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Restorative Composite Resins Col Kraig S. Vandewalle USAF Dental Evaluation & Consultation Service.

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Presentation on theme: "Restorative Composite Resins Col Kraig S. Vandewalle USAF Dental Evaluation & Consultation Service."— Presentation transcript:

1 Restorative Composite Resins Col Kraig S. Vandewalle USAF Dental Evaluation & Consultation Service

2 Official Disclaimer The opinions expressed in this presentation are those of the author and do not necessarily reflect the official position of the US Air Force or the Department of Defense (DOD) Devices or materials appearing in this presentation are used as examples of currently available products/technologies and do not imply an endorsement by the author and/or the USAF/DOD

3 Overview Direct restoratives –composition –classification –performance factors Flowable Packables Click here for briefing on composite resins (PDF)here

4 Composite Material with two or more distinct substances –metals, ceramics or polymers Dental resin composite –soft organic-resin matrix polymer –hard, inorganic-filler particles ceramic Most frequently used – esthetic-restorative material Leinfelder 1993

5 History 1871 – silicates –alumina-silica glass & phosphoric acid –very soluble –poor mechanical properties 1948 - acrylic resins –polymethylmethacrylate –high polymerization shrinkage Rueggeberg J Prosthet Dent 2002

6 History (cont.) 1962 – Bis-GMA –stronger resin 1969 – filled composite resin –improved mechanical properties –less shrinkage –paste/paste system 1970’s – acid etching and microfills 1980’s – light curing and hybrids 1990’s – flowables and packables 2000’s – nanofills Rueggeberg J Prosthet Dent 2002

7 Indications Anterior restorations Posterior restorations –preventive resin –conservative class 1 or 2

8 Contraindications Large posterior restorations Bruxism Poor isolation

9 Advantages Esthetics Conservation of tooth structure Adhesion to tooth structure Low thermal conductivity Alternative to amalgam

10 Disadvantages Technique sensitivity Polymerization shrinkage –marginal leakage –secondary caries –postoperative sensitivity Decreased wear resistance

11 Composition Resin matrix –monomer –initiator –inhibitors –pigments Inorganic filler –glass –quartz –colloidal silica Coupling Agent OCH 2 CHCH 2 O-C-C=CH 2 CH 2 =C-C-O-CH 2 CH-CH 2 O-C- CH 3 OH OO Bis-GMA Phillip’s Science of Dental Materials 2003

12 Monomers Binds filler particles together Provides “workability” Typical monomers –Bisphenol A glycidyl methacrylate (Bis-GMA) –Urethane dimethacrylate (UEDMA) –Triethylene glycol dimethacrylate (TEGMA) CH 2 =C-C-O-CH 2 CH 2 -O-C-NHCH 2 CH 2 CHCH 2 -C-CH 2 -NH-C- CH 3 OCH 2 CH 2 O-C-C=CH 2 CH 3 OOOO OCH 2 CHCH 2 O-C-C=CH 2 CH 2 =C-C-O-CH 2 CH-CH 2 O-C- CH 3 OH OO CH 2 =C-C-O-CH 2 CH 2 -OCH 2 CH 2 CH 3 OCH 2 CH 2 O-C-C=CH 2 CH 3 OO

13 Monomers Bis-GMA –extremely viscous large benzene rings –lowered by adding TEGDMA freely movable increases polymer conversion increases crosslinking increases shrinkage CH 2 =C-C-O-CH 2 CH-CH 2 O-C-OCH 2 CHCH 2 O-C-C=CH 2 CH 3 OH OO

14 Monomers Shrinkage –2 – 7 % –marginal gap formation

15 Filler Particles Crystalline quartz –larger particles –not polishable Silica glass –barium –strontium –lithium –pyrolytic sub-micron Phillip’s Science of Dental Materials 2003

16 Filler Particles Increase fillers, increase mechanical properties –strength –abrasion resistance –esthetics –handling 50 to 86 % by weight 35 to 71% by volume 0 0.5 1 1.5 2 Fracture Toughness 02837485362 % Filler Volume Ferracane J Dent Res 1995

17 Coupling Agent Chemical bond –filler particle - resin matrix transfers stresses Organosilane (bifunctional molecule) –siloxane end bonds to hydroxyl groups on filler –methacrylate end polymerizes with resin CH 3 -C-C-O-CH 2 -CH 2 -CH 2 -Si-OH CH 2 OOH Bonds with filler Silane Bis-GMA Bonds with resin Phillip’s Science of Dental Materials 2003

18 Inhibitors Prevents spontaneous polymer formation –heat –light Extends shelf life Butylated Hydroxytoluene Phillip’s Science of Dental Materials 2003

19 Pigments and UV Absorbers Pigments –metal oxides provide shading and opacity titanium and aluminum oxides UV absorbers –prevent discoloration –acts like a “sunscreen” Benzophenone Phillip’s Science of Dental Materials 2003

20 Visible-Light Activation Camphorquinone –most common photoinitiator absorbs blue light –400 - 500 nm range Initiator reacts with amine activator Forms free radicals Initiates addition polymerization OCH 2 CHCH 2 O-C-C=CH 2 CH 2 =C-C-O-CH 2 CH-CH 2 O-C- CH 3 OH OO Bis-GMA

21 Polymerization Initiation –production of reactive free radicals typically with light for restorative materials Propagation –hundreds of monomer units –polymer network –50 – 60% degree of conversion Termination Craig Restorative Dental Materials 2002

22 C=C polymerization Ferracane

23 Classification System Historical Chronological Based on particle size –traditional –microfilled –small particle –hybrid Phillip’s Science of Dental Materials 2003

24 Traditional (Macrofilled) Developed in the 1970s Crystalline quartz –produced by grinding or milling –large - 8 to 12 microns Difficult to polish –large particles prone to pluck Poor wear resistance Fracture resistant Examples: Adaptic, Concise Suitable for Class 3, 4 and 5 Phillip’s Science of Dental Materials 2003

25 Microfills Better esthetics and polishability Tiny particles –0.04 micron colloidal silica –increases viscosity To increase filler loading –filler added to resin –heat cured –ground to large particles –remixed with more resin and filler Ground polymer with colloidal silica (50 u) Polymer matrix with colloidal silica Phillip’s Science of Dental Materials 2003

26 Microfills Lower filler content –inferior properties increased fracture potential lacks coupling agent lacks radiopacity Linear clinical wear pattern Suitable for Class 3, 5 –exceptions with reinforced microfills Class 1 or 2 Click here for table of microfillshere

27 Small Particle 1 - 5 micron heavy-metal glasses Fracture resistant Polishable to semi-gloss Suitable for Class 1 to 5 Example: Prisma-Fil Silane-coated silica or glass (1-5 u) Polymer matrix Phillip’s Science of Dental Materials 2003

28 Hybrids Popular as “all-purpose” –AKA universal hybrid, microhybrids, microfilled hybrids 0.6 to 1 micron average particle size –distribution of particle sizes maximizes filler loading –microfills added improve handling reduce stickiness Silane-coated silica or glass Polymer matrix with colloidal silica Phillip’s Science of Dental Materials 2003

29 Hybrids Strong Good esthetics –polishable Suitable –Class 1 to 5 Multiple available Click here for table of hybridshere

30 PropertyTraditionalMicrofilled Small Particle Hybrid Compressive strength (MPa) 250-300 350-400300-350 Tensile strength (MPa)50-6530-5075-9070-90 Elastic Modulus (GPa)8-153-615-207-12 Coefficient of Thermal Expansion (10 -6 /ºC) 25-3550-6019-2630-40 Knoop Hardness555-3050-60 Phillip’s Science of Dental Materials 2003 Table of Properties

31 Newer Classification System Based on particle size –megafill 0.5 - 2 millimeters –macrofill 10 - 100 microns –midifill 1 - 10 microns –minifill 0.1 - 1 microns –microfill 0.01 - 0.1 microns –nanofill 0.005-0.01 microns Most new systems –minifillers Newest trend –nanofillers –trimodal loading prepolymerized Bayne JADA 1994

32 Midi-filler- 2 um (beachball) Mini-filler- 0.6 um (canteloupe) Nanofiller-.02 um (pea) Microfiller-.04 um (marble) Relative Particle Sizes (not to scale)

33 Nanofill vs. Nanohybrid Nanofills –nanometer-sized particles throughout matrix Nanohybrids –nanometer-sized particles combined with more conventional filler technology Swift J Esthet Restor Dent 2005

34 Nanofilled Composite Filtek Supreme (3M ESPE) Filler particles –filled: 78% wgt –nanomers 0.02 – 0.07 microns –nanocluster act as single unit –0.6 – 1.4 microns Click here for technical profile Click here for DECS evaluationhere

35 Performance Factors Material factors –biocompatibility –polymerization shrinkage –wear resistance –polish mechanisms –placement types –mechanical & physical properties

36 Biocompatibility Tolerated by pulp –with good seal Rare allergic reactions –HEMA Cytotoxicity –short lived not a chronic source Degree of cure important –decrease free monomer Phillip’s Science of Dental Materials 2003

37 Systemic Estrogenic effects seen in cell cultures –impurities in Bis-GMA-based resins Bis-phenol A in sealants –Olea EHP 1996 »click here for abstracthere –however, insignificant short-term risk literature review –Soderholm JADA 1999 »click here for abstracthere

38 Polymerization Shrinkage Significant role in restoration failure –gap formation secondary caries formation marginal leakage post-operative sensitivity Counteract –lower shrinkage composites –incremental placement

39 Composite Wear Less wear –small particle size less abrasion –heavier filled less attrition –non-contact areas 3 - 5 times less –less surface area –anterior location premolars vs. molars Hilton Oper Dentistry: A Contemporary Approach 2001

40 Composite Wear Reduced wear with smaller particles –less plucking leaving voids Higher filler loads for enhanced properties –correlations between wear and fracture toughness and flexure strength Higher cure of resin matrix to resist scratching and gouging by abrasives Hilton Oper Dentistry: A Contemporary Approach 2001

41 Polish Mechanisms Acquired polish –clinician induced Inherent polish –ultimate surface Microfills –high acquired, high inherent similar resin matrix and fillers wear more evenly Hybrids –high acquired, acceptable inherent Adept Report 1992

42 Small Particle HybridMicrofilled Composite Time Acquired Polish Inherent Polish Polish Mechanisms Adept Report 1992 Linear wear pattern

43 Shaded vs. Anatomic Placement Shaded –shade selected from middle third of tooth –shade guide gives recipe for multiple shades Anatomic –highly chromatic dentin matched to existing dentin –colorless enamel replaces existing enamel Click here for detailshere

44 ShadedAnatomic Trans Enamel A3/A4 Dentin Enamel Value A1 Dentin A1 Enamel Dentists Ceramists “Match Shade” “Create Shade” Trans Enamel

45 Placement Types Composite Brands Shaded –4 Seasons (Ivoclar Vivadent) –Esthet-X (Dentsply) –Filtek Supreme (3M ESPE) –Point 4 (Kerr) –Venus (Heraeus Kulzer) –Renamel (Cosmedent) –Gradia Direct (GC) Anatomic –4 Seasons (Ivoclar Vivadent) –Vitalescence (Ultradent) –Miris (Coltene/Whaledent) Jackson PPAD 2003

46 Composite Selection Anterior/stress (Class 4) –hybrid mini- or midi-fill –hybrid/microfill veneer combo Anterior/non-stress (Class 3 or 5) –hybrid mini-fill –microfill

47 Composite Selection Posterior –hybrid mini- or midi-fill –reinforced microfill

48 Selecting a Brand Contents of kit –shades –bonding agent –unit-dose compules vs syringes Indications –anterior, posterior, both? Cost of kit –refills Click here for synopsis of restorative composite resinshere

49 Government Price ($/gm of refill resin) Prices current as of Jan 05

50 Selecting a Brand Results of lab and clinical studies Compositional characteristics –% filler content –average filler particle size Click here for synopsis of restorative composite resinshere

51 Radiopacity (mm of aluminum) Source: USAF DECS Project 03-024 ISO Requirement

52 Surface Hardness (24 hrs) Horizontal lines connect nonsignificant differences (p<0.05); N=5 Source: USAF DECS Project 03-37 KHN

53 Flexural Strength (24 hrs) Horizontal lines connect nonsignificant differences (p<0.05); N=5 Source: USAF DECS Project 03-037

54 Volumetric Shrinkage % Horizontal lines connect nonsignificant differences (p<0.05); N=5 Source: USAF DECS Project 03-037

55 Composite Variants Packable Flowable

56 Packable Composites Marketed for posterior use –increase in viscosity better proximal contacts? handle like amalgam? Subtle alteration of filler –shape –size –particle distribution Similar resin chemistry and filler volume Click here for table of packable compositeshere

57 Packable Composites Mechanical properties –similar to hybrids Choi J Esthet Dent 2000 Click here for abstracthere 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 ALERT Solitare SureFil Heliomolar Z100 Fracture Toughness

58 Proximal Contact Studies Packables similar to hybrids –diameter and tightness Best contacts –sectional matrix system Peumans Dent Mater 2001 -c lick here for abstract Klein Am J Dent 2002here

59 Depth of Cure Packable Composite Resin % Hardness Ratio Choi J Esthet Dent 2000 Click here for abstracthere

60 Packable Vs. Hybrid Composites Mechanical properties similar Wear properties similar Curing depths similar Similar proximal contacts Drier, denser feel Choi J Esthet Dent 2000 Peumans Dent Mater 2001 Click here for more detailshere

61 Flowable Composites Marketed –class 1, 3, 5 –liner Particle size similar to hybrid composites Reduced filler content – reduces viscosity 0 10 20 30 40 50 60 70 80 Weight Percent Percent Filler Loading Aeliteflo FloRestore Revolution Ultraseal+ Prodigy Bayne JADA 1998 Click here for abstracthere

62 Liners Under Direct Composites Increased flow Increased shrinkage Improved marginal integrity? –laboratory studies equivocal most studies show no benefit –Braga JADA 2003 »click here for abstracthere Reduced post-operative sensitivity? –no clinical evidence of reduction –Perdigao Quint Int 2004 »click here for abstracthere

63 Polymerization Shrinkage % Tolidis JDR 1999

64 Radiopacity Reduced radiopacity? –product specific –may be more difficult to distinguish on radiograph Murchison Quint Int 1999 Click here for abstracthere 0 50 100 150 200 250 Tetric Flow Flow-it Enamel Revolution FloRestore UltraSeal+ Gray value

65 Flowable Composite Mechanical properties –inferior to hybrids 00.511.522.5 MPa Fracture Toughness Prodigy Ultraseal + Revolution FloRestore Aeliteflo 050100150200 MPa Flexure Strength Bayne JADA 1998 Click here for abstracthere

66 Flowable Composites Clinical applications –preventive resin restorations –small Class 5 –provisional repair –composite repair –liners??

67 Regular Material Usage* Civilian Practitioners Flowable Composite81% Hybrid Composite69% Amalgam67% All-Purpose Composite53% Microfill Composite52% Resin-modified Glass ionomer45% Packable Composite33% Compomer7% Other1% DPR 2005*Multiple responses

68 Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth) Hickel J Adhes Dent 2001 % Annual Failure

69 Manhart Oper Dent 2004 Click here for abstracthere Standard Deviation Longitudinal and Cross-Sectional Data Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth)

70 Purchasing Considerations Federal Service Universal hybrid systems are suitable for both anterior and posterior restorations –may not need to stock packable systems additional expense to maintain no improvement in mechanical properties no improvement in proximal-contact formation no increase in depth of cure Click here for more detailshere

71 Purchasing Considerations Federal Service Most cases often only need one shade type Complex cases may need multiple shades applied in layers –larger Class 4, direct veneers, diastema closures Wide diversity of kits available –simple kits with only a few shades –complete kits with multiple shades in various opacities; bonding agents, dispenser guns, shade guides Click here for synopsis of restorative composite resinshere

72 Purchasing Considerations Federal Service Simple universal hybrid kit in compact case for routine individual use in operatories or suites –many systems available e.g., Prodigy (Kerr) More complete universal hybrid kit for general use by entire facility or training program –several systems available e.g., 4 Seasons (Ivoclar Vivadent) Click here for synopsis of restorative composite resinshere

73 Future Composites Low-shrinking monomers –expanding spiroorthocarbonates –epoxy-based resins –liquid crystal Self-adhesive? Click here for detailshere

74 Acknowledgments Dr. Dave Charlton Dr. Jack Ferracane Dr. Tom Hilton Questions/Comments Col Kraig Vandewalle – DSN 792-7670 – ksvandewalle@nidbr.med.navy.milksvandewalle@nidbr.med.navy.mil


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