Posterior Composites: Using the Latest Materials and Techniques Robert Lowe, DDS Novemb mber2014Cour se-Expi r esNovemb mber30t h,2017 He r a eu sOn On l i n eL e ar n i n gCe n t e r Abs t r ac t
Amalgam, for years the most most widely used direct restorative restorative material, is gradually being replaced replaced by composite resin. The problem with composite restorations in general is that they are technique-sensitive and time-consuming to pl ace correctly, unlike their amalgam counterparts. Although dental science has yet to find a bulk-fill, tooth-colored material that is as simple to place as amalgam, practitioners can reduce the stress and difficulty of performing this common dental procedure by using appropriate materials, techniques, and tools designed specifically for predictable outcomes using direct composite. They can also offer patients the benefits of new “smart” restorative materials to help prevent, arrest, and reverse tooth decay using minimally invasive methods.
Ther ear ef e w mat er i al si nt hehi s t or yofd ent i s t r yt hathasun der goneasmu mu chofanev ol ut i onas c omp os i t er e si n .Th ef a ceo fr es t o r a t i v ed en t i s t r ych an ge df o r e v erwh ens uc c es s f u lb on di n gt oe na me me l a ndd en t i nwa sa ch i e v ed .Si n cet h en ,t h eg oa lo fc l i n i c ala ndma t e r i a ls c i e nc eh asbe ent ofi ndas i mp l e pr edi c t abl eappr oac ht ot hec ompo si t er es t or at i v epr oc es s .
malgam !s" Composite Compar edt odent al amal g am,t h epat r i c i anofdi r ec tr es t or at i v es ,t h epl ac ementofc ompos i t er e qui r es ma nymo mo r es t e psan de x ac t i n gt e ch ni q uet oac hi e v et h eb es tr e su l t s .Th ep r o ce ssofa dh es i o n, c ondi t i on i ngt het oo t hs ur f ac e,a ndappl i c at i o nofpr i mer sa ndadhes i v es ,whi c hi sf ol l o wedb yt he l a y er i n gofc ompos i t er es i nst oc ompl e t et h er es t o r a t i v epr o ces s ,i n vo l v esma man yi ndependents t epst hat mu stb ep r o pe r l ye x ec ut e dt oen su r ego odr e su l t s . Forpos t er i orc ompos i t er es t or at i onsi npar t i c ul ar ,t hec l i ni c i anmus tal s omanagec hal l engesr el at edt o oper at orac ces sandmo moi s t ur econt r ol ,aswel l ass of t t i s sue–r el at edpr obl emst hatof t enar i s ewi t hCl as s I Ic av i t i esduet os ubgi ngi v al mar gi npl ac ement .Bec aus ec ompos i t esar et r adi t i onal l ypl ac edi nl a y er s , t her ear enume r o uss t epsandma mat e r i al sr equi r edt ocompl e t et her es t or at i v epr oc es sand,wi t ht he m,t m, he po t ent i alf orpr obl emssuc hasv oi dsan dmar gi nall eak age,whi c hc anul t i mat el yl e adt or es t or at i on f ai l ur e . Thecompl e x i t yofper f or mi ngt hest epsr equi r edt opl ac ec ompo si t ec ont r as t ss har pl ywi t ht hos e r e qu i r e df o ra ma ma l g am,a l t h ou ghb ot hn ec es s i t a t et h eu seo fama t r i xs y s t e mt or e s t o r ea na t o mi mi cpr o x i ma l c on t o ur san dc on t a cta r e asan dp r e v en tp r o x i ma lg i n gi v a lo v er h an gs . Fo ra ma ma l g am p l a ce me me nt ,aCl a ssI Ip r o ce du r et y pi c al l yi n v ol v e su si n gaT offle mi mi r ema t r i xt oc on t a i nt h e r es t or at i v ema t er i al ,whi c hi st henc ondens edi nt ot hepr epar at i o n.Us i n ganappr opr i at ec ar v i ng i ns t r ument ,t her es t or at i oni scar v edi nt opr operanat omi cf or m.Fi nal l y ,t heoc cl us i oni schec k edwi t h ar t i c ul at i ngpaper ,andt her es t or at i oni sadj us t edasnec es sar y .
Howe ver ,wi t hc ompos i t es ,t hec l i ni c i anmus tfi r s tc ont r ol t hec l i ni c al en vi r onmentus i ngi s ol at i on t ec hni ques .Af t eri s ol at i ngt heoper at i v ear eat oc ont r olmoi s t ur ec ont ami nat i onandus i ngas pec i al l y d es i g ne dma t r i xs y s t e m—i e ,ase ct i o na lma t r i x —e ac hi n cr e me nto fc omp os i t ep l a ce me ntt y pi c al l y r equi r es :( 1)et c hi ng;( 2)r i nsi ng;( 3)dr y i ng;( 4)des ens i t i z i ng;( 5)pl ac ementofadhes i v e;( 6)l i ght c ur i ng; ( 7)pl ac i ngabas eorl i ner ,i fneeded( 8)l i ght c ur i ng;( 9)pl ac i ngt hei nc r e mentofc ompos i t e;and( 9) l i ght c ur i ng.Sev er ali nc r ement sma ybepl ac edandc ur edbef o r efi nal s c ul p t i ngoft heoc c l us al s ur f ac e oft her es t or at i on,c hec ki ngandadj us t i ngt hebi t e,t henpl ac i nganopt i onal s ur f ac es eal antt opr ot ec tt he mar gi nalar easoft hec ompos i t er es t or at i on.
Composite Material Selection Ama l g am i sama t e r i a lt h atc a nb ec o nd en s ed .I not h erwo r d s ,wh enp l a c i n ga ma l g am,t h ea c to f c ondens at i onac t ual l ypus hest hel at h ec utpar t i c l esofal l o yc l os ert o get her .Condens i ngamal gam ag ai ns tamat r i xcanac t ual l yc aus edef or mat i onoft h emat r i x ,hel pi ngt oc r eat eac ont ac twi t ht he adj ac entt oot hs ur f ac e. I nc on t r as t ,c omp os i t e ,a sac l a ssofma t e r i a l s ,c an no tb ec on de ns ed .Th ema t e r i a li spu sh eda r o un dt h e pr epar at i onwi t ht hepl ac ementi ns t r ument ,buti ti sno tc ondens edi nan ywa y .Thi smak esc ont ac t p l a ce me nta ndc a v os ur f a cema r g i n al a da pt a t i o nmo r eo fac ha l l e ng et ot h ed en t i s t .Unf o r t u na t e l y , ma ny d en t i s t st r e atc omp os i t easi fi twe r eama l g am,a ndt h ati swh er epr o bl e msc anbe gi n .Th eymu s tc ho os e f r om amo ngawi dev ar i e t yofmat er i al swi t hv ar y i ngvi s c os i t i esandcon si s t enc i es .So mear ev er y mo l d ab l ea nds c ul p t a bl e .Ot h er s ,s uc ha sc omp os i t e sd es i g ne df o ra nt e r i o ra r e asan de st h et i c s ,c anb e mo r e“ p as t e l i k e ”a ndl e sss t i ff .Co mp os i t er e si n sc omei nma nyt y pe s—fl owa bl e s,p ac k ab l e s,h y br i d s, mi c r oh ybr i ds ,nanomi c r oh ybr i ds ,andmi c r ofi l l s .I naddi t i on,ne wc hemi s t r i esar ebe i ngi nt r oduc edasan al t er nat i v et ot het r adi t i onalbi s GMA–bas edcompos i t es ,r educ i ngt hepr obl emsofs hr i nk age,s ens i t i v i t y , a nds t r e ngt hi nt h ep os t e r i o rr e gi o n.Amo ngt h em,au ni q uep r o du ctwi t hn an od i me rc o n v er s i o n ® t e ch no l o gy( i e ,Se pt o do ntN’ Du r a nc e ,Se pt o do nt , www. s e p t o do nt u s a . c o m) i ss a i dt ooff eramo no me r -
t opol y merc on ver s i onr a t et hati ss i gni fi cant l yhi ghert hant r adi t i onal bi s GMAc ompos i t es ,aswel l as 1 hi ghr a di opac i t y ,l owpol y mer i z at i onshr i nk age,andl owpol y mer i z at i onst r es s .
Main Challenges with Composites Es t abl i s hi ngt i ghtpr o xi mal c ont ac t sandel i mi nat i ngv oi dsbet weenl a yer s ,whi l ei mpr o vi ngpr edi c t abi l i t y a ndt i mee ffic i e nc yi np l a ce me nt ,r e ma i ns i g ni fi c an tc ha l l e ng eswh enp l a ci n gc omp os i t er e st o r a t i o ns . Voi ds Re cu r r e ntd ec a y—t h ep r i ma r yc au seo fc omp os i t ef a i l u r e —i sof t e nt r a ce dt ov o i d si nt h efl oo ro ft h e pr o xi mal bo xatt hec av os ur f ac emar g i nofaCl as sI Ic av i t y ,whi c hi smos tv ul ner abl et oi nc ompl et efi l l i ng 2 ( Fi gur e1) . Whi l egoo dmar gi naladap t at i oncanbev er i fi edvi s ual l y ,t hei nc r ement al pl ac ementpr oc es s ,
pl ust heet c hi ngandbondi ngbet weenl ay er s ,r el i esl ar gel yon“ b l i ndf ai t h”t hatt hear eahasbeen c omp l e t e l yfil l e d.Th es ea r e asof t e nc an no tb es ee nr a di o gr a ph i c al l yun l e sspl a ce di nt h es ame di r ec t i on alp l an east heac t ual x r a ybeam.
Th et r a di t i o na lme t h odo fp l a c i n gc o mp os i t ei ni n c r e me nt sofn omo r et h an2mm( Fi g ur e2) wasmeant t of ac i l i t at ec ur i ngandt oa v oi dpol y me r i z at i o ns hr i nk age,whi c hr es ear c hs ugges t si snol ongeramaj or 3 c on ce r nwi t hma nyo ft o da y ’ sa dv a nc edma t e r i a l s . Thet ec hni queofl a y er i ng ,h owe v er ,c ar r i esagr eat er
pot ent i alt oi nt r oduc ev oi dsi nt ot her es t or at i on.Bul k fi l l fl owabl es ,whi c har emeantt os er v eas“ d ent i n r e pl a c eme nt s , ”c a nb ec u r e di ni n c r e me nt so fu pt o4mm ( Fi gur e3) .Wh i l et h es ema t e r i a l sdoh av et h e pot ent i alt oel i mi nat eman yoft hevoi dsbydec r eas i ngt henumberofl a yer si nt her e st or at i on,t he yar e t y pi c al l ynotdes i gnedwi t ht heph ys i c al pr oper t i esr e qui r edt owi t hs t andf or c esofoc cl us i onand, 4 t her ef or e,anaddi t i onal c appi ng( enamel l ay er )i sr e qui r ed. Ther ear eal s obul k fi l l pac k abl est hatc an
b ep l a c e di n5mm i n c r e me nt s( Fi g ur e4) ;amo ngt hem i sasoni c al l ypl ac edbu l k fi l lc ompos i t esy s t em ® ( i e,Soni c Fi l l ,Ker r ,www. s oni c fil l . k er r dent al . c om)t hatpr o vi dessuffic i entphy s i c al pr oper t i est owi t hs t and 5 f unc t i onal f or c eswi t houtt heneedf orac appi ngl a yer .
Repl i cat i ngPr oxi malCont actandCont our I nmos ti ns t anc es ,t heTofflemi r euni v er s almat r i xus edf oramal g am i sno tappr opr i at ef orus ewi t h c o mp os i t e s( Fi gur e5) .Ther ear enowav ar i et yofs ec t i onal mat r i c esdes i gneds pec i fi cal l yt or epl i c at e notj us tt hepr o xi malc ont ac tbutal s ot hepr o xi mal c ont our ( Fi gur e6) .Th eyar ep os i t i o ne db et we ent h e r es t or i ngs ur f ac ean dadj ac entpr o xi ma ls ur f ac eandus ear i ngt ogent l ypus ht het ee t hapar t ,c r eat i ng pr o xi mal c on t ac tandal l o wi ngf ori dea lan at omi cpl ac ementofasec t i onal band,whi c hi sc onc av eont he i ns i dean dc on ve xonout s i de,andc anr epl i c at et hec on ve xc on t ouroft henat ur a lpr o xi malt oo t hs ur f ac e. Th eyi n c l u deCo mp os i Ti g ht3 D XR™ ( Ga r r i s o nDe nt a lSo l u t i o ns , www. g ar r i s on de nt a l . c om) ,V4 ® Cl ear Me t al Mat r i xSy s t em ( T r i odent , www. t r i od ent . c om) ,a ndPa l o de nt Pl usEZCoat( DENTSPL Y
Caul k ,www. d en t s pl y . c om) .Whenas ec t i onal mat r i xi spl ac edc or r ec t l y ,v er yl i t t l efi ni s hi ngwi t hr ot ar y i ns t r ument si sr equi r ed. Dept hofCur e Ac c or di ngt oas t udybyCampodoni c oe tal ,dept hofc ur e,l es st hanfi l l i ngt ec hni que,i st hemai ni s s ue 3 f orp r a ct i t i oner sus i ngt oday ’ smat er i al s . Var i ousme t hodsf orac hi e vi ngt hi sar edi s c us s edi nt h es ec t i on
on“ Bul kFi l l T ec hn ol o gi e si nCo mpos i t eMat er i al s . ”
Solutions Using #ew Methods and Materials Gi v ent het i meandc ar ei nv ol v ed,ab ul k fi l l i ngmat er i al t hatc anbepl ac edmor eeas i l yandpr edi c t abl y andt hatr equi r esf ewers t epsi sc l ear l ydes i r abl e,asl ongasi tdoesnotc ompr omi s et hequal i t yoft he fi nalr es ul t .Al t houghamat er i alt hatoffer scl i ni c i anst hees t het i c st hei rp at i ent swantc ombi nedwi t ht he eas eofpl ac ementandpr edi c t abi l i t yofamal gam i sst i l l i nt hef ut ur e,dent i s t scans t i l lgett hedes i r ed r e s ul t si nat i me l yan dc o s t e ffic i e ntma nn erb yus i n gr e c omme nd edma t e r i a l san dt e c hn i q ue sa nd u nd er s t a nd i n gh owt ou s et h em p r o pe r l y . Addi t i vePl acementofComposi t eMat er i al s Th et r a di t i o na ll a y er i n gme t h odu se db yt h ea ut h orf o rma nyy ea r si n cl u de st h eu seo fafl owa bl e c omp os i t e —n omo r et h an0 . 5 mm t h i c k —c o v er i n gt h ee nt i r eca v i t ypr e pa r a t i o n.Th efl owa bl el a y erwi l l adaptt ot hei nt r i c at egeomet r yoft heCl as sI Ipr epar at i on,i nc l udi ngal l oft hel i neandpoi ntangl es ,s o
t h att h os ea r e ast h ata r eh ar dt oc on de ns ea r ea de qu at e l yc ov e r e da ndp r o t e ct e dwi t hr e si n .Th e fl owabl emat er i alal s ouni f or ml ywet st hes ur f ac eoft headhes i v e,l es s eni ngt hec hanc ef orv oi ds b et we ent h ea dh es i v el a y era ndt h ec omp os i t e .Ne x t ,ana nomi c r o hy br i di sp l a ce di n2mm i n cr e me nt s , asdes c r i bedabo v e,u nt i lt hefi nal i nc r emen ti ss cul pt edi nt ot h epr operanat omi cf or m andt heoc c l us i on i sc h ec k e da ndad j u s t e da sne ed ed .Sc ul p t i n ga nds ha pi n gc omp os i t e sus i n gi n s t r u me nt st h atc an i mpar tacon ve x i t yandno tdec i mat et heoc c l us al anat omy ,s uc hasa“ n ee dl e ”i nt er pr o x i malfi ni s hi ng d i a mo nd ,a r er e co mme nd ed .Th i sme an sn otu si n ga ne l l i p t i c al o rr o un db urt h ati mp ar t sc on ca v i t i e st h at des t r o yt heanat omi cf or m oft heoc c l us al s ur f ac e. Fi ni s hi n gandpol i s hi ngt hepl ac edc ompos i t ei n v ol v esmor es t ep s,i nc l udi ngt heus eofr ubberabr as i v es andabr i s t l ebr us hwi t hani mpr egn at e dpol i s hi ngmedi um ordi amo ndpas t e.Af t erpol i s hi ng ,mar gi nal ar easar er ee t c hedf o raf ews ec ondst omak esur et hesur f ac ei sc l ean ,t he nasur f ac es eal anti s a pp l i e dt ofi l l mi n orr e ma i n i n gd i s c r e pa nc i e sb et we ent h ec omp os i t ea ndt h et o ot ht h atc an no tb es ee n orf el twi t hanex pl or erbutmays t i l l ex i s t . Al t er nat i veAppr oacht oI nci pi entCar i es Cl i ni c i ansc ommonl yappr oac ht r eat mentofi nc i pi entl es i onsbyt r eat i ngt hem ei t heraggr es s i v el yupon ® det ec t i onorbywai t i ngunt i l i ti sdeemed“ nec es sar y . ”Anewt y peofr es i nmat er i al ( i e,I c on ,DMG
Ame r i c a ,www. dmgamer i ca. com)i sar es i ni nfi l t r at et hatpr ov i desabar r i ert opr ev entac i di nfi l t r at i on andpr ogr es s i onofpr o xi mal dec ay ,whi c hc oul dl at e rr equi r et henee df o rmor eaggr e ss i v et r eat men t me t ho ds .I c onr es i ni nfi l t r at ewor k sb ybl oc k i ngt hei nfl uxofh ydr ogeni ons ,ab ypr odu cto fb ac t er i al me t abol i s mt h atpr e v ent sc al c i um an dphos phat ei o nsf r om l eac hi ngoutoft het oo t h.Thi smat er i al , whi c hi sv i r t ual l yaseal ant / pr ot ec t ant ,i spl ac edvi aamembr anedev i c eaf t eret c hi nganddr y i ngt he pr o xi mal s ur f ac eoft het oot h.Ac cor di ngt ot hemanuf ac t ur er ,I c onr ei nf or c esands t abi l i z es demi ner al i z edenamelwi t houtdr i l l i ngors a cr i fi ci ngheal t h yt oot hs t r uc t ur e. Af t e ri s ol at i n gt het oo t handpl ac i ngwedge st os epar at et het eet h,t heaff ec t edt oo t hs ur f ac ei spr e par ed wi t ha15% h ydr oc hl or i cac i dgel t oet c ht hedec al c i fi eds ur f ac eoft hel es i on.Ne xt ,t hes ur f ac ei sr i ns ed, dr i edwi t het hanol ( dr y i ngagent ) ,andf ur t herd r i edwi t hai r .TheI c onr es i ni nfi l t r at e,whi c hhasahi gh pene t r at i onc oeffic i en t ,i sap pl i edont ot hel es i o n,t h ee x ces si sr emo v edasnec es s ar y ,andt hemat e r i al i sl i ght c ur ed.Theman uf ac t ur e rr ec ommendsappl y i ngas ec ondl a y eroft hei nfi l t r at e,f ol l owedb y addi t i onal l i ght c ur i ng,t oens ur emax i mal pr ot ec t i on.
Minimall$ %n!asi!e Dentistr$ using &Smart' Materials Cl assI ISl otPr epar at i onandRest or at i onUsi ngGi omerComposi t es Ami ni mal l yi nv as i v eappr oac hf ort her es t or at i onofs mal lCl as sI Ic ar i ousl es i onsonpat i ent swi t h s ubop t i malh y gi enema yi nc l udes l otpr epar at i onwi t hafi s sur o t omyburorhar dt i s s uel as er ,whi c hi s f o l l o we db yt h ep l a ce me nto f“ s ma r t ma t e r i a l s ”t oh el pc omp en sa t ef o ri n ad eq uat eh y gi e neb yp r o v i d i n g addi t i onal mar gi nalpr ot ec t i ont hr ought her e l eas eoffl uor i dei ons ,whi c har et hena vai l abl et ohel p r ec al c i f ydec al c i fi edt oot hs t r uc t ur e.Gi omerc ompos i t escont ai ngl as sfi l l erpar t i c l esco ver edwi t ha gl a ss i o nomermat er i al .As ur f ac emodi fi edl a y ert hatc ov er st hegl as s i onomerl a y erpr o t ec t si tand
al l owsf ori onr el eas eo vert i me.Thi si onr el eas eatt hemar gi nsoft her es t or at i onc anhel pt opr ot ec tt he 1 0 a r e af r o ma ci dat t a ckan dp r o mo t er e mi n er a l i z at i o na sn ee de d6 .
OpenSandwi chTechni queUsi ngGl assI onomerCementf orDent i nRepl acementi nDeepl y Excavat edLesi ons Fo rmo r ed ee pl ye x c av at e dl e si o nswh os ed en t i nwi l l h av emo r et u bu l e se x po se da ndl e sspe r i t u bu l a r dent i nt owhi c ht obond,gl a ss i o nomerc emen tf or msa“ c hemi c al l yf us edseal , ”a ndi t shi g hfl uor i de r el eas eandi nt er nalr emi ner al i z at i onhel pt opr ev entf ut ur edec ay .Ther ef or e,t hi smat er i al c ans er v ewel l 1 1 1 5 asabas eorl i neri ndee pl yex c av at edl es i ons( Fi gur e6) .
OpenSandwi chTechni quef orRootCar i es I nt h ec as eofapat i entr e qui r i ngaCl as sI Ic av i t ypr epar a t i onwhos emar gi nsma yb eonr oo ts ur f ac e, g l a ss i o no me rc eme ntc anbepl a ce da sal i n ero rb as ef o l l o we db ya“ c omp os i t ec ap ”t oc omp l e t et h e r es t or at i on( Fi gur e7) .Fo rt h e“ o pe ns an dwi c h”t e ch ni q ue ,t h eg l a ss i o no me rc eme ntb as ee x t e nd st o t hei nt er nal s ur f ac eoft hemat r i xandwi l l bei nc ont ac twi t ht hei nt r ac r e v i c ul arenv i r onmentf orpur pos es 1 1, 1 6 o fi o ne x c h an ge .
(ioacti!e Liners and )oundation Materials Modi ficat i onof“Cl osedSandwi chTechni que”usi nga“Smar t ”Dent i nSubst i t ut e I nwhatmi ghtbec al l ed“ her oadont i a, ”asanal t er nat i v et oane xt r ac t i onandbr i dgeori mpl ant ,t he c l i ni c i anc anat t emptt or es t or eat oot hus i ngat r i c al c i um s i l i c at edent i ns ubs t i t ut e—i e,bul kdent i n ® r epl ac ement( eg,Bi odent i ne ,Sep t odo nt ) .Thi st y peofpr oduc tc anbeus edf ort hef ol l o wi ngt y pesof
s i t uat i ons :pul pex pos ur e,dent i nc ar i es ,pul pot omi es ,per f or mat i on,i nt er nal / e xt er nal r es or pt i on,api c al s ur ger y ,andape xi fi cat i on.I nt hi smodi fi cat i onoft he“ c l os eds andwi c h”t ec hni que,whi c ht r adi t i onal l y us esgl a ss i o nomerc ement ,t het r i c al c i um s i l i c at edent i nr e pl a cementpr oc edur ebegi nswi t hd eep c ar i ousex c av at i on,f ol l owedb yt oot hi s ol at i onanddi s i nf ec t i onus i ngapr oduc tt hatc ani nc l udea d es e ns i t i z e r( e g,GL UMA® Des ens i t i z er ,Her a eusKul z er , her aeus k ul z er us . c om; AcQuaseal BDent i n De s en s i t i z e r ,Ac Qu ame dT ec h no l o gi e swww. s t ops ens i t i v i t y . c om) .Thec av i t yi st henfi l l edt ot hec ement enamel j unc t i onwi t hBi odent i ne.Af t eri ti ss et ,t hema t er i al i sshape dands moo t hedwi t hanendc ut t i ng bur ;af t er war d,ac ompos i t er es t or at i oni spl ac edast heenamel i nc r ement ,c ompl e t i ngt her es t or at i on. Bi oa ct i v eCa v i t yLi ni ngAge nt s Ca vi t i eswi t hde epc ar i ousex c av at i ons ,whi c hc anpo t ent i al l yl eadt opul pe xpo sur e,c anbee x ca v at ed ® l es si n va si v el ybyus i nga“ s mar t ”r oundpol y merbur( i e,Smar t Bur I I ,SS
Whi t e,www. s s wh i t e de nt a l . c om)( Fi gur e8)t os el ec t i v el yr emo v eaff ec t edd ent i n,f o l l o wedb ypl ac ement ofa“ s mar tmat er i al ” —i e,abi oac t i v ec av i t yl i ni ngagentdes i gnedf ori ndi r ec tanddi r ec tpul pe xpos ur e ( i e,Ther ac al L C®,Bi s co,www. b i s c o . c o m) .T ogetagoodgi ngi v al s eal i nsi t uat i onswher eex c av at i ons ar edeepi nt heapi c al di r ec t i on,i ti ses sent i al t oc ont r olt hemoi s t ur eandbl eedi ngi nt heoper at i v ear ea. Ther ef or e,adi odel as eri scr i t i c al f orc ont r ol l i ngs of tt i s sue,bec aus ewhenc ar i esgoesbel owt he gi n gi v al c r es t ,t hes ur r o undi ngt i s s uei sof t eni nfl amed.Asanadj unc t ,ahemos t at i cagentc anbeus ed t ohel pc ont r olr es i dual bl eedi ngaf t erus eoft hedi odel as ert ogett het i s sueoutoft hewa y ,s ot he mat r i xcanbeeff ec t i v el ypl ac ed,s eal i ngt hegi ngi v al mar gi n.Ne xt ,t hec av i t yi sdi s i nf ec t ed,ands t eps
ar ec ompl et edt opl ac et her es t or at i v emat er i al .Cl i ni c al andr adi ogr aphi cf ol l owupar ei mpor t antt o d et e r mi n et h es uc c es so ft h ep r o ce du r e .
(ul*+)ill Technologies in Composite Materials Al t hought hes ear c hf orat oo t hc ol or ed“ amal g aml i k e”mat e r i alc ont i nues ,t heaut hordes c r i beshi s appr oac ht obul kfi l l i ngus i ngflowabl er es i nsandbul k fi l l c ompos i t es ,r es pec t i v el y . Bul kFi l lFl owabl eComposi t easaDent i nRepl acement Af t e rt hec ar i esi sr e mo v ed,t het oot hi si s ol at ed.Thepl ac ementoft hebandus i ngas ec t i onal mat r i xt o r es t or et hepr ox i mal c ont ourandc ont ac t si scr i t i c al .Af t erappl i c at i onoft headhes i v e,t hebul k fi l l fl owa bl ean dc omp os i t eca pp i n gl a y er sa r epl a ce da ndl i g ht c ur e d,a ndt h ema t r i xb an di sr e mo v ed .Th e c ont ac ti ssot i ghtwhenus i ngas ec t i on almat r i xt hatr emo v alof t enr equi r esahemos t at .No t et he i de nt i c al he i gh to ft her es t or edmar gi nal r i d geascompar edt oa dj a cen tt oo t hF (i gur e9) .Thi sac cur ac yi s duet ot hec ar ef ul pl ac ementoft hemat r i xt ol i mi tt heamountoffi ni s hi ngandpol i s hi ngt hatwi l l needt o bedonet ocompl et et her e s t or at i on. Pr i ort opl ac ementoft hebul k fi l l fl owabl er es i n,t hec l i ni c i anma yappl yei t heras el f et c hort ot al et c h b on di n ga dh es i v et ot h ee na me la ndd en t i ns ur f a ce s,wh i c ha r et h enl i g ht c ur e d.Th ed en t i n r e pl a ce me nti sac hi e v edu si n gi n cr e me nt sofu pt o4mm o fo neo ft h eb ul k fi l l fl owa bl ema t e r i a l s( e g, ® ® Sur efil SDR®;DENTSPL YCaul k; Venus Bul kFi l l ,Her aeusKul z er ;Fi l t ek ™ Bul kFi l l ,3M
ESPE,s ol ut i ons . 3m. c om;Xt r aBa s e ,VOCO, www. voco. com;Beaut i fi l Bul kFl ow, Shof u,www. s h o f u . c o m)andl i ght c ur ed,f ol l o wedb ypl ac ementofananoh ybr i denamel l a y er( eg, ® Venus Pea r l ,He r a eusKul z er ) .Eac hl a y eri spol y mer i z ed,t henfini s hedan dpol i s he d.I ti sc ommont o
ha v el ar geo v er hangsus i ngc on v ent i onal mat r i c esr a t hert hans ec t i ona lmat r i c es .I nt er pr o x i mal fi ni s hi ng i sac hi e v edu si n gs pe ci a l l yde si g ne dd i a mo nds t r i p s,wh i c hc ana l s ob eu se dt oc l e art h ec on t a ctwh en 17 t eet har eac ci dent al l ybondedt oget herwi t houtaffec t i ngt hec ont ac tofr es t or at i v emat er i al F ( i g ur e10 ) .
Ther ei sev i denc ei nt hel i t er at ur et hatbenz el k oni um c hl or i de,whenpr es enti nt heet c hi ngmat er i al , 18 hel psi nc r eas et hedur abi l i t yoft her es i nbondb yi nhi bi t i ngt her el eas eofmat r i xmet al l opr ot eas es .
Compos i t eRe s t or a t i onsUs i ngBul k Fi l lCompos i t eMa t e r i a l s Th er ea r en owc o nv e nt i o na lc o mp os i t e so nt h ema r k e twi t ha l t e r e dc h emi s t r yt oa l l o wf o r4 mm o r5 mm ® bul kfil l i ngwi t houtt heneedf oranaddi t i onal c appi ngl a y er .The yi nc l udeT et r i cEv oCer am Bul kFi l l
( I v oc l arVi v adent , www. i v oc l a r v i a vdent . us ) ;Xt r aFi l ( VOCO) ;Aur aBul kFi l l ( SDINor t h Ame r i c a ,www. s d i . c o m. a u) ;andBeaut i fi l Bul k .I naddi t i on,asment i onedabov e,t her ei st hebul k fi l l pac k abl e ,So ni c Fi l l ,whi c hus esauni quehand pi e cet ode l i v ers oni cener gyt ot hec ompo si t emat er i al , c hangi ngi t sv i s cos i t ydur i ngpl ac ement .Al t hought hes ebul k fi l l pr oduc t sc anbepl ac edi nas i ngl est ep, t heaut hors t i l lpr ef er st ous eafl owabl ec ompos i t easal i n erbec aus eoft he“ l ac kofc ondens at i on” i s sue,t hee xc ept i onbei ngSoni c Fi l l bec aus eoft hev i s cos i t yc hangedur i ngpl ac ement .Af t erl i ght c ur i ng t hefl owabl el a y er ,upt o4mm oft h ebul k fi l l pac k abl emat er i alc anbeus edt ofi l l t her emai nderoft he c av i t ypr epar at i on.Af t erbei ngs cul pt edi nt opr operf or m,t heoc cl us al s ur f ac ei sl i ght c ur ed,wi t hnoneed 1 9 2 1 f oranaddi t i onal c appi ngl a y er .
Conclusion
Awi dev ar i e t yofmat er i al sha v ebeenc r eat edi nr es pons et oden t i s t s ’des i r ef o rp r oduc t st hatc an s i mp l i f yt hep l ac ementofes t he t i cCl as sI Ic ompos i t er es t or at i ons ,whos epl ac ementc anbehi g hl y s t r es s f uld uet ot het ec hni ques ens i t i v eandt i mec ons umi ngl a y er i ngpr oc es s .Al t hought her ei sno ty e ta bul k fi l l mat e r i al c ompar abl et oamal g am i nt er msofeas eofpl ac emen t ,c ompos i t er es t or at i ons ,asa r ul e,c anbepl ac edf armor econs er v at i v el y .“ Smar t ”ma t er i al sdes i gne dt oco mbatdemi ner al i z at i onand r ec ur r entdec ayar ewel c omeadv anc es ,asar ebul k fi l l pr oduc t st hatenabl et hec l i ni c i ant omor equi c k l y andeas i l ycompl et et hepos t er i orr es t or at i onst hatar es uc has i gni fi cantpar toft hegener alr es t or at i v e dent al pr ac t i c e.
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Pe di a t rDentJ c ont ai ni ngpr er eac t edgl as si onomer . .2009; 19( 1) : 899 7. 8.Da i s uk eT,Sei t a r oS,Koj i Y,Mas at oH.Sal i v apr o t ei nwhi c hads or bst ocompos i t er es i ncont ai ni ngSPRG fi l l er .Th .2 0 10 ; 5 3( 2 ) : 1 91 2 0 6. eJ ap an es eSo ci e t yofCo ns er v a t i v eDe nt i s t r y 9.Sak uS,Kot ak eH,Sc ougal l Vi l c hi sRJ ,etal .Ant i bac t er i al ac t i v i t yofc ompos i t er es i nwi t hgl as si onomerfi l l erpar t i c l es .De .2 0 10 ; 2 9( 2 ) : 1 93 1 9 8. ntMa t e rJ 10.T ai z ouI ,Sei t ar oS,Koj i Y.Appl i c at i ont ot het oot hc oat i ngmat er i aloft hegl as sfi l l erc ont ai ni ngac i d r eac t i v efl uor i de. .2 0 09 ; 5 2( 3 ) : 2 37 2 4 7. Th eJ ap an es eSo ci e t yofCo ns er v a t i v eDe nt i s t r y 1 1.Fr a nc i s c on iL F,Sc aff aPM,d eBa r r o sVR,e ta l .Gl a ssi o no me rc e me nt san dt h ei rr o l ei nt h e r es t or at i onofnonc ar i ousc er v i c al l es i on s . Appl .2 0 09 ; 1 7( 5 ) : 3 64 3 69 . J Or al Sc i 1 2.Mc L e anJ W,Po wi sDR,Pr o s s e rHJ ,Wi l s o nAD.Th eus eo fg l a s s i o no me rc e me nt si nb on di n g c ompos i t er e s i nst odent i n. .1 98 5; 1 58 : 4 10 4 14 . BrDem J 1 3.Mo un tGJ .Cl i n i c a lp l a c eme nto fmo de r ngl a s si o no me rc e me nt s . .1993; 24 ( 2 ) : 99Qu i n t e s s en c eI n t 107. 14.Chr i s t ens enG.Gl as s i onomer r es i nr es t or at i ons .CRANe ws l e t t er . 1992; 16( 3) : l 2.
1 5.Mo un tGJ .Cl i n i c al r e qu i r e me nt sf o ras uc c es s f u l“ s an dwi c h” —d en t i n et ogl a ssi o no me rc eme ntt o c ompos i t er es i n . us .1 98 9: 3 4( 3 ) : 2 59 2 6 5. A tDentJ 16.Sa wan iS,Ar or aV,J ai s walS,Ni k hi l V.Compar at i v ee v al ua t i o nofmi c r ol eak agei nCl as sI I r es t or at i onsus i ngopenv s.c l os edc ent r i pet al bui l dupt ec hni queswi t hdi ffer entl i ni ngmat er i a l s . J
Conser vDent .2 0 14 ; 1 7( 4 ) : 3 44 3 48 . 1 7.Ro gg en do r fMJ ,Kr ä me rN,Ap pe l tA,e ta l .Ma r g i n alq ua l i t yoffl o wa bl e4 mm b as ev s .c on v en t i o na l l y l a y er edr es i nc ompos i t e . Dent .2 01 1; 3 9( 1 0) : 6 43 6 47 . J 1 8.Pa sh l e yDH,T a yFR,I ma za t oS.Ho wt oi n cr e as et h ed ur a bi l i t yofr e si n d e nt i nb on ds . Compe nd .2011 ; 32( 7) : 60 6 6. Cont i nEducDent 19.I l i eN,Buc ut aS,Dr aener tM.Bul k fi l lr e si nbas edc ompos i t es :ani nv i t r oas s es s mentoft hei r me c ha ni c a lp er f o r ma nc e . .2 0 13 ; 3 8( 6 ) : 6 18 6 25 . OperDent 20.J ul os k iJ ,Car r ab baM,Ar agones esJ M,e tal .Mi c r ol eak ageofCl as sI Ir es t or at i onsan dmi c r ot ens i l e bondst r engt ht odent i nofl o ws hr i n kag ec ompos i t e s .m JDent .2 0 13 ; 2 6( 5 ) : 2 71 2 7 7. A 21.VanEndeA,DeMunc kJ ,VanLandu ytKL,e tal .Bul k fi l l i n gofhi ghCf ac t orpos t er i orc av i t i es :eff ec t onadhes i ont oc av i t y bo t t om dent i n. .2 0 13 ; 2 9( 3 ) : 2 69 2 77 . DentMat er
Seemor eat :ht t ps : / / her aeus . c dewor l d. c om/ c our s es / 20199Pos t er i or _Compos i t es : Us i ng_t he_Lat es t _Mat er i al s _and_T ec hni ques # s t h as h . v b uL od 6p . d pu f