Indirect Restoration

Related terms:

Zinc, Dentistry, Cavity, Prosthetics, Composite Materials, Cementation, Dental

Composite, Restorative Material

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Learn more about Indirect Restoration

Reconstructions using alloys and ce-

ramics
S.E.P. Gonçalves, E. Bresciani, in Material-Tissue Interfacial Phenomena, 2017

2.2.4 Cements
The success of indirect restorations relies on correct material selection, and also on
the cement used to bond the restoration to tooth structure (Table 2.4).

Table 2.4. Cements

Material Advantages Disadvan- Indications Contraindica- Commercial

tages tions brand
Zinc phos- •Standard •No •Metallic •Low reten- •Zinc
phate cement
cement•- chemical inlay/onlay•- tive prepa- cement–SS
Longevity•- adhesion•- Metal–ce- rations white•Ce-
High initial Low tensile ramic ment
strength•Ad- strength feldspathic LS-Coltene
equate full
compres- crowns•Met-
sion al
strength•- prefabricat-
Low cost ed or
 customized
post•Partial
fixed
prosthesis
GIC •Friendly •Initial •Metallic •Intraradicu- •Vidrion C –
handling•- solubility•- crowns•Met- lar (SS White)
Fluidity•Ad- Sensibility al–ceramic posts•Par-
hesion to to humidity crowns•- tial fixed
tooth High prosthesis
structure strength in areas of
and metal-free high
metals•Fluo- crowns occlusal
ride release (alumina load
and and
uptake•Ade- zirconia)
quate
translucen-
cy•Ade-
quate
strength•-
Relative
low cost
Resin-modi- •Similar to •Initial •Metallic •Metal-free •Vitremer•-
fied GIC
GIC•Less solubility•- restorations- ceramic Vitrebond
soluble•Im- Sensibility •Metal–ce- restora-
proved to humidity ramic and tions,
compres- high-strengthsusceptible
metal-free crowns (alumina and zirconia)
sive and to
diametral erosion•In-
strength traradicular
post—due
to
hygroscop-
ic
expansion
Resin cements •Versatility•- •Hard •Metal-free •Areas •RelyX
Adequate excess and veneer where light Unicem•-
tensile and removal•- restorations- does not Panavia•Vari-
compres- Sensitive •Metal reach olink
sive adhesive restora- II•Variolink
 strength•- technique•- tions, Veneer•Re-
Low High metal–ce- lyx ART
solubility•- cost•If ramic
Esthetics. restora- crowns in
tions low-reten-
removal is tive
needed prepara-
tions•Glass
posts

GIC, glass ionomer cement.

2.2.4.1 Zinc phosphate

Zinc phosphate cements have been used for decades, with high success rates.
For this reason, they are the standard cement for assessing clinical efficacy.
Although the cement does not offer either covalent or ionic bonding to the tooth,
mechanical retention and high initial strength makes these materials suitable for
cementing indirect restorations. The properties of the zinc phosphate cements may
be influenced by powder/liquid ratio, mixing temperature, and presence of moisture
[32,33].

2.2.4.2 Glass ionomer

Glass ionomer (GI) cements are also an excellent choice for cementing indirect
restorations. The positive properties of the GI cement could be negatively influenced
by changes in powder/liquid ratio and contact with moisture. Excess moisture during
the cementation process leads to marginal cement loss, whereas excessive dry
conditions might result in microcracks [32,33].

2.2.4.3 Resin-modified glass ionomer

These cements are more promising for cementing indirect restorations due to the
incorporation of a light-activated component. They are less soluble and present
higher compressive and tensile strengths, resulting in a lower susceptibility to
erosion during the initial phase of cementation. The adhesive and film thickness
properties are similar to conventional GI cements. Moisture control should, howev-
er, be maintained to avoid marginal losses [32,33].

2.2.4.4 Resin cements

Resin cements were introduced in the 1950s. They form a polymeric matrix that
could eventually fill and seal any gap at the tooth/restoration interface. Resin ce-
mentation helps to dissipate stresses and to reduce microcrack formation at the
inner portion of ceramic restorations [34,35]. Initially, resin cements presented low
adhesion to tooth structure due to substantial polymerization shrinkage. They also
presented high coefficient of thermal expansion and water absorption, which
contributed to greater chance of microleakage. The removal of excess cement was
difficult. The primary advantage of these cements was their low solubility [36].

Resin cements can be classified according to the process of matrix formation and
adhesive technique, ie, matrix formation: self-cured, light cured, and dual, and
adhesive technique: total etch (acid + adhesive + cement), one step (acid/adhesive-
 + cement), and self-etching (cement). Overall, total etch cements show excellent
results and are currently preferred. If the main substrate is dentin, one-step cements
are the most suitable [32]. Self-etching cements can be used for cementing crowns,
both ceramic (alumina and zirconia) and metalloceramic crowns.

> Read full chapter

Precious metal alloys for dental applica-

tions
D.A. Givan, in Precious Metals for Biomedical Applications, 2014

5.4.1 High noble alloys for indirect restoration

The majority of precious metal alloys in dentistry are used for indirect restorations
such as inlays, onlays, crowns and bridges. ‘Full metal’ prosthetics is a common
dental term describing restorations without veneering porcelain for ceramic bond-
ing. A ‘full gold’ crown implies full metal crown with a high content of gold. Typical
examples of the high noble and noble alloys used in full metal and ceramo-metal
restorations including their composition and standard properties are shown in
Tables 5.5 and 5.6. Comprehensive descriptions of alloys used in dentistry are readily
available in the literature (Wataha and Messer, 2004; Moffa, 1983). ‘Full gold’ restora-
tions have long been used in dentistry, taking advantage of the excellent properties
of alloys, making this the standard by which most other restorative systems are
judged.

Table 5.5. Elemental constituents of common precious dental alloys

%Au %Pd %Pt %Ag %Cu %Other

High Noble
Au-Cu-Ag-Pd I 77.00 1.00 13.54 7.95 < 1 Zn, Ir
Au-Cu-Ag-Pd II60.00 3.75 26.70 8.80
 < 1 Zn, In,
Ir
Au-Pt-Pd-Ag 78.00 12.00 6.00 1.20 1 Fe, < 1
In, Sn, Ir
Au-Pd-Ag-In 40.00 37.40 15.00 6 In, 1.5 Ga,
< 1 Ir
Au-Pt-Pd 86.00 1.95 10.00 2 In, < 1 Ir
Noble
Ag-Pd 53.42 38.90 7 Sn, < 1-
 Ga, Ru, Rh
Au-Cu-Ag-Pd III46.00 6.00 39.50 7.49 1 Zn, < 1 Ir
Pd-Ag-Au 6.00 75.00 6.50 6 In, 6 Ga,
< 1 Ru
Pd-Cu-Ga 75.90 10.00 6.5 Ga, 7 In,
< 1 Ru
Pd-Ga-Au 2.00 85.00 10 Ga, 1.1 In,
< 1Ag, Ru
Pd-Ag-Au 6.00 75.00 6.50 6 In, 6 Ga,
< 1 Ru

Data summarized from manufacturer product information.

Table 5.6. Physical and mechanical properties of common precious dental alloys

Melting Density Heat Percent Vicker’s Ultimate Modu- Coeffic

range (g/cc) treat- elonga- hard- tensile lus of ient of
(°C) ment tion ness strength elasticity thermal
(VHN) (MPa) (GPa) expan-
sion ( ×
10–6/°C)
High Noble
Au-Ag-Pd-ln1175–128013.0 c 17 265 586 124 14.2 @
500 °C
Au-Cu-Ag-Pd
920–980
I 15.8 a 44 145 434 82.7 –
Au-Cu-Ag-Pd
900–990
II 14.2 b 45/20 165/245 455/689 –/96.5 –
Au-Pd-Pt-Ag1170–130017.2 c 4 255 689 103.4 14.3 @
500 °C
Au-Pt-Pd 1060–123018.7 c 6 190 586 82.7 14.5 @
500 °C
Noble
Ag-Pd 1190–130010.9 c 25 220 689 115.8 15.1 @
500 °C
Au-Cu-Ag-Pd
900–1000
III 13.1 b 40/20 170/250 448/689 –/103.4 –
Pd-Ag-Au 1130–134011.0 c 35 250 827 131 14.0 @
500 °C
Pd-Cu-Ga 1120–127010.5 c 7 365 1068 131 13.8 @
500 °C
Pd-Ga-Au 1105–133010.9 c 25 285 717 131 13.9 @
500 °C

Heat treatments used prior to mechanical testing: a = Quenched, b =

Quenched/Hardened, c = Porcelain firing cycle.Data summarized from manufac-
turer product information.
High noble alloys can be considered in three groups: Au-Pt, Au-Pd and Au-Ag-Cu
alloys. Au-Pt alloys are commonly used for both full metal and ceramo-metal appli-
cations. This alloy-type was original developed for platinum to serve as a palladium
substitute reducing the alloy cost. The addition of platinum adds resistance to sag-
ging distortion during porcelain firing because of the higher temperature. However,
this also results in a color change where the resultant alloy is white. Addition of small
amounts of iron strengthen the alloy by the formation of an intermetallic phase.
Other strengthening is accomplished by addition of zinc, which forms a dispersed
phase, or with silver, which is soluble with gold for solid solution strengthening. Tin
and indium are present if intended for ceramic bonding to diffuse to the casting
surface to form a surface oxides (Brantley and Laub, 2006).

Au-Pd alloys are a widely used high noble dental casting alloy for ceramo-metal
restorations despite the high cost. Typically, this alloy combination yields a white
alloy and has indium and iridium as oxide formers. Silver is present in some
formulations for solid solution strengthening, and as a class, the Au-Pd alloys have
higher strength, modulus and hardness over the Au-Pt alloys. However, the lower
density defining this alloy class decreases the potential casting efficiency (Powers
and Sakaguchi, 2006).

The final class of high noble alloys contains Au-Ag-Cu. This group is not typically
used for ceramo-metal bonding, as the temperature of the solidus is too low for
porcelain fusion. Therefore, these alloys have been used for many years for full metal
applications. The presence of copper often imparts a reddish-brown hue, although
the chroma is yellow to yellow-red. The alloy is considered to be easy to cast and
solder. Both copper and silver are miscible in gold, resulting in a single-phase alloy;
however, the relative content of gold varies. Lower gold alloys have a much higher
silver content decreasing both casting density and resistance to corrosion. Heat
treatments are used in the dental laboratory to harden or soften this high noble
alloy by solid solution hardening and ordered hardening for specific procedures. For
most Type III and Type IV casting alloys, this hardening is accomplished, altering the
copper content. Type I and Type II alloys typically do not contain enough copper to be
hardened by this mechanism reducing their mechanical resistance to oral stresses
(Powers and Sakaguchi, 2006).

> Read full chapter

Composites for Biomedical Applica-

tions
E. Wintermantel, ... T.N. Goehring, in Encyclopedia of Materials: Science and Tech-
nology, 2001

2 Dental Composites
Auto- and light-cured composites are used for direct and indirect restorations
in dentistry. Initially, composites were bonded to enamel only (Buonocore 1955).
Since bonding to dentin was established, composites became a standard restorative
material in western industrial nations (Lutz et al. 1993). Dental composites generally
comprise three phases: (i) an organic phase, the matrix; (ii) a dispersed phase,
the fillers, e.g., particles or fibers; and (iii) coupling agents, the interfacial phase
(Vanherle and Smith 1985). A concise review covering more than 300 publications in
the field of dental restoration materials, which includes dental composites, is given
by Whitters et al. (1999).

The common monomers are based on diacrylates of the formula M–R–M or

oligoacrylate of formula M–R–M (n) are used. R is the skeleton of the molecule and
M is the methacrylic group –O–CO–C(CH3)=CH2, which includes a double bond
for polymerization. The most important representatives for R are polycarbonate,
polyurethane, and polysiloxane, the latter and most recent also known as ormoceres.

Polymers are built up more or less completely in homo- or co-polymerization,

network formation and interlinking. High conversion rates of double bonds after
polymerization are desired for complete polymerization. Unreacted double bonds
can result in material softening and higher water absorption, which can lead to an
unwanted change of color and, even more important, can cause leaching of toxic
components and degradation of mechanical properties. Activated double bonds with
free radicals on free surfaces are useful for co-polymerization between compos-
ite-layers. The residual monomer content should be kept to a minimum, because
of its allergic and toxicologic potential.

2.1 Filler Systems

The available particulate filler systems can be subdivided according to filler size and
properties:

(a) Microfillers and microfiller-complexes

SiO2-microfillers of sizes ranging from 5 nm to 1000 nm with an average of about

200 nm have the problem of large active free surfaces, which makes their incorpo-
ration into the matrix difficult, limiting possible filler contents in the material. The
technical solution is the use of larger and/or spherical microfillers of 200–300 nm in
diameter, or the use of microfiller complexes. Splintered pre-polymerized microfiller
complexes are made by incorporating microfillers into an organic resin matrix and
milling the cured mixture into particles of diameter near 1 μm. The surface of these
complexes is not very reactive to the matrix. Naturally or artificially agglomerated
microfiller complexes are also 1 μm in diameter and almost purely inorganic. Their
surface might be mechanically retentive. Spherical pre-polymerized complexes are
made by mixing matrix and microfiller, forming spheres of about 1 μm in diameter.
Complex size distributions allow extremely dense packing at convenient viscosity.
Bonding to the matrix is rather weak.

(b) Solid and porous macrofillers

Solid macrofillers are prepared by grinding or crushing of inorganic materials

like quartz, glass, borosilicate, or ceramics to sizes ideally in the range 0.8–2 μm.
Heavy-metal glasses provide clinically desired radioopacity. Porous macrofillers are
prepared by etching or sintering solid fillers of diameter up to 20 μm and 30 μm.
Traditional macrofillers can be silanated or impregnated with monomer.

(c) Fibrous fillers

Besides glass and silica fibers, various fiber systems, e.g., carbon fibers, silicon
nitride, all being in the range of 5–10 μm in diameter and 60–100 μm in length,
are being investigated. Silicon nitride whiskers (diameter 0.4 μm, length 5 μm) have
been introduced, which are roughened with fused silica to enhance the interfacial
bonding to the polymeric matrix. Due to their high aspect ratio fibrous filler induce
anisotropy in the composite and rather high residual stresses in the cured resin.

Also in dental composites, the interfacial properties are of key importance for the
long-term performance of the material. A good interfacial phase can be achieved
by silanating or silicating of the inorganic fillers or by co-polymerization between
the matrix and combined organic and inorganic fillers. All current versions of inter-
face adhesion are still sensitive to chemical disintegration. Additionally, mechanical
interlocking is attempted with natural and artificial agglomerated microfiller com-
plexes and splintered pre-polymerized microfiller complexes. The highest degree of
interlocking is achieved in porous macrofillers.

2.2 Classification and Clinical Performance of Dental Composites

The types of fillers previously described represent the backbone of the classification
of composites (Lutz and Phillips 1983).

(a) Homogeneous microfilled composites

Homogeneous microfilled composites are constructed from a matrix and micro-
fillers of a diameter of 400 nm. They feature low filler content, have a low elastic
modulus, and are not radioopaque. Their surface is smooth, easy to polish, and
shiny. Wear of the restoration and of the antagonistic teeth is low. However, it is
deformable and has a low form stability.

(b) Inhomogeneous microfilled composites

Inhomogeneous microfilled composites are constructed from a matrix, microfillers,

and microfiller complexes. They feature moderate filler content, have a low elastic
modulus, and their radioopacity is acceptable. Their surface is also smooth, easy
to polish, and shiny. Wear of the restoration and the antagonists is low, but it is
deformable and has a low form stability. This confines their use to non stress-bearing
restorations.

(c) Traditional composites

Traditional composites are constructed from a matrix and solid and/or porous
fillers. They feature high filler content and high hardness, their Young’s modulus
is dentin-like, and their radioopacity is good. Depending on the degree of milling,
the surface is rough to nearly smooth. Depending on size and distribution of the
fillers, wear of the restoration and antagonists is low to high.

(d) Hybrid composites

Hybrid composites are constructed from a matrix, microfillers, traditional fillers, and
rarely from glass fibers. Depending on the size of the traditional fillers, these can
be divided into coarse and fine hybrid composites. They are always highly filled,
their Young’s modulus is dentin-like, and the radioopacity is good. In coarse hybrid
composites the traditional fillers are about 3–5 μm and their characteristics are
comparable to those of traditional composites. In fine hybrid composites the size
of the traditional fillers is 2 μm. The surface is nearly smooth, acceptable to polish,
and wear of the restoration and the antagonists can be equal to those of human
enamel. The stability of the restoration is good.

2.3 Prospects
Dental composites are hydrophobic in relation to human dental tissues. To achieve
bonding to enamel and dentin, a surface pretreatment is necessary. They are still
sensitive to humidity during processing in the oral cavity. The shrinkage of mod-
ern dental composite materials amounts to 2–3 vol.%. During polymerization the
shrinkage forces can reach 3–7 MPa with peaks of 30 MPa. For these reasons, an
advanced operative technique is necessary. A shrinkage-free composite with a good
wetting ability is highly desired to simplify the operative technique and is the object
of ongoing research.

Glass and Kevlar continuous fiber-reinforced thermoplastics are being developed

for specific applications, e.g., prosthodontic frameworks and orthodontic retainers,
however, these still require considerable improvement of the interfacial stability. To
explore possible enhancement of the mechanical properties of resin composites,
strong electric fields are investigated inducing an alignment of filler particles and,
thus, increasing the mechanical properties of filler-reinforced systems.

The hydrolytic sensitivity of the available systems compromising mechanical

strength and fracture toughness remains an unsolved problem that has to be
approached.

> Read full chapter

Volume 1
Li Wu Zheng, ... Ru Qing Yu, in Encyclopedia of Biomedical Engineering, 2019

Cements
Cements are used in dentistry for various purposes. Some are for cavity lining or
bases; others are used as luting agents to lute an indirect restoration to a prepared
tooth.

Basically, a liner is a thin layer of material (0.5 mm) placed on a prepared tooth to

protect it, whereas a base acts as the dentin to withstand the forces applying on it.
It is thicker than the liner and also protects the pulp from thermal and chemical
stimulates and galvanic shock. Thus a liner or a base should have good thermally
and electrically insulating properties, and not contain irritants. It should set rapidly,
exhibit enough strength to resist fracture, and not move or flow easily while the
filling material is being placed. Ideally, linings should be radiopaque so that any
caries around the filling material can be seen. The liner or base must not interfere
with the setting of the filling material or affect the properties of it.

Luting cements share similar properties with linings except for the setting time.
There should be enough setting time before the final seating of the restoration. In
addition, it should be strong enough to assist retention and have low solubility.

Commonly used cements are as follows:

•
Zinc oxide/eugenol cements are mixtures of zinc oxide (powder) and eugenol•
(liquid). They are mainly used as a lining or base under amalgam restorations
and as temporary luting cements or filling materials.
Zinc–phosphate cements have zinc oxide as the major component of the •
powder and phosphoric acid solution as the liquid. They are widely used
as luting cements and can also be used as linings with adjustment of the
powder/liquid ratio to change the consistency. However, they may have an
irritant effect as a liner in deep cavities.
Calcium hydroxide cements have a low strength and high solubility, and there-
fore are usually used as linings beneath the base of zinc phosphate cements or
other base materials, and are not suitable for luting. Nevertheless, this material
does have other properties that make it crucial to dentistry such as the fact that
it can be used for pulp capping and root canal sealing.

> Read full chapter

Dental Prostheses
Jing Zhao, Xinzhi Wang, in Advanced Ceramics for Dentistry, 2014

3.2.2 Inlays and Onlays

As mentioned before, direct fillings might not be the best choice for Class IV/VI
lesions or for the other lesions with more extensive defects. Indirect restorations,
like inlays and onlays, are recommended instead.

Inlay is a restoration that fits within the anatomic contours of the clinical crown of
a tooth. Onlay is useful for restoring a more extensively damaged tooth, especially
where cuspal fracture has occurred but there is still enough remaining tooth struc-
ture to work with. A schematic diagram showing inlay and onlay can be found in
Figure 3.4. Commonly used processing methods are casting, milling, and pressing
of the industrial prefabricated blocks. Thereby, the individual and precise geometry
of restorations are easy to obtain.

Figure 3.4. Diagram showing indirect intracoronal restorations.

Due to their ability to restore convex structures, inlays and onlays are also preferred
in the following four cases: a serious tooth defect with bad proximal relation, a
food impaction needing proximal contact recovery, an abutment with caries, or
an attachment with an inlay as retainer. An example of the use of inlay-supported
prostheses is shown in Figure 3.5. The ideal inlay preparation design was proposed
by Thompson et al.6

Figure 3.5. The missing second premolar and the defective abutments (a) were
restored by an inlay-supported prosthesis (b).

There are some limitations, however.7 Compared to direct fillings, more tooth
preparation is needed for inlays/onlays. The tooth preparation must allow enough
retention of restorations and the tooth structure must be thick enough to resist
fracture. This means that young permanent or deciduous teeth, which have high
pulp horn, are contraindications. Moreover, neither a small and superficial occlusal
surface defect nor a proximal and labial surface defect with an uninvolved incisal
angle is suitable for restoration by inlays/onlays. Inlays only replace lost tooth
structure and do not protect the remaining part of the tooth. Therefore, an inlay
cannot be used in cases where there is a serious defect; poor resistance or retention
shape; or where there are high requirements for aesthetics and long-term stability.

A lot of different materials are available for the fabrication of inlays and onlays,
comprising composite resins, metal alloys, and ceramics.8 The material selection
always depends on the individual application. Ceramic inlays and onlays have be-
come popular in the anterior area due to their excellent natural appearance and
biocompatibility. On the contrary, the application of metal fillings is limited to
the posterior area. Ceramic onlays, especially mesial-occlusal-distal (MOD) onlays,
should be fabricated carefully because without generous occlusal thickness, these
restorations are susceptible to fracture.9

> Read full chapter

Incorporation of nanoparticles in glass

ionomer cements: Clinical applica-
tions, properties, and future perspec-
tives
Abdul Samad Khan, ... Ihtesham Ur Rehman, in Nanobiomaterials in Clinical Den-
tistry (Second Edition), 2019

5.5 Clinical Applications of Nanoionomers in Glass Ionomer

Cement
GIC is known to be used in a wide range of applications in dentistry. Amongst
these, GIC is believed to be used in minimally invasive dentistry which has revo-
lutionized the approaches in restorative dentistry, pediatric dentistry, orthodontics,
and cosmetic dentistry. Incorporation of nanoparticles into the conventional GIC
brings modifications into the cement and due to the alterations in its composition,
it becomes highly useful in the field of dentistry. GIC can be used as bonding, luting,
lining, sealing, or in the restoration of anterior class III and V, and deciduous teeth
restorations. GIC has also been used for cementation of crowns and bridges, and
in orthodontic appliances. GIC can be used as a material for atraumatic restorative
therapy, and in restorations of teeth through the sandwich technique. GIC can be
used as bone cements as well due to their high bioactivity [79,80]. Moreover, it can
be used as cermets (restorative material used near the gingival margin of cavitated
tooth surface), as fissure sealants, in matrix techniques, dentine surface treatment,
core buildup, and temporary cementation of indirect restorations [66].

However, there is no known ideal material available that fills the perfections of all
dental applications. GIC is though tooth-colored, it releases fluoride, and adheres
well to the tooth. It still carries a number of setbacks such as inherent opacity, poor
wear resistance, brittleness, and hence, should not be subjected to heavy occlusal
load, sensitivity to moisture right after placement, and inadequate surface properties
[81]. Hence, the modification and incorporation of nanoparticles in conventional
GIC overcomes GIC’s poor mechanical and physical properties. Nanotechnology
uses the systems where the particle size ranges from 1 to 100 nm. Consequently,
for the improvement in mechanical and physical properties of GIC, nanotechnology
plays a major role in opening up a wide range of useful applications. As has been
mentioned earlier, a top-down approach has been used for the incorporation of
nanoparticles in GIC, that is, by removing the bulk material, such as replacing the
material to apatities, metal oxides, or silicate glasses [82].

Nanoparticles in glass powder of GIC give high mechanical strength to it because of

the wider particle size distribution of particles. Subsequently, the empty spaces are
equipped between the glass ionomer particles and strengthen the composition of
the material. The physical properties and bonding mechanism is improved by their
incorporation. The clinical indications of nanofillers are small Class I restorations,
Class III and V restorations, core build-ups, transitional restorations, improved wear
resistance, and excellent aesthetics [83].

Scientific reports suggest that secondary caries, that is, tooth cavitation after the
initial restoration and fracture of restoration are the major challenges in restorative
dentistry. Therefore, consistent release of fluoride ions, which has the ability to save
enamel and dentin for caries, is essential for any restoration. Resin-modified glass
ionomers with the release of fluoride ions and adhesion to tooth structure can fulfil
this requirement. In the same way, the biologically compatible material known as
HA, which is a major component of bone tissue and enamel, has had its usefulness as
a dental restorative material evaluated in several studies. Mu et al. [84] investigated
nanohydroxyapatite(nano-HAP)-added GIC, and through various experiments the
results showed that nano-HAP had the mineralizing potential has a good filling
property with no microleakage and also can be used as a liner for prevention.

Likewise, there are several other nanoparticles that have been incorporated to check
the functions and improvements in the material as shown in Fig. 5.7. It is also
clinically indicated for use in small Class I restorations, Class III and V restora-
tions, core buildups, sandwich restorations, and pediatric dentistry. In a nutshell,
nanofiller components of nanoionomers enhance the physical, mechanical, and
adhesive properties of GIC. The use of GIC has been extended in the last decade and
on combination with nanotechnology its range of applications has been widened
tremendously resulting in it being considered as the future material of choice.
Figure 5.7. Clinical applications of nanomodified GIC RMGICs, nano-HAP/FAP. GIC,
Glass ionomer cement; RMGICs, resin-modified glass ionomer cements; HAP/FAP,
hydroxyapatite/fluorapatite.

> Read full chapter

Biocompatibility of fiber-reinforced
composites for dental applications
A. Ballo, T. Närhi, in Biocompatibility of Dental Biomaterials, 2017

3.3 Clinical applications of fiber-reinforced composites in den-

tistry
The use of fiber-reinforced technology in dentistry dates back to the 1960s. Early
attempts to adapt the technology for dental applications involved the incorporation
of reinforcing fibers into polymethyl methacrylate (PMMA) denture base resin to
reduce the incidence of fracture. Once resin-based composites became established
as a restorative material in dentistry, attempts were made to use fiber reinforcement
technology to provide sufficient strength for use as a fixed bridge.Currently,
FRC materials have many applications in dental practice (Table 3.1). The potential
advantages, as well as disadvantages of this group of materials, are listed in Table
3.2. The development of FRCs with a new type of resin system, combined with
a better understanding of the design principles governing device construction,
has led to the use of FRCs in a variety of disciplines and applications: removable
prosthodontics, fixed prosthodontics, restorative dentistry, periodontology, ortho-
dontics, and in repairs of fractured porcelain veneers (Vallittu, 2013). In general, the
clinical uses of FRC fall into two categories: direct and indirect restorations. FRCs
can be used to produce definitive fixed dental prostheses (FDPs) (Kangasniemi et
al., 2003). Based on current clinical results, it is reasonable to expect FRC FDPs to
attain a longevity of 10 years (Kangasniemi et al., 2003). FDPs made from FRC are
classified in several different categories: surface-retained FDPs, inlay/onlay retained
FDPs, full coverage crown and hybrid FPDs. FRC FDPs were usually reinforced with
preimpregnated long fibers that are oriented mesio-distally in the main framework
of an FRC FPD, and a hybrid particulate composite veneer. Since the substructure
occupied a sufficiently large volume, the FDPs could serve for up to 4 or more
years (Freilich et al., 2002a,b,c). According to a published clinical report, FRC FDPs
could serve for 5–10 years (Feinman and Smidt, 1997). Moreover, FRCs have become
a choice of material for immediate tooth replacement because of the convenience
of this technique, which can be carried out at the dentist’s office (Kermanshah and
Motevasselian, 2010).

Table 3.1. Clinical application of fiber-reinforced composites in dentistry

Clinical application
●Reinforced direct composite restoration●Root canal posts●Single indirect restora-
tions●Inlay●Onlay●Partial/full veneer crowns●Teeth splinting●Periodontal splint-
ing●Post trauma splints●Fixed dental prostheses (anterior and posterior)●Sim-
ple cantilever●Fixed-fixed●Implant supported●Immediate replacement transitional
and long-term provisional bridges●Reinforced or repairing dentures●Fixed ortho-
dontic retainers

Table 3.2. Advantages and disadvantages of fiber-reinforced composites in dentistry

Advantages Disadvantages
●Metal-free restoration●Single-visit im- ●Potential wear or chipping of the overly-
mediate tooth replacements●Lower ing composite especially in patients with
treatment costs●Suitable for transitional parafunction●May lack sufficient rigid-
and long-term provisional restoration●- ity for long span fixed dental prostheses-
Easily repaired●Good esthetics●Suitable ●Careful moisture control is required for
for young patients (developing dentition) adhesive technique●Uncertain longevity
and old adults (time saving)●Simple pro- in comparison to traditional techniques
duction in laboratory without the need for
waxing, investing and casting●Very con-
servative with minimal or no tooth prepa-
ration●Wear to opposing teeth much re-
duced in comparison to traditional met-
al-ceramic restorations

The use of FRCs in root canal posts to anchor cores and crowns has rapidly increased
(Mannocci et al., 2005a,b,1999; Vallittu, 2013). FRC posts consist of a resin matrix, in
which structural reinforced carbon fibers or quartz/glass fibers are embedded. Black
carbon FRC posts are poorly suited for combination with translucent full ceramic
restoration due to their unfavorable optical properties in comparison with the nearly
tooth-colored quartz fiber and glass FRC posts. Glass FRCs can be used in root
canals as both prefabricated solid posts and individually formed posts (Vallittu, 2013).
Individually formed posts are made from nonpolymerized fiber-resin prepregs,
typically consisting of glass fibers and light-curing matrix.

FRCs can also be used for periodontal splinting and stabilization of tooth mobility
(Miller, 1993; Strassler et al., 1999; Strassler and Serio, 2007). There is no doubt
that splinting does reduce tooth mobility while the splint is in place (Laudenbach
et al., 1977). In the last decade, research supports the use of periodontal splinting
as recommended therapy to stabilize those teeth to improve long-term prognosis
(Wheeler et al., 1994; McGuire and Nunn, 1996; Bernal et al., 2002). In a long-term
clinical evaluation of splinting over a period of 48–96 months, FRCs have been
found to be very successful (Strassler et al., 2001). The success of these splints
can be attributed to close adaptation of the fiber to the tooth surface combined
with cross-stabilization of the mobile teeth by placing adhesive composite resin on
the facial surfaces (Strassler et al., 2003; Strassler and Brown, 2001). Splinting of
traumatized teeth with FRCs and adhesive composite resin has also been reported
(Yildirim et al., 2006; Rudo, 2000). In order to stabilize the traumatized tooth or
teeth or for tooth stabilization after transplantation, the tooth must be allowed to
have some movement which can be achieved with the use of FRCs (Trope, 1995;
McDonald and Strassler, 1999).

> Read full chapter

Dental pulp capping nanocomposites

Priyanka Rani, ... Amit Kumar Nayak, in Applications of Nanocomposite Materials in
Dentistry, 2019

4.4 Composites: An insight

A composite material, also known as composition material, is a material synthesized
by the treatment of two or more constituent materials having particularly diverse
chemical and physical characteristics that, after combination, result in the formation
of a material with properties different from the discrete components [9, 40]. Direct
composite restorations for posterior teeth have achieved more recognition during
the past few years, and are presently thought of as the foremost choice of treatment
[21]. Now, indirect restorations can also use composite materials in accordance with
their ability to persevere teeth in the face of occlusal loads, and for use in adhesive
cementations. The composite materials for pulp capping are comprised of three
constituents [21, 41]: a resin matrix (organic part), fillers (inorganic constituent), and
various coupling materials. The classification of various composites used in dentistry
on the basis of matrix components is presented in Table 4.1.

Table 4.1. Classification of various composites used in dentistry on the basis of matrix
components

Matrix Chemical system Group Examples

Conventional matrix Pure methacrylate Hybrid composite Tetric EvoCeram
Nanocomposite Filtek supreme XT
Inorganic matrix Inorganic polyconden- Ormocers AdmiraDefinite
sate
Acid modified Polar groups Compomers Dyract eXtra
methacrylate
Ring opening epoxide Cationic polymeriza- Siloranes Filtek Silorane
tion

Strong chemical bonding with the tooth structure, and their esthetic properties,
are the two major reasons that the resin-based composite materials are well-known
dental restorative materials [41]. These self-possessed resin matrices often contain
bis-GMA (bisphenol A glycol dimethacrylate), inorganic glass fillers, and silane
as coupling agents. The resin phase of composite materials is made of organic
monomers, such as triethylene glycol dimethacrylate (TEGDMA), pyromellitic glyc-
erol dimethacrylate (PMGDMA), urethane dimethacrylate (UDMA), bisphenol A-gly-
cidyl methacrylate (Bis-GMA), its ethoxylated version (BisEMA), and 2-hydroxyethyl
methacrylate (HEMA) [41]. Moreover, these materials can be classified into four
different groups on the basis of the matrix nature: (1) methacrylates, (2) ormocers,
(3) compomers, and (4) silorane-based.

4.4.1 Methacrylates
The most well-known materials in the dental composite material group are the
methacrylates hybrid composites [42]. The composition of methacrylates (MA) and
different varieties of fillers, coupled with silane (SinH2n + 2), are used in dentistry.
The fillers are composed of quartz, silica, ceramics, and other oxides. The enhanced
filler content results in polymerization shrinkage and water absorption, while the
linear expansion coefficient is minimized [43]. These composition materials contain
dissimilar filler particles, for example, agglomerated nanoclusters (prepolymerized
and finely milled); glass or silica particles (larger, submicron-sized), and individual
nanoranged particles. Examples of these materials include

Filtek supreme XTE and Filtek Z250 XT (3 M ESPE; St. Paul, Minnesota)

IPS Empress Direct and Tetric Evo Ceram (Ivoclar Vivadent; Amherst, New York)

Enamel Plus HRi (Micerium; Avegno (GE), Italy

Miris 2 and Synergy D6 (Coltene/Whaledent; Cuyahoga Falls, Ohio)

Herculite Ultra and Premise (Kerr; Orange, California)

4.4.2 Ormocers
Basically there are three constituents of ormocers: organic and inorganic fragments,
and the polysiloxanes. A change in a fraction of these components may alter the
optical, mechanical, and thermal attributes of the matter.

(i) The organic polymers are responsible for polarity, the capacity to cross link,
hardness, and optical attributes.
(ii) The glass and ceramic constituents (inorganic components) influence chemi-
cal stabilities and thermal expansion.
(iii) The polysiloxanes direct the interface characteristics, elasticity, and processing.

4.4.3 Compomers
The compomers category includes the chemical composition of composites and
glass ionomers. This material is an amended composite of polyacrylic-/polycar-
boxylic acid. The point of compomers is to combine the beneficial properties of
glass ionomers by using composite technology. However, this objective has been
only moderately achieved, owing to low fluoride release. Compomers are widely
acceptable for revamp in the ephemeral dentition because of their opposition to
moderate abrasion [44, 45]. In cervical restorations, compomer restorations behave
more positively, as compared with resin-modified glass ionomers, but slightly more
negatively than hybrid composites [46].

4.4.4 Silorane
Silorane-based composites originate from siloxanes and oxirans. A spectrum of
properties, such as less marginal discoloration, lower shrinkage, and longer resis-
tance to fading is the main attraction of this product category. There is a sharp
difference between silorane monomer rings and chain-monomers of hybrid and
fused composites. The siloxanes are accountable for increased hydrophobicity of
the material, such as reduced water absorption and exogenous discoloration. The
oxirane nucleus influences the physical properties, along with low polymerization
shrinkage (< 1% shrinkage), as compared with other composites (> 1.5% shrinkage),
which offer low microleakage and better marginal integrity. Siloranes are poly-
merized by a critical mass of cations, followed by the cationic reaction, which is
responsible for the highest ambient light stability, in contrast to methaycrylates and
crosslink via radicals. The photo initiating system is placed on three constituents:
a light absorbing camphor nucleus (camphorquinone), an electron donor group
(such as, amine), and an iodonium salt. The camphor component is activated, and
proceeds with the electron rich fragment, which decomposes the iodonium salt, and
hence an acidic cation is formed during the mechanism. Now, the process of oxirane
ring opening initiates in the course of the polymerization process, and this opening
compensates for the polymerization progression of contraction. The fillers present
 in Filtek Silorane, the only example of silorane accessible at the moment, consist
of radiopaque yttrium fluoride and 0.1–2.0 μm ranged quartz (silica) particles [47].
The siloranes’ low shrinkage promotes a reduced contraction stress [48–50]. The
silorane-based filling material was found to possess properties of minimum water
absorption and reduced water solubility [51]. The reduced adhesion of streptococci
was distinguished on the facet of silorane makeover, possibly due to its hydrophobic
properties, the distinguished tendency of nonpolar substances to cluster in aqueous
solution and eliminate water molecules [52].

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