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Restorative Composite Resins
Restorative Composite Resins Col Kraig S. Vandewalle USAF Dental Evaluation & Consultation Service
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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
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Overview Direct restoratives Flowable Packables composition
classification performance factors Flowable Packables Click here for briefing on composite resins (PDF)
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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
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History 1871 – silicates 1948 - acrylic resins
alumina-silica glass & phosphoric acid very soluble poor mechanical properties acrylic resins polymethylmethacrylate high polymerization shrinkage Rueggeberg J Prosthet Dent 2002
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History (cont.) 1962 – Bis-GMA 1969 – filled composite resin
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
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Indications Anterior restorations Posterior restorations
preventive resin conservative class 1 or 2
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Contraindications Large posterior restorations Bruxism Poor isolation
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Advantages Esthetics Conservation of tooth structure
Adhesion to tooth structure Low thermal conductivity Alternative to amalgam
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Disadvantages Technique sensitivity Polymerization shrinkage
marginal leakage secondary caries postoperative sensitivity Decreased wear resistance
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Composition Resin matrix Inorganic filler Coupling Agent monomer
initiator inhibitors pigments Inorganic filler glass quartz colloidal silica Coupling Agent Bis-GMA OCH2CHCH2O-C-C=CH2 CH2=C-C-O-CH2CH-CH2O -C- CH3 OH O Phillip’s Science of Dental Materials 2003
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Monomers Binds filler particles together Provides “workability”
Typical monomers Bisphenol A glycidyl methacrylate (Bis-GMA) Urethane dimethacrylate (UEDMA) Triethylene glycol dimethacrylate (TEGMA) OCH2CHCH2O-C-C=CH2 CH2=C-C-O-CH2CH-CH2O -C- CH3 OH O CH2=C-C-O-CH2CH2-O-C-NHCH2CH2CHCH2-C-CH2-NH-C- CH3 OCH2CH2O-C-C=CH2 O CH2=C-C-O-CH2CH2-OCH2CH2 CH3 OCH2CH2O-C-C=CH2 O
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Monomers Bis-GMA extremely viscous lowered by adding TEGDMA
large benzene rings lowered by adding TEGDMA freely movable increases polymer conversion increases crosslinking increases shrinkage CH2=C-C-O-CH2CH-CH2O -C- OCH2CHCH2O-C-C=CH2 CH3 OH O
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Monomers Shrinkage 2 – 7 % marginal gap formation
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Filler Particles Crystalline quartz Silica glass larger particles
not polishable Silica glass barium strontium lithium pyrolytic sub-micron Phillip’s Science of Dental Materials 2003
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Filler Particles Increase fillers, increase mechanical properties
strength abrasion resistance esthetics handling 50 to 86 % by weight 35 to 71% by volume % Filler Volume 2 1.5 Fracture Toughness 1 0.5 28 37 48 53 62 Ferracane J Dent Res 1995
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Coupling Agent Chemical bond Organosilane (bifunctional molecule)
filler particle - resin matrix transfers stresses Organosilane (bifunctional molecule) siloxane end bonds to hydroxyl groups on filler methacrylate end polymerizes with resin CH3-C-C-O-CH2-CH2-CH2-Si-OH CH2 O OH Bonds with filler Silane Bis-GMA Bonds with resin Phillip’s Science of Dental Materials 2003
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Inhibitors Prevents spontaneous polymer formation Extends shelf life
heat light Extends shelf life Butylated Hydroxytoluene Phillip’s Science of Dental Materials 2003
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Pigments and UV Absorbers
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
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Visible-Light Activation
Camphorquinone most common photoinitiator absorbs blue light nm range Initiator reacts with amine activator Forms free radicals Initiates addition polymerization OCH2CHCH2O-C-C=CH2 CH2=C-C-O-CH2CH-CH2O -C- CH3 OH O Bis-GMA
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Polymerization Initiation Propagation Termination
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
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C=C C=C C=C polymerization Ferracane
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Classification System
Historical Chronological Based on particle size traditional microfilled small particle hybrid Phillip’s Science of Dental Materials 2003
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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
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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
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Microfills Lower filler content Linear clinical wear pattern
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 microfills
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Small Particle 1 - 5 micron heavy-metal glasses Fracture resistant
Silane-coated silica or glass (1-5 u) Polymer matrix micron heavy-metal glasses Fracture resistant Polishable to semi-gloss Suitable for Class 1 to 5 Example: Prisma-Fil Phillip’s Science of Dental Materials 2003
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Hybrids Popular as “all-purpose” 0.6 to 1 micron average particle size
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
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Hybrids Strong Good esthetics Suitable Multiple available polishable
Class 1 to 5 Multiple available Click here for table of hybrids
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Table of Properties Property Traditional Microfilled Small Particle
Hybrid Compressive strength (MPa) Tensile strength (MPa) 50-65 30-50 75-90 70-90 Elastic Modulus (GPa) 8-15 3-6 15-20 7-12 Coefficient of Thermal Expansion (10-6/ºC) 25-35 50-60 19-26 30-40 Knoop Hardness 55 5-30 Phillip’s Science of Dental Materials 2003
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Newer Classification System
Based on particle size megafill millimeters macrofill microns midifill microns minifill microns microfill microns nanofill microns Most new systems minifillers Newest trend nanofillers trimodal loading prepolymerized Bayne JADA 1994
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Relative Particle Sizes (not to scale)
Midi - filler 2 um ( beachball) Mini 0.6 um canteloupe) Nanofiller .02 um (pea) Microfiller .04 um (marble) Relative Particle Sizes (not to scale)
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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
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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 evaluation
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Performance Factors Material factors biocompatibility
polymerization shrinkage wear resistance polish mechanisms placement types mechanical & physical properties
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Biocompatibility Tolerated by pulp Rare allergic reactions
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
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Systemic Estrogenic effects seen in cell cultures
impurities in Bis-GMA-based resins Bis-phenol A in sealants Olea EHP 1996 click here for abstract however, insignificant short-term risk literature review Soderholm JADA 1999
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Polymerization Shrinkage
Significant role in restoration failure gap formation secondary caries formation marginal leakage post-operative sensitivity Counteract lower shrinkage composites incremental placement
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Composite Wear Less wear small particle size heavier filled
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
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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
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Polish Mechanisms Acquired polish Inherent polish Microfills Hybrids
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
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Polish Mechanisms Acquired Polish Inherent Polish
Small Particle Hybrid Microfilled Composite Acquired Polish Time Linear wear pattern Inherent Polish Adept Report 1992
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Shaded vs. Anatomic Placement
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 details
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Shaded Anatomic Dentists Ceramists “Match Shade” “Create Shade” Trans Enamel Trans Enamel A1 Enamel Enamel Value A1 Dentin A3/A4 Dentin Enamel Value
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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
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Composite Selection Anterior/stress (Class 4)
hybrid mini- or midi-fill hybrid/microfill veneer combo Anterior/non-stress (Class 3 or 5) mini-fill microfill
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Composite Selection Posterior hybrid reinforced microfill
mini- or midi-fill reinforced microfill
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Selecting a Brand Contents of kit Indications Cost 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 resins
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Government Price ($/gm of refill resin)
Prices current as of Jan 05
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Selecting a Brand Results of lab and clinical studies
Compositional characteristics % filler content average filler particle size Click here for synopsis of restorative composite resins
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Radiopacity (mm of aluminum)
ISO Requirement Source: USAF DECS Project
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Surface Hardness (24 hrs)
Source: USAF DECS Project 03-37 KHN Horizontal lines connect nonsignificant differences (p<0.05); N=5
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Flexural Strength (24 hrs)
Source: USAF DECS Project Horizontal lines connect nonsignificant differences (p<0.05); N=5
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Volumetric Shrinkage % Source: USAF DECS Project 03-037
Horizontal lines connect nonsignificant differences (p<0.05); N=5
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Composite Variants Packable Flowable
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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 composites
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Packable Composites Mechanical properties similar to hybrids
1.8 1.6 Fracture Toughness 1.4 ALERT 1.2 Solitare 1 SureFil 0.8 Heliomolar 0.6 Z100 0.4 0.2 Choi J Esthet Dent Click here for abstract
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Proximal Contact Studies
Packables similar to hybrids diameter and tightness Best contacts sectional matrix system Peumans Dent Mater click here for abstract Klein Am J Dent 2002
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Packable Composite Resin
Depth of Cure % Hardness Ratio Choi J Esthet Dent Click here for abstract
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Packable Vs. Hybrid Composites
Mechanical properties similar Wear properties similar Curing depths similar Similar proximal contacts Drier, denser feel Click here for more details Choi J Esthet Dent 2000 Peumans Dent Mater 2001
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Flowable Composites Marketed
class 1, 3, 5 liner Particle size similar to hybrid composites Reduced filler content reduces viscosity Percent Filler Loading 80 Aeliteflo 70 60 FloRestore 50 Weight Percent 40 Revolution 30 Ultraseal+ 20 10 Prodigy Bayne JADA Click here for abstract
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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 abstract Reduced post-operative sensitivity? no clinical evidence of reduction Perdigao Quint Int 2004
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Polymerization Shrinkage
% Tolidis JDR 1999
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Radiopacity Reduced radiopacity? product specific
may be more difficult to distinguish on radiograph 50 100 150 200 250 Tetric Flow Flow-it Enamel Revolution FloRestore UltraSeal+ Gray value Murchison Quint Int Click here for abstract
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Flowable Composite Mechanical properties inferior to hybrids
Fracture Toughness Flexure Strength Prodigy Ultraseal + Revolution FloRestore Aeliteflo 0.5 1 1.5 2 2.5 50 100 150 200 MPa MPa Bayne JADA Click here for abstract
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Flowable Composites Clinical applications
preventive resin restorations small Class 5 provisional repair composite repair liners??
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Regular Material Usage* Civilian Practitioners
Flowable Composite 81% Hybrid Composite 69% Amalgam 67% All-Purpose Composite 53% Microfill Composite 52% Resin-modified Glass ionomer 45% Packable Composite 33% Compomer 7% Other 1% *Multiple responses DPR 2005
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Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth)
% Annual Failure Hickel J Adhes Dent 2001
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Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth)
% Annual Failure Standard Deviation Longitudinal and Cross-Sectional Data Manhart Oper Dent Click here for abstract
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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 details
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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 resins
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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 resins
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Future Composites Low-shrinking monomers Self-adhesive?
expanding spiroorthocarbonates epoxy-based resins liquid crystal Self-adhesive? Click here for details
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Acknowledgments Questions/Comments Dr. Dave Charlton
Dr. Jack Ferracane Dr. Tom Hilton Questions/Comments Col Kraig Vandewalle DSN
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