125 session 2

Introduction to restorative dentistry

Restorative dentistry
- Simple vs complex
- Simple
o Prevention and management of lesions and defect in teeth that require treatment that
is essentially confined within part of the crown of the tooth
- Complex
o Restoration of the entire crown of the tooth
o Replacement of missing teeth by means of
 Implants, fixed and removal prostheses

Simple restorative dentistry

- General goals
o Prevent and minimize the occurrence of lesions and defects on teeth
o Manage these conservatively when they occur
- Specific goals
o Respond professionally to patient needs and request
o Optimize the longevity of teeth and restorations
o Minimize the loss of tooth structure
o Maintain the continued viability of the dental pulp
o Harmonize with existing occlusal function
o Integrate the balance between aesthetics and longevity
Lesions and defects of teeth
- Caries
- Abrasion (마모): worst filing to do, as dentine keeps moving.
o Repetitive grinding or scrubbing of teeth with hard surface
- Attrition/wear: teeth grinding
- Erosion (부식): due to acid such as eating disorder.
- Tooth fracture
- Restoration fracture
- Pulpal involvement

Brief introduction to principal components of restorative dentistry

- Lesions and defects of tooth
- The dentist’s role
o Two-way communication: as well as “doing”
- the patient’s role
o Accepting responsibility
- Prepared cavities
o Remove the lesion
o Minimize recurrence
o According to material type

- Types of intra-coronal restorations

o Diet: built up in the mouth
 Glass-ionomer
  Composite resin
 Dental amalgam
o Indirect: built up in a laboratory
 ceramic
- Pulp involvement
- Complex restorative dentistry
Several examples of “complex” restorative dentistry
- Excessive tooth wear consequences management options
- Missing teeth causes options

Introduction to restorative materials

Typical steps in placement restoration
- Cavity preparation
- Lining (if required- need “conditioning”)
- Bonding (if required- need “etching”)
- Restorative material: placed & finished

Range of material used in restorative dentistry

Materials are used for

- Lining (and conditioning on the top of GI)
- Boning (and etching)
- Fissure sealing or fissure filing
- Restoration
- Luting (cementing)

Direct and indirect restoration

- Direct restoration
o Placed in “unset” form directly into the prepared cavity
- Indirect restorations
o After cavity is prepared, an “impression” is made. This is “poured” up in plaster/
stone in laboratory where the restoration is made.
o Restoration is returned to dentist who uses a “luting agent” to lute (or “cement”) it
into the cavity on a later appointment

Restorative materials placed “directly”

- Sealants
o Tooth-coloured materials: glass ionomer (GI- includes GIC and RMGI)
o Composite resin (CR)
- Metallic
o Dental amalgam
Restorative materials for “indirect” fabrication
- Typically, used for crowns: complete coverage of coronal tooth
- Veneers (glass): thin coverage of part of tooth in aesthetic region
- Onlays: partly “extra-coronal”
- Inlays: “intra-coronal”

- Tooth coloured
o CR (high viscosity)
o Ceramic (porcelain): including CAD-CAM
- Metallic: cast gold alloy
- Metal-ceramic: porcelain (outside) fused to metal (core)
Simple restorative dentistry makes uses of restorative materials that
- Are placed directly into the tooth in an “unset” condition and
- Subsequently “set” to a hardened condition within the prepared cavity

Key properties of restorative material for direct placement

Setting shrinkage
Glass ionomers 2-3 % take time
Composite resins 1.6-2.4%. 80% of them set in
20 sec Contraction, polymerise (중합하다)
Flowable resins 3-6.5%
amalgam 0-0.01%

Thermal dimensional changes: expand and contraction with temperature

Approx. value
Tooth structure 11.4
Glass ionomer cement 10
Amalgam 25
Composite resin 30-40
Flowable resins 60-80
Fissure sealants 80+
Adhesive resins 80-120
Gold /porcelain 10 to 12

Rigidity- stiffness
Measured by “modulus of elasticity” Not strong at all.
Enamel 82
Amalgam 55
Dentine 18 so flexible.
CR hybrid blends 6-14 Not strong at all.
CR microfilled 4-6 Not strong at all.
Flowables 4-6
GI 4 to 10 breaks easily
Strength: of limited clinical importance, provided material is set
Enamel 380
Dentine 300
Amalgam 390
Composite R 280 very weak

Radiopactiy
- Measured by comparison with thicknesses of aluminium
- It is currently though that the “optimum” radiopacity of a restorative material is
o A little more radio-dense than enamel
- Many CRs achieve this
o Amalgam and some older CRs are very radio-dense

Other properties of clinical relevance

- Aesthetics: CR superior to GI, amalgam poor
- Colour stability: GI and CR
- Wear resistance (material's ability to resist material loss by some mechanical action)
o GI and CR
- Water sorption (the weight gained when a dental material is immersed in water)
o CR and GI
- Degradation in oral environment: bonding agents
- Corrosion: amalgam

Introduction to dental biomaterials

Understand the definition and the principal function of the dental biomaterials

- Basic structure: enamel rods

- Highly organized prismatic structure
Basic structure: tubules
- Mineral phase: 70 wt%
- Organic matrix: 20 wt%
- Water: 10 wt%

Understand the basic physical, chemical and mechanical properties expected for the dental
restorative biomaterials

What are the properties expected of an ideal restorative material

- Biocompatibility
- Match the natural appearance of tooth structure and other visible tissue
- Exhibit mechanical properties similar to those of tooth enamel, dentin, and other
tissues
- Bone permanently to tooth structure or bone
- Be capable of initiating tissue repair or the regeneration of missing or damaged tissues
(SMART Materials)

Why do dental students and dentists need to understand the principles of dental materials science

Understand the limitation of the current restorative materials in the oral environment
Metal
- Advantage
o Favourable mechanical properties
- Disadvantages CAH
o Poor aesthetic
o Undergo corrosion
o Dense and heavy
Ceramics
- Advantages
o Aesthetic quality
o Biocompatibility
o High compressive strength
- Disadvantages
o Brittle
o Hard to make

Polymers (DENTURE)
- Advantages
o Aesthetic
o Easy to manipulate
- Disadvantages
o Prone to hydrolysis(분해)
o May degrade with time and temperature

Classifications of dental material

Preventive Restorative material Auxiliary

material

Fissue sealant Direct Indirect Temporary Acid-etching

Glass ionomer Impression
Liners Resin composite Gold Temporary cements materials
Bases Alloys Orthodontics wires, and Casting investment
Cements amalgam Ceramics Acrylic resins Gympsum cast
Acrylic resin Dental waxes
Used for temporary crown Acrylic resins
Bleaching trays
Acrylic resins
Finishing/
polishing abrasives

What are the current limitations of biomaterials

 - Fracture
- Microleakage
- Wear
- Distortion
- Colour change
- debonding

Be able to translate the theory information to the clinical scenario.

What is the implication of materials failure in dentistry

The primary reason for failure is due to

- material deficiencies
- design features
- dentist errors
- technician error
- patient factors

- microstructure, mechanical properties and composition are vey important in choosing the
material for the patient.

what are mechanical properties

 - all mechanical properties are measures of the resistance of a material to deformation, crack
growth, or fracture under an applied force

forces vs stress
- force is an external agent capable of changing the state of rest or motion of a particular
body. It has a magnitude and a direction
o unit: Kgf or N
- stress is the measure of an external force acting over the cross
sectional area of an object
o unit: N/mm2= MPa
- all bodies are deformable and those external forces generate internal
stresses

Types of stress: TCS

- tension: fracture 99% occurs due to tension
- compression

- shear: parallel force

deformation vs strain

- deformation is a measure of changing of the shape of a body due to the external forces
applied on it
- strain is the ratio between the deformation and the original length

Elastic vs plastic deformation

- Elastic deformation: temporary shape change that is self-reversing after the load is
removed
- Plastic deformation: shape change that is permanent after the load is removed.

Stress X strain relationship: Elastic region (elasticity)

- In the elastic region if stress is removed, the material will return back to its initial
diemnsions
- “elastic modulus” (young’s modulus) is measured by the slope of the elastic region of
the stress- strain graph

Elastic modulus
- Elastic modulus describes the relative stiffness or rigidity of a material
 - The higher the elastic modulus, the higher the stiffness of the material.

STRESS X
Strain

relationship: Plastic region (Plasticity)

- Plastic region (plasticity) is the region of permanent deformation
- Stress and strain are no longer proportional
- If stress is removed in the plastic region, the material will not return to its original
dimension and will have a permanent deformation

Stress strain relationship

- Proportional limit: the highest stress at which stress and strain are still proportional
- Ultimate strength: the maximum stress that the material can withstand.
- Elongation: the total amount that the object stretches before fracturing
- Resilience: (under the green straight line) is the energy absorbed by a material in elastic
deformation
- Calculated by the graph area under the elastic region.
- Toughness ( the whole area under green and red lines)
o Total energy needed to crack propagation which is related to material content
o ability to resist against crack propagation (균열전파)
o Calculated by the area under the entire stress-strain curve, or the total amount of
energy, which a material can absorb up to the fracture point.
Fracture toughness

Dentin has higher toughness (has higher ability to resist from crack propagation)
Enamel has higher stregnth (has less ability to resist from crackpropagation but can
withstand higher load)

Stress X strain relationship

- Ductility
o for an applied tensile stress the maximum degree of plastic or permanent
extension is a measure of the ductility e.g. metal
- Brittleness
o the relative inability of a material to sustain plastic deformation before fracture
o glass (too tough, breaks easily)
o very small plastic deformation
o fracture without any sign (like enamel)

Hardness
- Hardness is related to the material ability to resist scratching. It is a property used to predict
the wear resistance of a material and its ability to abrade opposing dental structures
Stress concentration

- Area or point of significantly higher stress

- Sharp changes in shape and properties: interface of bonded structures with different
mechanical and thermal properties
- Internal or surface flaws: porosity, grinding roughness and machining damage. Air
bubbles in composite resin or porcelain veneer
- Ways to minimise stress concentration
o Finely polishing the surface of materials to reduce the depth of the flaw
o The design of the materials should result in very gradual shape change rather than
abruptly. Make your cavities rounded to reduce the stress concentration
o The materials must closely match in the elastic modulus, and coefficients of
expansion of the tooth structure

Fatigue
 - Failure of materials at stresses below the ultimate strength due to cycles of loading
and unloading

BASICS OF BONDING

Glass Ionomer (GI) to Enamel and dentine

Prepare tooth for bonding

- Apply dentine conditioner (10% PolyAcrylic acid) for 20 sec
- Agitate with microbrush
o (to remove debris and keep fresh PAA contacting surface)

- Effect
o (Removes Smear Layer)
o Cleans surface for chemical adhesion
o Activates surface by supplying a polyalkenoic acid. (similar to what is present in
Gl)

- Apply Glass ionomer

o (containing alumino-silicate glass particles and polyalkenoic acid) to the cleaned,
activated surface.

- Result
o lon-exchange chemical adhesion (Ca, PO, Carboxylates) of glass ionomer

Resin to Enamel. (eg. For sealing using Flowable CR)

(If debris present on surface, eg in fissure, remove with brush (LS) and abrasive gel etc)

- Apply Etchant
o 37% orthophosphoric acid gel (H3POa) --- for 30 sec
o Use microbrush
o Agitate, using microbrush, to remove sludge of Ca, POs etc from tooth.
o Result: Preferentially etched enamel surface (ready for bonding)
- Rinse with water of Triple Syringe for 20 sec
o Sludge has to be rinsed off (goes into solution) --- can’t be blasted off
- Dry for 10 sec --- Air of Triple syringe
 - Result: Chalky, non-glossy appearance of etched enamel
- Apply
o Bonding agent (Adhesive)
o use Preben or microbrush
o Thin --- using air of Triple syringe
o Wait for 15 sec --- for adhesive to infiltrate into etched surface

- Cure 30 sec
- Result: Micromechanical retention of bonding agent into preferentially etched enamel/
surface
- Apply --- Sealant (unfilled resin) or CR --- which bond chemically.to the cured Bonding
agent.

Abrasion lesion restoration

Create abrasion lesion

- Hold tooh in hands
- Use HS handpiece + football shaped diamond
- Place substantial groove on root surface adjacent to CEJ
o Buccal surface
o Approx. 2.5-3mm wide
o Length 4.5 mm

How to matrix 5 filling

- Lie tooth on wax with buccal surface showing
- Select suitable side on loid matrix
- Need to extend at least 1mm beyond margin

Prepare surface of lesions

- Use PAA denture conditioner 10% PAA
- Apply with microbrush 15-20 sec
- Rinse 10 sec
- Dry! Important chemically
o Dry only sufficiently to remove surface moisture

Prepare Fiji IX- a GIe (auto setting)

- Depress capsule on bench
- Place in mixer
- Set for 10 sec
- Mix: material in setting don’t waste time

Fit capsule into despenser

Desense into cavity
- Aim imto have excess
- Remove only gross excess
- Use flat palastic (wipe on tissue)
 - Gently ease matrix into position
- Do not attempt to move or remove ( will result in voids)
- Ensure matrix extend beyond edge/ margin of lesion
- At 8 min approx. preclinically remove matrix
- Immediately coat surface thinkly with G coat- use microbruch (to protect surface from air)

Remove any gross excess only

- Ain to leave excess contour present to finish of next appt
- Use spoon excavator (large)
- Do not use rotatory instrument at this stage for GIC
- Wupe away (microbrush) any debris
- Apply another thin coat of G coat and cure

At this stage: some slight x3 remains

Do NOT rinse contour to be exactly correct
Want slightly XS
Why?
- To optimise: bonding of GI To county walls
- Adaption to margins
- Smoothness of furnished surface (when surfnished at next appt)
- Wanting for acid-vased reaction to got o completion by 23/21
- Next appoint: contour/ smooth

Fissure sealant
- Clean fissure system: pumice paste _bristle brush at very low speed
- Islocate with rubber dam
- Etch 30 sec with microbrush confine to near fissure system
- Agiate etchant with microbrush 37% H3PO4
- Wash 20 esc: water than water air/air spray
- Dry 10 sec: desiccate enamel to provide chalky matte appearance
- Apply tin bonding agent ( resin single bond)
- Use prebam brush
- DO NOT CURE : leave 15 sec, air thin
- This is rare occasion when we don’t use the bonding resin)
Apply sealant
- Squeeze small amount on to pad
- Cover with orange box (prevent setting)
- Use period probes
- Apply small amount from tip of probe into fissure and slightly onto adjacent line
- Avoid trapping air
- Wipe perio probes clean (use tissue)
- Cure 40 sec protect eyes use to orange paadle
Remove rubber dam
- Check occlusion: use articulating paper
- Remove spot ON SEALANT (high spot) use low speed handpiece + large roeemd beem.
INTRODUCTION TO CAVITY DESIGN

The ATMS of restoring teeth are to!

- Remove caries and weakened/defective tooth structure
- Restore aesthetics and/or function
- Maximize longevity of the restoration and tooth

In the restoration of most defects in teeth (eg caused by caries, trauma, erosion,
abrasion) it necessary to:

- Remove caries
- Manage the pulpal implications of the restorative procedures (mindful of the accumulated
effect of pulpal irritants)
- Prepare a cavity form that optimizes the longevity of the tooth and ensuing restoration
- Place the restorative material

The Design of the Prepared Cavity is influenced by:

- Site and extent of the caries/defect

- Properties and handling characteristics of the restorative material to be used

Over many years, it has been found that a number of prepared cavity designs are useful as a BASIS
FOR ADAPTING TO THE PARTICULAR CLINICAL SITUATION.

These cavity designs continue to be modified in order to reflect: Place the restorative material

The Design of the Prepared Cavity is influenced by:

 - Site and extent of the caries/defect
- Properties and handling characteristics of the restorative material to be used

Over many years, it has been found that a number of prepared cavity designs are useful as
a BASIS FOR ADAPTING TO THE PARTICULAR CLINICAL SITUATION.

These cavity designs continue to be modified in order to reflect:

- Changing concepts for the conservation of tooth structure n
- Research into the clinical performance of restorations and cavity design
- Advances in instrumentation for restorative work
- Development of new materials and clinical techniques

The most widely used designs for prepared cavities are BASED on cavity forms first developed by
G.V. Black in the early 1900s (and modified regularly since his time).

The designs developed by Black were based on his “Classification of carious lesions” which
identified the sites at which “carious lesions first develop”, For example, the

Class I prepared cavity form is the basic cavity design for the restoration of a Class carious lesion,

This basic cavity design is modified clinically according to such factors as the extent
of the caries and the type of restorative material/technique to be used.

Black's original "Classification of Carious Lesions" is:

Class I lesions in PITS and FISSURES in

- occlusal surfaces
- occlusal #3 of buccal or lingual surfaces of
posterior teeth
- palatal surface of surface of upper anterior
teeth

Class II lesions on SMOOTH SURFACES

- proximal surfaces of posterior teeth

Class III lesions. on SMOOTH SURFACES

- proximal surfaces of anterior teeth

Class 1V lesions on SMOOTH SURFACES

- proximal surfaces of anterior teeth with
involvement of incisal corner
Class V lesions on SMOOTH SURFACES
- gingival 1/3 of buccal and lingual surfaces of anterior and posterior teeth

In recent years, a Class VI lesion has been described. This lesion has generally referred to a lesion
on:

- the incisal edge of anterior teeth (not involving the incisal corner of the tooth) and
- to pits in the cusp tip areas of posterior teeth,

Aetiologically, these lesions are commonly associated initially NOT with caries (as was the case
with Black’s classification) but with a combination of attrition and erosion.

PRINCIPLES OF CAVITY DESIGN

In treating a carious lesion or some other defect, a cavity must usually be prepared in the tooth.
This prepared cavity always has a certain degree of precision and its definite form is related
particularly to the site and extent of the carious lesion and the physical properties and handling
characteristics of the restorative material.

Inevitably, cavity preparation further weakens a tooth. It is therefore important during cavity
preparation to be mindful not only of the longevity of the restoration but also of the continued
integrity of the remaining tooth structure.

Design principles for prepared cavities

To produce, most safety and conservatively, a cavity preparation with definite form, a systematised
procedure has been developed. As a general guide, aspects (“steps”) of the design of a prepared
cavity tend (commonly, but not always) to be carried out in the following order/

- Access
- Outline form
- Resistance form
- Retention form
- Convenience form
- Removal of any remaining carious dentine
- Completion of the cavo-surface angle
- Cavity debridement

It is apparent that, during cavity preparation, it is impossible to complete certain stages without
influencing subsequent ones. For example, an incorrect point of access will often alter the finished
outline of the cavity; during establishment of outline form it is essential to keep in mind the
requirements of resistance form, retention form, convenience form and the completion of the
finished cavo-surface angle. However, COMPLETION of one step out of sequence often results in
much waste of time, loss of further tooth structure X and greater likelihood of unnecessary pulpal
involvement.

These steps or principles were originally based on those of G.V. Black (1906) but have been
modified and amended due to an increased understanding of the nature of the carious process, the
benefits of fluoride and dietary control, reduced caries rates and the use of new restorative
materials.

These principles should be applied to the preparation of all cavities when removing caries
and replacing lost tooth structure.
The final cavity should reflect the need for removal of all infected and softened carious tooth
structure AND the fulfilment of mechanical requirements of the restorative material itself.

The ultimate goal is to remove diseased and defective tissue, to replace lost tooth structure
and to restore the tooth to its optimal function and, ideally, aesthetics.
Access

For the preparation of each cavity, a decision must be made as to the position on the surface
which will provide entry into the tooth for the intended cavity preparation.

Factors to be considered in deciding upon the most appropriate point of ACCESS are

- most conservative (eg. a posterior proximal surface lesion is usually approached from the

occlusal)

- most aesthetically acceptable (eg. a palatal approach is used, almost always, to restore
anterior proximal surfaces)
o unless there’s already access to cavities due to size ALWAYS to from palatal

- most direct to the location of the caries (eg. occlusal and buccal surface lesions) for class 5.
o when pt gingiva is soaked from coke and acid and we already have direction access
to the cavities.
 - most simple route to the dentine (eg. on the occlusal surface, access is usually made into
the deepest part of the fissure system)

Outline form

This determines the area of tooth surface to be included in the prepared cavity.

Factors influencing this are

- Anatomy of the surface (eg. the depth and extent of the fissure system will influence the
outline on occlusal surface - especially of molar teeth)

- Extent of peripheral caries --- this refers to caries in the enamel, at the enamel-dentine
junction, and up to approx 0.5 mm into the dentine along cavity walls. Removal of
peripheral caries influences outline form.
o deep caries will not be removed until all peripheral caries will be removed to have a
good access and open to the deep caries.
o Research-based (and, to some extent, empirically-based) findings with respect
to the location of the cavity margin --- examples:

 margins on the occlusal surface are not located in deep fissures; and,
proximal margins of posterior teeth are not located in contact with the
adjacent tooth
 Convenience form --- at times, the outline needs to be extended/widened for
reasons of convenience form
 Removal of already fractured enamel and, possibly, unsupported enamel
—-- careful removal of this enamel will slightly increase the outline form

 Considerations such as specific needs for a smooth outline, conservation of

tooth structure, a path of withdrawal for an inlay/onlay cavity (O 4),
diverging walls of a proximal cavity (O 5), etc.

 there are several factors that are influencing outline form of cavities
Resistance form and Retention form

The resistance and retention forms of a cavity arc closely related and were described together by
G.V. Black. For the sake of clarity, however, each is usually discussed separately. It is worth
remembering that the establishment of resistance form may contribute significantly to the retention
form of a cavity and that the retentive requirements of a cavity preparation may necessitate
modification to the features of resistance form.

RESISTANCE FORM

On occasions, the requirements of resistance and retention form demand some modification to the
outline form of the cavity. eg. diverging the buccal and lingual walls of a Class II cavity, to provide
retention, will also increase the outline form.

Specifically, the goals of Resistance form are to prevent fracture of the restoration or
remaining tooth structure (by the forces of mastication).

Resistance form is concerned with

- Depth of the cavity towards the pulp --- "Ideally", for most restorations, the depth towards
the pulp will be approx. 0.5 mm into dentine. ( to see if we included caries at enamel-
deintine junction + also it allows to provide good thickness of the restoration material)
It has been found, empirically, that this allows reliable removal of peripheral caries (eg.
at enamel-dentine junction), and provides adequate thickness/bulk of restorative
material
o To prevent/ minimising fracture

Consider:
- Concern for the pulp
- Convenience form --- if a lining (like GIC: seals dentine tubes) is to be placed, there must
be adequate depth for both lining and restorative material(12mm).
- Requirements of adequate bulk --- for amalgam and composite resin, pulpal wall must be at
least 0.5 mm into dentine.
- Retentive features must often be in dentine
Internal form of the cavity
- Internal walls and line angles are not specifically sharpened.
- This reduces the likelihood of cusp fracture.

Protection of remaining tooth structure

- at times, resistance form requires that other cusps on the tooth are reduced and "protected"
to prevent subsequent untoward fracture.

Cavo-surface angle (angle between surface and cavity wall)

- this is the angle between the surface of the tooth and the cavity wall.

The opposing tooth

- Frequently, "plunger" opposing cusps should be reduced to prevent further complications
for the tooth being restored. The most common "plunger" cusps are the mesio-palatal
cusps of upper 6s and 7s.
RETENSION FORM

Specifically, the goal of Retention form is to prevent displacement of the restoration from the
cavity (by force) in all possible directions.

Examples of providing retention form are:

- Occlusal "lock", for two surface Class II restorations (amalgam)

- Divergence, of the buccal and lingual walls, towards the gingival on the proximal surface
of cavities for Class II restorations. (amalgam)

- Placement of a gingival groove, where indicated, in the gingival wall of cavities for some
Class V, III, IV and IT restorations. (GI, resin) only B-L

- At times, retention form will be partly provided by aspects of resistance form.

Convenience form

This part of the cavity preparation ensures that the cavity is of suitable size and shape to enable
proper placement of the restoration.

This is often overlooked in order to “conserve” tooth structure.

Adequate convenience form ensures:

- preparation without damage to adjacent teeth
- access to remove caries optimally
- opportunity to place the matrix correctly
- optimal placement of linings, etchants, bonding agents and restorative material.

Removal of any remaining carious dentine

This critical part of the cavity preparation refers to the removal of remaining caries --- that is, of
caries deeper than approx 0.5mm into the dentine beyond the enamel-dentine junction (which
defined the extent of “peripheral caries”, which contributed to the determination of Outline form).

By this stage of cavity preparation, the preceding five steps have usually been completed.
Occasionally, this step de already been removed.

Caries remaining at this stage occurs on the pulpal surface of the cavity (pulpal or axial walls) at a
depth greater than “ideal” (0.5mm into dentine).

Clinically, in an extensive deep dentine lesion, the carious dentine exhibits different
textures/moisture contents (but not all lesions exhibit all of these).
From the enamel-dentine junction towards the pulp (as detected with a spoon excavator):

- Stage 1 Soft, mushy

- Stage 2 Wet leathery (peels away in denatured chunks)

- Stage 3 Drier, large flakes of dentine

o Stage 4 Fairly hard and dry, small flakes/powder/chips of dentine

- Stage 5 Relatively normal dentine

The clinically important term, "affected" dentine implies dentine that has been involved in the
caries process that, so far, has been relatively uninfected. This has been found to be commonly
associated with the clinical signs in "Stage 4" --- fairly hard, dry, powder/small flakes of dentine.

This will be discussed in more detail later in the course.

Completion of the cavo-surface angle

The cavo-surface angle is located at what is the cavity margin and refers to the angle between the
cavity wall and the tooth surface.

The cavo-surface angle is often finished optimally using rotary or hand instruments during the
establishment of outline, resistance or retention forms. If further change is-required (for example,
to accommodate requirements that are specific to the material being used to restore the tooth),
completion is carried out at this stage.

Cavity debridement(괴사 조직 제거)

Accumulated loose debris is removed from the prepared tooth.

CLINICAL STEPS IN RESTORING A TOOTH

1. Establish REQUIRED OUTLINE AT OPTIMUM (“ideal”) DEPTH

- “Optimum” depth is 0.5 mm into dentine (only rare exceptions to this)

- Required outline includes
- removal of peripheral caries --- caries that is:
o in enamel
o at EDJ :
o up to 0.5 mm, approx, into dentine
- extension
o free of adjacent tooth contact,
o beyond deep pit/fissure
o as required, to satisfy Resistance and Retention forms

2. Satisfy RETENTION, RESISTANCE, CONVENIENCE REQUIREMENTS.

3. Remove DEEPER CARIES

- Normally, remove ALL cariously involved dentine.

- At times, it may be appropriate to apply the principles of Indirect Pulp Therapy.
- Work in from periphery of deep caries towards the deepest patt.
- Use -“large” round bur (low speed). excavator

- Use tactile senses to determine the "likely" condition of remaining cariously involved
dentine, if the cavity is getting very deep/close to the pulp.

4. Complete cavity

- Adjustments, as required, to cavity margins

- Debride the cavity

5. Pulp therapy, Lining/Seal tubules, (as indicated)

- Spot application of therapeutic agent (if required)

o Ledermix Cement or “Calcium hydroxide” material.
o Seal in the therapeutic agent with GI or GI lining.
- Lining, if required.

6. Matrix

- Select, Trim, Apply (as appropriate).

7. Bonding procedures, if required.

8. Place Restorative material.

GLASS IONOMERS

DEFINITIONS AND TERMINOLOGY

The following terminology is consistent with current understanding of the chemistry and the
properties of the materials and has received general endorsement (McLean et al., 1994).

Glass ionomer --- GI

This refers to a material in which an acid—base reaction contributes to a setting process which
takes place within a clinically acceptable time (that is, a few minutes). There are two types of glass
ionomers --- GIC and RMGI.

Glass ionomer cements—GIC

This term is reserved exclusively for a material consisting of an acid-decomposable glass and
a water soluble acid that sets by an “acid-base” neutralisation reaction.

Resin-modified glass ionomers -- RMGI

These materials consist of the components of a glass ionomer, as described previously,

modified by the inclusion of a small quantity of additional resin — mostly HEMA (hydroxyethyl
methacrylate). They set partly by an acid—base reaction and partly by a photochemical
polymerisation (light is required). In addition, in some materials, the polymerisation of the resin
component may involve a chemical initiator mechanism.

General description --- GIC

Glass ionomer materials contain water, both bound in and free, the system therefore being
regarded as water based.
In the early stages of setting, the material can take up extra water and, as the newly forming
calcium polyacrylate chains will be highly soluble, it is possible that they may wash out and be
lost. Also, during the setting period, if the material is left exposed to air (therefore, GI coat
need to be applied right after the matrix is removed to protect it from the air), water may be
lost rapidly and physical properties will be downgraded.

Types of setting (or “cure”) in RMGI

A modification to the setting process includes a light activation mechanism using HEMA, photo-
initiators and traces of other resins and reactive chemicals.

The first stages of the chemistry, the acid—base reaction between the glass and the
polyalkenoic acid, will still take place as described above. The polyacrylate chain formation will
continue in the same fashion but at a slower rate under a protective umbrella of set resins. In the
long term, any cement not set by light activation will set by autocure and achieve the same
physical properties.
Finally, in the presence of an incorporated 'oxidation—reduction' reaction, remaining unset
resins will also “self-cure”, ensuring that the total restoration is cured throughout.
Glass powder
fuck Queen great singer
The mixture is fused, quenched, ground and sieved to obtain a particle size of 4-50 µm,
depending upon the proposed clinical application for each material.
Generally, finer particles are used for luting cements and for some lining cements; coarser
particles are used for restorative materials because these are likely to provide better translucency.
FQGS

Reactivity

The reactivity of the glass is controlled by the fusion temperature and the heat history. Materials
formed with higher temperature glasses, set more quickly and reactivity can be varied by modifying
the annealing process.
Radiopacity
Radiopacity can be achieved by the incorporation of barium, strontium or lanthanum.

Fluoride content

Fluoride is an essential component because of its effect on the temperature of glass fusion, working
characteristics and ultimate physical properties.
Its presence promotes remineralisation in surrounding tooth structure. The fluoride content of
the glass can be varied and a moderate fluoride reduction will enhance translucency without
unduly reducing the remineralisation potential.

Resin-modified GI powder
In some of the resin-modified materials in which the setting mechanism is initiated by light, part of the
light-activated catalyst is incorporated in the powder, thus making the powder susceptible to
ambient light.

Poly(alkenoic acid) liquid

A typical liquid for a glass ionomer contains a 40-55% solution of 2 : 1 acrylic-acid–itaconic-acid

copolymer in water or, alternatively, a copolymer of maleic acid and acrylic acid.
The use of copolymers improves storage compared with the aqueous solution of polyacrylic acid
used in the original glass ionomers, which tended to become more viscous relatively quickly. It is
also possible to incorporate variations in the liquid.

Tartaric acid

This assists the extraction of ions from the glass powder, retains the working time and sharpens
the setting time. It also allows the use of lower fluoride-containing glasses, which are more
translucent, thereby improving the aesthetic characteristics of the set cement.
Liquid for resin-modified systems

In resin-modified systems the liquid contains a 15-25% resin component in the form of HEMA
together with <1% polymerisable groups and a photoinitiator.
After initial light-activation of the resin, the usual acid-base chemical reaction continues with the final
maturation being achieved over approximately the same time span as for the auto-cure materials.

Depending upon the powder : liquid ratio used in the mix, there will be a residual HEMA content in
the set cement ranging from 4.5% where there is a high powder content, to possibly 15% in a thinly
mixed lining cement. Because HEMA is hydrophilic, there is potential for water uptake and
subsequent degradation with release of HEMA into the surrounding dentine.
Some manufacturers incorporate further trace chemicals into the liquid, to create an oxidation—
reduction reaction thereby enhancing the set in any remaining unset resins and reducing the
susceptibility to water uptake.

SETTING REACTIONS

For GICs --- acid-base reaction only

The setting mechanism involves the dissolution of the surface of the glass particles with the release of
calcium and aluminium ions, which then combine with the polyacrylic acid (conditioner) to
form calcium and aluminium polyacrylate chains. The calcium chains form first, producing an
early set, but are fragile and highly soluble in water. The aluminium chains form thereafter; these
are strong and insoluble and provide the major physical properties of the set restoration.

The essential setting mechanism is an acid—base reaction between the poly(alkenoic acid)
liquid and the glass, which leads to a diffusion-based adhesion between the glass particles and
the matrix. Calcium and aluminium ions are released by proton attack on the surface of the glass
particles; these ions ultimately cross-link the poly-acid chains into a network that remains
porous, thus allowing free passage of both hydroxyl and fluoride ions out of and back into the
cement matrix.

Stage 1— dissolution(용해)
The surface layer of the glass particles is attacked by the polyacid to produce a diffusion-based
adhesion between the glass particles and the matrix. Approximately 20-30% of the glass is
decomposed and ions (including calcium, aluminium and fluoride ions) arc released, leading to
formation of a cement sol.

Stage 2 — precipitation of salts; gelation and hardening

During this stage, calcium and aluminium ions bind to polyanions via the carboxylate groups.
The initial clinical set is achieved by cross-linking of the more readily available calcium ions. This
reaction is relatively rapid, usually forming a clinically 'hard' surface within 4-10 minutes from
the start of mixing. Maturation occurs over the next 24 hours as the less mobile aluminium ions
become bound within the cement matrix, leading to more rigid cross-linking between the
poly(alkenoic acid) chains. Fluoride and phosphate ions form insoluble salts and complexes. Sodium
ions contribute to the formation of an orthosilicic acid on the surface of the particles and, as the pH rises,
this converts to a silica gel which assists in binding the powder to the matrix.

Stage 3— hydration of salts

Associated with the maturation phase is a progressive hydration of the matrix salts, leading to a
sharp improvement in the physical properties.

Setting reaction of the resin-modified glass ionomers

In theory, two distinct types of curing/setting reactions occur in this type of glass ionomer
· Acid—base neutralisation reaction.
· Free-radical methacrylate cure.

The relationship between these two reactions may take one of two forms.
· Formation of two separate matrices OR Multiple cross-linking

Cross-linking of the polymer chains may then take place through one or more of the following
reactions.
· Acid—base reaction.
· Light-cure mechanism (in the presence of a photo-initiator such as camphorquinone.
· Oxidation—reduction reaction (resin “autocure” mechanism).

STRUCTURE OF THE SET GLASS IONOMER

The set material contains particles of unreacted glass, surrounded and supported by a siliceous
hydrogel, embedded in a polysalt matrix of cross-linked polyalkenoic acid molecules rich in
calcium (or strontium) and aluminium ions. This framework can be regarded as porous to the extent
that ions with small dimensions (such as hydroxyl and fluoride ions) are free to move through the
material.

- In the early stages, the calcium polyacrylate chains can take up further water and be washed
out and lost.
- In the later stage, the cement is exposed to air it may lose some of the unbound water and
dehydrate, losing both physical integrity and strength.

DISPENSING AND MIXING

Glass ionomers are available in two forms.

 Encapsulated, for mechanical mixing.
 Powder and liquid supplied separately, for hand mixing.
Capsules
Capsule acts as a syringe for the placement of the mixed material into the cavity.

Hand Mixing
Hand mixing of all types of cements is possible, although great care is required when dispensing the
powder to avoid under-dispensing or over-dispensing.

WATER BALANCE

Successful management of the water balance required as approximately 24% of the set glass
ionomer is water.

Susceptibility to water uptake and loss

 GICs

Susceptible to WATER IN --- for 24 hours after placement

Susceptible to WATER OUT --- for 6 months

 Fast-set GICs and RMGIs

Susceptible to WATER IN --- for 5 minutes

Susceptible to WATER OUT --- for 2 weeks

The cement is most susceptible to moisture contamination during stage 2.

Slow-set autocure cements

- early water contamination will result in

o loss of calcium polyacrylate chains
o absorption of water
o loss of translucency
o loss of physical properties,
- dehydration will result in
o cracking and fissuring of the cement,
o softening of the surface
o loss of the matrix-forming ions.

- ensure water stability for the next 24 hours. This can best be achieved using a single-
component, low viscosity, light-activated bonding agent.
- Final contouring should be delayed for at least 24 hours and must always be carried out
under air–water spray to avoid dehydration.

Fast-set GICs

- resistant to water uptake at about 4 minutes after mixing.

- The main limitation is that they lack translucency,
 - remain susceptible to water loss
o cracking, for about 2 weeks after placement.
o the cement is likely to be exposed to air for more than 5 minutes it should be
sealed with a resin bonding agent as discussed above.
Resin-modified glass ionomers

- Modifications to allow for light initiation of the glass ionomers mean “fast-setting” with
immediate resistance to water uptake and some protection against water loss.
- The addition of 5-15% HEMA, as well as light-activation catalysts, offers protection to the
calcium polyaciylate chains against dissolution in water while the usual acid—base reaction
continues.
- Research favours final contouring and smoothing to take place at the next appointment.

PLACEMENT OF THE GLASS IONOMER

Conditioning the tooth surface

Logically, adhesion will take place best in a clean environment. Various agents have been
proposed:
i) to remove some or all of the smear layer and
ii) possibly, to pre-activate the enamel or dentine.

Low molecular weight acids such as citric acid or hydrogen peroxide were recommended initially.

Polyacrylic acid
The most desirable material has proven to be a low concentration polyacrylic acid applied for a brief
period and then washed thoroughly from the tooth surface.
- Any remaining residue will not interfere with the setting reaction.
- will lower the surface energy of the tooth and thus increase the wettability of the surface and
encourage adaptation of the material to the tooth.
- will not demineralise the tooth surface unduly or penetrate the dentine tubules.

Placement routine
The following routine is recommended for the placement of any glass ionomer material.
· Prepare the cavity surface
· Clean the tooth surface, where access permits, using a slurry of plain pumice and water.
· Apply a liberal coat of 10% polyacrylic acid for 10 seconds.
· Wash vigorously with air/water spray for 10 seconds.
· Dry lightly, to remove all surface moisture, but do not dehydrate the surface.

Delayed Finishing of the Placed Glass Ionomer Restoration

AT THE NEXT APPOINTMENT.

This allows time for the acid-base reaction (in both GIC and RMGI) to go to completion.
As a result, the following characteristics are achieved (by Delayed Finishing)
1. Optimum adaptation / seal --- the acid-base reaction is principally responsible for this.
2. Surface smoothness --- surface texture --- again the acid-base reaction that forms the main
“matrix” of the GI has gone to completion.
3. Translucency --- Aesthetics ---- GIs finished in the next appointment show superior aesthetics by
being more translucent. There is also less “crazing” (fine scratching) on the surface.
PROPERTIES

Biocompatibility

Resistance to plaque
- It has been shown that bacterial plaque fails to thrive on the surface of glass—ionomer;
unable to thrive in the presence of fluoride.

Pulp response to glass ionomer

- The pulpal response to glass ionomer materials is favourable.
- The freshly mixed material is very acid with the pH ranging between 0.9 and 1.6. However,
dentine is an excellent buffer and even thin layers of dentine remaining between the
restoration and the pulp are sufficient to prevent a reduction of pH within the pulp tissue.
- A mild inflammatory response has been noted the inflammation will resolve within 10-20 days.

Post-restoration / Post-insertion Sensitivity after application of GI

- glass ionomer can be the cause of postinsertion sensitivity when used as a luting agent
under full crowns.
- However, it has been shown that the results are the same when using zinc phosphate
cement.
- Do not remove the smear layer by conditioning or scrubbing the dentine in an attempt to
develop adhesion. In order to ensure seal of dentinal tubules, some have suggested
the use of a mineralising solution or a resin-dentine bond at the time of cavity
preparation and before recording the impression.

Solubility and disintegration

- the surface of glass ionomer can be damaged in the presence of a low pH, such as occurs
during the application of some topical fluoride solutions.
- Caution should be exercised when using these solutions near glass ionomers, particularly
in hostile environments such as those found in patients with xerostomia.

Fluoride release

- The large release of fluoride ions during the first few days after placement declines
ra pidly during the first week and stabilises after 2-3 months.
- The long-term rate of release, although substantially lower, appears to be sufficient
to ensure protection from caries for the surrounding tooth structure as well as adjacent
teeth.
- The fluoride ions arise initially from the surface of the glass powder and are held in
the siliceous hydrogel matrix. This means that a continuing exchange of fluoride ions
can occur, depending on the gradient of fluoride available in the mouth at any given
time.
 - Fluoride release normally takes place from the matrix into the adjacent environment but,
in the presence of a high fluoride concentration in the mouth (such as during a
professional application of fluoride as a preventive measure), fluoride ions can be taken
up into the cement again.
Glass ionomer restorative materials can, therefore, be regarded as a fluoride
reservoir.

No longer “Fluoride release” --- Now “acid/caries resistance”

Dimensional change
- show a volumetric setting contraction of approximately 3%, which develops slowly
through the setting process.
- the shrinkage is somewhat controlled and, in view of the time taken for the setting reaction,
there is a degree of stress relaxation leading to a reduced marginal discrepancy.

- Slower setting cements= traditional cements,

o early exposure to water will result in dissolution of the calcium polyacrylate chains=
This may minimise shrinkage but will reduce physical properties.

- The resin-modified glass ionomer restorative materials contain <5% of additional resin and
show a very small initial shrinkage of the resin component at the time of light activation.
Subsequent shrinkage from the continuing acid—base reaction will develop rather slowly and
is controlled to a degree by adhesion.
- In contrast, light-activated composite resins show immediate shrinkage, with development of
considerable stress at the tooth—resin interface.

Resistance to fracture

major limitations of glass ionomers = brittle fracture.

- glass ionomer materials are weak and lack rigidity.
o Clinical use should avoid situations that subject the restoration to heavy occlusal load
or bending. NO OCCULUSAL FILLING

Stiffness / Rigidity --- Modulus of Elasticity

The rigidity (or stiffness) of GIs is indicated by the “modulus of elasticity”.

The rigidity of GICs (4-6 GPa) is at or below the rigidity of microfilled composite resins.
Greater rigidity (7-13 GPa) has been demonstrated by some RMGIs.

In general, however, GI materials of whatever type should NOT be placed in situations where they
will be subjected to direct loading.

Abrasion resistance

Immediately after placement, glass ionomers are less resistant to abrasion than composite resins, but
their resistance improves considerably as they mature. So long as the material is well supported
and protected with remaining tooth structure, abrasion resistance is satisfactory.
Colour and translucency

The GIC and RMGI materials, that have been developed for aesthetic restorative situations provide
adequate colour matching and translucency, although translucency will take several days to develop
in the GICs.

Resin-modified glass ionomers generally show excellent translucency immediately after light
activation. Research (even recent research), however, indicates that optimum aesthetics and surface
smoothness and optimum seal to tooth structure will be achieved for RMGIs by delaying the
contouring and smoothing until the next appointment.

USES OF GLASS IONOMERS

The principal uses of glass ionomer materials are for:

Restorations

- used in situations requiring tooth-coloured aesthetics but without the highest aesthetic
demands (where composite resins are usually preferred)
- restore Class V situations and abrasion lesions.

Linings beneath restorations

- their reliable bonding to dentine and excellent seal, glass ionomers have largely replaced
all other materials that were previously used to “line” a cavity beneath a restoration of
composite resin, amalgam, ceramic etc.
- By sealing the dentinal tubules= flow fluoride within the tubules
o controlling post-restoration sensitivity
o preventing micro-leakage of irritants, bacteria and their toxins into the tubules.
- used at times to replace much of the lost dentine of the prepared cavity, thereby reducing
the effects of the polymerization shrinkage of an overlying composite resin restoration.

Luting “indirectly fabricated” restorations.

- when little enamel remains on the tooth prepared for the indirectly fabricated restoration
(such as for a crown, onlay or some veneers), glass ionomer-based luting agents are often
the preferred method for luting the restoration, because of the GI’s capacity to seal the
dentinal tubules and because of its relatively low solubility and disintegration, compared
with that of zinc phosphate cements.

Other uses of Glass Ionomer materials

Use is also made of glass ionomer materials for other purposes:

 Temporary restorations
  Core/foundation or other extensive build up beneath a crown etc. In this situation, it has
been suggested that the majority of the preparation for the crown should be on tooth
structure rather than glass ionomer.
 Fissure sealant --- GI fissure sealants, although relatively weak and prone to fracture and
dislodgement, are of value therefore when the tooth to be sealed is only partially erupted.

Resin Modified Glass ionomer (RMGI)

- Consists of the components of a GIC modified

- by the inclusion of a small quantity of resin (mostly HEMA)

The polyacrylate chain (from the acid-base reaction) continues to form in the same fashion as for a
GIC --- but at a slower rate than the cross-linking associated with the resin component --- and
under the “protective umbrella” of the set resin (set by light activation)

Types of setting mechanisms

- GIC Chemical --- acid-base reaction
- RMGI
o Chemical --- acid-base reaction
o Photochemical --- light activation
[Chemical --- oxidation-reduction]

Glass Ionomers
Composition and Chemistry

- Supplied in one of three forms:

o In capsule --- powder and liquid: for outer layer of the tooth
o Hand-mixed --- powder and liquid: for lining
o As powder, that is mixed with water: of historical interest only

Glass Powder —
Approx Composition

Weight %
Powder SiO2: (quartz) 29.0. = silicon dioxide
AL2O2: (alumina) 16.6
CaF; (fluorite) 34.2
Queen are flyinggggggggg

Glass Powder
- Mixture is
o Fused- quenched- ground- sieved
- To obrain particle size of 4-50um
- Finer particle: for luting and lining (easier to stick around)
- Coaser particles: for restoration as they look better
- Note: New generation of restorative glass ionomers also have “ultra-fine” particles

Powder particle size influences:

- Physical properties
- Aesthetic characteristics
 - Therapeutic potential

Radiopacity (“white” area on a conventional radiograph. The light can’t go through the object)
- Achieved by incorporation of: Boys Love Sass
o Barium
o Strontium
o Lanthanum

Reactivity
- Materials formed with higher temperature glasses, set more quickly.

Fluoride content
- Essential component for
o fusion temp (결합 온도)
o working characteristics and
o physical properties

- Reducing fluoride level enhances

o Translucency
- Fluoride has
o Remineralization(인체에 무기요소를 재공급시키는 것) potential
o some inhibitory effect on plaque

RMGI modified powder (for lining)

- Light activated catalyst is usually incorporated in the liquid--- but MAY be present in
powder
- Therefore, protect from ambient light
o Make sure you cover them in orange box to prevent harden up and get thicken
for lining

Liquid

Poly(alkenoic acid) Liquid

- Typical liquid for GI contains 40-55% solution of:

o EITHER 2:1 acrylic acid — itaconic acid copolymer in water
o OR a copolymer of maleic acid and acrylic acid

- Plus: 5-15% tartaric acid to improve setting time and translucency

Liquid for Resin-modified systems

- Liquid contains (additionally)

 o 15-25% resin component (largely HEMA)
o Photoinitiator

Concern with HEMA

- Set cement contains 4-15% residual HEMA
o Approx 4% where high powder content (eg used for restoration}
o Approx 15% for low powder content (eg used for lining)
o Well polymerised or it can damage the pulp

- Hydrophilic --- therefore, potential for

o Water uptake and Degradation of resin

Setting Reactions and Structure of Glass lonomers

Setting Reactions
(Refer GT lecture notes for greater detailed information on Setting Reactions)

- Both GICs and RMGIs have an acid-base reaction that forms the essential structure

Chemical acid-base reaction has THREE-stage setting reaction

1. Dissolution
2. Precipitation of salts --- gelation & hardening
3. Hydration of salts --- combined with water

Setting Reaction --- Stage 1

- Glass particles attacked by Polyacid: every particle is coated with polyacid (using a
mixer)
o Without coating of polyacid cause colour difference and malfunction of GIC
- 20-30% of glass decomposed
- ions released (Ca, Al, I etc)

Setting Reaction --- Stage 2

- Ca and Al ions bind to polyanions (almost immediately) via COOH groups
- Initial set
o cross-linking of Ca ions
o produces hard surface
- Maturation over next 24 hours
o Al ions provide more rigid cross-linking

- F and PO4 ions form insoluble salts and complexes

- Na ions contribute to formation of silica gel which assists in binding remaining (unreacted)
powder to matrix
Setting Reaction --- Stage 3

- Maturation phase
- Hydration of matrix salts: therefore requires to be in the saliva
- Results in sharp improvement in physical properties
Structure of the Set GIC

- Particles of the unreacted glass, Surrounded and supported by a siliceous hydrogel

- Embedded in a poly-salt matrix cross linked to polyalkenoic acid chain

- Structure is “porous”(구멍이 많은)

o ions of small dimensions (OH and F) are free to move through the GI
o it allows to be become reservoir for inflammation

Setting Reaction of the RMGI

- Two distinct types of setting reactions occur:

o Acid-base neutralisation reaction
o Free radical polymerisation: can open carbon double bond

Setting in the RMGI

- Application of the light initiates

o rapid hardening to depth of light penetration
- Photo-initiated cross-linking
o -- of HEMA and of methacrylate groups

- RESULT: “Clinically set” feel firm definitely set as it takes 24 hours to set

- Full physical properties achieved when acid-base reaction complete (24 hours +)

Water Balance

- Most important for GICs

- Approx 24% of set Gl is water
- GI materials --- espec GICs -- very susceptible to water loss and uptake
- Most susceptible in Stage 2 of setting

Water balance and RMGIs

- Regard as Fast setting GICs with
o Some resistance to water uptake 5: first 5 minutes it should not contact the water
o Some protection against water loss: first 2 weeks it should not be dried out.
- Can still dehydrate --- espec over next 2 weeks
Placement of the GI conditioning the tooth surfaces
- Various agents have been suggested/ used conditioning is carried out using polyacrulic acid
(low concentration)--- reactively weak acid

- Aim
o To remove some or all of the smear layer
 In order to provide a clean surface for chemical bonding to the tooth
structure
o To pre-active the surface of the enamel and dentine

Placement of the GI restoration Delayed Finishing

- Delay finishing in order to “optimize”:

o adaptation to tooth
o seal
o surface smoothness
o wait till to finish acid-base reaction which is 24 hour until it hardens up.

Note: Optimal clinical characteristics are obtained when the “final finishing” (contouring and
smoothing) are carried out AFTER completion of the acid-base reaction (at the next appointment)

PROPERTIES OF GLASS IONOMERS

Biocompatibility
- Resistance to plaque
- Pulp response
- Sensitivity

Resistance to plaque
- Response of soft tissues to Gls is favourable
o Bacteria don’t thrive
o S Mutans don’t thrive in presence of F
o High tissue tolerance to Gls

Pulp Response
- Freshly mixed GI has pH of 0.9 to 1.6.
- BUT Dentine tubule fluid is excellent buffer
- pH (of restorative Gls) rises rapidly in first hour (very little irritation of pulp from GI)

- Generally, NO additional protection is placed beneath the GI

- ---- unless cavity is very close to the pulp.
 - G1 is usually the lining material beneath other restorative materials.
Sensitivity to Luting GI Materials

Ensure:
- Conditioning
o Careful application (not excess time)
o Remove smear layer
o Leave smear plugs intact
- Correct mixing and handling
o Correct Powd/Liq ratio

Solubility and Disintegration

- LOW --- but care with:

o Low pH solutions
 eg some topically applied fluorides
o Dry mouth conditions (xerostomia)
 eg Sjogren’s syndrome

Note: GI materials that are hand-mixed for use as a lining, have a lower powder: liquid ratio (more
liquid) and are more soluble. Therefore, materials for use specifically as linings should NOT be
present at the margin of a restoration (where exposed to saliva etc).

Fluoride Release –1 Major importance (from GI)

- Large initial release

o Declines rapidly in first week
o Stabilizes after 2-3 months

- Long-term release
o protection from caries, for Surrounding tooth Adjacent
tooth

Fluoride Release – 2

- Initially --- from hydrogel matrix

- Later --- continuing exchange depending on gradient of fluoride in mouth

- GI materials can act as “fluoride reservoirs”= acid/caries release

Dimensional change

- Potential 3% volumetric contraction on setting

- GICs
o some stress relaxation during slow setting
- RMGIs
o overall contraction may be controlled partially by adhesion

- Subsequent water absorption may reduce interface stress with tooth

- Resistance to Fracture and Abrasion
- Major limitations for GI materials !!
- Clinical use should avoid situations that subject the restoration to heavy load

Rigidity and Stiffness

Elastic Modulus (GPa)

4 to 10 GI (more susceptible than composite as it can bend more)

5 to l4 CR
18 Dentine
55 to 60 Amalgam
82 Enamel

CLINICAL USES of Glass lonomer materials are also used Glass Ionomer materials occasionally
for:
- As restoration
- As lining beneath restoration
- For luting of indirectly fabricated restoration

Other occasional uses

- As Restoration Fissure sealant
- Temporary restoration
- Core/foundation or other extensive build-up beneath a crown (not recommended)
Restoration of a Class V lesion using Glass Ionomer (GI)

Terminology

According to Black’s classification of carious lesions, the Class V lesion occurs in the
gingival one-third of the buccal or lingual surfaces of anterior or posterior teeth

After placement of the glass ionomer, the restoration may be referred to as:
- (traditional terminology) --- Class V Glass ionomer restoration
- (in Aust Dent Assoc terminology) --- “One surface (anterior or posterior) adhesive
restoration”
- (in Aust DA item numbers) --- Item 521 --- if on an anterior tooth
Item 531 --- if on a posterior tooth

Clinical Scenario

The Class V lesion occurs on the smooth surface of a tooth.

The presence of such a lesion is closely related to poor dictary practices. Contributing factors, in
some cases, are poor oral hygiene and the failure to optimize the fluoride content of the enamel by
regular use of a fluoride-containing toothpaste. Such a lesion, therefore, should never be restored
without prior counseling in diet and oral hygiene.

Class V lesions may be restored in glass ionomer or composite resin --- rarely, these days, in
amalgam
The choice will depend on such factors as:

Location of the tooth in the mouth --- consider aesthetics, moisture control

Location on the tooth --- crown or root surface

Caries rate

Size of the restoration

- Lesions in the anterior part of the mouth are usually restored with composite resin because
of the superior aesthetic potential of that material
- Lesions on or near the root surface are often restored in glass ionomer because of the
more reliable (although potentially weaker) bonding to root surface dentine of GI
compared with composite resin.

Principles in the Preparation of the Class V cavity for Glass Ionomer

Access
Initial access is usually made into the tooth by way of the cavitated part of the lesion.

Outline form
Clinically, the carious lesion that occurs in the gingival one-third of the buccal and lingual surfaces
of teeth can take a variety of shapes.
The outline of the restoration that is placed clinically will usually be closely linked to the
extent of the peripheral caries.

At times there may be an exception to this:

Because of the potential for demineralized, but relatively intact, enamel to be

subsequently remineralized --- by changing the environment on the tooth surface (by
long-term diet change, repeated fluoride applications, applications of Tooth Mousse Plus,
etc) --- at times, the clinical decision will be made to restore the cavitated part of the
lesion, but to finish the margin of the glass ionomer restoration on relatively firm, but
demineralized (so called “white spot”) enamel.

This decision to be “conservative” of tooth structure is considered to be wise, providing

that:

- the clinician is confident about the patient’s commitment to achieving future change in the
environment on the tooth surface
- a glass ionomer restorative material (which is fluoride-releasing) is to be used.

In clinical simulation work (preclinical), whether plastic or extracted teeth are used, the

most technically demanding type of cavity outline form is prepared.

This is done partly because of the limited preclinical time available and partly to ensure
that students are equipped with technical skill to handle this more demanding situation
competently.

The prepared outline for preclinical work therefore usually extends from mesial angle to
distal angle of the tooth and parallels the shape of the gingival tissue (or CEJ)

For preclinical work, the specific cavity dimensions required are:

Premolar or anterior tooth:

- Length 4.0 to 4.5 mm (mesio-distal)

- Width Approx 1.5 mm (occlusal — gingival)
(Depth 1.0 to 1.2 mm)

Molar tooth:
- Length 6.0 to 6.5 mm (mesio-distal)
- Width Approx 1.5 mm (occlusal — gingival)
(Depth 1.0 to 1.2 mm)

For preclinical work, the gingival margin of the prepared cavity

- Is located on Enamel,
- Parallels the gingival tissue or CEJ and
- Is located approximately 1.0 mm from the gingival tissue (plastic) or CEJ (the occlusal
margin is approximately parallel to the gingival margin)

The margins of the cavity are rounded.

Resistance Form

Depth of the cavity

Al the same time as the outline is being prepared, the DEPTH of the cavity is being influenced.

On natural teeth (clinical or extracted), the optimum depth of the Class V cavity, when
restoring a carious lesion, is approximately 0.5 mm into dentine.

On plastic teeth, the optimum (specified) depth is approximately 1.0 to 1.2 mm from the
surface.

Curvature of the axial wall.

Because of the curvature of the outer surface of the tooth, in a mesial — distal direction,
the axial wall of the prepared cavity will also be curved.

Failure to provide this curvature during cavity preparation can result in an axial wall very
close to the dental pulp.

Other walls of the cavity

The mesial, distal, occlusal and gingival walls of the cavity are prepared so as to meet the

surface of the tooth at approximately 90 degrees.

This ensures optimum bulk of enamel and restorative material at the margin of the restoration.

Retention

The retention of the glass ionomer is by two means:

- Direct chemical bonding to the tooth structure
- Mechanical retention by way of a gingival retentive groove

Where enamel is thin or absent, a retentive groove can assist retention by

- providing mechanical retention
- increasing the surface area available for chemical bonding

When required, the groove is placed in the gingival wall of the cavity, just inside the
enamel-dentine junction. Where no enamel is present, the groove is approximately 0.5

to 1.0 mm into the dentine of the gingival wall.

Finishing the Cavo-Surface Angle

Around all margins of the cavity, the Cavo-Surface Angle is finished --- to remove
already fractured or weak tooth structure --- using either rotary instruments or hand
instruments
Preparing the Class V cavity for Glass Ionomer
Steps in the preparation of the “Preclinical” cavity are described.

Access is made approximately in the centre of the anticipated cavity.

Because of the need to prepare a cavity of approximately even depth, resulting in a

curved axial wall, the Outline is achieved in three main steps

- A central portion is prepared to approximately correct depth

- A distal portion is prepared
- A mesial portion is prepared
Finally, these three portions are connected in a smooth curve.

A small cylindrical bur is used (eg. 010 or 008)

After the central portion has been prepared to approximately correct depth,
in order to prepare the distal portion, the bur is placed initially at the location that is likely
to be the distal extent of the cavity. The bur is angled so that it will be at right angles to
the surface at this point.

The bur is then held at this angle, brought back into the distal limit of the prepared central
portion, and

The cavity is then gently extended from here to the distal extent required --- with the bur
kept at this angle.

A similar procedure takes place at the mesial end of the cavity.

The cavity is now checked for:

- Outline approx parallel to CEJ -- slight curve to occlusal at mesial and distal ends
- Approx even width
- There is a slight curve on the axial wall
- The walls at the mesial and distal ends meet the surface at approx 90 degrees
- Adjustments are made, as required.

The retentive groove is now placed along the gingival wall of the cavity.
Around Half bur is used at Low speed
It is easiest to place this, if we start at one end of the cavity and move towards the other

end --- and then do any adjustments that are needed.

Clinically, the bur is placed at one end of the cavity ---- just inside the enamel-dentine
junction and drawn along the gingival wall.
In preclinical work on plastic teeth, the groove is placed approx 0.5 to Imm in from the
margin and is made to a depth of approx half the bur diameter (approx 0.4mm)
After preparing a portion of the groove, this is checked with a probe --- by making sure
that there is some resistance to displacement of the probe towards the outside of the tooth.
The remainder of the groove is prepared and checked.

The cavity margin is now finished.

A gingival margin trimmer is used.
This instrument has a sharp pointed corner and one corner that is more at an obtuse angle.
On this occasion, the sharp pointed corner is directly into the cavity
(Note: the sharp pointed corner of a GMT is usually directed out of the cavity)
A scraping action is used.
To achieve this the clinician needs good control and good support for fingers.
The largest size of trimmer that fits the cavity is used.

‘The cavity is now complete.

Outline requirements are satisfied
Depth is into dentine
A slightly curved axial wall has preserved the dentine and the pulp
Some mechanical retention has been provided by the gingival groove
The margins have been planed to remove already fractured and weak
enamel.

The steps in the restoration of this cavity with glass ionomer are:
- A matrix is selected and trimmed
- The cavity is conditioned
- The GI is placed
- Initial trimming is carried out --- any gross excess is removed
- The surface is protected
- Finishing takes place at the next appointment.

Selection of a suitable matrix

Research has recommended strongly that for optimum adaptation and surface finish, the
G1 material, when placed, should be covered and gently “pushed into place” using a pre-
contoured matrix.

Because a Resin Modified Glass-Ionomer (PhotacFil) is to be used, and because this

material is also light activated, a clear matrix needs to be used.

The matrix is required to extend beyond all margins of the restoration by at least Imm.
At times, the matrix may need to be trimmed to allow optimal placement.

A clear matrix is checked for size and trimmed if necessary.

Preparation of the surface for restoration

The tooth surface is “conditioned” using PolyAcrylic Acid (PAA)

The Role of the Dentine Conditioner which contains 10% PAA, is

- Remove smear layer (leaves smear plug)

- Cleanse the surface of any other debris
(protein, oil etc)
- Optimize adaptation and bonding of the GI

Dentine Conditioner is applied to the tooth surface with a microbrush or cotton wool
pellet.

After application, with a light rubbing action, for about 15 seconds, the surface is rinsed
to remove all Dentine Conditioner and dried sufficiently to ensure there is NO remaining surface
moisture.

To optimise bonding and adaptation, excessive drying should be avoided prior to

application of a GI.

The Glass-Tonomer restorative material

PhotacFil is an encapsulated RMGI. wp ( X US Gea £2 ii

This is activated and then placed in a mixing machine for 10 seconds.
After mixing, the capsule is attached to a Dispenser and brought to the tooth.

The material is setting at this stage, by virtue of its acid-base components, and any time

delay before application should be minimised.

Placement of the Glass-Ionomer material and matrix

A small quantity of material is expressed into all aspects of the cavity --- providing a
small excess.

Any area of gross excess should be removed quickly using either a flat plastic instrument
or a spoon excavator.

The matrix is now brought to the cavity and GENTLY EASED into position.
Great care is required at this stage.
1) The material is NOT compressed with excessive load --- this can result in a restoration
which lacks adequate contour.

2) Once the matrix has been placed in position, it must not be disturbed. Any attempt to
move the matrix can result in the entrapment of air/porosity on the surface of the restoration.

Therefore, any attempt to remove excess at this stage should be done with great care
--- it is usually wiser to wait for initial set of the material.

Because a Clear matrix (for a RMGI) is being used, the matrix must be held WITHOUT
ANY MOVEMENT until the surface of the restoration has been light-cured. The GI is
fora total of 40 secands (the matrix may be remoyed after 20 sec)

Initial trimming of the restoration

Contrary to common practice by many dentists,

and, regardless of whether a GIC or a RMGI is used,

research has clearly indicated that there are several very sound reasons for delaying the
final contouring and finishing of the restoration until a subsequent appointment.

This delay will optimise

1) Bonding of the GI to the cavity walls

2) Adaptation to the margins

3) Smoothness of the final surface finish

The delayed finishing, after the surface of the restoration has completely set, will also
usually result in superior aesthetics and contour.

Initial trimming of any gross excess may be carried out after the matrix has been
removed.

Immediately after removal of the matrix, the surface of the GI is covered with a THIN
application of “G-Coat” ---- this is NOT cured.
The goal of the G-Coat is to ensure that the GI surface is protected from air while the

restoration is assessed for excess.

For the RMGI, because the light-activated component has been cured but the acid-base
reaction is still taking place, rotary instruments must be used WITH CARE during this

brief initial trimming. Water spray should be used.

Any trimming should cease as soon as a relatively smooth surface, with slightly excessive
contour, has been achieved.

Do NOT attempt to finalize the contour.

A further THIN layer of G-Coat is now applied and CURED.
The patient is dismissed (preclinically, no further work is carried out on this restoration
until a subsequent session)
Finishing of the Restoration

At a subsequent session/appointment, the restoration, in which the acid-base component

has now gone to completion, can now receive
- Final contouring
- Smoothing

During these finishing procedures, the surface of the restoration should be kept moist ---
either by water spray from the handpiece or by direct application from a triple syringe.

Contouring
Contouring may be achieved using rotary stones, tungsten carbide burs and diamonds.
Interproximally, finishing strips may be used.

Some examples of these are shown.

The contour needs to be checked from three different perspectives:

- Labial/buccal view
- From anterior or posterior perspective (for incisal-gingival contour)
- From an incisal/occlusal perspective (for mesio-distal contour)

Smoothing can be achieved using rubber finishing points.

Do not use discs to finalize contour

Reasons:

1. Discs used in any part of the mouth can cause SEVERE trauma to the lips, tongue and
cheek of a patient, if the patient unexpectedly moves of the clinician loses concentration.
2. 2. Discs can easily flatten contour excessively.
INTRODUCTION TO CARIES

Understand the size and impact of dental caries

Caries
- Definition of caries: dental caries is a pathology process resulting in localised destruction
of tooth tissue

Caries experience of children

- Caries affect 60-90% of school aged children worldwide

Caries affects nearly 100% of adults worldwide

The burden of dental caries

Understand the basic microbial aetiology of caries

Dental caries requires

- Cariogenic bacteria
- Bacterial plaque (the biofilm)
- Stagnation area
- Fermentable bacterial substrate
- Susceptible tooth surface
- Time

Cariogenic bacteria
- Anaerobic
- Oxidation-reduction negative
- PH <5.5

Bacterial plaque- the bilfilm

- Dental plaque is the soft, non-mineralized, bacterial deposit which forms on teeth (and
dental prostheses) that are not adequately cleaned.
- The biofilm is composed mostly of bacteria, their by-products, extracellular matrix, and
water
Common sites for plaque build-up
- Gingival site
- Margins of restoration
- Interproximal contact
- Within groove: mainly the pits and fissue system on occlusal surface
- Black’s classification system

Understand the dynamic demineralisation and remineralisation process

Saliva
- Lubrication
- Dilution of sugars after food and drink intake
- Antimicriobial and cleaning activity, degrading some bacterial cell walls and inhibiting
growth
- Remineralisation of enemal with calcium and phosphates
- Tissue repair
- Buffering (neutralising) acid production and controlling plaque PH with bicarbonate
 Mechanical / biological / chemical function of saliva

- Therefore people who have poor saliva quality and quantitively are higher at risk of
developing cavities

Time

Describe the clinical manifestation of dental caries

The caries balance

- Pathological factor: SAP fat
o Acid-producing bacteria
o Frequent sugar intake
o Salivary flow
o Poor oral hygiene
- Protective factors: SaP Gooodddd
 o Antimicrobials
o PH modification
o Saliva flow
o Good oral hygiene

It is important to have differential diagnosis to conclude final diagnosis. This allows to make
shared decision making.

ICCMS 4D
- Determine
o Patient-level caries risk
- Detect and assess
o Caries staging and activities
- Decide
o Personalised care plan
o Patient and tooth level
- Do
o Appropriate tooth
o Preserving caries
o Prevention and control intervention

Dental Amalgam

- The amalgam “Phase down”

- Composition and structure
- Setting reactions
- Properties
- Clinical performance next year
- Vs. Composite Resin

The amalgam “Phase Down”

- Australia become a signatory to the Minamata Conversion in 2016
- Refer the statement by the ADA NSW president
o Phase down rather than phase out
o Some advantages of amalgam in certain situation
o Amalgam separators need to be installed in dental practices
- The phasedown- implications for dental school
o Experience of dental school
 In 2018, most continue to teach amalgam those that ceased
 Problems with acceptance of their graduates (Aust, UK) one
(Canadian) re-instated amalgam teaching
o Associated benefits from the teaching of amalgam cavities and restoration
 Learning of handpiece control, hand-eye coordination, replacement of
restorations, preparation for fixed pros etc.
 o Currently CSU
 While amalgam is still available
 Aim is to equip students with competence by the time they graduate, to use
amalgam for
 Challenging situations: access, moisture control, size complex and
large restoration

- The main reason for teaching amalgam

o 30% of respondent no longer use amalgam
o 87% of the opinion that we should continue to teach amalgam
o Graduates since 1992 more in favour of use of amalgam than those graduating
before 1992.

o widespread abuse of posterior composites and the widespread abuse of patients in

whom posterior composites are placed so poorly by such a large number of dentists

Composition, types, and structures

- capsule contains powder: dental amalgam alloy.
- Silver+ tin + copper on lathe
- Particles reacted with mercury
- Mercury hits the surface of the particles. It is liquid at room temperature and mixed with
silver + tin + copper and at certain ratio precipitate produced.
- Which forms the matrix
Types and setting reactions

DENTAL AMALGAM

COMPOSITION AND STRUCTURE

TERMINOLOGY

Amalgam: A combination of a metal or metals with mercury

Dental amalgam: Specific type of amalgam used in Dentistry*

Alloy or Amalgam alloy: Used in Dentistry to refer to particles before reaction or to the
portion of the particles remaining after reaction with
mercury
Amalgam The product of the reaction of particles of alloy (dental
(as used in Dentistry): amalgam alloy) with mercury

*To avoid excessive repetition in the field of Dentistry, the word "dental" is frequently omitted
when reference is made to (dental) amalgam and (dental) amalgam alloy.

Descriptors used for comparisons among amalgams and amalgam alloys

1. Copper content

2. Particle shape and type

3. Zinc content

4. Minor elements
5. "2 content"

6. "Packability"
Copper content

Until mid-1960s - all Low-Cu (<6% Cu). Example is NTDA

First high copper - (Implies 12+% Cu) Dispersalloy - mid-1960s (we use this)
Dispersalloy is hard to pack therefore no longer used anymore

Intermediate - eg. 8-9% - did not - Remove 2

- Reduce creep
These are no longer available

Today - should not be using low Cu - price is the only advantage.

- wide range of high-Cu dental amalgam alloys available
which offer great variety in handling characteristics.

Partical shape and type

Lathe-cut - until early 1960s - all were LC (“or chip”)

Method of manufacture - Metals melted - poured into ingots in air atmosphere.

Tendency to oxidise ---  Zn included as a scavenger(안정화 시키는 것) for oxygen.

To provide uniform structure

 homogenizing heat treatment - 425ºC for 8-24 hours
 effect - Ag-Sn, Cu-Sn in discrete regions.
Every particle can have Sn.

By tradition, all Lathe-cut alloys are homogenized.

Spherical: this is the current amalgam that we use + blended amalgam

Atomizing process developed - early 1960s:

 first low Cu Spherical alloys

Result spherical or spheroidal shaped alloys

Atomized in inert (Argon) atmosphere - Zn not necessary

First Spherical alloys were NOT homogenized

 by tradition, Spherical alloys are NOT homogenized

Effect  different reactivity from LC

Zn content

Zinc Content of Dental Amalgams

Supply of dental amalgam alloys

Dental amalgam alloys are supplied
Zinc-free OR Zinc-containing (up to 1%)

Examples of Zn-containing alloys

Dispersalloy --- approx 1% Zn
Permite --- approx 0.2%

Reason for presence of Zn

Required as SCAVENGER for oxides for alloys manufactured in air
This includes:
- All low-copper lathe-cut alloys (especially before 1970) and
- lathe-cut components of high copper alloys

Zinc in the microstructure of dental amalgams

Consistent with its acting as a scavenger, Zinc tends to accumulate principally in the voids and
porosity regions of an amalgam.

Advantage of presence of Zinc

Clinical studies into the clinical performance of dental amalgams --- as assessed by the level of
margin fracture --- have consistently shown that amalgams containing Zinc have LESS margin
fracture (margin breakdown) than amalgams from Zinc-free alloys.

The size of the difference (between Zn-containing and Zn-free amalgams), although statistically
significant and evident in research, may not be sufficient to be of clinical significance.

The problem of moisture contamination of the amalgam during condensation (packing)

1. ALL dental amalgams (regardless of Zn content) will exhibit increased corrosion and
tarnish (discoloration) if contaminated with moisture during condensation= low copper
amalgam which used to be long time ago.

2. In addition to this general effect of contamination on all amalgams, Zinc-containing alloys, if

contaminated with moisture during condensation, exhibit “Excessive delayed expansion”.=
need to use zinc-free amalgam
That is, the amalgam expands, with time.
This Zinc-containing, contaminated amalgam therefore shows signs of
i) Corrosion and Tarnish (as for all contaminated amalgams)
ii) A delayed expansion which tends to expand the amalgam “out of the cavity”.
Note: this delayed expansion does NOT improve the seal of the amalgam to
the cavity walls --- the expansion is “out of the cavity”
(Seal is mainly influenced by the texture of the alloy particles)

This excessive delayed expansion commences after 3-5 days and may continue for
several months, reaching in excess of 400 µm at times with low-Cu amalgams.
The delayed expansion is caused by an electrolytic reaction, between zinc, water
and anodic elements present, which results in the liberation of hydrogen gas into the

amalgam.

Minor elements - apart from Ag, Sn, Cu ( Zn)

Pd. - 0.5% Less Tarnish

Possibly increased hardness (palladium)

In - Up to 1 - 4%
Better reactivity
But increased tarnish
Clinical performance of Indiloy (indium)

Pt - 0.05%: commercial reasons for inclusion (useless) (platinum)

2 content horrible phase

The aim of High Cu - remove 2 Improved: Properties and Clinical Performance

2 (Gemma) :Sn-Hg phase - only present in Low-Cu amalgams

- Slow setting
- Soft
- Weak
- Corrodible (부식 시키는)
Shit x2, weak cow
Refer diagram "Copper Content and 2 Content"
- 4 available ways of getting 2 -free amalgams
- Not used anymore. Due to this, high copper amalgam is developed

Packability
Descriptor commonly used by dentists.
Refers to resistance to packing pressure.
CLASSIFICATION -- SIX TYPES OF ALLOYS/AMALGAMS

Classification of dental amalgam alloys and amalgams is based on

i. Copper content
Low: less than 6% total Cu content
High: containing approximately 12% total Cu content, or greater.

ii. The type of particles present

It is usual for:
Lathe-cut (or chip) particles to have been cut from homogenized alloy
(Ag3Sn and Cu3Sn phases appear in discrete regions)

Spherical and spheroidal particles to have been prepared by atomization and not
subjected to an homogenizing process.

iii. The major elements present in spherical particles (Ag-silver, Sn-tin and Cu, or Ag-Cu)
of blended alloys/amalgams.

Types of alloys/amalgams
1. Low-copper, lathe-cut: don’t use anymore
2. Low-copper, spherical: don’t use anymore

3. High-copper, spherical: tytan= main one

4. High-copper, lathe-cut: we don’t use it. Too hard to handle

5. High-copper blend, Ag,Sn(tin),Cu: dominant one “Permite”= main one

6. High-copper blend, Ag-Cu: dispersed alloy

Almost all new amalgams, that have been developed since the mid-1970's, have been of the
high-copper spherical or high-copper blend varieties (Types 3, 5, 6, above). This reflects
the improvement in handling characteristics, properties and clinical performance of
amalgams resulting from developments in the technology with high-copper amalgams.

Many names have been used in the literature to describe these six types of alloys/
amalgams. In particular,
i. the terms "conventional" or "Ag3Sn" or "silver-tin" have been used to
describe low-copper alloys/amalgams.
ii. the term "single melt high copper" has referred to high-copper spherical
materials.
iii. the terms "dispersion modified" and "Ag-Cu dispersed" have referred to
high-copper blend, Ag-Cu alloys/amalgams.
iv. the general term "admixed" has been used to describe all alloys/amalgams
containing blended particle types.
All 7 images are the
Property of R Bryant
COMPONENTS OF THE AMALGAMATION REACTION

The reactants in the amalgamation process are varied in several ways:

 Alloy -- element composition

-- type of particles present

 Mercury -- initial Hg content

1. Alloy -- The element composition of the alloy

Total element composition of some representative dental amalgam alloys

Alloy type Alloy Approx. composition (weight %) by element

Ag Sn Cu Zn Other
Low-Cu lathe-cut "Average" 69.5 26 3.5 05. 0.5
High-Cu spherical Lojic Plus (SDI) 60 28 12 Pt 0.05
In 0.5

Tytin (Kerr) 59 28 13

Valiant (Dentsply) 48 30.5 21 Pd 0.5

Sybraloy (Kerr) 41 32 27
High-Cu blend, Valiant PhD (Dentsply) 48 30.5 21 Pd 0.5
Ag-Sn-Cu Vivacaps HR (Vivadent) 46.5 30 23.5
Permite C (SDI) 56 27.9 15.4 0.2 In 0.5
High-Cu blend, Dispersalloy (J&J) 70 17.5 12 1.0
Ag-Cu
As Ag decreases, Cu content increases. Cu reacts with Zinc.

The original composition for an amalgam proposed by G.V. Black in 1895 (Ag 68.5%,
Sn 25.5%, Au 5%, Zn 1%) was similar to that of the low-copper alloys of the 1960s
and 1970s.

2. Alloy -- The type of particles present

These may vary according to
i. shape
ii. size
iii. relative proportion of different types
 PARTICLE TYPES (BY SHAPE) PRESENT IN SOME AMALGAM ALLOYS

Lathe-cut Particles Spherical particles

Alloy type Low High Low,Med,High Ag-Sn-Cu Ag-Cu
Cu Cu Cu Low-Cu High-Cu

Low-Cu LC X
Low-Cu Spherical X
High-Cu Spherical X
High-Cu LC X
High-Cu Blend
Ag-Sn-Cu X X
High-Cu Blend
Ag-Cu(-Sn) X X

3. Mercury -- The initial mercury content

Of the total weight of components in the amalgamation reaction, the amount of mercury
may vary from approximately 40 to 53% according to the shape, size and copper content
of the particles. Microfine lathe-cut alloys require most mercury and spherical alloys
the least amount.
Requirement: Sufficient Hg to “wet” the surface of all particles.

INITIAL MERCURY TO ALLOY RATIO OF SOME AMALGAMS

Amalgam Type Initial % Hg

New True Dentalloy Low-Cu LC* 48

F-400 Low-Cu LC 53
G-C's Hi Atomic Low-Cu Sph* 45

Tytin High-Cu Sph 42.5 final: 38.5

Lojic Plus High-Cu Sph 40
Sybraloy High-Cu Sph 46

Valiant PhD High-Cu Blend (1) 47

Vivacaps HR High-Cu Blend (1) 49

Dispersalloy High-Cu Blend (2) 49.5

* LC = Lathe-cut (1) = Ag-Sn-Cu

Sph = Spherical (2) = Ag-Cu (-Sn)
The lower cupper is, more mercury is required for the reaction. Copper content,
particle size impacted the mercury content
PHASES PRESENT IN DENTAL AMALGAMS

Element composition of the phases

i. Phases / components present in the original alloy

ii. Phases formed in the reaction (reaction products)

Composition of major "phases" present in dental amalgam

Approximate composition (weight %)

Code* Phase or component
Ag Sn Cu Hg

Present in original alloy and the amalgam : form high temp

γ gammaAg3Sn 73.2 26.8.

they were present in the beginning of the reaction
ε epsilon Cu3Sn 38.4 61.6

d Ag-Cu eutectic 71.9 28.1

Formed in the reaction : form in mouth / room temp

γ1 gamma-1 Ag2Hg3 largely silver-Mercury that is set matrix. This is the reason why amalgam get hard
Ag22SnHg27 30.7 1.8. 67.5

γ2 gamma-2 SnxHgy 82.5 17.5. usually nothing left as most of them were used for CuSn

ηı eta-prime Cu6Sn5 61 39. This is the one that forms first and allow to limit SnHg

 for use in dental literature

REACTION IN HIGH-Cu SPHERICAL AND HIGH-Cu LATHE-CUT AMALGAMS: Exam question

High-Cu Total Cu Main original phases Phases

alloy type required % present formed
Spherical 12 + Ag3Sn and Cu3Sn 1. Cu6Sn5
Or
Lathe-cut 25 + Ag3Sn and Cu3Sn 2. Ag-Hg (+Sn)

Reaction:

(Ag3Sn + Cu3Sn) + Hg → Cu6Sn5 + Ag-Hg (+Sn) + Unreacted (Ag3Sn+Cu3Sn)

(γ + ε) + Hg → ηı + γ1 + Unreacted (γ + ε)

Note: There is NO free mercury remaining after reaction

REACTION IN LOW-Cu SPHERICAL AND LOW-Cu LATHE-CUT AMALGAMS: NOT IN THE

EXAM

Low-Cu Total Cu Main original phases Phases

alloy type required % present formed
Spherical 1. Cu6Sn5
Or <6 Ag3Sn (and Cu3Sn) (very small amount)
Lathe-cut 2. Ag-Hg (+ Sn)
3. Sn-Hg: slow
setting

Reaction:

Ag3Sn (+ Cu3Sn) + Hg → Ag-Hg (+Sn) + Snx Hgy + Unreacted Ag3Sn (+ Cu3Sn)

γ (+ ε) + Hg → γı + γ2 + Unreacted γ (+ ε)

Note: a very small amount of ηı phase (Cu6Sn5) is also formed in this reaction, mainly associated with the
release of Cu from the ε phase.

Note: There is NO free mercury remaining after reaction

 REACTION IN HIGH-Cu BLEND, Ag-Cu (-Sn) AMALGAMS (DISPERSABLE ALLOY)

Cu Content Cu content Main original

Particle of particle of particle phases (components) Phases
type (average %) (average %) formed
Low-Cu <6 Ag3Sn 1. Cu6Sn5
lathe-cut (and Cu3Sn)
12+ 2. Ag-Hg (+Sn)
Ag-Cu 28
eutectic Ag-Cu eutectic 3. For 3 hours: Sn-Hg

Reaction:

Ag3Sn (+ Cu3Sn)}
+ } + Hg → Cu6Sn5 + Ag-Hg (+Sn) + Sn-Hg (for 3 hrs) + Unreacted [d + γ (+ε)]
Ag-Cu

γ (+ε) }
+ } + Hg → ηı + γ1 + γ2 (3 hours) + Unreacted [d + γ (+ ε)]
d }

Note: γ2 phase (Sn-Hg) may be detected electrochemically in the amalgam for about three hours after
reaction. Solid state changes, in the presence of excess Cu, result in its rapid disappearance.
Note: There is NO free mercury remaining after reaction

REACTION IN HIGH-Cu BLEND, Ag - Sn - Cu AMALGAMS( PARMITE): Exam question

Total Cu Main original phases Phases

Partical type required % present formed

Spherical 12% + Ag3Sn and Cu3Sn 1. Cu6Sn5

and
Lathe-cut Low-Cu—High-Cu Ag3Sn and Cu3Sn 2. Ag-Hg (+Sn)

Reaction:
(Ag3Sn + Cu3Sn)
(γ + ε) spherical
Cu6Sn5 + Ag-Hg (+Sn) + Unreacted (Ag3Sn + Cu3Sn)
(Ag3Sn + Cu3Sn) spherical and lathe-cut
(γ + ε) + Hg →
high copper lathe-cut
OR
Ag3Sn (+Cu3Sn) ηı + γ1 + Unreacted (γ + ε)
γ (+ ε) spherical and lathe-cut
low-copper lathe-cut

Note: There is NO free mercury remaining after reaction

Dental caries

determine caries risk

- dental caries risk assessment involves quantification of risk factors such as
o diet
o Saliva quality and quantity
o plaque characteristics
o oral hygiene habits
o use of fluoride product
- assess the probability of
o developing new caries lesion
o progression of existing lesion
- clinical decision making

patient level caries risk factors

- Head and Neck Radiation
- Dry mouth (conditions, medications/recreational drugs/self report)
- Inadequate oral hygiene practices
- Deficient exposure to topical fluoride
- High frequency amount of sugary drinks/ snacks v
- Symptomatic-driven dental attendance
- Social-economic status/Health access barriers
- For children: high caries experience of mother or caregivers

Intraoral level caries risk factors

- Hypo-salivation/Gross indicators of dry mouth
- PUFA (Exposed Pulp, Ulceration, Fistula, Absess) – dental sepsis
- Caries experience and active lesions
- Thick plaque: evidence of sticky biofilm in plaque stagnation a r e a s
- Appliances, restorations and other causes of increased biofilm retention
- Exposed root surfaces
 Patient’s risk status
Low risk status Lack of any high caries risk factor (item :1 red text) and other risk factors
are within "safe" ranges (e.g. sugary snacks, oral hygiene practice, fluoride
exposure).
Moderate risk status A stage where the individual is not deemed to be definitely at Low risk or
definitely at High risk of developing new caries lesions or of lesion
progression.
High risk status Presence of any of the high-risk factors in item 1or caregivers with very high
caries experience or where the level of several of the lower risk factors in
item 1 suggests a combination likely to
lead to a high risk status- the number and levels of these factors will vary
according to geographical location and the
prevailing socio-economic conditions.

Detect
Activity status : For initial and moderate caries lesions (ICDA 1-4)

- Active
o Surface of enamel is whitish/yellowish
o Opaque with loss of lustre (feels rough to gentle probing)
o Lesion is in a plaque stagnation area (pits and fissures, near the gingival margin or,
proximal surfaces) ‐ The lesion may be covered by thick plaque before cleaning

- Inactive
o Surface of enamel appears whitish, brownish or black
o Enamel may be shiny and feels hard and smooth
o For smooth surfaces, the caries lesion is typically located at some distance from the gingival
margin (lesion may not be covered by thick plaque before cleaning)

Activity status : Extension caries lesion (ICDA 5-6)

- Active
o Dentine feels soft or leathery on gentle probing

- Inactive
o Dentine is shiny and hard on gentle probing
Decide: Personalised care plan: Patient and tooth levels
- Determines what type of treatment to provide for each tooth (preventive versus surgical)
- helps to maintain good oral health
- allocate resources appropriately based on risk
- Requires patient’s ACTIVE ENGAGEMENT on the importance of oral health
- determine the recall interval for the patient.

Management option

- Tooth & surface level

o tooth preserving operative care (TPOC)= drilling
o non-operative care of lesions (NOC)
o preventing new caries

- patient level
o homecare approaches & clinical intervention
o actions to improve the risk status

Do: preventive care

- planning + implementation: ensure patient can support their own oral health

tooth & surface level

- inactive
o no treatment required unless aesthetic is a concern
o preserving new caries
- active
o providing tooth-preserving operative care for only those lesions that needs it

management options for ACTIVE caries lesion

Composite Resins (CRs)

Principal uses of CRs in restorative dentistry

- direct application
- restorations in anterior teeth
o class 3,4 and 5
- restorations in posterior teeth
o class 1 and 2
- indirect applications
o restorations: onlays
o luting agents
- other uses include
o temporary restoration
o splinting teeth

components of a composite resin

- organic resin component -- forms the “matrix”
- inorganic filler: glass particles with different sizes
- coupling agent: to unite filler with resin matrix
o fill the particle with coupling agent to make a bond
- initiator system
o to initiate the setting mechanisms.
- stabilizers: inhibitors to control setting mechanisms
- pigments: to provide range of colours

Resin component

Resin component of the CR

- high viscosity monomers (majority of resin)
o bis-GMA
 still present in all components
o UDMA

- Low viscosity monomers --- to assist handling (decide the viscosity of the resin)
o TEGDMA
o EGDMA
o HEMA
 lowest molecules weight component. Not fully cured, it can be pass by the dentine
and irritate the pulp

- C=C bonds at each end of the monomer molecule to enable polymerization and cross-linking

Inorganic Fillers

Filler “Loading”
- = % of inorganic filler present in the cured CR
- Range (by wt) : 52% (microfilled CR) to 88%
- Weight % vs Volume %. As it looks more compared to volume.
- Volume % usually approx 11-16% less than Weight %
Filler particle types

Macrofillers (Similar as GIC)

- Composition --- glass, quartz, ceramic (Queen crack the glass)
- Obtained by --- fusing, quenching, crushing, grinding, sieving
- Size
o Early products: 5-30 micrometre
o Current products: 0.5-5 um

- Radiopacity
o Include: Ba, Sr, La glasses

Microfillers
- Composition --- Amorphous silica --- SiOz
- Obtained by --- hydrolysis and precipitation
- Size --- Diameter --- 0.04 micrometre
- Radiolucent

Nanofillers (been used in last 10 years and till today)

- Composition --- glasses
- Clusters obtained by sintering
- Size ~~ 5-20-75 nm (0.005-0.020-0.075 um)
o Note: Microfiller particles are 0.04 pm. Smaller than microfillers
- Present
o In clusters
o As individual particles

Silane Coupling Agent

- To produce a bond between the filler particles and the resin matrix

Classification of Composite Resins

Christensen Classification of Composite Resins (2005/2011)

This classification of CRs is based on the TYPE and COMBINATION of filler particles.

1. Nanofill Contains ZrO particles <100 nm (<0.1 μm)

Particles present
 in clusters -- "nano-clusters" (0.6-1.4 μm)
 as individual particles 5-20 nm (E, D, Body shades); 75 nm (Translucent)
Advantage of clusters (prepared by sintering)
 increased filler loading
 individual particles can wear off -- this ensures surface remains smooth over time.
Example: Filtek Supreme XTE most widely used composite

2. Nanohybrid Contains
 "Nano" particles (ZrO or SiO2 -- approx 40 nm or less)
 Ground glass particles up to 1 μm.
Examples: Gradia, Premise, EsthetX, TPH3, Herculite Ultra
 [Similar to microhybrid, but higher proportion of smaller (“nano”) particles
Fillers vary in size and type]
3. Microfilled Contains only SiO2 particles of approx 40 nm (0.04 μm) Particles present
 in prepolymerized blocks
 as individual particles.
More easily finished than nanofills (smooth, but not as strong) it shows chipping too much on the
edge not being used anymore
Examples: Heliomolar

4. Microhybrid Contains
 Microfiller -- 0.04 μm particles.
 Ground glass particles up to 1 μm size (usually 0.6-1.0 μm)
 Strong, but not as smooth over time
Examples: Herculite, Surefil popular group. Not as smooth as microfilled but has natural looks.

5. Hybrid Contains
 Microfiller -- 0.04 μm particles.
 Ground particles up to 5 μm (approx) size
(Note: coarser ground particles are infrequent in current hybrid composites)
Examples: Z250, Z100, P60
Comments
This classification scheme uses terminology that is common in brochures describing current
composite resins.

Christensen Classification of CRs

- Based on Type and Combination of filler particles present
o Nanofilled
o NanoHybrid
o Microfilled
o MicroHybrid
o Hybrid

Other descriptors for types of CRs

(Other térms used --- often inaccurately_
- “Flowable”
o Thinner, less viscous, less filler content than restorative CR
- “Packable” —- a misleading term
- “Self”/ “Auto”/Chemical cure
o No light required for polymerization
o Polymerize by chemical initiation only (CA --- activation)
- “Bulk Fill”
o Materials developed with much greater depth of cure.
o Aim is to support the use of a bulk placement technique - a technique that was discredited in
1990s but now. “revived” in order to allow composites to be placed morerapidly ---
controversial
Polymerization and structure
Initiator system
- Visible-Light Activation (VLA)
o light cured
- Chemical activated (CA) it is NOT on the market anymore.
o Self / auto cured
- Dual cured is required as the bottom of the resin cannot be reached with light so it needs to be
chemically cured.
Visible-light activation: developed in Mid-1970s
- Two component
o Photosensitive di-ketone --- usually 0.2-0.7% CQ
o CQ = camphorquinone
- Tertiary Amine
o CQ absorbs radiant energy of approx 470 nm wavelength (blue light)
- The “excited” di-ketone combines with the amine to form complexes that break down to release
free radicals which initiate polymerization.

Chemical Activation -Developed in Mid-1960s

- Types of delivery systems:
o Two paste
o Powder-liquid
- Initiator --- benzoyl peroxide
- Accelerator --- tertiary amine
- Combination of the two yields free radicals which initiate polymerization

“Dual-Activated” systems
- Packaged as two pastes
o Contain BOTH VLA and CA components
- Light activation mechanism initiates the polymerization
- Chemical activation is relied on to continue and complete the setting.

Polymerization Composite Resins

Polymerization to form Composite Resins

- Free radicals --- generated by “initiator system”
- Collide with C=C bonds of monomer = polymerization
- Pair with one of the double bonds of the monomer
- Leave other member of pair free
o So monomer molecule then becomes a “free radical” and process continues

Type of polymerization within the CR

- For CA CR – fairly. Uniform reaction throughout material
- For VLA CR – uneven reaction resin closest to light polymerizes FIRST Of clinical importance “to
optimize adaptation”
Extent of Polymerization in CR
- Measured by “Degree of conversion” of C=C double bonds near the surface of an “optimally” cured
CR
- This has been found to be: between 44 and 75% that goes conversion.
- That is
o Unreacted methacrylate groups remain
o Half-life of remaining potentially reactive radicals is 30-50 hours
- For VLA CR
o 80% of polymerization occurs
o within 20 sec of commencing curing

Polymerisation

The free radicals, generated by the initiator system, collide with the carbon—carbon double bonds of
the monomer and pair with one of the electrons of the double bond, leaving the other member of the pair
free. The monomer molecule itself then becomes a free radical and the process continues.
In a chemically-activated composite resin, the reaction takes place almost uniformly throughout the bulk
of the material.
In light-activated systems,
i. the composite resin closest to the light source will polymerize first --- to optimize adaptation to the tooth,
care is taken with the direction of the curing light.
ii. the depth to which activation will occur is dependent on a number of factors. It is important to
note that much of the resin not activated initially by the light at the time of curing will remain
incompletely set.
In both systems, a significant proportion of the methacrylate groups remain unreacted even after
some hours. The “degree of conversion” of double bonds 0.2 mm below the surface of an “optimally”
light-cured composite is between 44% and 75%. Therefore, the quantity of unreacted methacrylate
groups is 25-56% and this will be influenced by the concentrations of the different monomers. Greater
conversion increases the polymerisation contraction and the only way this can be counteracted is by
increasing the filler loading.
Double bonds remaining at the end of the initial cure decay rapidly over the next 24 hours and become
unavailable for future bonding. The half-life of the remaining potentially reactive radicals is only 30-50
hours. This means that most of the chemistry of the setting reaction and the consequent contraction
will take place within the first few seconds during light activation and the remainder will be complete
within 2 days.
The relatively rapid decay of double remaining after the initial cure affects the capacity of the composite
to bond to subsequently applied CR (for example, in repairs and additions).

Oxygen inhibition
Polymerisation is retarded in the presence of oxygen, which is taken up by the free radicals.
Any resin which comes in contact with air during polymerisation will develop an incompletely polymerised
surface layer (feels “sticky”) as a result of diffusion of atmospheric oxygen into the liquid resin.
This 'air-inhibited' layer is thinner (10-20µm) for the visible light-activated composites than for chemically
activated materials.
Oxygen / Air Inhibition of Polymerization in CR
- Polymerization in the resin is retarded in the presence of O: (or air)
- O: (or air) inhibition results in:
o An incompletely polymerized
o (slightly sticky) surface layer
o that is approx 10-20 micrometre thick

Resin Bonding Agent

- Usually contain NO filler
- Diluted by additional monomers to provide low viscosity

Resin-based Fissure Sealants

- Filler content varies between 0 and 40%
- Require sufficient thickness to ensure “optimal” polymerization in depth of fissure because of
“0: inhibition” layer

Flowables
- “Used almost everywhere OR virtually nowhere” Opinion is very divided
- Polymerization contraction
o Flowables 3-6%
o Regular CRs 1.6-2.4%
- Thermal coefficient
o Aim is to be as close to tooth as possible (expands and contracts like tooth)
o Tooth 11, GIC 10, Amalgam 25, CR (restorative) 35-40, Flowables 50-70
- Rigidity (Elastic modulus)
o Microfilled CR, GT 4-8, Flowables 6-10,
o Restorative CRs 8-14, Dentine 18
o Amalgam 55-60, Inamel 82

Properties

Biocompatibility of Composite Resins

- Response of the dental pulp
- Microleakage
- Response of gingival tissue

Response of the Dental Pulp

- If cured as far as possible CR —> minimal pulpal irritation, when placed on dentine of pulpal
wall
- If incompletely cured, CR is potential hazard
o E.g. where there is thin layer + “air inhibition™

- HEMA can traverse the dentine easily and may — irritation and/or allergic response

Microleakage into Dentine Tubules

- If CR loses its seal at the margin — Opened tubules are susceptible to
o Sensitivity
 o Pulp irritation: polymerization pull inner structure and can cause pulp irritation
o Caries
- From: fluid flow and ingress of bacteria and their toxins

Irritation from the activating light

- Prolonged exposure of eye to light of 470 nm A
o Can — damage to retina
- Some light-activation units generate heat Temp rise of 3-4 degrees is potentially sufficient to cause
pulpal injury

Response of Gingival Tissue to CR

- Gingival tissue cells respond less favourably to CR than to GI
- Incompletely cured CR is an irritant
- In contrast to GI and Amalgam, the surface of the CR offers NO resistance to plaque accumulation

Water Sorption= reduction in interface structure and causes swelling in resin

- Potential for water sorption and swelling is greater with a greater proportion of resin (less
filler) in the set CR
- Softening and cracking of the surface, associated with sorption, may result in increased surface
porosity
- Hydrolytic degradation of Ba and Sr glass fillers can resull in crack formation

Colour Stability
- CR may undergo significant colour change
- When placed, CR is porous
- Over time, it hydrates
- Maximum sorption of fluids/stains in first 7-10 days especially first 24 hours
- Strongly staining liquids
o tea, coffee, cola drinks etc may be incorporated into CR in depth

Polymerization Contraction
- Approx Volumetric contraction is 1.6 -2.4%
- One recent CR has Vol Contr of 0.8%
- CR nearest the light sets first --- aim to apply light so that curing process favours adaptation to cavity
wall
- Polymerization Contraction is the MAJOR problem of current CRs --- discussed in later lectures

Mechanical Properties of CR--1

- Wear --- concern is with wear of both CR and opposing enamel
- Rigidity (GPa): Resin bends more than dentine
o Microfilled CRs 4-8
o “Flowables” 6-10
o Coarser CRs 8-14
o Dentine 18
o Enamel 82

Mechanical Properties of CR –2
- Fracture Toughness
o Reflects energy required to propagate a crack Comparison (units)
o Microfiled 0.7 to 1.0
 o “Small particle” (<1pm) 0.0 to 1.3
o “Coarse particle” 1.4 to 2.0
o Fibre-reinforced CR. 3.0 can be used for splinting

- Clinically, FT reduces with time, because of Water sorption and Degradation

- Strength: Of uncertain clinical importance NOT IMPORTANT AT ALL

Thermal Properties of CR
- Thermal coefficient of expansion (and contraction) (units)
- Tooth Structure 11.4
- GIC 10
- Amalgam 25
- Coarse-filled CR. 30 to 35
- Microfilled CR. 50 to 70
- “Flowables” 50 to 70
- Unfilled resin 80to 120

Clinical considerations
Depth of Cure (DoC)
- Refer additional important information in the lecture notes for CR
- Many factors influence the depth (or thickness) to which a VLA CR is cured
o Thickness of CRT -- ↑ DoC
o Curing time t= ↑ DoC
o Filler particle size ↑ -- ↑DoC
o Colour of CR Darker ↓ DoC
- Keep tip of curing light close to CR

Principal Factors influencing the Clinical Selection of a CR

- Location and size of restoration
- Composition of CR
o Especially: filler loading, particle size, particle type, quantity of CQ, physical, thermal
optical, radiographic
- Properties:
o Physical
o Thermal
o Optimal
o Radiographic
- Handling characteristics
o “Stickiness”
o Resistance to “slumping”
o Working time
o Finished surface texture

CLINICAL CONSIDERATIONS
Depth of cure
The only setting reaction which is possible in a light-activated restorative composite resin is that which is
initiated by exposure of the resin to light of the required wavelength. There will be no other chemical reaction
initiated within the material. By the time of placement, approximately 40-60% of the available resin bonds will
have been used in polymerization, including cross-linking. With most composite resins there will be no more
than a 10% improvement from that point and this will occur within the next 2 days.
[Note: “Dual” activated resins, which also have a chemical initiation system, are frequently used for the
luting of restorations --- this ensures that the deeper layers of the resin (which are not directly exposed to the
visible light) will achieve adequate polymerization]

Failure to light-activate a composite resin to the full depth of the restoration has important implications for the
success and longevity of the restoration. In particular, adhesion to the underlying tooth structure will be at risk if
the resin is not fully cured.

Depth of cure has been traditionally tested by measuring the hardness of a certain thickness of CR. If the
hardness at the bottom (away from the curing light) is approx 98% of the hardness at the top, or better,
then this is said to be a thickness (depth) at which the CR is adequately cured.

The degree of cure (DOC) is defined as a number between 0 and 1 (or 0% and 100%), where the latter is a
fully cured resin

Depth of cure was measured by scraping the uncured material and by using a Knoop Hardness
profile, starting from the surface exposed to the light

Depth of cure: the thickness of composited cured by a typical light source

Many factors influence effective depth of cure (DoC):
 Degree of cure decreases with increasing depth (thickness of the CR).
 Increased time of exposure to the light increases depth of cure
A 40-second cure will achieve greater depth of cure than a 20-second cure.
 The larger the particle size the greater depth of cure.
Microfilled resins will cure to a depth of approx 2 mm, whereas composite resins
with an average particle size greater than 1µm usually have a greater “depth of
cure”.
It is recommended that Current CRs (with nanoparticle fillers) be cured in
increments no thicker than 1.5mm (to ensure optimum polymerization)
 Lighter shades of material are cured to greater depths.
 Materials that are more translucent are cured to greater depths.
 Light-activator units vary in their light output over time as well as with power fluctuations. The
efficiency of each unit should be checked frequently.
Polymerisation continues at a significant rate for 20 minutes after activation and
then more slowly for 1-2 days.
 The tip of the light source should be placed as close as possible to the restoration and, if possible,
should not be more than 4 mm away.
Curing through tooth structure will reduce the depth of cure to the same extent as curing through a compos-
ite resin of similar opacity.
Bonding to Enamel and Dentine
Bonding of Resin to Enamel

- Introduced in early 1970s

- Since then:
o Increased understanding of how to optimize the bond
o Resin to Enamel bending has proven to be VERY reliable
 consistently good SEAL
 predictable bond strength
o If carried out under optimum conditions, with respect
 condition of the enamel
 moisture control
 clinical technique

BASIS of Resin to Enamel Bonding Resin bonding to Enamel

“Micromechanical bonding Preferentially etched enamel surface”

Typical Clinical Protocol for

- Acid-etch for 30 sec with agitation: to optimise the bond
- Rinse/Wash for 20 sec
- Dry thoroughly for 10 sec
- Thin application of bonding agent
- Wait 15-20 sec: wait longer
- Light cure for 20 sec

Acid-Etching
- Most commonly, approx 37% Orthophosphoric Acid
- Acid-etchants vary in Viscosity
o low viscosity (liquid) to
o high viscosity (gel) removed

- and therefore, their ability to spread over and to wet the surface the surface of the enamel
- etching time
o currently 30 sec is time though necessary to achieve optimal etching
o longer required for
 strongly fluoridated enamel
 primary enamel (vs permanent teeth)
o 20 sec for enamel + dentine (as dentine requires shorter time)

Chemical effect of acid etchant on enamel

- surface is deminiralized = chemical effect therefore, keep irritate for “etching”
- Ca, PO4 and other Enamel constituents are removed
- A “sludge” of Enamel constituents forms on the enamel being etched
- Clinical implication:
o To optimize the etching, the etchant should be agitated continually

MICROSTRUCTURAL Effect of Acid Etchant on Enamel

The Enamel is “Preferentially Etched”
Factors influencing Microstructural effect of Etching ~=1
- Concentration of the Acid
o Weak acid (eg PAA) --- na effect, only “cleans surface”
 o 37% H3PO4 --- reliable etching, if technique optimal
o Less than 37% H3PQO4 --- compromised bonding

- Etching time (using 37% H3P04)

o 30 sec --- regarded as optimal (for low/mod F exposure)
o Surface exposed to high levels of F --- requires more than 30 sec (you can observe the change
of colour on tooth / non reflect + mat)
o Excessive time (eg 2min) --- yields “fragile” enamel surface due to excessive penetration of
acid

Factors influencing Microstructural effect of Etching — 2

- Permanent vs Primary enamel
o There is a microstructural difference between “primary” and “permanent” enamel (primary
enamel has a less regular prism structure == bonding is less predictable) = the filing falls
off easily
- Type of tooth surface being etched Surface vs Sub-surface enamel
o Surface enamel has high proportion of “aprismatic enamel” —- which pH regular
arrangement of enamel prisms = take off 20-30 pum
- Removal of the surface 20-30pum provides an optimal surface for etching and yields a classical
etche appearance

Factors influencing the Microstructural effect of Etching --- 3

- Orientation of exposed E prisms
o Cross-section (section parallel to tooth surface)
o Provides optimally etched surface
o Longitudinal section of prisms (on cavity wall)
 Provides adequate but less than optimal surface for bonding (max depth 3 to
4pm)
o Oblique section (prepared by placing a “bevel”)
 Provides improved bonding/sealing potential compared with etched cavity wall
(longitudinal section)
- Orientation of crystallites within prisms
o Either prism “cores” or “peripheries” are removed by the etchant: etch will work both
of them
Rinsing/Washing after Etching
- Need to dissolve off any sludge / precipitates that have formed
- Takes TIME --- not force !
- Cannot be “blasted” off.
- Clinical Implication
o Must ensure precipitates/sludge removed Rinsing for 15-20 sec )

Drying the surface of the Enamel --- 1

- IF ONLY Resin bonding agent (“Adhesive”) is to be used:
o Enamel surface must be absolutely dry “desiccated” or else loss its physical properties
o Fiched E surface is “porous” and “highly receptive” to contamination
o Contamination with saliva, gingival fiuid, blood etc for just ONE sec results in significant
compromise to bonding

- Clinical Implication
o If contaminated AT ALL, then re-gtch for 10 sec, then rinse and dry
Micromechanical Retention of the Enamel to Acid-Etched Enamel
Achieved by:
 - Preferentially etched enamel surface (tooth surface, cavity wall)
- Surface is porous and highly receptive to resin-bonding agent
- Optimal etching provides for “resin tags” of length = 10-20um
- Allow 15-20 sec for resin to penetrate fully into porous, etched surface BEFORE applying the
curing light
- Delay of 15-20 sec provides for significantly better bonding and seal

Bonding of Glass Ionomer to Enamel and Dentine

BASIS of Glass Ionomer bonding to Enamel and Dentine

- Chemical Adhesion to mineralized tissue: chemical bonding
- Based on an “ion-exchange” process involving both diffusion and absorption
- Resin sealant is strong but it is strong when it is 100% dried therefore, use GIC as it can tolerate with
moisture control (may not last long) + ion exchange still works even if sealant falls off.

Process of Adhesion
- Initiated by polyalkenoic acids contacting tooth structure
- Result is shallow demineralization as Ca and PO(phosphate) are displaced from apatite by
carboxyl groups
- With the setting, it is thought that there is a re-precipitation of minerals at the GI-tooth interface
- As a result, an “ion-exchange” layer is formed at the GI-tooth interface, comprising: Ca and Al,
POs and polycarboxylates

Clinical implication of this bonding

Loss of a GI restoration is associated with:

- Continued adhesion of the ion-exchange layer (which has a higher tensile strength to tooth
structure, than the cohesive strength of the GI)
- Cohesive failure within the GI

Note: Micracracks in the enamel may be associated with failure occurring in the tooth structure

Adhesion to collagen (very weak)

- Adhesion to the organic component of dentine may also occur by way of;
o Hydrogen bonding
o Metallic ion bridging
- Between carboxyl groups (of the polyacid) and collagen molecules (of the dentine)

Conditioning the Enamel or Dentine surface

- Agents used in the past --- citric acid, H202
- Currently, the material most commonly used is: 10% PAA (polyacrylic acid) applied for 10-15 sec

- Aims of the PAA:

o Clean the surface of protein, oil, other debris etc
o Remove some or all of the smear layer
o Leave smear plugs (reduce dentine fluid flow)
o Possibly, “pre-activate” the E or D for improved adhesion

Optimizing the GI to Enamel or Dentine bond

- Clean surface with slurry of pumice and H:0 when access allows
 - Apply 10% PAA with a rubbing action, using a microbrush, for 10-15 sec
- Rinse vigorously for 10 sec
- Dry to remove ALL surface moisture but do NOT desiccate
- Note: the setting and bonding of Gls require moisture to be available

Terminology --- Conditioning and Etching

- Recently, the term “conditioning” has been applied loosely by some authors and speakers
- Conditioning
o Refers to the use of a WEAK acid to prepare the surface of the tooth or cavity wall for ion-
exchange adhesion

- Etching
o Refers to the use of a STRONG acid to remove mineral component from Enamel and Dentine
to provide for micromechanical retention (for E) and hybrid fayer formation (for D)
MANAGEMENT OF THE EARLY CARIOUS LESION

Accessible smooth surface (class 5)

Detection
1. Sub-Surface Demineralization (SS)
2. Obvious break in enamel

Advice to patient
The main problem is SUGAR: Sugar in Drinks / Sugar in foods

If the patient wishes to reduce the problem:

It is the Patient’s Responsibility to reduce the number of “sugar attacks”

Management by the dentist

AFTER discussing “Sugar Attacks”:

Discuss
Use of Tooth Mousse Plus --- remineralization
Use of Fluoride rinses
Optimizing Plaque control

? Application of fluoride gels/varnish/solutions

(for Remineralization and Protection)
Generalized --- Fluoride gels
Localized --- Duraphat varnish (NaF)
Fluoride solutions (2% NaF, 20% SnF2)

Treatment options
1. Fluoride --- Localized --- Duraphat Varnish (NaF) (Approx 2.5% F)
20% SnF2 (posterior only)
2. Fluoride --- Generalized --- 2% NaF
3. Tooth Mousse Plus
4. Restore

Pit or Fissure

Detection
1. Visible cavitation
2. Discoloration evident beneath enamel adjacent to a pit or fissure
3. Radiolucency in dentine (in bitewing radiograph)
4. Electronic methods
• Sensitivity and Specificity of a detection method
 • Factors complicating Occlusal caries detection
• Electronic diagnostic methods

Clinically, detection of occlusal caries is of great importance in regions where young patients have fluoride-
protected enamel.
Note: Avoid forcibly placing a probe in the depth of a pit or fissure.

Advice to patient
Depth and complexity of Fissure Anatomy of occlusal surfaces of molars

Genetics !
Variation between different people

Treatment options
1. Nil
2. Fluoride -- ? 20% SnF2 solution, ? Duraphat Varnish
3. Fissure seal (in the absence of any evidence of caries in the pit/fissure)
4. Fissure fill
5. Preventive Resin Restoration (PRR)
6. Restoration with amalgam or composite resin

Principal preventive strategy:

Fissure Sealing
Erupted tooth --- Opaque Resin sealant (6-7 year old)
Partly erupted tooth --- GI -- eg Fuji VII

Other preventive approaches:

Application of fluoride solutions, gels etc
Reducing number of sugar attacks
Optimizing plaque control & use of fluoride-containing toothpastes

Restorative management
- Restore when cavited:
o Fissure filling
o Preventive resin restoration (PRR)
o Occlusal restoration

Proximal surface (inaccessible smooth surface)

Detection
1. Mirror and probe (to detect a break in the continuity of surface enamel)
2. Fibre-optic Transillumination (with strong light, you can detect colour change in enamel)
• Based on the principal that sound tooth structure has a higher index of light transmission than
a carious tooth
• Used primarily for detection of proximal surface caries (especially on anterior teeth).
• It may also improve visual detection of occlusal lesions
• Carious lesions limited to enamel appear as grey shadow
• Carious lesions in the dentine appear orange-brown or as a bluish shadow

3.Bitewing radiograph
 • Clinically, on proximal surfaces of posterior teeth which are in contact with an adjacent tooth, the
presence of CAVITATION is widely accepted as the indication for “surgical intervention”
(restoration)
• From a minimum intervention perspective over the life-time of a tooth, it is far preferable to
restore when the cavitated lesion is small than to delay until restoration requires the replacement
of a much greater volume of tooth structure.
• “No radiographic method exists that is capable of discerning between lesions with or lesions
without cavitation”
• The wish therefore is to be able to identify, with some confidence,
the point at which (as evidenced by the progress of proximal caries on a radiograph) there is the
likelihood that the vast majority of these proximal surfaces will be cavitated.

4. ?? Electronic detection methods

The “Treatment Threshold” for Surgical Intervention (Restoration)

• Caries extending radiographically beyond the Enamel-Dentine Junction
• Approx 90% of dentists in a practice-based research network reported that, regardless of the caries
risk, they would restore a proximal lesion that is evident in the outer one-third of the dentine”
--- that is, the lesion is evident radiographically in the dentine.

Advice to patient

Principal strategy
Diet control --- Reduce “Sugar Attacks”

Supporting strategies

Optimize plaque control using

Dental floss
Interdental brushes

Management by Dentist
AFTER discussing “Sugar Attacks”
and optimizing plaque control:
Discuss
Use of Tooth Mousse Plus --- remineralization

Consider
Application of fluoride gels/varnish/solutions
for Remineralization and Protection
Generalized --- Fluoride gels
Localized --- Duraphat varnish (NaF)
Fluoride solutions (2% NaF, 20% SnF2)

Treatment options
1. Fluoride -- Localised --- 20% SnF2, Duraphat Varnish
2. Fluoride --- Generalized --- 2% NaF
3. Restore

Restorative management
Restore
• When cavitation detected on the inaccessible smooth surface
• When the radiographic evidence of caries indicates caries extending beyond the enamel-dentine
junction (into the dentine)