Recent advances in direct tooth coloured restoration [autosaved]

Dental Materials

1. Recent Advances in Direct Tooth Coloured Restorative Materials Asmat Fatima JR-II

2. Introduction With the advancement in the field of dentistry, the demand of esthetics has gained popularity. The search for an ideal esthetic material for restoring teeth has resulted in significant improvements in both esthetic materials and techniques for using them. An interpretation of esthetics primarily is determined by an individual's perception and is subject to wide variations.

3. In 1959, Skinner wrote, "The esthetic quality of a restoration may be as important to the mental health of the patient as the biological and technical qualities of the restoration are to his physical or dental health."

4. History 1873 - Thomas Fletcher - first tooth- colored filling material - silicate cement . 1904 - Steenbock introduced an improved version 1948 - first dental acrylic resins - better color stability but significant shrinkage, limited stiffness, and poor adhesion. 1951 - Swiss chemist Oscar Hagger - first dimethacrylate molecule - more durable and color -stable. 1955 - Michael Buonocore - acid etching for increasing the adhesion of acrylic fillings to enamel. 1962 - Ray Bowen - hydrophobic dimethacrylate monomer - Bis-GMA - limited shrinkage and increased fracture resistance. It was first used in a composite in 1969. 1974 - Wilson and Kent , with the assistance of John McLean - first glass-ionomer cement.

5. Properties of ideal tooth- colored restorative material Inhibit Caries Adhere to enamel and dentin Maintain a smooth surface Resemble tooth structure in stiffness Resist water (Insolubility) Maintain marginal integrity Not irritate pulpal tissues Resist leakage Maintain desired colour Place and repair easily Resist wear and fracture

6. Types Of Esthetic Restorative Materials Silicate cements Acrylic resins Glass ionomers Composites

7. Silicate cement First translucent filling material introduced in 1878 by Fletcher in England Used extensively to restore carious lesions in the anterior teeth for over 60 years Powder - acid-soluble glass made by fusing CaO , SiO 2 , Al 2 O 3 , and other ingredients with a fluoride flux at 1400 o C. Liquid - buffered phosphoric acid solution

8. Advantages High caries index patients Tooth-matching ability Ease of manipulation Anticariogenic quality Good insulator Coefficient of thermal expansion equals to enamel Disadvantages Contra indicated in Mouth breathers Tendency to stain and erode in oral fluids and to eventually disintegrate Poor strength Irritation to pulp(Ph - 1.43 at 2 min, becomes 5 after 24 hr ) Brittleness

9. Acrylic resin Self-curing (chemically activated) acrylic resin for anterior restorations was developed in Germany in the 1930s Rarely used today, but, as with silicate cement restorations, may be seen in older patients. Was most successful in protected areas of teeth where temperature change, abrasion, and stress were minimal.

10. A dvantages Aesthetic Insolubility in oral fluids Low cost and ease of manipulation Disadvantages Lack of abrasion and wear resistance High polymerisation shrinkage and LCTE Poor marginal seal - microleakage Colour changes No bonding to tooth structure Irritation and injury to pulp Poor strength and hardness

11. Glass ionomer cements First developed by Wilson and Kent in 1972 Release fluoride into the surrounding tooth structure, yielding a potential anticariogenic effect , and possess a favorable coefficient of thermal expansion . Unlike the silicate cements that have a phosphoric acid liquid, glass ionomers use polyacrylic acid , which renders the final restorative material less soluble .

12. Glass ionomer is a water- based material that hardens following an acid base reaction between fluroaluminosilicate glass particles and an aqueous solution of polyalkenoic (polyacrylic) acid. Composition POWDER (Calcium Fluroaluminosilicate ) Alumina (28.6%) Alumina: Silica --> 1:2 Silica (41.9%) Calcium Fluoride (15.7%) Aluminium Phosphate (3.8%) Cryolite Na + , K + , Ca 2+ La 2 O 3 , SrO LIQUID Polyacrylic acid (40 to 50%) Polyacrylic: Itaconic-- > 2:1 Itaconic acid Maleic acid Tricarboxylic acid Tartaric acid (5-15%) Polyphosphates Metal oxides Water

13. Setting Reaction

14. Properties ADHESION: The chemical adhesion of GIC to enamel and dentin is achieved by reaction of phosphate ions in the dental tissue with carboxylate groups from the polyacrylic acid. Aesthetics - Translucency due to glass fillers Bond strength - Enamel- 2.6 to 9.6 Mpa ; Dentin – 1.1 to 4.5 Mpa Strength: Compressive strength- 150 Mpa Tensile strength- 6.6 Mpa KHN - 48 Abrasion resistance : Satisfactory if material is supported by sound tooth structure.

15. Advantages Ability to release fluoride Initial release of up to 10 ppm and a constant long-term release of 1 to 3 ppm over 100 months was reported

16. Classification Type I- Luting Type II- Restorative Type III- Liner/ Base Type IV- Pit & Fissure Sealant Type V- Luting for Orthodontic Purpose Type VI- Core build up material Type VII- High fluoride releasing command set Type VIII- ART Type IX- Geriatric & Paediatric GIC In endodontics - Sealing and restoring the pulp chamber and repairing the perforation

17. Recent Advances In GIC High viscosity GIC Low viscosity GIC Metal modified GIC Resin modified GIC Smart GIC Fiber reinforced GIC Giomers Compomers Nano-ionomers

18. High Viscosity GIC Developed as an alternative to amalgam. Packable / condensable glass ionomer cements INDICATIONS : Primary molar restoration Intermediate restoration Core build up material For ART ADVANTAGES : Improved wear resistance Low solubility Rapid finishing possible Decrease moisture sensitivity DISADVANTAGES : Limited life Moderately polishable Not esthetic FUJI-IX GP FUJI-IX GP FAST

19. Low Viscosity GIC Also called as Flowable GIC Low P:L ratio thus increase flow. Use for lining, pit and fisure sealer, endodontic sealer and for sealing hyper sensitive cervical area. Fuji lining LC Ketac -Endo

20. Metal- Modified GIC Seed & Wilson (1980) invented miracle mix – Spherical silver amalgam alloy + Type II GIC in ratio 7:1 Mc lean & Gasser (1985) invented ceremet – Glass powder sintered to metal fillers (<5%) at 800 °C Minimal improvement in mechanical property Compressive strength – 150 Mpa Modulus of elasticity is slightly lower KHN – 39 Tensile strength – slightly more 6.7 Mpa Slight increase in wear resistance Fluoride release Maximum for miracle mix (3350 µg - 4040 µg ) Minimum for cermets (200 µg - 300 µg )

21. Resin Modified GIC The strength of glass ionomers was improved through the addition of methacrylate monomer in the aqueous polyalkenoic acid solution as well as the addition of monomer containing free radical double bonds in the fluoroaluminosilicate -containing component Defined as hybrid cement that sets partly by acid base reaction and partly by polymerisation reaction (Mc Lean) Powder – Ion leachable glass and initiators Liquid – water, Poly acrylic acid, HEMA (15-25%), methacrylate monomers. Setting reaction:- Dual cure

22. Properties Esthetic – Superior than conventional GIC Fluoride release : Conventional GIC - 440 µ gF after 14 days ; 650 µ gF after 30 days RMGIC-1200 µ gF after 14 days ;1600 µ gF after 30 days Strength : Diametral strength Conventional GIC: 6.6Mpa RMGIC: 20 Mpa Compressive strength Conventional GIC:150Mpa RMGIC: 105Mpa Hardness : Conventional GIC:48KHN RMGIC:40KHN Marginal adaptation: poor compared to conventional GIC

23. Uses As a luting cement (FUJI PLUS, Ketac-cem , Fuji Cem )

24. As a liner and bases (Fuji LC) As a pit and fissure sealant ( Vitre Bond) Core build up material (Fuji I LC) Retrograde filling material

25. Self hardening RMGIC Activated purely by chemical polymerisation reaction Contains benzoyl peroxide and T-Amines Advantages Ease of handling Fluoride release Higher compressive strength No additional set up for light activation Uses : Luting of stainless steel crown, orthodontic brackets, space maintainers.

26. Low pH “Smart” GIC Smart materials are materials that have properties which may be altered in a controlled fashion by stimuli, such as stress, temperature, moisture, pH, electric or magnetic fields Releases fluoride when pH falls below the critical level Fluoride release is episodic and not continuous

27. Fiber-reinforced Glass Ionomer Cements Al and SiO 2 fibers added to glass powder (PRIMM - Polymer rigid Inorganic matrix material) Diameter of fiber is 2 µm. Advantages : Increased wear resistance. Improved handling characteristics Increased depth of cure Reduction of polymerization shrinkage Improved flexure strength(50Mpa)

28. Giomers True hybridization of GIC and composite Based on PRG (Pre-reacted Glass) technique - PRG composites These products contain pre-reacted glass–ionomer filler in a resin matrix. The fluoro - alumino -silicate glass has been prereacted with polyacid to form a glass–ionomer matrix structure and then blended with resin As a more extensive acid–base reaction has been carried out before blending with resin, the hydrogel layer of the glass filler in the giomer is more extensive than that in the compomers. If the glass–ionomer hydrogel matrix is the key factor to control fluoride uptake and re-release, it is expected that the giomer will demonstrate a more effective fluoride recharging characteristic than other resin–matrix materials.

29. Combine fluoride release and fluoride recharge of GIC Esthetic with easy polishability and strength of composite Considered as light-cure composite - does not have a significant acid-base reaction as part of its curing process and cannot set in the dark. Bonding system - Reactmer bond ( Shofu Inc. Kyoto, Japan). Giomers contain essential components of glass ionomer cements but they cannot be classified as compomers as the acid base reaction has already occurred

30. Indications Class I, II, III, IV, and Class V cavities Restoration of cervical erosion and Root caries Laminates and core build up Restoration of primary teeth. Repair of fracture of porcelain and composites

31. Polyacid Modified composite resin Also called as compomer Composites to which some glass-ionomer components have been added. Defined as : material that contain both the essential components of GIC but in an amount insufficient to carry out acid base reaction in dark. They are developed to combine the best properties of fluoride release of GIC and durability of composite No water Set via a free radical polymerization reaction Significantly lower levels of fluoride release than GICs

32. Composition : one paste system containing ion leachable glass, sodium fluoride, polyacid modified monomer but no water Recently 2 paste or powder liquid system is introduced. Powder : Strontium aluminium flurosilicate glass particles, metal oxides,and intiators Liquid : Polymerizable methacrylate/ caboxylic acidic monomers multi functional acrylate monomers and water

33. Setting reaction Initially light curing forms resin network around the glass After 2 to 3 month there is water uptake which initiates slow acid base reaction and fluoride release. Properties Adhesion –Micromechanical, absence of water thus no self adhesion Fluoride release minimal ( 20% of a conventional glass ionomer ) Physical properties better than conventional GIC but less than composite. Optical properties superior to conventional GIC.

34. Uses Pit and fissure sealant Restoration of primary teeth Liners and bases Core build up material For class III & V lesions Cervical erosion / abrasion Repair of defective margins in restorations Sealing of root surfaces for over dentures Reterograde filling material.

35. Commercial Products Compoglass F Principle Compoglass Flow

36. Significant differences were seen in fluoride release of different days and materials (p<0.05). The maximum cumulative fluoride release of days 1-7 was related to Fuji VII, followed by Fuji IX Extra, Fuji II LC, Fuji IX, Dyract Extra and Beautifil in descending order and this order remained the same until the 21 st  day.

37. Nano-ionomer Combination of fluoroaluminosilicate glass, nanofillers , and nanofiller clusters. It also shows high fluoride release that is rechargeable after being exposed to a topical fluoride source.

38. Powder-Modified Nano Glass Ionomers Modification Using Nano-Apatite Modification with Nano-Sized HAp / Zr , CaF2 and TiO2 Particles

39. Modification Using Nano-Apatite Due to their chemistry being similar to that of mineralized bone and dental tissues nano hydroxyapatite (nHAp) crystals can favor remineralization of enamel Addition of apatite to GIC powder increases the crystallinity of the set GIC, hence improving the chemical stability and water insolubility. Superior bonding to the tooth surface due to the possibility of the formation of the strong ionic linkages between the apatite crystals/particles in the cement and Ca-ions in the tooth structure. Lee, J.J.; Lee, Y.K.; Choi, B.J.; Lee, J.H.; Choi, H.J.; Son, H.K.; Hwang, J.W.; Kim, S.O. Physical properties of resin-reinforced glass ionomer cement modified with micro and nano-hydroxyapatite. J. Nanosci . Nanotechnol . 2010, 10, 5270–5276

40. Composites 42

41. Composites Three dimensional combination of at least two chemically different materials with a distinct interface separating the components Filled resins – reinforced with inorganic fillers Composition Resin matrix – monomer- BISGMA, TEGDMA, UDMA – initiator (Chemical- Benzoyl Peroxide (Light- Camphorquinone ) – inhibitors – pigments Inorganic filler – glass, quartz, colloidal silica, barium , lithium Coupling Agent – Silane coupling group ( difunctional)

42. History 1962 – Bis-GMA – stronger resin 1969 – filled composite resin – improved mechanical properties – less shrinkage 1970’s – acid etching and microfills 1980’s – light curing and hybrids 1990’s – flowables and packables 2000’s – nanofills 2010’s – New monomers, low shrinkage

43. Classification ( based on filler) Homogenous composites – Macrofill (10-100µm) Midifill (1-10µm) Minifill (0.1 -1µm) Microfill (0.01-0.1µm) Nanofill (0.001-0.01µm) Heterogeneous composites Hybrid composites . Microhybrids (0.6 to 1 lm and 40 nm). Nanohybrid -combination of microhybrid and nanofilled -size particles

44. Properties FLEXURAL STRENGTH 100- to 150-megapascal LINEAR COEFFICIENT OF THERMAL EXPANSION (LCTE) The LCTE of improved composites is approximately three times that of tooth structure; that for hybrid glass ionomer is 1.5 to 2 times that of tooth structure. WEAR RESISTANCE The filler particle size, shape, and content affect the potential wear of composites.

45. WATER ABSORPTION Materials with higher filler contents exhibit lower water absorption values. SURFACE TEXTURE The size and composition of the filler particles primarily determine the smoothness of a restoration, as does the material's ability to be finished and polished. Modulus of Elasticity A more flexible material such as a microfill composite allows the restorations to bend with the tooth, thereby better protecting the bonding interface. Stress breaking liners that possess a lower elastic modulus also can be used to better protect the bonding interface.

46. Polymerization Shrinkage Potential problems associated with composites Minimized but cannot be totally elimination CONFIGURATION FACTOR (C-FACTOR) The C-factor is the ratio of bonded surfaces to the unbonded, or free, surfaces in a tooth. Higher the C-factor, the greater is the potential for bond disruption from polymerization effects.

47. How to minimize shrinkage (1) " soft-start" polymerization instead of high-intensity light-curing, (2) incremental additions to reduce the effects of polymerization shrinkage, and (3) a stress-breaking liner, such as a filled dentinal adhesive or RMGI.

48. Recent Advancement

49. Flowable Composites (1996) Micro filled or hybrid resins with a reduced viscosity . Lower filler levels results in reduced strength and wear resistance. More resin- higher shrinkage value Used today more as a base and liner because of its flow characteristics, which allow it to adapt to tooth surfaces quite well COMMERCIAL PREPARATIONS FioRestore Flow-it Tetric Flow ( Vivadent )

50. Uses Pit & Fissure sealants Class V restorations Cervical wear processes Preventive resin restoration (Minimally invasive occlusal Class I restorations Cavity liners Bonding orthodontic brackets Baroudi, K. (2015).  Flowable Resin Composites: A Systematic Review and Clinical Considerations. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH.

51. Packable Composites (1998) Composite resins with a high percentage of filler (Higher viscosity) This system is composed of a resin matrix and an inorganic ceramic component. PRIMM – Polymeric rigid Inorganic matrix material. Fillers – Scaffold of Ceramic fibres (2micron) Ceramic fibres : Aluminium , Silicon Dioxide Silanization

52. Advantages -condensability (like silver amalgam) - greater ease in achieving a good contact point - better reproduction of occlusal anatomy -Increased flexural strength -Reduced polymerization shrinkage D isadvantages - difficulties in adaptation between one composite layer and another - difficult handling -poor aesthetics in anterior teeth. Their main indication is Class II cavity restoration in order to achieve a better contact point

53. Available materials Solitaire Alert Surefill Filtek P60 Prodigy condensable Pyramid BISCO Synergy Compact

54. Low Shrinkage Composite In the last few years, low shrinkage composites have been presented, with a concept of bulk filling in a flowable consistency for use as a cavity base/liner, and also in a regular consistency to be conventionally used in the entire restoration. A more recent generation of resin composites with photoinitiators , such as urethane-based patented monomer, allowed for indication of bulk filling of layers up to 4 mm thickness. This composite was named Smart Dentin Replacement (SDR) flowable composite (Dentsply, York, PA, USA). Hirata, R., Kabbach , W., de Andrade, O. S., Bonfante , E. A., Giannini, M., & Coelho, P. G. (2015).  Bulk Fill Composites: An Anatomic Sculpting Technique. Journal of Esthetic and Restorative Dentistry, 27(6), 335–343.  

55. Techniques for improved shrinkage stress distribution The Layering Technique By using an incremental layering technique, the resin composite is bonded to a reduced number of cavity walls that decreases the C-factor thus reducing its shrinkage levels

56. Hirata, R., Kabbach , W., de Andrade, O. S., Bonfante , E. A., Giannini, M., & Coelho, P. G. (2015).  Bulk Fill Composites: An Anatomic Sculpting Technique. Journal of Esthetic and Restorative Dentistry, 27(6), 335–343.  

57. Bulk Fill Flowable and Regular Composite: Two-Step Amalgam-Like Sculpting Technique

58. Hirata, R., Kabbach , W., de Andrade, O. S., Bonfante , E. A., Giannini, M., & Coelho, P. G. (2015).  Bulk Fill Composites: An Anatomic Sculpting Technique. Journal of Esthetic and Restorative Dentistry, 27(6), 335–343.  

59. Bulk Fill Regular Composite: One-Step Amalgam-Like Sculpting Technique

60. Hirata, R., Kabbach , W., de Andrade, O. S., Bonfante , E. A., Giannini, M., & Coelho, P. G. (2015).  Bulk Fill Composites: An Anatomic Sculpting Technique. Journal of Esthetic and Restorative Dentistry, 27(6), 335–343.  

61. Alqudaihi , F., Cook, N., Diefenderfer , K., Bottino , M., & Platt, J. (2018).  Comparison of Internal Adaptation of Bulk-fill and Increment-fill Resin Composite Materials. Operative Dentistry.  

62. Loguercio , A. D., Rezende, M., Gutierrez Reyes, M. F., Costa, T. F., Armas-Veja , A., & Reis, A. (2019).  Randomized 36-month Follow-up of Posterior Bulk-Filled Resin Composite Restorations. Journal of Dentistry

63. Ceromers (Ceramic Optimized polymer) Microfilled hybrid resins or universal composite resins Utilizes combinations of ceramic fillers to provide precise and controlled placement, wear, and aesthetic properties.

64. Composition Specially developed and conditioned fine particle ceramic fillers of sub-micron size (0.04 and 1.0 micron), which are closely packed (75 – 85 weight percent) and embedded in an advanced temperable organic polymer matrix. Consists of a paste containing barium glass (<1 mm), spheroidal metal oxide, ytterbium trifluoride, and silicon dioxide (57 vol%) in dimethacrylate monomers (bis-GMA and UDMA). Tetric Flow (Flowable Ceromer ) and Tetric Ceram (Direct Ceromer , lvoclar Vivadent , Amherst, NY) incorporate a catalyst system which renders the material less sensitive to ambient light.

65. Ormocer Organically modified ceramics ( ormocers ) were introduced to overcome problems of polymerization shrinkage associated with conventional methacrylate-based resin composites. Ormocers contain inorganic-organic copolymers in addition to inorganic filler particles. Ormocers have shown lower wear rates compared to other composites and similar shrinkage to hybrid composites despite their lower filler content. Commercially two types of Ormocer based materials are available: Definite (Degussa) Admira

66. Due to their organic and inorganic elements, the structure of Ormocers closely resembles that of a natural tooth. Their coefficient of thermal expansion also approximates that of natural tooth structure, which is very practical. In the mouth, which may be exposed to considerable temperature fluctuations, no stresses are recorded between the tooth structure and filling material in extensive cavities. Due to their cross-linking and chemical structure, it is a highly biocompatible filling material.

67. SMART Composites Introduced as Ariston pHc ( Vivadent ) in 1998. Involve embedding micron-size sensor particles or "tags" into a composite product which interact with their host structures and generate quantifiable ions. Smart Composites containing ACP (amorphous calcium phosphate) have an extended time release nature and is one of the biologically important source for calcium and phosphates, exhibiting the most rapid conversion to crystalline hydroxyapatite (HAP)

68. So when the pH level in the mouth drops below 5.8, these ions merge within seconds to form a gel. In less than 2 minutes , the gel becomes amorphous crystals, resulting in release of fluoride, hydroxyl, and calcium and phosphate ions in the area immediately adjacent to the restorative material. This results in a reduced demineralization and a buffering of the acid produced by caries forming micro-organisms. When low pH values (at or below 5.8) - during a carious attack ACP converts into HAP and precipitates Replacing the HAP lost to the acid

69. Fiber- Reinforced Composites FRCs are structural materials that have at least two distinct constituents. The reinforcing component provides strength and stiffness, while the surrounding matrix supports the reinforcement and provides workability FRCs can be divided according to the reinforcement and polymer matrices used Glass fibres are the most commonly used reinforcing fibre in dental applications. Carbon/graphite, aramid, boron and metal fibres are also use Silane coupling agents have been used successfully to improve the adhesion between the polymer matrix and glass fibres Eg : Vectris FRC Material

70. Properties Higher flexure strength Excellent in compression, increased hardness Increased resistance to crack propagation Increased resistance to contact damage. Potential for unique optical and thermal properties. Very low thermal expansion (structural stability) Decreased wear of opposing dentition (as compared to porcelain)

71. Badakar , C. M., Shashibhushan , K. K., Naik, N. S., & Reddy, V. V. S. (2011).  Fracture resistance of microhybrid composite, nano composite and fibre-reinforced composite used for incisal edge restoration. Dental Traumatology, 27(3), 225–229

72. Specialized Formulations Specialized composite for Core build-up Composites for cementing post and core Orthodontic composite Luting and cementing composite

73. Nano composites Composite resin characterised by containing nanoparticles measuring approximately 25 nm and nanoaggregates of approximately 75 nm , which are made up of zirconium/silica or nanosilica particles. Nanohybrid and nanofilled are generally the two types of composite restorative materials characterized by filler-particle sizes of ≤100 nm referred to under the term “nanocomposite”. Nanofilled composites use nanosized particles throughout the resin matrix, nanohybrids include a mixture of nanosized and conventional filler particles The main aim of incorporating nanofillers into resin composites ( ie , nanocomposites) is to create materials that can be used to restore both anterior and posterior teeth with a high initial polish and gloss

74. 2 kinds of nanofiller particles Nanomeric particles (NM) Nanoclusters (NC) monodisperse non-aggregated zirconia-silica particles particles of silica and non-agglomerated silica nanoparticles

75. Advantages More filler can be accommodated if smaller particles are used for particle packing. Theoretically, with the use of nanofillers, filler levels could be as much as 90 - 95% by weight The lower size of the particles leads to less curing shrinkage Negligible marginal leakage, colour changes, bacterial penetration and possible post operative sensitivity Superior flexural strength, modulus of elasticity, and translucency

76. Disadvantages The drawback is that since the particles are so small they do not reflect light, so they are combined with larger-sized particles, with an average diameter within visible light wavelengths (i.e. around or below 1μm), to improve their optical performance and act as a substrate

77. Properties Of Nano-composites Polymerization shrinkage : 1.4% to 1.6% Water Sorption : nanohybrid composites show less water sorption than nanofill composite higher sorption and solubility values were found for nanocomposites compared with hybrid composites Flexural strength of nanocomposites were found to be statistically equivalent or higher than those of the hybrid or microhybrid composites and significantly higher than those of the microfill composites Commercially available nanocomposite materials do not hold any significant advantage over hybrid composites in terms of strength and hardness. Alzraikat , H., Burrow, M., Maghaireh , G., & Taha, N. (2018).  Nanofilled Resin Composite Properties and Clinical Performance: A Review. Operative Dentistry, 43(4), E173–E190.  doi:10.2341/17-208-t 

78. Other features of Nano-composites

79. TYPES OF NANOCOMPOSITES

80. Trade names Filtek O Supreme Universal Restorative Pure Nano Premise, Kerr/Sybron, Orange Trade name of nanohybrids : NANOSIT™ nanohybrid composite ( Nordiska Dental, Angelholm , Sweden Trade name of nanofills : Filtek ™ Supreme Plus [3M ESPE], Estelite ® Sigma [Tokuyama America, Inc., Encinitas, CA, USA]

81. Conclusion In the quest for a single material that might meet all requirements for the ideal restorative, composites and glass ionomers have both evolved as a good option.