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8/6/2019 Case Presentations & Online CE

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CS0411Putting ideas into practice.

Many articles have addressed the challenges faced by the clinician in placing

posterior composites. The inherent chemical nature of todays composite

resins still force the clinician to deal with polymerization shrinkage, which can

range from 23% for hybrids, microls, and nanolled composites1,2,3 and low

viscosity or owable composite resins which are often used as liners, or initial

increments in proximal boxes which can demonstrate a volumetric contraction

of up to 5% because of their lower ller content4. These shrinkage values

are only approximate for each composite, as the shrinkage depends on the

polymerization reaction which is proportional to the degree of conversion5

(exposure time x light irradiance or radiant exposure measured in J/cm2).6 To

address or compensate for this chemical contraction, many composite insertion

techniques have been proposed which usually incorporate an incremental

placement of the composite resin such as the three site technique using

clear matrices with reective wedges,7,8 a horizontal layering,9,10 the oblique

technique,11,12 or a segmental technique as described by Jackson which may

include an initial bulk placement in 3 to 3.5 mm increments.13

In spite of the various techniques used to place these composite resins, these

materials challenges can lead to post-operative sensitivity,14,15 wear higher

than tooth structure,16 marginal leakage with recurrent caries,17,18 and open

contact areas.13,19,20 For posterior Class II restorations especially, open contacts

result in food impaction into the interproximal space resulting in periodontal

inammation and disease, due to bacterial ingress into the periodontium,21,22

with subsequent bone loss23,24 (Figure #1), and recurrent caries25 (Figure #2).

The high incidence of open contacts with food impaction may be one of the

reasons why, as Strassler states, clinical evidence has demonstrated that

Class II composite resins have signicantly higher rates of caries at the gingival

margin when compared to amalgam restorations.26

The clinical challenge of creating tight interproximal contacts has been

discussed in many published articles. Liebenberg states that the clinicians

achievement of an intact proximal contact when delivering a direct restorative

option is reliant on tooth separation greater than or equal to the thickness of

the matrix used.27 I would submit that due to post light-cure polymerization

The Use of Separating Rings in the Placement of Class II Composite Resinsby Dr. Len Boksman D.D.S., B.Sc., F.A.D.I., F.I.C.D.

Case Presentation

Figure 1

Figure 2


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The Use of Separating Rings in the Placement of Class II Composite Resinsby Dr. Len Boksman D.D.S., B.Sc., F.A.D.I., F.I.C.D. Pa

contraction, the separation required for the creation of routinely tight

interproximal contacts for direct placement should always be greater than the

thickness of the matrix band. The re-establishment of the correct interproximal

contact and convex contour (bucco-lingually and occluso-gingivally) requires

a properly contoured matrix which is stabilized and adapted gingivally with a

properly inserted and contoured wedge.28 The use of a Tofemire metal matrix

and retainer that is not contoured (Figure #3), and even if contoured, stabilized

gingivally with a wedge only, without the use of auxiliary tooth separation,

will often result in open or light contacts.29 A circumferential matrix will cause

the band to atten out interproximally due to tensioning (it often has to be

released somewhat), and when the interproximal contact is wide, an open

contact is the only possible clinical outcome. A non contoured circumferential

matrix creates a at interproximal contour which migrates the contact pointfrom the upper middle third to the marginal ridge occlusally (Figure #4).30 This

translocation can create an open contact when proper marginal ridge convexity

is created and will result in premature interproximal fracture due to lack of

support for the marginal ridge which can often be in an area of a centric stop

(Figure #5).31

Many authors have looked at various other methods of creating tight

interproximal contacts. Early literature looked at the effect of pre-wedging

as it not only creates some initial separation of the teeth, but also protects

the rubber dam interproximally and the interproximal tissue as well.32The clinician should note that the wedge should be continually advanced

during the preparation phase, as the wedge may back out, or soften due

to saliva, if a wooden wedge is placed. Packable composite resins have

been evaluated,33,34 but not only did these show increased wear and surface

roughness35,36 (being no better than a hybrid), their use did not ensure

reliably tight contacts.37 It is important to note that the use of a separating

ring when restoring Class II composite restorations has a greater inuence

on the obtained proximal contact tightness compared to the inuence of the

consistency of the composite resin.38 Ceramic inserts or pre-polymerized resin

particles have been used which can wedge the contacts interproximally as

well as decreasing the overall amount of composite used, thereby reducing the

overall amount of shrinkage.39,40 Special instruments to help hold the matrix

in better adaptation in contact with the adjacent tooth, such as the Contact

Pro (Clinical Research Dental, Brookeld CT) can be especially helpful41 when

Figure 3

Figure 4

Figure 5


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the preparation is very wide interproximally, which can negate the use of some

small tine matrix rings. The thickness of the matrix band used can have an

effect on contacts, as these can vary from .030 mm to .058mm.42

Since Class II posterior composite resin restorations placed with a combination

of sectional matrices and separation rings result in the strongest contacts,43,44

and since the use of a contoured matrix results in a stronger marginal ridge45

this article will now look at one of those systems.

Of the ring systems currently available, the Garrison Composi-Tight 3D gives

the author one of the most predictable results.

The Garrison Composi-Tight 3D sectional matrix system has a Soft-Face which

is different from other available rings (Figure #6). The ring is made of polished

stainless steel which is circular in shape, with the bow section encased in

plastic that stiffens the ring (Figure #7). The hard and soft plastic combination

of the tine area creates separating pressure while entering the interproximal

area to minimize ash and enhances the grip on the contoured matrix band

which comes in a number of sizes and shapes. The

U-shaped gingival contour of the soft face allows

the ring to be placed over the wedge. The system

has the option of using the regular contoured

bands or the new Slick bands (Figure #8) which are

designed to minimize sticking to the bonding agent.

The Garrison Fender Wedge (Figures #9 and 10) is an excellent way to protect

the rubber dam, interproximal gingival tissues, and the tooth surface adjacent

to the preparation.

Figure 6

Figure 7

Figure 8

Figure 9 Figure 10


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proteins in the tubules, acts as a pre-primer, and has residual

antimicrobial effects. MPa (Clinicians Choice, Brookeld CT),

a fth generation bonding agent was placed in a single layer,

air thinned with the solvent evaporated, and light cured with

a Valo (Ultradent, Salt Lake City, UT) broad spectrum curing

light for 10 seconds. A thin layer of DeMark, a hyper-opaque,

owable hybrid lining composite (Cosmedent, Chicago, IL)

was teased into the base of the proximal box, into the deeper

carious excavation areas, and lightly teased over the pulpal

oor (Figure #14) followed by light curing for 10 seconds.

Its radiopacity can be clearly seen on the radiograph (Figure

#15), which minimizes the chance for erroneous diagnosis

of caries under the composite due to radiolucent lining

materials. The placement of a owable liner also creates an

elastic cavity wall46 interface which minimizes the effect

of C-factor shrinkage.47 An incremental insertion technique

was used to restore the tooth with Cosmedent Nano A2

(Cosmedent, Chicago, IL), with each layer no more than 2

mm, laterally placed to reduce the C factor, and light cured

for 10 seconds. The restoration was shaped on the occlusal

with a 7803 multi-uted bur, and the mesial interproximal

shaped with a 7901. On tooth #20 the Garrison contoured

matrix was placed, followed by a G-Wedge, and the Composi-

Tight 3D ring applied to separate the teeth and minimizeCase

Pr

esentatio

n

Figure 16

Figure 14

Figure 15


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interproximal ash (Figure #16). After each placement of the

contoured matrix band, a ball burnisher should be used to

verify contact with the adjacent tooth. The DO restoration was

placed following the above protocol (Figure #17). The nal

excellent contour and contact that can be routinely achieved

with this system is shown in Figure #18. Because of a tear in

the rubber dam, a new dam was placed to adequately isolate

tooth #18 and pre-wedging initiated. Even with the rubber

dam clamp on the same tooth, if well placed apically, Figure

#19 shows the application of the Garrison contoured matrix

and the Composi-Tight ring over the rubber dam clamp.

Case

Pr

esentatio

n

Figure 19

Figure 17

Figure 18


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Figure #20 shows the easy 90 degree direct access allowed

by the shape and design of the Valo curing light, which

allows maximum curing penetration. After restoring tooth

#18 as above (Figure #21), and polishing the restorations

with an occlusal diamond impregnated Groovy bristle brush

(Clinicians Choice, Brookeld, CT), the immediate post

operative photo is shown in Figure #22.

This article has presented a predictable method of obtaining

tight, well contoured, interproximal restorations utilizing

separation rings. Clinical predictability is assured when

following the above protocol.

Dr. Leendert (Len) Boksman D.D.S., B.Sc.,

F.A.D.I., F.I.C.D. is a part-time consultant to

Clinical Research Dental acting as Director of

Clinical Affairs, an Adjunct Clinical Professor at the Schulich

School of Medicine and Dentistry and is in private practice

in London, Ontario. He can be reached at lboksman@

clinicalresearchdental.com.

This article is a portion of one previously published in Oral HealthNovember 2010

Figure #5 is courtesy of Dr. David Clark

Case

Pr

esentatio

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Figure 22

Figure 20

Figure 21


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Bibliography:

1. Farracane JL. Using posterior composites appropriately. J Am Dent

Assoc 1992;123:53-58

2. Stansbury JW. Cyclopolymerizable monomers for use in dental

resin composites. J Dent Res 1990;69:844-8

3. Stansbury JW . Synthesis and evaluation of novel multifunctional

oligomers for dentistry. J Dent Res 1992;71:434-7

4. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G.

Polymerization shrinkage and elasticity of owable composites and

lled adhesives. Dent Mater 199;15:128-137

5. Lim B-S, Ferracane JL, Sakaguchi RL, Condon Jr. Reduction ofpolymerization contraction stress for dental composites by two step

light activation. Dent Mater 2002;18:436-444

6. Sakaguchi RL, Berge HX. Reduced light energy density decreases

post gel contraction while maintaining degree of conversion in

composites. J Dent 1998;26:695-700

7. Lutz F, Krejci I, Barbakow F. The importance of proximal curing

in posterior composite resin restorations. Quintessence Int

1992;23:605-607

8. Lutz F, Krejci I, Luescher B, Oldenburg Tr. Improved proximal marginadaptation of Class II composite resin restorations by use of light

reecting wedges. Quintessence Int 1986;17:659-64

9. Tjan AH, Bergh BH, Lidner C. Effect of various incremental

techniques on the marginal adaptation of class II composite resin

restorations. J Prosthet Dent 1992;67(1):62-66

10. Lutz F, Krejci I, Barbakow F. Quality and durability of marginal

adaptation in bonded composite restorations. Dent Mater

1991;7(2):107-113

11. Spreaco RC, Gagliani M. Composite resin restorations onposterior teeth. In: Roulet JF, Degrange M. Adhesion: The silent

revolution in dentistry. Chicago: Quitessence;200:253-276

12. Weaver WS, Blank LW, Pelleu GB.A visible light activated resin

cured through tooth structure. Gen Dent 1988;36:236-237

13. Jackson Rd, Morgan M. The new posterior resins and a simplied

placement technique. JADA 2000;131:375-383

14. Perdigao J, Anauate-Netto C, Carmo AR, et al. The effect ofadhesive and owable composite on post-operative sensitivity:

2-week results. Quintessence Int 2004;35:777-784

15. Perdigao J, Geraldeli S, Hodges JS. Total etch versus self etch

adhesive: effect on post-operative sensitivity. JADA 2003;134:1621-

1629

16. Christensen GJ. Preventing sensitivity in Class II resin restorations

JADA 2001;129:1469-1470

17. Opdam N, Loomans B, Roeters F, Bronkhorst E. Five year clinical

performance of posterior resin composite restorations placed bydental students. J of Dent 2004;32(5):379-383

18. Ockson RD, Opdam NJ, Roeters FJ, Feilzer AJ, Verdonschot EH.

Marginal integrity and post-operative sensitivity in Class II resin

composite restorations in vivo. J Dent 1998;26:555-562

19. Christensen GJ. Overcoming the challenges of Class II resin based

composites. JADA 2006;137(7):1021-1023

20. Miller MB, Castellanos IR, Vargas MA, Denehy GE. Effect of

restorative materials on microleakage of Class II composites. J Esthet

Dent 1996;8(3):107-13

21. Bliedent TM. Tooth related issues. Annals of Perio December

1999;4(1):91-6

22. Padbury A, Eber R, Wang HL. Interactions between the gingiva

and the margin of restorations. J of Clin Perio May 2003;30(5):379-

385

23. Koral SM, Howell TH, Jeffcoat MK. Alveolar bone loss due

to open interproximal contacts in periodontal disease. J of Perio

1981;52(8):447-450

24. Nielsen IM, Glavind L, Karhing T. Interproximal periodontal

intrabony defects. J of Clin Perio June 1980 7(3):187-198

25. Ash MM. Wheelers dental anatomy, physiology and occlusion.

Dental Anatomy, Physiology and Occlusion. 8th ed. Philadelphia:

Saunders 2003


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26. Strassler HE. Meeting the challenge of the Class II composite

resin proximal contact. Oral Health August 2010;60-73

27. Liebenberg WH. The proximal contact precinct in direct posteriorrestorations: Interproximal integrity. Pract Proced Aesth Dent

2002;14(7):587-594

28. Varlan CM, Dimitriu BA, Bodnar DC, Varlan V, Simina CD, Popa

MB. Contemporary approach for re-establishment of proximal

contacts in direct class II resin composite restorations. Timisoara

Medical Journal 2008;58(3-4):236-243

29. Wirshing E., Loomans BAC, Staehle HJ, Dorfer CE. Clinical

comparison of proximal contacts obtained with different matrix

systems. #2860 http://iadr.confex.com/iadr/2008Toronto/

techprogram/abstract_103904.htm

30. Keough TP, Bertolotti RL. Creating tight, anatomically correct

interproximal contacts. Dent Clin N Am 2001;45(1):83-103

31. Loomans B, Roeters F, Opdam N, Kuijs R. The effect of proximal

contour on marginal ridge fracture of class II composite resin

restorations. J Dent 2008;36(10):828-832

32. Eli I, Weiss E, Kozlovsky A, Levi N. Wedges in restorative dentistry:

principles and application. J of Oral Rehab 1991;18(3):257-264

33. Sarrett DC, Brooks CN, Rose JT. Clinical performance evaluationof a packable posterior composite in bulk-cured restorations. JADA

2006;137:71-80

34. Francci C, Loguercio AD, Reis A, Carrilho MRDO. A novel lling

technique for packable composite resin in class II restorations. J. of

Esthet and Rest Dent 2002;14(3):149-2002

35. Cobb DS, McGreggor KM, Vargas MA, Denehy GE. The physical

properties of packable and conventional posterior resin based

composites: a comparison. JADA 2000;131:1610-1615

36. Ferracane JL, Choi KK, Condon Jr. In vitro wear of packabledental composites. Compend Cont ed Dent 1999;20(supplement

25):S60-S66

37. Leinfelder KF, Bayne SC, Swift EJ Jr. Packable composites overview

and technical considerations. J Esthet Dent 1999;11:234-249

38. Loomans BAC, Opdam NJ, Roeters JF, Bronkhorst EM, Plasschaert

AJ. Inuence of composite resin consistency and placement technique

on proximal contact tightness of class II restorations. J Adhes Dent.

Oct 2006;8(5):305-10

39. Bott B, Hannig M. Optimizing class II composite resin esthetic

restorations by the use of ceramic insert. J of Esthet and Rest Dent

1995;7(3):110-117

40. Prakki A, Cilli R, Saad JO, Rodrigues JR. Clinical evaluation of

proximal contacts of class II esthetic direct restorations. Quintessence

Int. 2004 Nov-Dec;35(10):785-9

41. El-Badrawy WF, Leung BW, El-Mowafy O, Rubo JH, Rubo MH.

Evaluation of proximal contacts of posterior composite restorations

with 4 placement techniques. JCDA March 2003;69(3):162-167

42. Boksman L, Margeas R, Buckner S. Predictable interproximal

contacts in class II composite restorationsa fusion of separation

armamentarium, composite material selection and insertion

technique. Oral Health March 2008:10-16

43. Loomans B, Opdam N, Roeters N, Bronkhorst E, Burgersdijk R,

Dorfer C. A randomized clinical trial on proximal contacts of posterior

composites. J of Dent 2006;34(4):292-297

44. Saber MH, Loomans BA, El Zohairy A, Dorfer CE, El-Badrawy

W. Evaluation of proximal contact tightness of class II compositerestorations. Oper Dent 2010 Jan-Feb;35(1):37-43

45. Loomans BAC, Roeters JJM, Opdam NJM, Kuijs RH. Effect of

proximal contour of restorations on fracture resistance. #0031 http://

iadr.confex.com/iadr/2008Toronto/techprogram/abstract_103114htm

46. Uterbrink GL, Liebenberg WH. Flowable resin composites as

lled adhesives: literature review and clinical recommendations.

Quint Int 1999;30:249-257

47. Van Meerbeek B, Willems G, Celis JP, Roos JR, Braem M,

Lambrechts P, Vanherle G. Assessment by nano-indentation of thehardness and elasticity of the resin-dentin bonding area. J Dent Res

1993;72:1434-1442


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Clinical Solutions to Common Problems Faced When Placing Class II Direct CompositesBy Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D.

Dr. Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD, maintains a private practice in Charlotte, N.C. A Diplomate of the American Board ofAesthetic Dentistry, Dr. Lowe lectures internationally and is chairman of the Advanstar Dental Medias continuing education advisoryboard. He can be reached at 704-364-4711 or at [email protected]

Call Today Toll-Free 888.437.0032

or order online www.garrisondental.com

GarrisonDental SolutionsWe put ideas into practice.

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CS004

Introduction: The Class II Challenge

Direct composite restorations that involve posterior proximal suraces are still a common nding in many dental

patients. Unlike dental amalgam, which can be a very orgiving material technically and can be condensed against a

matrix band to create a proximal contact, proper placement o composite restorative materials present a unique set o

challenges or the operative dentist. The adhesion process itsel is well understood by most clinicians as ar as isolation

and execution, however, there are some steps in the placement process that cause diculty and ultimately lead to a

less than desirable end result. In this article we will look at three specic areas, 1) Management o the sot tissue in the

interproximal region, 2) Creation o proximal contour and contact and 3) Finishing and polishing o the restoration.

Management of the Interproximal Gingival Tissue

The most common area or the adhesion process to ail is the proximal gingival margin. Compounding this problem

is the inability to gain access to the area to aect a repair without removal o the entire restoration. As stated by

Dr. Ron Jackson, bonded restorations are unique in that minor deects (decay or microleakage) at the marginal

interace can oten be renewed, or repaired by removal o the aected tooth structure and repair with additiona

composite restorative material. Because o the bond o the restorative material to enamel and dentin, the recurrence

is usually sel limiting. This is not true with metallic restorations that are not bonded to tooth structure. However, i

the deective area is at the proximal gingival margin or line angle, access is not possible. Thereore precise margina

adaptation o the direct composite restorative material and the seal o this margin in the absence o moisture or

sulcular fuid contamination is o paramount importance! However, whether due to the subgingival level o decayand/or gingival infammation, it can be hard to seal the gingival margin with a matrix in the presence o blood.

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Proximal Contact and Contour

Another challenge or the dentist has always been to recreate contact to the adjacent tooth and at the same time

restore proper interproximal anatomic orm given the limitations o conventional matrix systems. The thickness o the

matrix band and the ability to compress the periodontal ligaments o the tooth being restored and the one adjacent to

it can sometimes make the restoration o proximal tooth contact arduous at best. Anatomically, the posterior proxima

surace is convex occlusally and concave gingivally. The proximal contact is elliptical in the bucco-lingual direction

and located approximately one millimeter apical to the height o the marginal ridge. As the surace o the tooth

progresses gingivally rom the contact point toward the cementoenamel junction, a concavity exists that houses the

interdental papilla. Conventional matrix systems are made o thin, fat metallic strips that are placed circumerentially

around the tooth to be restored and axed with some sort o retaining device. While contact with the adjacent tooth

can be made with a circumerential matrix band, it is practically impossible to recreate the natural convex/concave

anatomy o the posterior proximal surace because o the inherent limitations o these systems. Attempts to shape

or burnish matrix bands with elliptical instrumentation may help create non-anatomic contact, but only distorts

or indents the band and does not recreate complete natural interproximal contours. Without the support o tooth

contour, the interdental papilla may not completely ll the gingival embrasure leading to potential ood traps and

areas or excess plaque accumulation. Direct Class II composite restorations can present even more o a challenge to

place or the dentist because o the inability o resin materials to be compressed against a matrix to the same degree

as amalgam making it dicult to create a proximal contact.

Finishing and Polishing Composite Restorations

Direct composite material does not carve like amalgam, although many clinicians wish that it did! Unortunately this

means that most posterior composites are carved with a bur. This is not part o the nishing and polishing o the

restoration. It must be remembered that cuspal orms are convex and cannot be carved with a convex rotary instrument

that imparts a concave surace to the restorative material. Composite should be incrementally placed and sculpted to

proper occlusal orm prior to light curing. The nishing and polishing process is done to accomplish precise marginaadaptation and make minor occlusal adjustments. Rubber abrasives urther rene the surace o the composite, and

surace sealants are used to gain additional marginal seal beyond the limitations o our instrumentation.

Case Report: A Class II Direct Composite Restoration

Figure 1:

This occlusal preoperative view shows a maxillary molar that has radiographic decay on the mesio-proximal surace.

The patient shown in Figure 1 presented with radiographic decay on the mesial

proximal surace o tooth number 3. The operative area is isolated using an OptiDam

(Kerr Hawe). Next, a unique piece o armamentarium called a FenderWedgeis placed in the mesial proximal area prior to preparation with a 330 carbide

bur. The decay is minimal, so the operative plan is to keep the preparation very

conservative. The Fender Wedge will protect the adjacent proximal surace rom

the accidental excoriation by the bur while preparing the proximal box o the

cavity preparation.

Clinical Solutions to Common Problems Faced When Placing Class II Direct CompositesContinued By Robert A. Lowe, D.D.S., F.A.G.D., F.I.C.D., F.A.D.I., F.A.C.D.

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3

Ater removal o the decay, and completion o the proximal and occlusal cavity

orm, the operative area is isolated with a rubber dam (Figure 2) in preparation

or the restorative process. Figure 3 clearly shows that the proximal gingival tissue

was abraded during cavity preparation and there is evidence o hemorrhage. It is

not advisable to try and wash the hemorrhage away with water and quickly

apply the matrix band. Even i this is successul, it is likely that blood will inltrate

into the preparation in the gingival area and make etching and placement o the

dentin bonding adhesive without contamination impossible. An excellent way to

manage the proximal tissue hemorrhage quickly and completely to apply Expa-syl

(Kerr Corporation) to the area, tap it to place with a dry cotton pellet, and wait 1

to 2 minutes (Figure 4). Using air-water mixture, rinse away the Expa-syl leaving

a little bit o the material on top o the tissue, but below the gingival margin o

the preparation (Figure 5). The Expa-syl will defect the tissue away rom the

preparation margin, maintain control o any hemorrhage, and acilitate placement

o the proximal matrix without the risk o contamination o the operative eld.

Class II preparations that need a matrix band or restoration will require rebuilding

o the marginal ridge, proximal contact, and oten a large portion o the

interproximal surace. The goal o composite placement is to do so in such a way

that the amount o rotary instrumentation or contouring and nishing is limited.

This is especially true or the interproximal surace. Because o the constraints o

clinical access to the proximal area, it is extremely dicult to sculpt and correctly

contour this surace o the restoration. Proper reconstitution o this surace is

largely due to the shape o the matrix band and the accuracy o its placement.

Ater removal o caries and old restorative material, the outline orm o the cavity

preparation is assessed. I any portion o the proximal contact remains, it does

not necessarily need to be removed. Conserve as much healthy, unaected tooth

structure as possible. I the matrix band cannot be easily positioned through

the remaining contact, the contact can be lightened using a Fine Diamond Strip

(DS25F - Komet USA).

The Composi-Tight 3D Matrix System has been chosen to aid in the anatomic

restoration o the mesial proximal tooth morphology o this maxillary frst molar.

The appropriate matrix band is chosen which will best correspond anatomically

to the tooth being restored and also, to the width and height o the proximal

surace. The height o the sectional matrix should be no higher than the adjacent




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2

2a

Figures 25:

2) An occlusal view during cavity preparation. 2a) Note how the FenderWedge protects the adjacent proximal surace while the proximabox is rened with a 330 carbide bur. 3) Ater the cavity preparation is completed, bleeding is seen in the proximal area. 4) Expa-syl (KerCorporation) is placed into the proximal area with the delivery syringe then tapped to place using a dry cotton pellet. 5) Ater rinsing away themajority o the Expa-syl, (note that a small amount o Expa-syl remains sub marginal or additional hemorrhage control) the proximal tissue is

defected away and bleeding is absent allowing or easy placement o the sectional matrix band.


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marginal ridge when properly placed. Because o the concave anatomic

shape, the proximal contact will be located approximately one millimeter

apical to the height o the marginal ridge. The Composi-TightMatrix

Forceps is used to place the selected sectional matrix band in the correct

orientation in the proximal area. The positive grip o this instrument

will allow or more exact placement than a cotton plier, which could

damage, or crimp the matrix band. The sectional matrix band (Garrison

Dental Solutions) is positioned and placed using the Composi-Tight

Matrix Forceps to the mesial proximal area o tooth number 14

(Figure 6). The orientation o the band and the positive t in the makesprecise placement possible, even in posterior areas with tight access.

Next, the gingival portion o the band is stabilized and sealed against

the cavosurace margin o the preparation using the appropriate size

WedgeWand fexible wedge (Figure 7). The size o the WedgeWand

fexible wedge should be wide enough to hold the gingival portion

o the matrix band sealed against the cavosurace o the preparation,

while the opposite side o the wedge sits rmly against the adjacent

tooth surace. To place the wedge, the Wedge Wand is bent to 90

degrees where the wedge meets the handle. The fexible wedge can

now be placed with pressure conveniently, without the use o cotton

orceps, that oten times can be very clumsy. Once the wedge is in thecorrect orientation, a twist o the wand releases the wedge. The G-Ring

orceps is then used to place the Sot Face 3D-Ring into position. The

eet o the Sot Face 3D-Ring are placed on either side o the fexible

wedge and the ring is released rom the orceps. The orce o the 3D-

Ring causes a slight separation o the teeth due to periodontal ligament

compression and the unique pads o the Sot Face 3D ring hug the

proximal morphology o the buccal and lingual suraces o the adjacent

teeth while at the same time creating a unbelievably precise adaptation

o the sectional matrix to the tooth cavosurace margins! (Figure 8).

The goal o the perect proximal matrix is to eliminate the need to

have to use rotary instruments to remove overhangs due to a poorlyadapted matrix. Once the sectional matrix is properly wedged and the

Sot Face 3D-Ring is in place, the restorative process can be started. A

15 second total etch technique, 10 seconds on enamel margins and 5

seconds on dentin suraces is perormed using a 37% phosphoric etch.




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6

Figures 68:

6) A sectional matrix band gripped by Composi-TightMatrix Forceps,an instrument that enables precise placement o sectional matrixbands without deormation. 7) The WedgeWand during clinical application with the wedge bent at a 90 angle to the handle7a) WedgeWands provide an excellent seal. 8) The Sot Face 3D-Ring in place. Note the precision o the cavosurace and marginal seal bythe sectional matrix.

7

7a


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9a

The etchant is then rinsed o or a minimum o 15 to 20 secondsto ensure complete removal. The preparation is then air-dried and

rewet with AcQuaSeal desensitizer (AcQuaMed Technologies) to

disinect the cavity surace, create a moist surace or bonding,

and begin initial penetration o HEMA into the dentinal tubules.

A th generation bonding agent (Optibond Solo Plus: Kerr

Corporation) is then placed on all cavity suraces. The solvent is

evaporated by spraying a gentle stream o air across the surace

o the preparation. The adhesive is then light cured or 20

seconds. The rst layer o composite is placed using a fowable

composite (Revolution 2: Kerr Corporation) to a thickness o

about .5 millimeters. The fowable composite will fow intoall the irregular areas o the preparation and create an oxygen-

inhibited layer to bond subsequent layers o microhybrid material.

Ater light curing or 20 seconds, the next step is to layer in

the microhybrid material. First, using a unidose delivery, the rst

increment o microhybrid composite (Premise: Kerr Corporation)

is placed into the proximal box o the preparation. A smooth

ended condensing instrument is used to adapt the restorative

material to the inside o the sectional matrix and preparation.

This rst increment should be no more than 2 millimeters thick.

Ater light curing the rst increment, the next increment should

extend to the apical portion o the interproximal contact andextend across the pulpal foor. Facial and lingual increments

are placed and sculpted using a Goldstein Flexithin Mini 4 (Hu

Friedy). A #2 Keystone brush (Patterson Dental) is lightly dipped

in resin and used to eather the material toward the margins

and smooth the surace o the composite. Figure 9 shows the

restoration ater completion o the enamel layer prior to matrix

band removal. The Composi-Tight Matrix Forceps is used to

remove the sectional matrix ater removal o the fexible wedge

and Sot Face 3D-Ring.




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9

Figures 99a:

9) The composite restoration in completed prior to removal o the matrix band. Placement o the matrix precisely reconstructs the proximatooth orm. 9a) The restoration immediately ater matrix removal. The Composi-Tight 3D-Ring reduces lash to a minimum.

Finishing and polishing will be accomplished using Q-Finisher Carbide Finishing Burs (Komet USA). Typically, 3 grits

and correspondingly, 3 dierent burs are used to nish composite materials. With the Q-Finisher system, the blue-

yellow striped bur with its unique blade conguration does the work o two burs with one. An excellent surace

quality on composite and natural tooth is achieved due to the cross cut design o the cutting instrument.


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13

6

10

11

12

The small, pointed (H134Q - 014) Q Finisher is used to make minor

occlusal adjustments on the restorative surace as needed and to

smooth and rene the marginal areas o the restorative material where

accessible (Figure 10). The ne, white stripe (H134UF - 014) ultra ne

nishing bur is used in the adjusted areas or precise ne nishing

(Figure 11). Komet Diamond Composite polishing points (Green

Polishing and Gray High Shine) are then used to polish and rene the

restorative surace (Figure 12). Once polishing is complete, the nal

step is to place a surace sealant (Seal and Shine:Pulpdent Corporation)

to seal and protect any microscopic imperections at the restorativemarginal interace that may be let as a result o our inability to access

these areas on the micron level. Remember, an explorer can eel a

30 micron marginal gap at best. Bacteria are 1 micron in diameter. The

purpose o the Seal and Shine is to ll these areas. Figure 13 shows an

occlusal view o the completed Class II composite restoration.

Conclusion

A technique has been described 1) to control proximal tissue bleeding

prior to matrix placement with Expa-syl (Kerr Corporation), 2) utilize a

sectional matrix system (Composi-Tight 3D, WedgeWand: GarrisonDental Solutions) and a nanolled microhybrid composite (Premise: Kerr

Corporation) to create an anatomically precise proximal surace, and 3)

Use the Q Finisher, two bur composite nishing system (Komet USA)

to nish then polish with diamond composite abrasives (Komet USA)

rening marginal integrity without destroying occlusal anatomic orm.

The interproximal surace has been recreated with natural anatomic

contour and has a predictable, elliptical contact with the adjacent

tooth. With proper occlusal and proximal orm, this invisible direct

composite restoration will service the patient or many years to come.




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Figures 1013:

10) The pointed Q-Finisher carbide nishing bur is used to make minor occlusal adjustments and rene the restorative margins. 11) Theulta ne pointed composite nishing bur is used to urther rene and nish the restorations adjusted areas. 12) A ne pointed diamondcomposite polisher smoothes adjusted areas during polishing. 13) An occlusal view o the direct MO composite restoration ater applicationo Seal-n-Shine sealant.


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A Series o Photos Showing A MO Composite on #3By Dr. Rosenfeld

Dr. Rosenfeld is a graduate of Cornell University and Northwestern University Dental School.

He served a year of General Practice residency and a second year as chief-resident at Long

Island Jewish Medical Center. Dr. Rosenfeld has completed additional training in aesthetic

dentistry from numerous sources, including the Nash Institute, where he has also served as

a mentor. He is a member of the American Academy of Cosmetic Dentistry. He practices

privately in Westwood, New Jersey.

Pre-operative image showing ailed amalgam with recurrent carries:

Figure 1

Pg. 1 of 6

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Rubber dam in place::

Figure 2

Tooth is prepped::

Figure 3

A Series o Photos Showing A MO Composite on #3: ContinuedBy Dr. Rosenfeld


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Matrix band and WedgeWand placed::

Figure 4

Sot Face 3D-Ring in place. Matrix band burnished to adjacent tooth:

Figure 5



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Bond and etch::

Figure 6

Cure bonding agent::

Figure 7



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Incrementally ll and cure:

Figure 8

Restoration immediately ater removal o the matrix band. Note the lack o fash:

Figure 9



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Completed restoration:

Figure 10



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A Series o Photos Showing A MO Composite on #4By Dr. Rosenfeld

Dr. Rosenfeld is a graduate of Cornell University and Northwestern University Dental School.

He served a year of General Practice residency and a second year as chief-resident at Long

Island Jewish Medical Center. Dr. Rosenfeld has completed additional training in aesthetic

dentistry from numerous sources, including the Nash Institute, where he has also served as

a mentor. He is a member of the American Academy of Cosmetic Dentistry. He practices

privately in Westwood, New Jersey.

Pre-op image

Figure 1

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Rubber dam in place

Figure 2

Tooth is prepped

Figure 3

A Series o Photos Showing A MO Composite on #4, ContinuedBy Dr. Rosenfeld


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Matrix band and WedgeWand in place

Figure 4

Sot Face 3D-Ring in place note the excellent buccal/lingual matrix band adaptation

Figure 5



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Bond and etch

Figure 6

Cure bonding agent

Figure 7



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Composite placed and cured in increments

Figure 8

Restoration immediately ater matrix band removal. Note the lack o buccal/lingual fash

Figure 9



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Post operative

Figure 10



28/55PennWellisan ADACERPRecognizedProvider 1-888-INEEDCE


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Educational ObjectivesOverall goal: The purpose o this article is to provide dental

proessionals with expanded inormation on direct posterior

composites.

Upon completion o this course, the clinician will be able to

do the ollowing:

1. Describe the modes o ailure, advantages and disadvan-

tages o amalgam restorations.2. Describe the modes o ailure, advantages and disadvan-

tages o composite restorations.

3. Describe the properties o an ideal restorative material.

4. Describe the types o composite materials and recent new

materials and their application.

AbstractEarly tooth-colored restorative materials were weak and

only suitable or anterior teeth. Over time, composites were

developed that oered improved properties enabling theiruse in posterior teeth where subject to occlusal loading and

orces o mastication. Secondary caries is the main reason

or ailure o both amalgam and composite restorations.

Amalgam restorations oer ease-o-use but poor esthetics.

In the case o composite restorations, minimizing polym-

erization shrinkage, wear and discoloration increase the

longevity o these restorations. Posterior composite resins

oer excellent esthetics, the main driver or patients who

preer composite llings.

IntroductionHistorically, posterior direct restorations involved the use o

amalgam. The rst modern tooth-colored restorations used

acrylic, which was introduced more than six decades ago.

Subsequently, silicates and (di)methacrylate materials were

investigated. Silicate cements and early composite materials

were suitable only or anterior restorations due to their weak

physical properties, and the silicate cements needed to be

placed in one movement incremental placement was not

an option. Silicate cements had a high ailure rate. Old sili-

cate restorations were assessed or longevity in a 1986 study

and were ound to have an estimated 66% replaced due to

marginal discrepancies and lost llings.1 Early resin-based

composite restorations were an improvement over silicate

cements; however, they were sel-curing and required mix-

ing o a base and a catalyst or curing, resulting in operator

error during mixing and diculties in timely and accurate

placement. In addition, strength, bonding and retention

were poor. Light-cured dimethacrylate composite restora-

tions were introduced in the 1970s.2 By the 1980s, posterior

tooth-colored restorations had been introduced, and thesehave continued to evolve to oer improved physical proper-

ties, user-riendliness and esthetics. Bonding systems and

Figure 1. Introduction o tooth-colored restorations

Acrylic filling

material introduced1944

Investigation of

epoxy filling materials1955

UV-cured resins introduced1973

Introduction of

BisGMA composites1958

Dimethacrylate

based fillings investigated1964

Silicate cements and early

composites dominate1970s

Posterior composites in use1980s

Improved composites

and adhesive systems1990s

Investigation and introduction

of siloranebased material2006-2008

The trend over the last decade has been placement o a

increasing number o posterior composite restorations an

a decreasing number o amalgams. By 1999, at least 39%

direct posterior restorations were composites, compared t

at least 11% in 1990 (in both cases, or the purposes o tren

analysis, conservatively making the assumption that all ama

gam placements estimated in the ADA surveys were posterio

restorations) (Table 1).3

Table 1. Trends in pos terior composite placement

1999Numberplaced

% ageo total

1990Numberplaced

% ageo tota

Posteriorcomposites

46,116,300 39.38% 13,130,200 11.68%


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and light-curing options may have reduced the time required

or composites, more chairside time is still required than with

amalgams. Amalgam is also bactericidal, which helps to re-

duce bacterial colonization and biolm ormation.16,17

Bulk ractures and marginal degradation have been ound

to be the main material actors in the replacement o amal-

gam restorations.18 Bulk racture rates have been ound to be

similar with or without bonding o amalgams (such as withAmalgamBond Plus) in large restorations, although smaller

restorations benet rom bonding.19 Bonded amalgam res-

torations have been ound to oer support o undermined

enamel equal to that o composites, but inerior marginal

adaptation.20 Creep-atigue may be a major actor in marginal

racture o amalgam restorations.21 Amalgam restorations are

subject to expansion, which can result in cuspal stress over

time, depending upon the design o the preparation and/or

the location o the initial lesion. Expansion o amalgam results

rom internal phase changes over time, that must be relieved

to reduce stress it is believed this occurs as a result o creepo the amalgam rom the connes o the restoration and its

subsequent extrusion. On the other hand, development o a

reduced amalgam-tooth margin interace gap size over time

and improved marginal seal may occur due to such creep.22

Amalgam restorations require more tooth preparation

than composites, and careul disposal o the mercury-

containing amalgam is mandatory. The poor esthetic results

provided by amalgams are a major concern or patients, and

amalgam staining o the tooth over time urther compromises

the appearance. Corrosion is also an issue. Poor esthetics with

amalgam is the main reason why patients increasingly preerthe use o direct posterior composites as well as tooth-colored

indirect restorative materials and techniques.

Table 3. Modes o ailure, advantages and disadvantageso amalgams

Modes o Failure

Secondary cariesBulk racture

Marginal degradationExpansion and cuspal stress

Advantages

Ease o useCost-eective Can be bondedBactericidal

Disadvantages

More tooth preparationPoor esthetics

CorrosionMercury disposal

Composite RestorationsMaterial ailures accounted or more replacements o compos-

ites than amalgams in a review o surveys o dentists across the

United States, Scandinavia and the United Kingdom rom the

1980s and 1990s. These ailures included bulk racture, mar-ginal degradation, discoloration and loss o anatomic shape.23

Nonetheless, the main reason or replacement is the same

composite restorations have improved over time, and recen

studies have shown longevity to more closely reach the lon

gevity o amalgams (albeit over a shorter tested time span).

Table 4. Modes o ailure, advantages and disadvantageso composites

Modes o Failure

Secondary cariesBulk ractureMarginal degradation

DiscolorationLoss o anatomic shape and wear

Advantages

Less tooth preparationEective bonding

Excellent estheticsNo expansion over time

Disadvantages

Technique-sensitiveIncreased chairside time

Polymerization shrinkageIncreased bacterial adhesion

While amalgams expand over time, composite restorationare subject to polymerization shrinkage. This is regarded a

the largest problem associated with composite use.24 Polym

erization shrinkage results in stresses that can lead to enam

cracks, marginal degradation and microleakage, and postope

ative sensitivity. Other associated problems include potenti

debonding o the tooth-composite interace.25 Polymerizatio

shrinkage occurs due to the aliation o the resin molecul

with one another and the ormation o chemical bonds th

reduce the materials bulk. Shrinkage and occlusal loadin

o composites result in cuspal defection, which results i

enamel cracks and hypersensitivity. The amount o defectiohas been ound to be greater in larger restorations (MOD

than smaller ones (MOs).26 The amount o shrinkage and re

sulting stresses also varies with the composite lling materi

used.27,28 It is infuenced by the materials fow, chemistry an

curing dynamics, and the size and shape o the preparation

The intensity and duration o light curing have been ound

aect polymerization shrinkage.29 Shrinkage can be reduce

by increasing the amount o ller in composite restorativ

materials, as well as by having pre-polymerized clusters in th

material.30 A recent study by Bouillaguet et al. ound that cu

pal defection (tooth deormation) was statistically similar o

conventional hybrid composites and fowable composites.31

Table 5. Potential eects o polymerization shrinkage

Enamel cracks

Marginal degradation

Microleakage

Postoperative sensitivity

Debonding o tooth-composite interace

Composite restorations generally oer poor antibacteri

properties compared to amalgam. One in vitro study ound


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ew days. It was suggested that this might explain the greater

biolm growth seen on composites compared to amalgams.32

A second study assessed the behavior o three dierent com-

posites (Charisma, Heraeus Kulzer; Dyract, Dentsply; and

Pertac, 3M ESPE) in the presence o three common oral

bacteria (S. mutans, S. oralis and A. naeslundii) or up to 35

days and ound that the bacteria colonized the composites in

a matter o hours and ormed deep biolms. The study alsoound, using scanning electron microscopy, that the poly-

acid modied composite demonstrated surace damage and

roughness.33 Fluoride-releasing composites appear to oer no

benet over nonfuoride composites.34

While polymerization shrinkage in particular and biolm

ormation on the surace o the restoration are disadvantages

o composites compared to amalgams, composites still oer

several advantages over amalgams superior esthetics, no ex-

pansion over time, as well as highly eective bonding systems

or adhesion and retention that enable minimal preparation

and improved tooth structure preservation. From the patientsperspective, the most obvious advantage o composite resto-

rations is esthetics. Improved color stability, luster and stain

resistance have urther improved esthetics as composites have

evolved. Improvements in handling and user-riendliness

continue to be developed since the introduction o a choice in

bonding agents and unit doses, and recent developments are

aimed at overcoming the physical weaknesses o composites.

Recent Composite Material DevelopmentsComposites have been modied to provide greater physical

and biological properties. Biolm-ormation reduction hasbeen tried by modiying composites as well as dentin bonders,

such as by including glutaraldehyde in the dentin bonder or

incorporating an acidic property.35

Recent investigations have included researching novel pos-

terior composite materials with the objective o nding materi-

als that oer reduced polymerization shrinkage and improved

esthetic stability. Silsesquioxane (SSQ)-based nanocomposites

have been ound in in vitro testing to oer reduced polymer-

ization shrinkage and rigidity, oering potential solutions or

stresses and clinical issues associated with shrinkage.36 Simi-

larly, oligomeric thiolene-based materials have been ound in

in vitro testing to exhibit up to 92% less polymerization stress

compared to conventional dimethacrylate-based composites.37

A recently developed composite material based on silorane has

been used and tested clinically and has been ound to result in

reduced polymerization shrinkage and stresses.38

Silorane-based Posterior RestorationsSilorane-based posterior composite material (Filtek LS

Low Shrink Posterior Restorative, 3M ESPE) has been ound

to reduce polymerization shrinkage and associated stresses,39

which would also reduce microleakage and postoperative hy-

persensitivity while demonstrating other physical properties

age is decreased due to the materials chemical composition

and polymerization dynamics. Silorane is derived rom the

combination o siloxane and oxirane and has a compact ring

structure (Figure 4a) that unlinks during polymerization.

When polymerization shrinkage begins, the silorane ring si-

multaneously opens up and compensates or material shrink-

age by expanding its molecular volume and bulking up the

material. Shrinkage has been ound to be less than 1% usingthis material (Figures 4bd).41 An initiator included in the ma-

terial starts the ring-opening process in a controlled manner

and, according to the manuacturer, increases operating time.

Figure 4a. Silorane molecule

Figure 4b. Application o primer

Figure 4c. Silorane-based material in preparation ater separateapplications and curing o both primer and adhesive

Figure 4d. Light-curing o silorane-based material opens silorane

ring structure, reduces shrinkage


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In vitro testing has ound lower polymerization shrinkage

and reduced polymerization stress and tooth deormation

compared to leading methacrylate-based conventional and

fowable composite resin materials.42,43,44 At the same time,

adhesion and shear bond strength have not been compro-

mised, and reduced shrinkage helps preserve the tooth

bond-composite adhesive interaces. Other desired physi-

cal properties, such as compressive and fexural strength,have been ound to be similar to those o leading composite

materials. The silorane-based restorative is a microhybrid

composite that contains ne silane-coated quartz ller

with yttrium fuoride or radiopacity. Bacterial adhesion

o common oral bacteria has been ound to be reduced in

in vitro testing using silorane-based composite, associated

with its hydrophobic chemistry.45 One-year clinical testing

has ound good clinical perormance using this new mate-

rial compared to other posterior composite material.

Case StudyThe case shown here demonstrated the use o posterior com-

posite material (Filtek LS restorative) in the restoration o

a carious upper let rst bicuspid. On examination, a distal

lesion was identied (Figure 5a). A rubber dam was placed

prior to the DO preparation.

Figure 5a. Distal lesion in upper let irst bicuspid

Figure 5b. Rubber dam placement prior to preparation

Figure 5c. Cavity preparation and Composi -Tight matrix and

wedge placed

Ater the matrix and wedge (Composi-Tight, Garriso

Dental) were placed around the distal box, a thin layer o

sel-etching primer (LS System Adhesive Sel-Etch Prime

3M ESPE) was placed on the dentin in the preparation usingmicrobrush or 15 seconds, dispersed using air, then cured o

10 seconds. The primer has a pH o 2.7, produces mild etchin

and increases the hydrophobicity o the area prior to placemen

o the adhesive (LS System Adhesive Bond, 3M ESPE).

Figure 5d. Sel-etching primer placed

Figure 5e. Curing o sel-etching primer

The next step is to place a thin layer o the adhesive in thpreparation over the cured primer, and to light-cure the ad

hesive or 10 seconds beore placing any composite materi


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and the LS System Adhesive must unction as a bridging

mechanism between the primer and the composite. Only the

LS System Adhesive Sel-Etch Primer and Bond are compat-

ible with Filtek LS restorative chemistry (the use o other

primers and adhesives is contraindicated).

The composite shade is selected and injected rst as a 2 mm

increment in the distal box, where it is condensed using a #9

Garrison. The remainder o the void is lled by injecting morecomposite, taking care not to overll the area, and the #9 com-

posite instrument is used to remove fash prior to light-curing

the composite or 20 seconds (note: plasma lights, lasers and

other high-power curing lights should not be used with Filtek

LS restorative). A long working time under operatory light

aids detailed shaping and fash removal prior to curing.

Figure 5. Injecting distal box with Filtek LS restorative

Figure 5g. Condensing composite with #9 Garrison

Figure 5h. Flash being removed rom illed preparation prior to curing

Figure 5i. Cured composite ater removal o matrix and wedge

Figure 5j. High polish created using Jiy polisher

Figure 5k. Final polished restoration

Ater removal o the matrix and wedge, the restoration is

polished using a So-Lex disk (Ultradent) used to remove

any fash and a Jiy Polisher (Ultradent) is then used to cre-

ate a high shine. The nal restoration using the low shrinkage

posterior composite oers excellent esthetics and unction.

Case StudyThe second case here shows replacement o a degrading

and ractured amalgam restoration with a silorane-basedposterior composite. Ater preparation and application o

a liner, the primer and adhesive were separately applied


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injected, condensed and light-cured prior to nishing and

polishing the restoration.

Figure 6a. Fractured, degrading amalgam

Figure 6b. Preparation with liner mesially

Figure 6c. Application o primer

Figure 6d. Application o adhesive ater primer was cured

Figure 6e. Finished restoration

SummaryIncreasingly, composites are being placed in preerence t

amalgams in large part due to patient demands or estheti

as well as the clinical desire to do minimal preparation wher

possible and provide patients with bonded, esthetic restor

tions. Since their introduction, the properties o composithave improved dramatically. Amalgam and composite re

torations both have advantages and disadvantages. Whi

amalgam restorations ail by secondary caries and are subje

to expansion, composite restorations ail by secondary carie

and are subject to shrinkage. Recent developments and inve

tigations o materials are aimed at reducing polymerizatio

shrinkage o composites to increase the longevity o thes

restorations and reduce the potential or ailure.

References1 Qvist V, Thylstrup A, Mjr IA. Restorative treatmen

pattern and longevity o resin restorations in Denmark. AcOdontol Scand. 1986;44(6):351-6.

2 Small BW. Direct resin composites or 2002 and beyonGen Dent. 2002;50(1):30-3.

3 ADA Survey o Services Rendered, 2002.4 Hickel R, Manhart J. Longevity o restorations

posterior teeth and reasons or ailure. J Adhes Den2001;3(1):45-64.

5 Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BAA retrospective clinical study on longevity o postericomposite and amalgam restorations. Dent Mate2007;23(1):2-8. Epub 2006 Jan 18.

6 Manhart J, Chen H, Hamm G, Hickel R. BuonocoMemorial Lecture. Review o the clinical survival o direand indirect restorations in posterior teeth o the permanedentition. Oper Dent. 2004;29(5):481-508.

7 Hickel R, Manhart J, Garca-Godoy F. Clinical results annew developments o direct posterior restorations. AmDent. 2000;13(Spec No):41D-54D.

8 Hickel R, Manhart J. Longevity o restorations posterior teeth and reasons or ailure. J Adhes Den2001;3(1):45-64.

9 Deligeorgi V, Mjr IA, Wilson NH. An overview o reasonor the placement and replacement o restorations. PriDent Care. 2001;8(1):5-11.

10 Mjr IA, Moorhead JE, Dahl JE. Reasons or replacemeo restorations in permanent teeth in general dental practicInt Dent J. 2000;50(6):361-6.

11 Allander L, Birkhed D, Bratthall D. Reasons or replacemeo Class II amalgam restorations in private practice Swe


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12 Kidd EA, Toenetti F, Mjr IA. Secondary caries. Int Dent J. 1992;42(3):127-38.

13 Forss H, Widstrm E. Reasons or restorative therapy andthe longevity o restorations in adults. Acta Odontol Scand.2004;62(2):82-6.

14 Roulet JF. Benets and disadvantages o tooth-colouredalternatives to amalgam. J Dent. 1997;25(6):459-73.

15 Ibid.16 Beyth N, Domb AJ, Weiss EI. An in vitro quantitative

antibacterial analysis o amalgam and composite resins. JDent. 2007;35(3):201-6. Epub 2006 Sep 25.

17 Willershausen B, Callaway A, Ernst CP, Stender E. Theinfuence o oral bacteria on the suraces o resin-baseddental restorative materials: an in vitro study. Int Dent J.1999;49(4):231-9.

18 Qvist V, Thylstrup A, Mjr IA. Restorative treatment patternand longevity o amalgam restorations in Denmark. ActaOdontol Scand. 1986;44(6):343-9.

19 Lindemuth JS, Hagge MS, Broome JS. Eect o restorationsize on racture resistance o bonded amalgam restorations.Oper Dent. 2000;25(3):177-81.

20 Franchi M, Breschi L, Ruggeri O. Cusp racture resistancein composite-amalgam combined restorations. J Dent.

1999;27(1):47-52.21 Williams PT, Hedge GL. Creep-atigue as a possible

cause o dental amalgam margin ailure. J Dent Res.1985;64(3):470-5.

22 Osborne JW. Creep as a mechanism or sealing amalgams.Oper Dent. 2006;31(2):161-4.

23 Deligeorgi V, Mjr IA, Wilson NH. An overview o reasonsor the placement and replacement o restorations. PrimDent Care. 2001;8(1):5-11.

24 Giachetti L, Scaminaci Russo D, Bambi C, GrandiniR. A review o polymerization shrinkage stress: currenttechniques or posterior direct resin restorations. J ContempDent Pract. 2006;7(4):79-88.

25 van Dijken JW. A 6-year clinical evaluation o Class I poly-acid modied resin composite/resin composite laminaterestorations cured with a two-step curing technique. DentMater. 2003;19(5):423-8.

26 Gonzlez-Lpez S, Vilchez Daz MA, de Haro-GasquetF, Ceballos L, de Haro-Muoz C. Cuspal fexure o teethwith composite restorations subjected to occlusal loading. JAdhes Dent. 2007 Feb;9(1):11-5.

27 Rttermann S, Krger S, Raab WH, Janda R. Polymerizationshrinkage and hygroscopic expansion o contemporaryposterior resin-based lling materials: a comparative study.J Dent. 2007;35(10):806-13. Epub 2007 Sep 10.

28 Cadenaro M, Biasotto M, Scuor N, Breschi L, DavidsonCL, Di Lenarda R. Assessment o polymerization

contraction stress o three composite resins. Dent Mater.2008;24(5):681-5. Epub 2007 Aug 31.

29 Visvanathan A, Ilie N, Hickel R, Kunzelmann KH. Theinfuence o curing times and light curing methods on thepolymerization shrinkage stress o a shrinkage-optimizedcomposite with hybrid-type prepolymer llers. Dent Mater.2007;23(7):777-84. Epub 2006 Aug 17.

30 Kleverlaan CJ, Feilzer AJ. Polymerization shrinkage andcontraction stress o dental resin composites. Dent Mater.2005;21(12):1150-7. Epub 2005 Jul 22.

31 Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics o composite polymerization mediates the development o cuspal strain. Dent Mater.2006;22(10):896-902. Epub 2005 Dec 20.

32 Beyth N, Domb AJ, Weiss EI. An in vitro quantitativeantibacterial analysis o amalgam and composite resins. JDent 2007;35(3):201 6 Epub 2006 Sep 25

infuence o oral bacteria on the suraces o resin-baseddental restorative materials: an in vitro study. Int Dent J.1999;49(4):231-9.

34 Imazato S. Antibacterial properties o resin composites anddentin bonding systems. Dent Mater. 2003;19(6):449-57.

35 Ibid.36 Soh MS, Yap AU, Sellinger A. Physicomechanical

evaluation o low-shrinkage dental nanocomposites basedon silsesquioxane cores. Eur J Oral Sci. 2007;115(3):230-8.

37 Carioscia JA, Lu H, Stanbury JW, Bowman CN. Thioleneoligomers as dental restorative materials. Dent Mater.2005;21(12):1137-43. Epub 2005 Jul 25.

38 Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics o composite polymerization mediates the development o cuspal strain. Dent Mate2006;22(10):896-902. Epub 2005 Dec 20.

39 Ilie N, Jelen E, Clementino-Luedemann T, Hickel R. Low-shrinkage composite or dental application. Dent Mater J.2007;26(2):149-55.

40 Ilie N, Hickel R. Silorane-based dental composite: behaviorand abilities. Dent Mater J. 2006;25(3):445-54.

41 Weinmann W, Thalacker C, Guggenberger R. Siloranes indental composites. Dent Mater. 2005 Jan;21(1):68-74.

42 Musanje L, Sakaguchi RL, Ferracane JL et al. Light-source,material and measuring-device eects on contraction stressin composites. IADR 2005;Abstract 0294.

43 Bouillaguet S, Gamba J, Forchelet J, Krejci I, Wataha JC. Dynamics o composite polymerization mediates the development o cuspal strain. Dent Mate2006;22(10):896-902. Epub 2005 Dec 20.

44 Ernst CP, Meyer GR, Klcker K, Willershausen B.Determination o polymerization shrinkage stress bymeans o a photoelastic investigation. Dent Mater.2004;20(4):313-21.

45 Lang R, Groeger G, Rosentritt M, Handel G. Adhesion oS. mutans to dental restorations. CED 2005, abstract 0426.

Author Profile

Robert C. Margeas, DDS, FAGD

Dr. Robert Margeas currently serves as Adjunct

Proessor in the Department o Operative Dentistry

at the University o Iowa College o Dentistry. He is

also the Clinical Director and Instructor at the Center

or Esthetic Excellence, Chicago, IL. Dr. Margeas

has published numerous articles on esthetic dentistry and is a highly

sought ater international lecturer on the subject. His credentials

include board certication by the American Board o Operative Den-

tistry and he is a Fellow o the Academy o General Dentistry (AGD).

Dr. Margeas is a consultant in Oral Health matters or the country o

Canada. He maintains a very successul private practice, with a ocus

on comprehensive esthetic restorative dentistry, in Des Moines, IA.

DisclaimerDr. Margeas has been a speaker on behal o 3M ESPE as well

as other composite manuacturers.

Reader FeedbackWe encourage your comments on this or any PennWell course.For your convenience, an online eedback orm is available at


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Questions

1. Historically, posterior direct restorationsinvolved the use o _________.a. lamentsb. amalgamsc. compositesd. all o the above

2. Old silicate restorations were oundin a 1986 study to be replaced due to_________ and _________.a. expansion, microleakageb. expansion, lost llingsc. marginal discrepancies, lost llingsd. expansion, contraction

3. Posterior tooth-colored restorationshad been introduced _________.a. by the 1960sb. by the 1970sc. by the 1980sd. none o the above

4. By 1999, at least 59% o direct posteriorrestorations were composites.a. Trueb. False

5. The ideal posterior restorative materialshould oer _________.a. ease o placementb. biocompatibilityc. appropriate fexural and compressive

strengthd. all o the above

6. Posterior Class I and II restorationsmust resist _________ and _________.

a. occlusal orces, buccal orcesb. occlusal orces, orces o masticationc. buccal orces, orces o dysphagiad. none o the above

7. Annual ailure rates in a study o directposterior restorations predominantlyplaced since 1990 were _________and _________.a. 2% or amalgams, 4.5% or compositesb. 1% or composites, 3% or amalgamsc. 3% or amalgams, 2.2% or compositesd. none o the above

8. As a result o recent developments, the

ideal restorative material now exists.a. Trueb. False

9. The quality o a restoration and thepatients (preventive) home care areimportant actors in precluding repeatreplacement o restorations.a. Trueb. False

10. The main material actors in thereplacement o amalgam restorationshave been ound to be _________and _________.

a. bulk ractures, marginal degradationb. polymerization shrinkage, microsopic

ractures

11. The longevity o restorations dependsonly on clinical technique.a. Trueb. False

12. Bonded amalgam restorationshave been ound to oer support oundermined enamel equal to that o

composites, with _________.a. superior marginal adaptationb. inerior marginal adaptationc. inerior obtusiond. none o the above

13. Creep-atigue may be a actorin _________.a. marginal racture o amalgam restorationsb. bulk racture o amalgam restorationsc. reducing stress caused by expansion o

amalgam restorationsd. a and c

14. Poor esthetics with amalgam is the

main reason why patients increasinglypreer direct posterior composites overamalgams.a. Trueb. False

15. Reasons or composite restorationailure include _________.a. marginal degradationb. discoloration and loss o anatomic shapec. bulk ractured. all o the above

16. Secondary caries is the single mostcommon reason or the replacemento both amalgam and posteriorcomposite restorations.a. Trueb. False

17. Polymerization shrinkage ocomposites results in stresses that canlead to _________.a. enamel cracksb. postoperative sensitivityc. marginal degradationd. all o the above

18. Polymerization shrinkage occurs dueto the aliation o resin moleculeswith one another and the ormation

o chemical bonds that reduce thematerials bulk.a. Trueb. False

19. Polymerization shrinkage isinfuenced by the _________.a. intensity and duration o light curingb. materials shadec. materials chemistry and curing dynamicsd. a and c

20. A recent study by _________ound that cuspal defection (toothdeormation) was statistically similaror conventional hybrid compositesand fowable composites.a. Bourguignon et al.b Bouillaguet et al

21. Composite restorations generallyoer superior antibacterial propertiescompared to amalgam.a. Trueb. False

22. Fluoride-releasing composites appeato oer substantial benets overnonfuoride composites.a. Trueb. False

23. Currently-available composites oe_________ compared to the earliestcomposites.a. improved color stability and estheticsb. improved physical propertiesc. improved handlingd. all o the above

24. Biolm-ormation reduction oncomposites has been tried by ________a. modiying compositesb. modiying dentin bondersc. including glutaraldehyde in the dentin

bonderd. all o the above

25. Silsesquioxane-based nanocompositeand oligomeric thiolene-basedmaterials have been investigated orreductions in shrinkage.a. Trueb. False

26. Silorane-based posterior compositematerial has been ound to reducepolymerization shrinkage to


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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

For immediate rsuls, go o ww w.nc.co

n clck on h buon tk tss Onln. answrshs cn b fx wh cr cr pyn o(440) 845-3447, (216) 398-7922, or (216) 255-6619.Payment of $59.00 is enclosed.

(Checks and credit cards are accepted.)

If paying by credit card, please complete thefollowing: MC Visa AmEx DiscoverAcct. Number: _______________________________

Exp. Date: _____________________

Charges on your statement will show up as PennWell

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026or fax to: (440) 845-3447

AUTHOR DISCLAIMERr. Margeas has been a speaker on behalf of 3M ESPE as well as other composite manufacturers.

SPONSOR/PROVIDERhis course was made possible through an unrestricted educational grant rom 3M ESPE.o manuacturer or third party has had any input into the development o course content.l content has been derived rom reerences listed, and or the opinions o clinicians. Pleaserect all questions pertaining to PennWell or the administration o this course to Machelealloway 1421 S Sheridan Rd Tulsa OK 74112 or macheleg@pennwell com

INSTRUCTIONSAll questions should have only one answer. Grading o this examination is done

manually. Participants will receive conrmation o passing by receipt o a vericationorm. Verication orms will be mailed within two weeks ater taking an examination.

EDUCATIONAL DISCLAIMERThe opinions o ecacy or perceived value o any products or companies mentionedin this course and expressed herein are those o the author(s) o the course and do notnecessarily refect those o PennWell

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questions correctly) on the

examination will receive a verication orm veriying 4 CE credits. The ormal continuingeducation program o this sponsor is accepted by the AGD or Fellowship/Mastershipcredit. Please contact PennWell or current term o acceptance. Participants are urged tocontact their state dental boards or continuing education requirements. PennWell is aCaliornia Provider. The Caliornia Provider number is 3274. The cost or courses rangesrom $49.00 to $110.00.

RECORD KEEPINGPennWell maintains records o your successul completion o any exam. Please

oces or a copy o your continuing education credits report. This report, wall credits earned to date, will be generated and mailed to you within ve buo receipt.

CANCELLATION/REFUND POLICYAny participant who is not 100% satised with this course can request a ucontacting PennWell in writing

ANSWER SHEET

The Properties and Selection of Posterior Direct Restorations

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home () Ofce ()Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all

information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn

you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Educational Objectives

1. Describe the modes o ailure, advantages and disadvantages o amalgam restorations

2. Describe the modes o ailure, advantages and disadvantages o composite restorations

3. Describe the properties o an ideal restorative material

4 Describe the types o composite materials and recent new materials and their application

Course Evaluation

Please evaluate this course by responding to the ollowing statements, using a scale o Excellent = 5 to Poor = 0.

1. Were the individual course objectives met? Objective #1:YesNo Objective #3:YesNoObjective #2:YesNo Objective #4:YesNo

2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0

3. Please rate your personal mastery o the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the authors grasp o the topic? 5 4 3 2 1 0

6. Please rate the instructors efectiveness. 5 4 3 2 1 0

7. Was the overall administration o the course efective? 5 4 3 2 1 0

8. Do you eel that the reerences were adequate? Yes No

9. Would you participate in a similar program on a diferent topic? Yes No

10. I any o the continuing education questions were unclear or ambiguous, please list them.

___________________________________________________________________

11. Was there any subject matter you ound conusing? Please d escribe.

___________________________________________________________________

___________________________________________________________________

12. What additional continuing dental education topics would you like to see?

___________________________________________________________________

___________________________________________________________________ AGD Code 253


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40/55

3D Case Picture StudyBy Dr. Jeffrey M. Rosenberg, DDS

Temple University School of Dentistry 1982

PrivatePracticeDentistry25yrs.TheDentalHealthCareGroup,PhiladelphiaPA

Fellow-AcademyofGeneralDentistry

DiplomatAmericanAcademyofPainManagement.

MemberAmericanDentalAssociation

MemberAmericanAcademyofCosmeticDentistry

Founder/CEOQuanotechResearch&DevelopmentCompany.Holds3patents.




Mention cod

CS002

Pg.1of5

Pre-Op Radiograph of Proximal Distal Caries:

Figure 1


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Mention cod

CS002

Pg.2of5

Pre-Wedge:

Figure 2

Mark Occlusion and Place Dam:

Figure 3

3D Case Picture Study: Continued...By Dr. Jeffrey M. Rosenberg, DDS


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Mention cod

CS002

Pg.3of5

Conservative Preparation:

Figure 4

Sectional Band and 3D Ring Placed: Note contour of proximolingual-ooclusal of band to compensate forrotated tooth position.

Figure 5



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Mention cod

CS002

Pg.4of5

Tooth Prepared For Adhesion:

Figure 6

Conservative Resin Filled:

Figure 7



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Mention cod

CS002

Pg.5of5

Initial Contour Before Polishing:

Figure 8

Final Restoration:

Figure 9



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Mention cod

CS003

Restoration of a Class II Lesion

By Dr. Robert G. Ritter, DMD

Robert G. Ritter D.M.D. received his dental degree rom The Medical University o South

Carolina College o Dental Medicine in 1994. He has served as the Clinical Director or

IOAD, The Institute or Oral Art and Design in Sarasota, Fl with Master Ceramist Lee Culp

C.D.T. He has been the program leader o PowerPAC or the Pacifc Aesthetic Continuum

(P.A.C.~Live.) He has taught at TEAM dental seminars and 3:1 Foundation hands on programs

helping dentists implement the newest esthetic dentistry into their ofces. Dr. Ritter is also

an Editorial member o REALITY.

Dr.

case presentations & online ce

Documents