Class 2 composite restoration

[Anonymous]

In a class 2 composite restoration, what sort of retentive factors or bonding technique should be imbibed to ensure longevity and avoid microleakage?

        

[drmithila]

Over the years, one of the most challenging restorations to place has been on a tooth presenting with a Class IV fracture. Dentists have universally experienced difficulty in providing a long-lasting restoration that exhibits all of the color properties necessary for a successful shade match, as well as harmonious texture and polish. Due to their past experiences, many clinicians have regarded a direct-bonded Class IV restoration as a temporary solution. They will often advise their patients that the affected tooth will require a porcelain restoration as the definitive treatment.
However, there has been a flurry of progress in the research and development of composite resins during the first decade of this millennium. New techniques have been introduced, and an improved protocol has been developed in the clinical environment to maximize these advances. Because of this, there should no longer be a reason to regard composite resin restorations as temporary or substandard. It is, however, important to update your knowledge on the properties of the composite resin material that you are utilizing in order to consistently create beautiful restorations. In order to realize long-lasting results, adhering to protocol is even more importantPreparation and Composite Resin Placement Protocol
Local anesthetic (3% Isocaine plain [Septodont]) was administered and the fractured teeth were prepared with a long star-burst shaped bevel (48L bur [Brasseler USA]) ).3-5 Teflon tape would have been necessary to cover the enamel of the adjacent tooth if an interproximal contact had been present. In this case, the adolescent had diastemas present, which were left open in anticipation that future orthodontic treatment would be able to properly position the teeth.
Beginning with the right central incisor, the teeth were restored. Tooth No. 8 was etched (UltraEtch [Ultradent Products]) and bonding agent applied (PQ-1 [Ultradent Products]). To ensure an invisible margin, both the etchant and the bonding agent were applied well beyond the fracture line in a gingival direction. Longevity of the restoration depends upon utilizing a maximum amount of the remaining facial enamel. The increase in surface area improves the bonding anchorage value of the restoration to such an extent that this restoration should rival the cosmetic life of any all-ceramic counterpart. Since the fracture in tooth No. 8 only involved the enamel, and occurred at the line of translucency, no dentin shade or lingual opaque shade was needed. Therefore, only Pearl Neutral was used, thus preserving the translucent zone as well as continuing the incisal halo of the natural tooth.
After preliminary shaping of No. 8, the enamel and dentin surfaces of No. 9 were prepared with UltraEtch and PQ1 bonding agent, again extending in a gingival direction well beyond the fracture line. The lingual enamel layer was placed using a universal lingual opaque shade (Opaque Snow). It is important to note that it was left short of the final distal and incisal edges of the tooth, allowing for the creation of a thin band of translucency that was required for optimal aesthetics in this case (Following the simplified layering technique protocol, the dentin-enamel junction (DEJ) was used as a guide for the placement of the dentin layer. Dentin shade A1 was placed to restore the portion that was missing from the fracture. This was placed directly over the lingual enamel layer (The final facial enamel layer was then placed using Pearl Neutral.

        

[drmithila]

Finishing and Polishing
Finishing and defining of the facial anatomy were completed using a 48L bur (Brasseler USA). An egg-shaped finishing bur (H379 [Brasseler USA]) was used for lingual anatomy reproduction and for the occlusal adjustments. Polishing was carried out using Jiffy cups (yellow and white) (Ultradent Products), ending with a Jiffy brush (Ultradent Products). Interproximal polishing was done using Epitex (GC America) polishing strips.
The final clinical result (Figures 9 and 10) showcases the remarkable manner in which modern resin chemistry has allowed dentists to duplicate color and light-handling capabilities of natural teeth, while be confident of restorative longevity.

DISCUSSION
The resin utilized in this case (Vit-l-escence) is a microhybrid resin. It is indicated for use in both anterior and posterior teeth. The authors chose this resin because of the ease in shade matching to the natural tooth, the manner in which the material handles, and the finishing and polishing results that it produces. The shade tabs are fabricated out of the actual Vit-l-escence resin (other systems use dissimilar materials) and are divided into the individual enamel and dentin shades. This unique feature allows the clinician to directly match a resin shade tab to exposed dentin—and the same with the enamel.
Most of the information on shade matching is based on determining an average hue by placing a shade tab on the facial of the tooth to be restored or on the adjacent intact tooth. The problem with this method is that it does not take into account the individual contributions of the dentin and the enamel. On most fractures, the DEJ can be seen, which clearly separates the dentin and enamel components as well as indicates the thickness of each layer. The interplay between the thickness of each layer and how they change from gingival to incisal provides the polychromatic effect visually perceived by the human eye. The authors based their simplified layering technique on this unique anatomical characteristic of the tooth: thinner enamel at the gingival third and thicker enamel at the incisal third

        

[Drsumitra]

 POLISHING TRIAGE

First of all, it is imperative that the dental hygienist makes an evaluation regarding the polishing environment and situation, ie, conduct a polishing triage determining exactly why you are polishing any particular restoration. Polishing to smooth down a rough surface? Smoothing down a margin? Removing plaque? Removing extrinsic stain on the restoration? Restoring shine and luster to a dull surface? Is there a true “reason” to polish? You may wish to consider selective polishing as a viable option.¹

RESTORATIVE MATERIALS
Not only is determining why you are polishing important, it is also important to know what dental material you are polishing. Quite simply, different polishing pastes will have a different effect on different materials. Aesthetic indirect all-ceramic materials fall into 2 general categories: composite or porcelain (ceramic). 
Composite, or resin-based materials, are mechanically polished to a shine. Also, the filler particle size of the composite is directly related to the optimal surface luster. Normal particle size can range from 0.04 to 1 µm, affecting the material’s potential to achieve a high shine. Fillers may be made of resin, glass, or silica; or a combination of these. Composite resin materials require regular care to maximize their longevity simply because they are not as strong in comparison to the strength that porcelain materials possess. Composites are also a viable direct restorative choice in the dental office.²

Table 2. Ranking System of Mohs as to Hardness Value

Mineral Hardness (Mohs) Talc 1 Gypsum 2 Calcite 3 Fluorite 4 Apatite 6 Quartz 7 Topaz 8 Corundum 9 Diamond 10

With porcelain materials, an enamel glaze is baked on the surface of the restoration to provide a smooth glossy/shiny surface. Advances in dental technology offer more ceramic/nonmetallic options. The use of computer-aided design/computer-aided manufacturing systems has enhanced the availability of aesthetic choices, whether restorations are fabricated in the office or in the dental laboratory. For example, in the laboratory, copings can be milled out of zirconium oxide, and porcelain can be pressed (or layered) onto the substructure. Options for crowns and veneers include layered/stackable feldspar-based porcelains or pressed-ceramic utilizing the lost wax technique. Pressed ceramic can include materials such as leucite glass-ceramic and lithium disilicate glass-ceramic. Strength is gained once the porcelain restorations are bonded to the tooth structure.³ It is important for the hygienist to be aware of the interface between the tooth structure and the restoration, as it can stain and abrade more readily. Also, it is pertinent for the hygienist to help maintain a smooth glasslike surface to the restorations. Any roughness will attract bacteria and stain, contributing to a less aesthetic appearance, and possibly compromising the integrity of the restoration itself

        

[Drsumitra]

 ELATIVE DENTIN ABRASION VALUE

Once you have determined the aesthetic material and the purpose of polishing, the polishing agent itself should be evaluated for its main abrasive ingredient. The relative dentin abrasion orradioactive dentin abrasivity (RDA) should be reviewed and assessed (Table 1). This value indicates the abrasivity of a material in relation to dentin. The relative enamel abrasion (REA) value can be taken into consideration as well, but the RDA value relates better to the sensitivity of dentin. Abrasives are based on the hardness, particle size, and quantity of the abrasive. The ADA has adopted a standardized test to determine the RDA and REA value of a product. Basically, to determine RDA value, extracted human teeth are irradiated with mild neutrons, stripped of enamel, and subjected to simulated tooth cleaning procedures. The rinse water is then measured for its radioactivity and recorded. Thus, after a few calculations (taking into consideration speed of rotation of the prophy cup, time, and the pressure applied, etc), a score or index is given to the product being tested (Table 1). Any value over 100 is considered to be abrasive.⁶ The ADA recommended limit is 250, whereas the FDA limit is 200. (Note: Toothpastes are also given a RDA value for FDA approval, but often are not published for marketing purposes). As for the hardness, abrasives are ranked on the Mohs scale of mineral hardness. The hardness is based upon 10 readily available minerals, on a scale of 1 to 10. Diamonds are assigned a 10 since it is the hardest mineral, and talc, the softest, is assigned a 1.0.7 

        

[Drsumitra]

Table 4. Examples of Pastes

Polishing Agent Example Indication Manufacturer Silicon dioxide Proxyt Coarse Removal of stains on porcelain and composite materials Ivoclar Vivadent Silicon dioxide Proxyt Medium Proxyt Fine Plaque removal, polsihing on porcelain and composite materials Ivoclar Vivadent Perlite Clinpro Removal of stain, plaque removal on porcelain and composite, starts out course and breaks down to fine 3M ESPE Aluminum oxide Nupro Shimmer Enamelizer Improve luster, shine, polish on composites DENTSPLY  COSMEDENT White sapphire Novamin CRP Softshine NuCare Gentle stain removal and restoration of luster on porcelain and composite materials. Gentle stain removal without pumice, reduces sensitivity,safe for porcelain and composite materials. Pumice free. ICCare Waterpik Sunstar Butler Diamond paste Diamond Polish Luminescence Plus Topex Brilliance Micrograin Paste DirectDia Paste Improves shine, luster, high gloss on porcelain Ultradent Premier Dental Sultan Dental Products Shofu Dental Recaldent (CPP-ACP) (No abrasive present) MI Paste Final/Post polishing to decrease sensitivity GC America

        

[drmithila]

 Advantages of direct composite over indirect aesthetic restoration include:

Minimal preparation—While most indirect restorations require preparation of the tooth to develop "draw" and eliminate undercuts, direct restorations can be built into undercuts and around corners, often requiring less preparation. Indirect restorations need a certain thickness for strength and then need to be cemented or bonded in to place. Directly applied composite resin can be made to be "paper thin" in areas.

Lower fee to the patient—Fees can often be lower for direct than for indirect procedures because of the time savings (no second appointment or laboratory charges).

Easily removed—When it is necessary or desirable to remove composite resin from the tooth, it can be accomplished by using a carbide-finishing bur in a high-speed handpiece without damaging the underlying natural tooth structure.

Easily repaired—When it is necessary to repair a fracture or chip, composite resin can be roughened by microabrasion (or with a diamond bur) and treated with phosphoric acid to clean the abraded surfaces. Then, a bonding agent can be applied and new composite resin can be added and light-cured. Once the new material has been finished and polished, the repair is often imperceptible and long-lasting

        

[drmithila]

 

Figure 1. Preoperative facial view.	Figure 2. Preoperative incisal view.
Figure 3. Facial view of prepared teeth.	Figure 4. Incisal view of prepared teeth.
Figure 5. Facial view of completed composite application; the first tooth (tooth No. 8).	Figure 6. Incisal view of completed composite application; first tooth.
Figure 7. Facial view of finished restoration; first tooth.	Figure 8. Incisal view of finished restoration; first tooth.
Figure 9. Completed buildup of second tooth (tooth No. 9).	Figure 10. Facial view of final result.
Figure 11. Incisal view of final result.	Figure 12. The patient’s smile, preoperatively.

Figure 13. The patient’s smile, after treatment.

        

[drmithila]

This is an alternative to gold or all ceramic inlays and onlays. They still perform the same function, namely that of treating a damaged or decayed tooth and are considered a stronger and more appealing option than a normal filling.

It is easy to become confused by composite (white) fillings and composite inlays and onlays so here is a way of distinguishing between the two.

DIRECT COMPOSITE (WHITE) FILLING
The composite white filling (also known as a direct white filling) is similar to your standard type of filling, for example the amalgam filling. Except that it is white in colour instead of the usual silver grey colour.

This is completed in one visit and all within the dentist’s surgery.

Direct white fillings are discussed in more detail in a separate section.

INDIRECT COMPOSITE INLAY
The composite inlay is similar in appearance to the composite filling except that it is larger and covers more of the surface of the tooth.

This is completed in two visits and the composite inlay itself is produced in a dental laboratory.

We hope this explains the difference between the two.

WHAT ARE COMPOSITE INLAYS AND ONLAYS?
A composite inlay/onlay is similar to other types of indirect fillings apart from the material used to treat a cavity or damaged tooth. This material is a composite resin which is white in appearance and enables the inlay/onlay to match the rest of your teeth.

Composite resin is an acceptable choice of material for an inlay or onlay, for people who tend to grind their teeth or have malocclusion (misaligned jaw which causes problems with their bite).

Composite inlays and onlays are a good choice for people with tooth decay which is too far advanced for a filling but not serious enough for a crown.

ADVANTAGES OF COMPOSITE INLAYS AND ONLAYS
A major advantage is their natural looking appearance. They have a white (or slightly off white) colour which allows them to blend in with the rest of your teeth.

Plus they provide a watertight seal between the tooth and the indirect filling which prevents the risk of bacteria entering that gap and causing an infection.

They do cause any friction with neighbouring teeth and are easy to polish and care for in general.

DISADVANTAGES OF COMPOSITE INLAYS AND ONLAYS
There are a couple of disadvantages which you need to be aware of. Firstly, composite resin or ceramic are not as tough and long lasting as other materials, e.g. gold which means that they are likely to fracture.

Plus composite inlays/onlays have a tendency towards staining, often causes by food colouring/additives, which occurs after a few years.

There is a risk of the inlay/onlay becoming loose and falling off the tooth or being washed away although this is rather small.

HOW ARE COMPOSITE INLAYS AND ONLAYS FITTED?
These are fitted in two stages. The first stage involves the preparation of the tooth for the inlay/onlay. The tooth is cleaned and any decay removed. The dentist then takes an impression of the tooth via a mould and dental putty.

He or she will ask you to bite into the mould which will leave an imprint (impression). This is sent to a dental laboratory for the production of the onlay/onlay.

The dentist will place a temporary inlay/onlay onto your tooth as a short term measure which will be removed once your new inlay/onlay is ready.

The second stage is the placing of the inlay or onlay. The dentist will clean your teeth before cementing the inlay or onlay in place. This may require some reshaping to fit the surface of the tooth. Your teeth are given a final polish.

 

        

[Drsumitra]

 An easy video on how one can simplify restoration of class II with composites,, a very easy and innovative trick

Have a look

http://www.dentalcomposites.com/technique-videos/class-ii-composite-restoration/

        

[drmithila]

 The FenderMate flexible wing separates the teeth, pressing the matrix toward the cervical margin, avoiding overhang. Its optimal curvature and preshaped contact ac­commodate the most conservative Class II preparation; no ring is needed. In traditional methods of Class II preparation, the em­phasis has been to break contact and extend the walls in order to ac­commodate the ma­trix band. With the facility to insert FenderMate lingually and/or buccally, the dentist can maintain a smaller, more conservative preparation

 

        

[drmithila]

        

[DENTAL TRACKER]

 a very good video. Thanks for sharing. I also would recommend Dr. Veerendra Darakh’s hands on course. its quite comprehensive

        

[Drsumitra]

 It is a very helpful trick that they have illustrated in the video..it is such a logical step and simplifies the entire matter of doing a good restoration of one of the difficult restorations of class 2 composites

        

[siteadmin]

 Thank you Dr. Kevalfor the compliment. However please not that there is not much evidence to support the use of flowables. You can do excellent restorations even without the use of flowables. The idea of creating a proximal wall first is good. All composite restorations must be done in small increments

regards,

Dr. Veerendra Darakh

        

[Author]

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