instructions Provide this instruction sheet to patient Be familiar with the instructions and be able to explain to patient verbally 63 Post-op insturctions 64  Knowledge Test QUESTION: After removing the dental dam and while adjusting the occlusion of the Class I occlusal restoration on tooth #19, you notice a deficient area with composite. What is the next protocol at CDMI? ANSWER: Re-apply the dental dam, redo bonding steps, add composite to the deficient area, re-assess for any remaining deficiencies, remove dental dam, check and adjust occlusion, finish and polish. 65  References Heynmann, H., Swift, E., Ritter, A. Sturdevant’s Art and Science of Operative Dentistry 6th edition Hilton, T., Ferracane, J., Broome, J., Summitt’s Fundamentals of Operative Dentistry, 4th edition Demarco FF, Collares K, Correa MB, Cenci MS, Moraes RR, Opdam NJ. Should my composite restorations last forever? Why are they failing? Braz Oral Res. 2017 Aug 28;31(suppl 1):e56. doi: 10.1590/1807-3107BOR2017.vol31.0056. PMID: 28902236 Yazici AR, Antonson SA, Kutuk ZB, Ergin E. Thirty-Six-Month Clinical Comparison of Bulk Fill and Nanofill Composite Restorations. Oper Dent. 2017 Sep/Oct;42(5):478-485. doi: 10.2341/16-220-C. Epub 2017 Jun 5. PMID: 28581919 66 [email protected] A big thank you to Dr. Alabsy 67