Dental composites and advances

Dental composites and advances

1. 24-09-2023 1

2. DENTAL COMPOSITES PRESENTED BY : GUIDED BY : V. Sindhu Dr. P. Venkata karteek varma 1 st yr PG Reader 24-09-2023 2

3. 24-09-2023 3 COMPOSITES MIND MAP HISTORY INTRODUCTION COMPOSITION PROPERTIES CLASSIFICATION FUNDAMENTALS IN COMPOSITE PREPARATION CLINICAL TIPS TYPES OF COMPOSITES ADVANCES -Resin -Filler -Coupling agent - Acti /inhibitor -Optical modifiers - uv stabilisers -Co thermal expansion -wear -poly shrinkage -water sorption -degree of conversion - colour stability - radioopacity -biocompatibility -optical properties - longivity Based on filler size Based on matrix composition Based on viscosity Based on poly method Based on particle size - macrofilled -small particle - microfill -hybrid - nanocomposite -PRIMM -Indirect composite resins - ormocer - Giomer - Compomer -masking composites -self healing -smart -Antibacterial composites - Bioactive composites CONCLUSION REFERENCES

4. INTRODUCTION Dental composite resins (better referred to as ‘resin based composites’ or simply ‘filled resins’) are types of synthetic resins that are used in dentistry as restorative material or adhesives. Micro-mechanical retention property makes composite more effective for filling small cavities, where amalgam fillings are not as effective and retentive. 24-09-2023 4

5. COMPOSITE Composite material may be defined as a compound of two or more distinctly different materials with properties that are superior or intermediate to those of the individual constituents. DENTAL COMPOSITE A highly cross-linked polymeric material reinforced by a dispersion of amorphous silica, glass, crystalline or organic resin filler particles and/or short fibers bonded to the matrix by a coupling agent. Philips Science of dental materials 11 th edition – K J Anusavise 24-09-2023 5

6. HISTORY SILICATE CEMENTS = Phosphoric acid + Acid soluble glass UNFILLED ACRYLIC RESINS = Polymethylmethacrylate COMPOSITES 24-09-2023 6

7. 24-09-2023 7 Cangül , Suzan & Adıgüzel , Özkan . (2017). The Latest Developments Related to Composite Resins. International Dental Research. 7. 32-41. 10.5577/intdentres.2017.vol7.no2.3.

8. COMPOSITION RESIN MATIX FILLERS COUPLING AGENT ACTIVATOR-INITIATOR INHIBITOR OPTICAL MODIFIERS UV STABILISERS 24-09-2023 8

9. RESIN MATRIX Active component Undergoes polymerization to convert c=c into c-c Aromatic or aliphatic diacrylates BIS-GMA UDMA TEGDMA 24-09-2023 9

10. BIS-GMA Bisphenol A + Glycidyl dimethacrylate Bowen in 1962 Less polymerization shrinkage Dimethacylate improves cross linking and enhances resistance to degradation by solvents 24-09-2023 10 UDMA Introduced by Foster and Walker in 1974 Difunctional resin Contains one or more urethane groups and two methacrylate end groups These bis -GMA and UDMA are highly viscous and difficult to manipulate.

11. TEGDMA Resin of lower molecular weight Reduces viscosity Enable filler loading 24-09-2023 11 To overcome these issues, a low molecular weight, highly fluid monomers such as Triethylene glycol dimethacrylate (TEGDMA) to blend and dilute the viscous consistency.

12. FILLERS Inorganic composition Improves the properties of the composite Quartz, borosilicate or lithium aluminium silicate glasses, barium, strontium, zinc glasses 30 to 70% by volume 50 to 80 % by weight 24-09-2023 12

13. FUNCTIONS OF FILLERS: Improves mechanical properties such as compressive strength, modulus of elasticity and hardness Reduces water sorption and coefficient of thermal expansion Contributes to aesthetics - glass is able to reflect the color of the surrounding tooth material Reduces the polymerization shrinkage Give radio-opacity if barium or strontium glasses are incorporated 24-09-2023 13

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16. COUPLING AGENT Produces a bond between filler particles and resin matrix γ- methacryloxypropyl trimethoxy silane – Organosilane most commonly used Zirconates and Titanates ACTIONS: Improves physical and mechanical properties Prevents gradual loss of filler particles from composite surface Provides hydrolytic stability by preventing water from penetrating the filler resin interface . Allows transfer of stresses from more flexible polymer to stiffer filler particles . 24-09-2023 16

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18. ACTIVATOR-INITIATOR SYSTEM 24-09-2023 18

19. INHIBITORS Prevents spontaneous start of polymerization of monomers Extends shelf life- Storage 0.01 wt% Butylated Hydroxytoluene 24-09-2023 19

20. UV- STABILIZERS To prevent discoloration with age of composites Compounds are incorporated which absorb electromagnetic radiation Improves color stability 2-hyroxy-4 methoxy benzophenone 24-09-2023 20

21. COLOR MODIFIERS To achieve various shades of dentin and enamel dental composites have visual coloration and translucency that can simulate the tooth structure. Pigments such as various metal oxides in minute quantities OPACIFIERS: TiO2 Al2O3 COLOR PIGMENTS : Cadmium/ gold- Yellow Nickel- Grey Ferric- Red Copper- Green Tin- Brown 24-09-2023 21

22. PROPERTIES OF COMPOSITES 24-09-2023 22

23. WORKING AND SETTING TIME Chemically activated composites, ADA specification no. 27 Working time no less than 90 seconds . Since polymerization is an exothermic reaction ,the setting time ranges from 3 - 5 minutes. Light-cured composites - Polymerization initiated when composite is first exposed to light. Although the composite appears hard and fully cured after recommended exposure time of curing light source, curing reaction continues for a period of 24 hours. 24-09-2023 23

24. COEFFICIENT OF THERMAL EXPANSION To prevent development of stresses, the CTE of composite should be as close to that of the tooth structure as possible. Incorporation of filler particles results in lowering of CTE of composite resins , but it is still higher than that of the tooth structure. Linear CTE of composites - 25–38 × 10−6/°C and 55–68 × 10−6/°C Microfilled resins contain a high amount of resin in the form of resin matrix and pre polymerized resin filler particals - tend to have a higher CTE as compared to fine partical composites. Filler loading is the only way to lower the CTE of composite resins. 24-09-2023 24

25. 24-09-2023 25 Eighteen-month clinical performance of preheated nanoceramic resin-based composites in Class I occlusal cavities: A randomized clinical trial Neha Taufin at al This study (split-mouth design, RCT) aimed to evaluate effect of preheated nanoceramic resin-based composite (RBC) (Ceram-X-Mono) placed in Class I occlusal cavities over a period of 18 months. Preheating of nanoceramic RBC to 60°C for 10 min was performed before insertion of the material into 30 prepared cavities, whereas 30 restorations in the nonpreheated group were placed according to the manufacturer's instructions. Kappa index, Friedman and Wilcoxon matched pair test, and Kruskal-Wallis and Mann-Whitney tests were used for statistical analysis. Preheated nanoceramic RBC restorations showed better clinical performance compared to nonpreheated group.

26. WATER SORPTION Occurs mainly as a direct absorption of water by the composite resin. Filler particles adsorb water onto its surface when the quality of the silane bond between the resin matrix and the fillers is compromised. Bis-GMA molecules - high values of sorption -1%–2%. Results in expansion of restoration which hampers longevity of restoration Microfilled composites owing to higher resin content have higher water sorption value (26–30 mm g/mm3) as compared to hybrid composites (5–17 mm g/mm3). . 24-09-2023 26 Philips Science of dental materials 11 th edition – K J Anusavise

27. High water sorption values of composite resins may be attributed to many factors 1.The material may have a high solubility rate, which dissolves and leaves a space into which water can enter. 2. The resin may contain air voids introduced during mixing or placement, into which water can be adsorbed 3. Hydrolytic breakdown of the bond between the fillers and the resin can occur allowing adsorption of water onto the surface of the filler particals 24-09-2023 27

28. SOLUBILITY Self-disintegration of the material. Inadequate light intensity and duration, particularly in the deeper areas of the restoration, result in incomplete polymerization and an increased solubility rate of this unpolymerized resin matrix. Higher values of water sorption and solubility lead to reduced wear and abrasion resistance as well as color instability 24-09-2023 28

29. RADIO OPACITY The resin needs to be radiopaque as detection of caries is virtually impossible under radiolucent restorations. The radiopacity is provided by - Ba, Sr, and Zr. ADA specification no. 27 requires that composite resins have radiopacity equivalent to 1 mm of aluminum , which is approximately equal to that of dentin. 24-09-2023 29

30. COLOR STABILITY Aesthetics being the major factor in the use of the composite resins ,the longevity of the restoration depends on the material retaining its color and polish. Discoloration can be seen in either of the three ways—marginal, surface, and bulk discoloration. 24-09-2023 30

31. COLOR STABILITY . Marginal discoloration - due to improper adaptation of the material to the margins of the cavity. Surface discoloration - due to surface roughness of composite. Composite resins containing larger particle size fillers lead to entrapment of debris in the spaces between protruding filler particles. Bulk or deep discoloration - common with chemically activated composites . Occurs due to chemical degradation of components in the resin matrix and absorption of fluids from oral environment. 24-09-2023 31

32. POLYMERIZATION SHRINKAGE Curing shrinkage arises as the monomer is converted to polymer and the free space it occupies reduces (approximately 20% less than that among unreacted monomers) Decreases with increase in filler content Leads to cracks in enamel margin Causes Marginal gaps, Marginal staining, recurrent caries 24-09-2023 32

33. CONTROL OF SHRINKAGE C-factor = Number of bonded surfaces/ Number of unbonded surfaces, should be low. Use of flowable or low viscosity bases Incremental layering Size , shape and positions of the increments Different types of resin curing 24-09-2023 33

34. CONFIGURATION FACTOR Ratio of surface area of fixed walls bounding a tooth preparation versus unbounded walls When there is a smaller ratio of bonded to free surface area, flow of composite resin undergoing polymerization occurs easily minimizing the stress caused during polymerization shrinkage . with a C-factor >1, adhesion could not be maintained. In such cases: 1. Use of adhesive linings 2. Layering techniques 3. Different curing methods is needed 24-09-2023 34

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36. 24-09-2023 36 Soft-Start” (SS) polymerization. This concept proposes to increase pregelation time, so that a slower rate of conversion will allow for better flow of resin with a decrease in contraction stress. SS polymerization may be divided into three separate techniques: stepped, ramped or pulse-delay.  A stepped program emits a low irradiance for 10 seconds, then increases immediately to a maximum value for the duration of the exposure. In a ramped program, the irradiance gradually increases from a low value to maximum intensity over a short period, after which it remains constant for the duration of the exposure. Pulse-delay uses a short, low-level burst, a delay for polishing and finally a long exposure at full intensity.

37. WEAR Wear is a complex phenomenon that depends on several intrinsic and extrinsic factors. Composites have low wear resistance owing to the softer resin matrix wearing at a faster rate than the fillers, leaving them exposed to be plucked out from the matrix during further abrasion. 24-09-2023 37

38. DEGREE OF CONVERSION Degree of conversion (DC) reflects percentage of consumed methacrylate monomer double bonds The DC for bis-GMA based composites - 50% to 60% The number of double bonds of carbon converted to single bonds during the polymerization reaction. The DC depends on various factors: 1.resin composition and volume 2.amount of activator-initiator present 3.depth of transmission of light through the material 24-09-2023 38 Philips Science of dental materials 11 th edition – K J Anusavise

39. OXYGEN INHIBITION 24-09-2023 39 Dental composites get cured by free-radical-induced polymerization reaction which is strongly inhibited by free-radical scavengers such as oxygen in the air. This free oxygen in contact with composite resin diffuses and inhibits polymerization reaction forming peroxide radicals that have low reactivity toward monomers.This free monomer layer remaining on the surface after curing is known as the oxygen-inhibited layer. It Is about 19um thick various among different composites Panchal , Aarti C, and Geeta Asthana . “Oxygen inhibition layer: A dilemma to be solved.”  Journal of conservative dentistry : JCD  vol. 23,3 (2020): 254-258. doi:10.4103/JCD.JCD_325_19

40. 40 Borges MG, Silva GR, Neves FT, Soares CJ, Faria -e-Silva AL, Carvalho RF, Menezes MS. Oxygen inhibition of surface composites and its correlation with degree of conversion and color stability. Brazilian Dental Journal. 2021 Apr 2;32:91-7. The degree of conversion of the composite resins surface can be improved by using glycerin to reduce the oxygen presence and the surface staining can be reduced if this previous procedure is associated with immediate finishing and polishing procedures

41. LONGEVITY OF COMPOSITES The most commonly cited reasons for failure of composites in clinical studies are secondary caries, fractures, marginal deficiencies and wear. Nonetheless, properly placed composite can last many years even in posterior regions, where the wear and bite forces are great. Opdam and colleagues published a retrospective study in which they have concluded with survival rate of composite resin of 91.7% at 5 years and 82.2% at 10 years. The survival rate overall for composite in permanent teeth after 7 years was 67% compared with 94% for amalgam restorations according to the study done by chadwick et al. 24-09-2023 41

42. OPTICAL PROPERTIES TRANSLUCENCY REFLECTIVENESS HUE, VALUE , CHROMA 24-09-2023 42

43. TRANSLUCENCY Composite resin with less translucency should be used for dentin, whereas with more translucency should be used for enamel ( Villarroel M et al., 2011). Mostly depends on the type and nature of the unreacted particles. 24-09-2023 43 Translucency is the property of a substance that permits the passage of light but disperses the light so that objects cannot be seen through the material

44. REFLECTIVENESS Smoother the surface, more rays are reflected Major modifying factor for any shade Saliva will impart certain reflectiveness on the surface of the tooth and material While choosing a shade the tooth should be covered by saliva 24-09-2023 44

45. HUE, VALUE, CHROMA 24-09-2023 45 • Hue is the color tone ( ie , red, blue, yellow, etc). The term “hue” is synonymous with the term “color,” and is used to describe the color of a tooth or dental restoration. • Chroma is the intensity or saturation of the color tone (hue), ie , light blue or dark blue. For instance, chroma is used to describe the orange or yellow hue of a tooth or a restoration. • Value is the relative lightness (brightness) or darkness of the hue.

46. RESPONSE OF GINGIVAL TISSUES Respond less favourable when compared to GIC Incompletely cured resin might be a tissue irritant Roughness and porosities might lead to accumulation of plaque 24-09-2023 46

47. BIOCOMPATABILITY Limited problems of biocompatibility with composite Unpolymerized materials are cytotoxic or even carcinogenic Adequately polymerized composites are biocompatible Inadequately cured composites serve as reservoir of diffusible components at the floor of the cavity 24-09-2023 47

48. IDEAL REQUIREMENTS OF COMPOSITE Coefficient of thermal expansion should be equal to that of tooth Should not absorb water Low Polymerization shrinkage High Wear resistance Smooth surface texture Radiopaque Higher Modulus of elasticity Less soluble in oral fluids 24-09-2023 48

49. INDICATIONS Sealants and preventive resin restorations Class I, II, III, IV, V, VI restorations Aesthetic enhancement procedures Composite inlays Cementation of indirect restorations Temporary restorations Non caries lesions like abrasion, erosion Repair of old composite restoration Foundations or core buildups For splinting 24-09-2023 49

50. CONTRA-INDICTIONS When proper isolation is not possible When occlusion is on composite restoration When preparing cavity extending on to root surface or subgingival area Poor oral hygiene High caries index Patient’s with abnormal habits (bruxism) 24-09-2023 50

51. ADVANTAGES Aesthetics Conservation of tooth structure Less complex when preparing the tooth Insulative having low thermal conductivity Bonds to tooth structure (good retention) Repairable Non corrosive Strengthens the tooth structure 24-09-2023 51

52. DISADVANTAGES Technique sensitive Increased C.O.T.E. than tooth structure Polymerization shrinkage More difficult, time consuming Increased occlusal wear Low modulus of elasticity Staining 24-09-2023 52

53. CLASSIFICATION OF COMPOSITES Based on the Filler Particle size: i.Homogenous composites Mega-fill – 0.5-2 μ m Macro-fill – 10-100 μ m Midi-fill – 1-10 μ m Mini-fill – 0.1-1 μ m Micro-fill – 0.01-0.1 μ m Nano-fill – 0.005-0.01 μ m ii.Heterogenous composites Hetero-midi-fill Hetero-mini-fill Hetero-micro-fill iii .Hybrid composites Midi-micro hybrid Mini-micro hybrid Mini-nano hybrid 24-09-2023 53

54. Based on matrix composition: Bis-GMA UDMA Based on polymerization method: Self/ chemically curing system Light curing system Based on viscosity Packable composites Flowable composites 24-09-2023 54

55. Based On Partical Size : Traditional Small-particle Filled (Spf) Composite Micro-filled Composite Hybrid Composite Nano-filled Composite 24-09-2023 55

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57. TRADITIONAL (MACROFILLED) Developed in 1970‘s Finely ground amorphous silica or glass Average size 8-12µm Filler loading- 70-80 wt% or 60-70 Vol% Improvement in the compressive strength from unfilled resin Roughening of the surface due to abrasive wear Examples: Adaptic, Concise 24-09-2023 57

58. SMALL PARTICAL Mean particle diameters between 0.1 and 10 µm Higher filler loading 77-88% than macrofilled Higher degree of hardness and strength than macrofilled Surface smoothness that is closest to the microfills Greater wear resistance and some decrease in the polymerization shrinkage Excellent balance among polishability, appearance, and durability make this category suitable for general anterior use. 24-09-2023 58

59. MICROFILL Particle size- 0.01-0.1 µm Smoother surface Surface roughness and low translucency eliminated Final filler content- 50 wt% 24-09-2023 59 Colloidal silica (0.01 -0.1um)

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62. 24-09-2023 62 Despite having lower filler fraction, will not shrink as much as expected Bond between composite particle and clinically cured matrix is relatively weak, facilitating wear by chipping mechanism Resins of choice for restoring teeth with carious lesions in smooth surfaces (classes III and V) but not in stress-bearing situations( II and IV)

63. HYBRID Popular as “ all-purpose” Types: conventional hybrid, Microhybrid and Nanohybrid. Consists of mixture of microfiller and small filler particals that result in a considerably smaller average partical size of 0.4-1µm Filler loading- 75%-85% by weight Superior because of particulate reinforcement Increase stress bearing capacity 24-09-2023 63

64. PROPERTIES: Physical and mechanical properties range between traditional and small particle Superior to those of Microfilled composites Radiopacity sufficient Anterior restorations including class 4 Can also be used as posterior restorations- stress bearing areas 24-09-2023 64

65. NANOFILLED/NANOHYBRID/NANOCOMPOSITES 0.005-0.01µm particle size Pyrolytic precipitation process used for colloidal silica The particle size is similar to that in microfilled composites, but the difference is that the particles in microfilled composites are in three-dimensional agglomerates that increase viscosity, whereas those in nanofilled composites are mostly discrete and have a minimal effect on viscosity. Thus, these composites have optical properties and superior polishability like those of microfilled 24-09-2023 65

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68. PACKABLE COMPOSITES Developed for use in class I and II restorations, with the concept of condensation similar to that of amalgam. Composed of dimethacrylate resins, and a filler content of 66%–70% by volume. ADVANTAGES: 1. Greater depth of cure 2 . Lower polymerization shrinkage, radiopacity, and lower wear rate (3.5 mm/ year) 3. Ease of achieving good contact area. DISADVANTAGES: 1 . Difficulty in handling due to its high viscosity 24-09-2023 68

69. FLOWABLE COMPOSITES Flowable composites are low viscosity, light-cured composites Filler loading of 42%–53% by volume. Used as a liner over the hybrid layer in class I and II restorations and composite build-up is done. They are also used in cervical class V and in minimal occlusal restorations. 24-09-2023 69

70. DISADVANTAGE: Due to its lower filler loading, it exhibits high curing shrinkage and lower mechanical properties 24-09-2023 70 ADVANTAGES: 1. Forms a thin layer of composite over the hybrid layer. 2. Owing to its high flexibility, it acts as a stress reliever in high stress concentration areas such as cervical areas. 3.It is also claimed that it increases marginal adaptation in a class II restoration, thereby reducing microleakage.

71. BULKFILL COMPOSITE Reduced polymerization shrinkage Increased depth of cure - Novel photo initiators, polymerizati on boosters or by increasing translucency. Incremental pattern can be avoided . Ease of flow& adaptability. Higher strength & Better wear resistance . Good esthetic properties. 24-09-2023 71

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78. Comparison of polymerization shrinkage of a new bulk‐fill flowable composite with other composites: An in vitro study Somayeh Khoramian Tusi at al Assess the polymerization shrinkage of a new bulk‐fill flowable composite (G‐aenial bulk injectable [GBI]) and compare it to other bulk‐fill and conventional composites. G‐aenial bulk injectable and G‐aenial universal flo showed significantly higher polymerization shrinkage than other composites at 30, 60, and 1800 s after light irradiation, while X‐tra fil and Filtek Z250 showed the lowest polymerization shrinkage at the aforementioned time points. According to the results , the new composite had polymerization shrinkage similar to the conventional one. Bulk‐fill composites reported similar or lower shrinkage to conventional composites. 24-09-2023 78

79. 24-09-2023 79 FUNDAMENTALS IN COMPOSITE RESTORATIVE TECHNIQUE

80. 24-09-2023 80 CLINICAL TECHNIQUE: 1. Cleanse the tooth with pumice . 2. Evaluate the shade of the tooth before isolation (from the middle third of tooth). 3. Use articulating paper to determine the location of occlusal contacts so that they can be avoided, if possible, during preparation. CLINICAL TIP : If the occlusal surface is intact, fabricate a registration of the occlusal surface with a clear polyvinyl siloxane bite registration material (e.g., Memosil , Heraeus Kulzer , Inc.; Sharp Parkell , Inc.) or a thermoplastic button (Advantage Dental Products). (This step decreases the need for subsequent carving and occlusal adjustment.) FUNDAMENTALS IN COMPOSITE RESTORATIVE TECHNIQUE

81. 24-09-2023 81 4. Administer local anesthetic if necessary. 5. Isolate the area with a rubber dam 7. Etch the enamel for 15 seconds and the dentin for 10 seconds. 8. Wash with water and/or water/air spray for a minimum of 10 seconds for gel or liquid etchants. . 9. Air dry the enamel and blot the dentin, leaving it slightly moist. The cavity preparation can be disinfected with a cavity disinfectant and the excess blown off and blotted with a cotton pellet. However, in some systems the smear layer is not removed but only modified, and bond strengths may decrease as a result of disinfection.

82. 24-09-2023 82 10. Repeat the procedure if the enamel does not have a frosted white appearance after air drying. If the dentin is dry, moisten the dentin again with a cotton pellet moistened with water. 11. Place the dentin-enamel bonding agent according to the manufacturer’s instructions. 12. With a syringe, place an increment of a dentin shade posterior composite resin against the pulpal floor and against one of the buccal cusps. Light polymerize for 40 seconds through the cusp. Build up the other buccal cusp and subsequently the lingual cusps in a similar manner. This creates appropriate fissure position and depth. TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

83. 24-09-2023 83 Place tints and opaques to achieve a natural appearance. Place brown and ochre tints into pits and fissure and white or colored opaques at the crest of triangular ridges (e.g., Kolor1, Kerr Corp.; Creative Color, Cosmedent , Inc.). 14. Place a layer of an enamel/ incisal composite resin to build up the definitive contour. This anatomic layering technique reduces stress within the adhesive interface . 15. Place glycerin to reduce the air-inhibited laye r. Light polymerize for 40 seconds. CLINICAL TIP : The previously fabricated occlusal registration can be used at this time. It is pressed back into position, and the resin is light polymerized for 60 seconds from the occlusal direction. Occlusal adjustments are minimal when this technique is used.

84. 24-09-2023 84 18. Sealant and postcuring procedures 16. Finish the restoration. 17. Polish the restoration. finishing after 10-15 minutes is advised . Approximately 75% of the polymerization of photo-polymerized composite resins takes place during the first 10 minutes Microcracks resulting from trauma due to finishing procedures particularly at the cavosurface margins can propagate over time . Liquid polishers/surface sealants are low-viscosity resins with little or no filler that provide a gloss over composite restorations improving the final appearance of the restoration. Sealants fill irregularities and reduce microleakage at composite margins . Thus, sealant application may prevent surface wear, thereby improving the longevity of composite restorations . If needed, sealant can be reapplied biannually. This is a simple but efficient method to improve surface quality but an additional step for the dentist to complete the procedure. Vishwanath , Sankar et al. “Finishing and Polishing of Composite Restoration: Assessment of Knowledge, Attitude and Practice Among Various Dental Professionals in India.”  Cureus  vol. 14,1 e20887. 3 Jan. 2022

85. 24-09-2023 85 a. Rinse off polishing debris with water; air dry. b.Etch for 15 seconds c. Rinse with water for a minimum of 10 seconds. d. Air dry the surface. (If the surface is not enamel, leave it moist.) e. Apply sealant (e.g., Fortify, Bisco , Inc., Optiguard , Kerr Corp., PermSeal , Ultradent Products, Inc.) f. Air thin. g. Light polymerize for 40 seconds . 18 . Sealant and postcuring procedures are the following : TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

86. CLINICAL TIPS FOR COMPOSITE FILLINGS 24-09-2023 86

87. 24-09-2023 87 Beveling provides a gradual transition between the composite resin restoration and the tooth . Bevels of 45 degrees and 1 to 2 mm wide are used in facial areas, whereas a smaller (0.5-mm) bevel is used in other areas. (A wider bevel is placed on the facial surface to achieve better blending in the esthetic zone .) Bevels (on the occlusal surface) should be avoided in Class I and Class II restorations because thin composite resin margins are subject to fracturing. Widening the preparation to allow a bevel may extend the restoration into areas of occlusal function Adequate contouring of a restoration before polymerization is essential for minimizing finishing time and reducing damage to the composite resin. (Finishing procedures can cause microcracks .) Damage to the composite resin results in a higher wear rate, an increased fracture rate, and a greater tendency for opening of margins. TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

88. 24-09-2023 88 Surface-penetrating sealants (e.g., Fortify, Bisco , Inc.; Optiguard , Kerr Corp.) can be used to repair surface defects created during finishing , which improves the wear of posterior composite resins and decreases microleakage around Class V composite resins . In addition, the composite resin that is closest to the light is often the most polymerized and therefore the hardest part of the restoration. Because this layer is removed with occlusal adjustment and polishing, placement of the sealant and postcuring are necessary. Vishwanath , Sankar et al. “Finishing and Polishing of Composite Restoration: Assessment of Knowledge, Attitude and Practice Among Various Dental Professionals in India.”  Cureus  vol. 14,1 e20887. 3 Jan. 2022

89. 24-09-2023 89 Placing a sectional matrix decreases sensitivity because an overly tightened circumferential matrix can pull the cusps together (i.e., Contact Matrix System, Danville Materials, and Composi -Tight 3D, Garrison Dental Solutions; V3 Ring [Narrow and Universal], Triodent Ltd.). Sectional matrixes influence on post-op sensitivity TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

90. 24-09-2023 90 Luciwedges ™ Classic ( kerr dental )   Reduced marginal gaps by effective curing light reflection in combination with transparent matrices more effective in producing better polymerization than clear wedges

91. 24-09-2023 91 Contact forming devices Trimax contact forming instrument . The light from the curing unit is transmitted through the adjustible light conducting tip into the composite resin. (Courtesy AdDent , Inc., Danbury, CT. TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

92. 24-09-2023 92 CERVICAL MATRICES TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY

93. 24-09-2023 93 Anterior Matrix Systems for Composite Restorations: A Review

94. DISTANCE BETWEEN LIGHT AND RESIN Ideal distance -1mm Intensity drops off rapidly as the distance from the light to the composite increases BASED ON FILLER: Microfilled composites are more difficult to cure than Macro-filled composites Heavily loaded large inorganic fillers- more easily cured. SHADE OF RESIN: Darker shades cure more slowly and less deeply than lighter shades When aesthetics is not critical lighter shades should be used 24-09-2023 94

95. ANGLE AND PATH OF LIGHT 90 degrees As the angle diverge, light energy is reflected and penetration is reduced In molars, the marginal ridge of the adjacent tooth blocks light when placed at an angle 24-09-2023 95

96. FAILURES A composite restoration is said to have failed when any one or more of the following features are seen clinically: 1.Discoloration 2.Marginal ditching 3.Fracture of the restoration 4.Abnormal wear 5. Secondary caries under or around the restoration etc. 24-09-2023 96

97. FACTORS FOR FAILURE Some of the factors for the failure are: 1. Choice of material for the particular clinical situation 2. Isolation of the operating field 3. Etching and bonding technique 4. Composite layering techniques 5. Adaptation of the composite to the cavosurface margins 6. Curing light intensity and wavelength 7. Distance from the curing tip to the composite 8. Curing time 9. Care during finishing and polishing procedures A well-bonded and adapted , contoured composite resin restoration which has been finished and polished to perfection is considered to last for a long time. 24-09-2023 97

98. RECENT ADVANCES 24-09-2023 98

99. Condensable composites or packable composites or polymer rigid Inorganic matrix material (PRIMM) 24-09-2023 99 This system is composed of a resin matrix and an inorganic ceramic component . Unlike in conventional composites; in this system, the resin is incorporated into the fibrous ceramic filler network rather than including the filler particles into the composite resin matrix. The filler mainly consists of Aluminium oxide, Silicon oxide glass particles or barium aluminium silicate or strontium glasses. Further, colloidal silica ultrafine particles are also incorporated to control the handling characteristics such as viscosity, resistance to flow, condensability and reduced stickiness . The physical and mechanical behaviour of these materials is better than that of hybrid-composites and similar to that of silver amalgam . However, the clinical performance of these materials is identical to that of the hybrid composites . Condensable composites are indicated in class II cavities Rao DB, Chandrappa V. Recent Advances in Dental Composites: An Overview .

100. INDIRECT COMPOSITE RESINS Because of major clinical problems with direct posterior composite resins, the indirect composite inlay/on lay system was introduced. ADVANTAGES: 1. Has superior adaptation . 2. Contour and proximal contact 3. Wear resistance 4. Good aesthetics 5. Control over polymerization technique 24-09-2023 100

101. SECOND GENERATION INDIRECT COMPOSITES These new materials included Artglass ( Heraeus-Kulzer ), BelleGlass HP (Kerr), Targis ( Ivoclar ), Colombus ( Cendres et Métaux ) and Sinfony (ESPE) Sculpture/ FibreKor Gradia Herculite XR & XRV (Kerr) Indirect composites: restorative material systems Dr G. Vasudeva and Dr R. Kaur

102. 24-09-2023 102 Art glass is a nonconventional dental polymer marketed since 1999. It is widely used in making indirect restorations such as inlays, onlays , and crowns. These materials exhibit improved wear resistance and other physical and mechanical properties due to the greater level of crosslinking . A special light curing unit such as Xenon stroboscopic light-curing device with the emission ranges from 300-500 nm is used for curing of these resins . The advantages of these materials include high wear resistance compared to traditional composites, good marginal adaptation and superior proximal contac ART GLASS Rao DB, Chandrappa V. Recent Advances in Dental Composites: An Overview.

103. BELLGLASS HP (Kerr) ( Dentron ) 24-09-2023 103 These materials have increased polymerization rate as they are cured under pressure (29 PSI) at an elevated temperature of 1380C and in the presence of nitrogen gas Wear resistance of the Bellglass HP is increased due to curing in the presence of nitrogen gas. Rao DB, Chandrappa V. Recent Advances in Dental Composites: An Overview GRADIA (GC LAB TECHNOLOGIES) The unique chemistry of Gradia couples a micro-fine ceramic/pre-polymer filler with a urethane dimethacrylate matrix to produce a superior ceramic composite with exceptionally high strength, wear resistance and superior polishability .

104. 24-09-2023 104 Objective The study aimed to evaluate survival and failure behavior of Direct Composite Restorations (DRC) and Indirect Composite Restorations (ICR) on molars and anterior teeth , in a Randomized Controlled Trial (RCT). Methods Patients with generalized severe tooth wear were included, and randomly assigned to one of 2 protocols: (1) DCR: All teeth were restored with directly applied micro-hybrid composite restorations ( Clearfil AP-X, Kuraray) for load bearing areas and nano -hybrid composite restorations (IPS Empress Direct, Ivoclar Vivadent ) for buccal veneers; (2 ) ICR: First molars were restored with indirect composite  ‘tabletop’  restorations and maxillary anterior teeth were restored with indirect palatal veneer restorations ( Clearfil Estenia C&B, cemented with Panavia F, Kuraray). Remaining teeth were restored directly. Restorations were evaluated after 3 years, focusing on clinical acceptability. Statistical analysis was performed using Kaplan Meier curves, Annual Failure Rates (AFRs), and univariate Cox regression analyses (p < 0.05). Crins LAMJ, Opdam NJM, Kreulen CM, et al. Randomized controlled trial on the performance of direct and indirect composite restorations in patients with severe tooth wear.  Dent Mater . 2021;37(11):1645-1654. doi:10.1016/j.dental.2021.08.018

105.  Conclusion This randomized controlled trial showed that for molar restorations, the applied indirect composite is not suitable for use in severe tooth wear patients . Indirect composite restorations in anterior teeth and direct composite restorations for anterior and posterior teeth showed a satisfying performance after a 3-year observation period. 24-09-2023 105

106. ORMOCER Organically Modified Ceramic contains inorganic organic co-polymers in addition to the inorganic silanated filler particles such as urethane and thioether methacrylate alkoxysilanes. Synthesized through a sol-gel process. Described as 3-dimensionally cross-linked co-polymers. Indications: 1. For classes I to V cavities 2. Fractured anteriors 3. Veneering 4. Core buildups 5.Orthodontic bonding adhesives 24-09-2023 106

107. 24-09-2023 107 Comparison of microleakage of Conventional Microfilled Composite resin restorations, Nano composite resin and ORMOCER- An in vitro study The objective of the current study was to determine and compare the microleakage of restorations made with newer materials ORMOCER and Nanocomposite resin with that of Conventional microfilled composites Methodology: 30 premolars were used and prepared with Class II cavities. They were randomly divided into three groups of 10 teeth each, based on the restorative material used. Group I was filled with a Conventional Microfilled Composite ( Filtek Z250 Universal restorative + DX. Bond, which is a total etch light cure adhesive System) Group II with Nanocomposite ( Filtek Supreme XT by 3M ESPE, St Paul, MN, USA + Scotchbond Multipurpose, 3M ESPE) and Group III with ORMOCER ( Admira Fusion Voco + Admira Bond ). The microleakage was assessed by sectioning the teeth and examining them under a stereomicroscope. Conclusion: Compared to Nanocomposite and Conventional microfilled composites , ORMOCER materials demonstrated the least microleakage .

108. FIBER REINFORCED COMPOSITE Glass fibres, carbon fibres, polyethylene fibres, aramid fibres These fibres can be unidirectional, weave type, mesh type etc in the resin matrix to improve physical and mechanical properties. CLINICAL APPLICATIONS: 1. Reinforced direct composite restoration 2. Single indirect restoration 3. Periodontal splinting/ Post- trauma 4. Reinforcing or repairing dentures 5. Fixed orthodontic retainers 24-09-2023 108

109. The purpose of this study was to explore the effects of fibre -reinforced composites and onlay restorations on the fracture resistance of the cracked teeth . The experiments were grouped as follows: intact teeth, cracked teeth, crown; onlay ; annular ribbond + onlay , laminated ribbond + onlay and fibre post + onlay ; annular ribbond + crown, laminated ribbond + crown and fibre post + crown. The maximal Von Mises stress of dentin, the maximal Von Mises stress at the crack, the fracture resistance and fracture pattern under static loading were analysed by single-factor analysis of variance (ANOVA) and post-test by LSD. The annular ribbond + crown had a significant difference in fracture resistance than the crown (P < 0.05). The annular ribbond + onlay had more favourable fractures than crown in fracture pattern, and there were significant differences (P < 0.05). Compared with crown restoration, fibre -reinforced composites and onlay can improve the fracture resistance of the cracked teeth . 24-09-2023 109 Shi R, Meng X, Feng R, et al. Stress Distribution and Fracture Resistance of repairing Cracked Tooth with Fiber-reinforced Composites and Onlay .  Aust Endod J . 2022;48(3):458-464. doi:10.1111/aej.12578

110. GINGIVAL MASKING COMPOSITES An aesthetic gingiva-shaded light-cured composite resin recently introduced, providing practitioners with the option of correcting gingival recession with a minimally invasive and less costly procedure. Pink- colored composite : available in one translucent gingival color and 3 pink flowable opaquers mixed together to better match an individual's gingival shade 24-09-2023 110

111. COMPOMERS Contains the major ingredients of both compo sites and glass Iono mer cements except for water Resin component- bulky macro-monomers, such as bisGMA or UDMA with viscosity-reducing diluents, such as Triethylene glycol dimethacrylate (TEGDMA). Fillers - fluoride containing glasses Advantages: Superior working characteristics to RMGIC Ease of use Easily adapts to the tooth Good aesthetics' EX: DYRACT extra, Compo glass F, Compo glass flow, F2000, Hytac, Glasiosite 24-09-2023 111

112. GIOMERS 24-09-2023 112 The Giomer concept is based on PRG technology where PRG filler are induced in to resin matrix They are: S-PRG (Surface Pre Reacted Glass Ionomer ) marketed as BEAUTIFIIL ( shofu ) F-PRG (Full Pre Reacted Glass Ionomer ) marketed as REACTMER ( shofu ) INDICATIONS: Restoration of root caries Non- carious cervical lesions Class V cavities Caries in deciduous teeth

113. SMART COMPOSITES/STIMULI RESPONSE COMPOSITES Active dental polymers that contain bioactive amorphous calcium phosphate (ACP) filler capable of responding to environmental pH changes by releasing calcium and phosphate ions and thus become adaptable to the surroundings . These are also called as Intelligent composite 1) Ariston phc 2) self repairing/ self healing composites 3) smart monochromatic composites XEX EXEEEX. 24-09-2023 113 Smart composites – A new era in dentisitry , Archieves of dental research 2023

114. SELF –REPAIRING MATERIALS These materials are made of epoxy system with the resin filled microcapsules.

115. SILORANES Sil oxane + oxi ranes Siloxane backbone – hydrophobic nature Ring opening monomers, cationic in nature As silorane-based composite polymerizes, “ ring-opening” monomers connect by opening, flattening and extending toward each other 24-09-2023 115

116. ANTIBACTERIAL COMPOSITES 24-09-2023 116 Various materials are incorporated such as low molecular wieght antibiotics, zinc ions, silver ions, iodine and chlorhexidine Methacryloxydodecyl Pyridinium Bromide( MDPB) By Imazo et al in 1994 Combined antibacterial agent ( hydroxydodecyl pyridinium bromide ) with methacryl group. Bio-active restorative materials with antibacterial effects: new dimension of innovation in restorative dentistry Dental Materials Journal 2009; 28(1): 11－19 Microbes may be killed on direct contact with these materials or through leaching of the antimicrobial materials into the oral environment.

117. The world’s first antibacterial adhesive system ( Clearfil Protect Bond), employing a self-etching primer containing 5％ MDPB. The experimental antibacterial dentin primer was prepared by incorporating MDPB into the primer of a commercial self-etching system (Liner Bond 2 system, Kuraray Medical, Tokyo, Japan) ;

118. HRI enamels The HRI enamels use high refractive index Nano-Zirconium Oxide particles (12%), together with a specially developed silanisation process. The HRI enamels also contain a high refractive index glass filler (68%), and have a Vickers hardness of 700mpa, and a flexural strength of 13,500mpa. Possess same light refractive index as that of natural tooth enamels , and consequently they can be applied over the dentine composite as a much thinner layer; this being virtually as thin as that of the natural tooth enamel. Functions of this material was to balance light reflection and refraction effects. Optident Ltd, International Development Centre , www.optident.co.uk

119. 24-09-2023 119 Sonicfill Composite SonicFill is a bulk fill system comprised of a specially designed handpiece and new, bulk-filled composite material in Unidose tips. SonicFill’s composite incorporates a highly-filled proprietary resin with special modifiers that react to sonic energy. Sonic energy is applied through the hand piece the modifier causes the viscosity to drop upto 87% increasing the flowability the composite, enabling quick placement and precise adaptation to cavity walls. When stopped ,the composite returns to a more viscous,non slumping state for carving and contouring. One can go from placement to a polished restoration in less than 3 minutes in cavities upto 5mm in depth.

120. 24-09-2023 120 ADVANTAGES: - Better flow of material into the cavity than using hand placement + Reliable bulk fill - Reportedly low shrinkage - Excellent for use in core build-ups - no voids DISADVANTAGES: - Possible waste of material due to overfills - longer tips should be manfactured . - Limited variation of shades USAF Dental Evaluation & Consultation Service

121. 24-09-2023 121 SELF ADHESIVE COMPOSITE Self-adhering composites are also called as compobonds An all-in-one etchant, adhesive and restorative allowing one-step placement for most challenging cases. It is the only tooth-colored restorative material balancing the speed and ease of a glass ionomer with the longevity of a bonded composite .

122. 24-09-2023 122 Randomized clinical split-mouth study on a novel self-adhesive bulk-fill restorative vs. a conventional bulk-fill composite for restoration of class II cavities – results after three years Fabian Cieplik at al Randomized prospective split-mouth study evaluated the clinical performance of a novel, tooth-colored, self-adhesive bulk-fill restorative (SABF, 3M) for restoration of class II cavities as compared to a conventional bulk-fill composite ( Filtek One, 3M; FOBF) over 36 months. self-adhesive bulk-fill restorative exhibited clinically fully acceptable results over 36 months of clinical service similar to a conventional bulk-fill restorative used with a universal adhesive , but with slight shortcomings in esthetic properties. Therefore, both restorative materials may be recommended for clinical use.

123. BIOACTIVE COMPOSITES Calcium phosphate and its modified varieties are being used as fillers. Composite releases Ca & phosphate ions form hydroxy apatite-Ca 10( po 4)6 (OH) 2 Enhances reminerlization but have low strength & less stable Journal of biomedical materials research. Part B, Applied biomaterialsDental glass-reinforced composite for caries inhibition: Calcium phosphate ion release and mechanical properties Advantages : Remineralizing potential Disadvantages Calcium- phosphate composites have flexural strengths half of that of unfilled resin Cannot be used as bulk restoratives

124. CONCLUSION 24-09-2023 124 Contemporary composite resin materials have improved significantly over the years, now the materials have good wear resistance and wide variety of shades and translucencies. They are quite polishable and provide excellent esthetics. Major disadvantages like technique sensitivity and polymerization shrinkage can be avoided by placing restorations in excellent isolation in conjunction with meticulous bonding procedures. Properly placed composite resin can provide a very esthetic and durable restoration and the results are gratifying to both patients and clinicians

125. REFERENCES Philips Science of dental materials 11 th edition – K J Anusavise Sturdevants art and science of operative dentistry 4 th edition – T M Roberson Restorative dental materials 11 th edition - Robert G. Craig Dental Materials Science- Rama Krishna Alla TEXTBOOK OF ESTHETICS AND RESTORATIVE DENTISTRY Anterior Matrix Systems for Composite Restorations: A Review Rao DB, Chandrappa V. Recent Advances in Dental Composites: An Overview Indirect composites: restorative material systems Dr G. Vasudeva and Dr R. Kaur Smart composites – A new era in dentisitry , Archieves of dental research 125

126. 24-09-2023 126 Cangül , Suzan & Adıgüzel , Özkan . (2017). The Latest Developments Related to Composite Resins. International Dental Research. 7. 32-41. 10.5577/intdentres.2017.vol7.no2.3. Crins LAMJ, Opdam NJM, Kreulen CM, et al. Randomized controlled trial on the performance of direct and indirect composite restorations in patients with severe tooth wear.  Dent Mater . 2021;37(11):1645-1654. doi:10.1016/j.dental.2021.08.018 Comparison of microleakage of Conventional Microfilled Composite resin restorations, Nano composite resin and ORMOCER- An in vitro study Shi R, Meng X, Feng R, et al. Stress Distribution and Fracture Resistance of repairing Cracked Tooth with Fiber-reinforced Composites and Onlay .  Aust Endod J . 2022;48(3):458-464. doi:10.1111/aej.12578 Bio-active restorative materials with antibacterial effects: new dimension of innovation in restorative dentistry Dental Materials Journal 2009; 28(1): 11－19

127. 24-09-2023 127 Randomized clinical split-mouth study on a novel self-adhesive bulk-fill restorative vs. a conventional bulk-fill composite for restoration of class II cavities – results after three years Fabian Cieplik at al Comparison of polymerization shrinkage of a new bulk‐fill flowable composite with other composites: An in vitro study Somayeh Khoramian Tusi at al Borges MG, Silva GR, Neves FT, Soares CJ, Faria -e-Silva AL, Carvalho RF, Menezes MS. Oxygen inhibition of surface composites and its correlation with degree of conversion and color stability. Brazilian Dental Journal. 2021 Apr 2;32:91-7.

128. 24-09-2023 128 Bio-active restorative materials with antibacterial effects: new dimension of innovation in restorative dentistry Dental Materials Journal 2009; 28(1): 11－19 Vishwanath , Sankar et al. “Finishing and Polishing of Composite Restoration: Assessment of Knowledge, Attitude and Practice Among Various Dental Professionals in India.”  Cureus  vol. 14,1 e20887. 3 Jan. 2022

129. 24-09-2023 129 THANK YOU