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Update in direct restoratives. Caries incidence globally. Dental caries is still a major public health problem to most countries of the world Petersen, Baez, Kwan & Ogawa 2009 Future Use of Materials for Dental Restoration

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Update in direct restoratives
Update in direct restoratives


Caries incidence globally
Caries incidence globally

  • Dental caries is still a major public health problem to most countries of the world

    Petersen, Baez, Kwan & Ogawa 2009

    Future Use of Materials for Dental Restoration

    Report of the meeting convened at WHO HQ, Geneva, Switzerland.


“ Dentists spend approximately 70% of their time replacing restorations ”

Minimal intervention dentistry: a review.

FDI Commission Project. Tyas et al 2000


Dental amalgam
DENTAL AMALGAM restorations ”

  • bonded vs non bonded AR

  • longevity of AR

    • cavity size

    • operator experience

  • comparison with PCR

  • issue of mercury toxicity


Bonded vs nonbonded ar
Bonded vs nonbonded AR restorations ”

  • Longevity

    bonded AR > nonbonded AR

    ?


Adhesively bonded versus non bonded amalgam restorations for dental caries
Adhesively bonded versus non-bonded amalgam restorations for dental caries

  • randomized clinical trials

  • split mouth or paired tooth

  • Class I, II, or V restorations

  • with any adhesive

  • minimum follow up of 2 years

    Fedorowicz et al, Cochrane Database Syst Rev 2009 ; CD007517


Adhesively bonded versus non bonded amalgam restorations for dental caries1
Adhesively bonded versus non-bonded amalgam restorations for dental caries

  • “ …no evidence to show a difference in amalgam restoration survival on the basis of whether the restoration was adhesively bonded or not.”

    Fedorowicz et al, Cochrane Database Syst Rev 2009 ; CD007517


How long do direct restorations placed within the general dental services in England and Wales survive ?

  • 80 000 subjects, 503 965 restorations

  • 11-year duration

  • AR mainly for posterior load bearing

    CR for Class III and IV

    GIC for Class V

    Burke & Lucarotti 2009, 206:E2, discussion 26-7


How long do direct restorations placed within the general dental services in England and Wales survive ?

  • small AR showed the best 10-year survival rates ( 58%)

  • large MOD AR showed poorer 10-year survival rates ( 43% )

  • pin placement associated with reduced survival time

  • CR including incisal angle – reduced survival by 2 years

  • GIC – 10-yr survival rate of 38%

    Burke & Lucarotti 2009, 206:E2, discussion 26-7


Longevity of restorations
Longevity of restorations dental services in

  • AR – 16 years irregardless of restoration classification

  • CR – 6 years with Class 2 showing lowest longevity

  • High caries risk – reduced CR longevity compared to low or moderate caries

    Sunnegardh-Gronberg et al 2009


Longevity of restorations1
Longevity of restorations dental services in

  • Operator experience

    dentists with 15 or more years of experience provided restorations with > longevity for both AR and CR

    Sunnegardh-Gronberg et al 2009


1997 consensus statement on dental amalgam
1997 dental services in Consensus Statement on Dental Amalgam

  • ‘ No controlled studies have been published demonstrating systemic adverse effects from amalgam restorations ”

  • ‘ .... the small amount of mercury released from amalgam restorations, especially during placement and removal, has not been shown to cause any …adverse health effects. ’

    FDI World Dental Federation & WHO


1998 dental services in

  • Major review of the literature

    • “ based on available scientific information, amalgam continues to be a safe and effective restorative material “

    • “ there currently appears to be no justification for discontinuing the use of dental amalgam ”

      ADA’s Council on Scientific Affairs


2004 dental services in

  • Expert panel reviewed literature from 1996 – 2003

  • “ the current data are insufficient to support an association between mercury release from dental amalgam and various complaints that have been attributed to this restorative material. ”


2006 dental services in

  • 2 independent clinical trials

  • “ there were no statistically significant differences in adverse neuropsychological or renal effects observed over the 5-year period in children whose caries are restored using dental amalgam or composite materials …………….


2006 dental services in

  • ………. “ children ………..did not, on average, have statistically significant differences in neurobehavioral assessments in nerve conduction velocity when compared with children who received resin composite materials or amalgam ”


2006 dental services in

  • “ ……….amalgam should remain a viable dental restorative option for children ”

    Journal of the American Medical Association

    Environmental Health Perspectives


Environmental concerns
Environmental concerns dental services in

“ If environmental contamination by mercury containing waste from dental practices is not cut down to very low levels, then it is likely to be the main reason for government action against the use of amalgam in the future ”

Eley 1997


2008 dental services in

  • “ …dental amalgams are effective and safe, both for patients and dental personnel and also noted that alternative materials are not without clinical limitations and toxicological hazards ”

    Scientific Committee of the European Commission


2009 dental services in

  • Literature review from 2004 – 2009

  • “ the scientific evidence supports the position that amalgam is a valuable, viable and safe choice for dental patients ”

    ADA Council on Scientific Affairs


2009 dental services in

  • classified encapsulated dental amalgam as a class II medical device

  • “ …..the material is a safe and effective restorative option for patients ”

    FDA, US


2009 dental services in

“ …dental amalgam remains a dental restorative material of choice, in the absence of an ideal alternative and lack of evidence of alternatives as a better practice. If dental amalgam were to be banned, a better and more long-lasting replacement would be needed than the materials available to date ….”


2009 dental services in

“ …. while the harmful effects of mercury on health and the environment are recognized, the possible adverse effects of alternative materials require further research and monitoring.

Providing the best care possible to meet patients’ needs should be of paramount importance. ”


2009 dental services in

“… complete ban may not be realistic, practical and achievable. It may be prudent to consider ‘phasing down’ instead of ‘phasing out’ of dental amalgam at this stage ”

Future use of materials for dental restoration

Report of the meeting convened at WHO HQ, Geneva, Switzerland. 2009


Ethical issues
Ethical issues dental services in

  • correlate amalgams to adverse health symptoms/disease

  • removal of amalgams to provide placebo effect

  • removal of amalgams at patient’s request

  • amalgam - free practice


Minimata convention on mercury treaty
Minimata Convention on Mercury Treaty dental services in

  • ........treaty to rein in the use and emission of health-hazardous mercury

  • amid pressure from dentist groups, the treaty also did not provide a cut-off date for the use of dental fillings using mercury amalgam, but did agree that the product should be phased down.

    UN Environmental Program ( UNEP) Geneva , 19th Jan 2013


The World Alliance for Mercury-Free Dentistry called for phasing out dental amalgam by 2025 and by 2018 for baby teeth.


“ majority of patients prefer a tooth – coloured material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

Espelid et al 2006


DIRECT material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

TOOTH COLOURED

RESTORATIVE MATERIALS


classical material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

classical

Glass Ionomer Cements

Composite Resins

GI – RESIN HYBRIDS

RMGIC

PM COMP RESIN


GIC material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

Resin Modified GIC

Antonucci et al 1988, Mitra 1988

GIC + monomers + photoinitiators


Issues rmgic
Issues - RMGIC material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • retention

  • margins

  • wear, loss of anatomic form

  • colour change

  • fluoride leaching


Rmgic
RMGIC material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Clinical evaluations of resin-modified glass-ionomer cements

    Sidhu, Dent Mater, 2010 , 26 (1) : 7-12

  • Clinical performance of cervical restorations—A meta-analysis

    Heintze et al, Dent Mater, 2010, 26 ( ) : 993-1000


Retention
Retention material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • retention rate range from 87.5% - 100%

  • 2-step SE > 3-step E & R > GIC > RMGIC > 2-step E & R > PMCR > 1-step SE


Anatomic form and wear
anatomic form and wear material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • occurs in the mid- to long term


Secondary caries
secondary caries material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • No secondary caries was found in carious and non carious cavities

    for up to 5 years.

    Neo et al 1996

    Abdalla et al 1997

    van Dijken et al 1999

    Folwaczmy et al 2001

    Loguercio et al 2003


Caries preventive effect of gic and rmgic
Caries preventive effect of material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ” GIC and RMGIC

  • 4 out of 220 studies

  • RMGIC restorations remain as free of recurrent caries as did conventional GIC restorations

    Mickenautsch et al. Absence of carious lesions at margins of GIC and resin-modified GIC restorations. A systematic review . Eur J Prosthodont Rest Dent 2010:18:139-145


Colour stability
colour stability material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

initial colour may be acceptable but changes over time


classical material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

classical

Glass Ionomer Cements

Composite Resins

GI – RESIN HYBRIDS

RMGIC

PM COMP RESIN


Composite resins
Composite Resins material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

Developments of CR

  • materials

  • bonding systems

  • light systems


Material what s new
Material material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ” what’s new ??

  • monomer /matrix

  • filler


Monomers
Monomers material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • traditionally bis-GMA ( Bowen 1960 ) + TEGDMA

  • UDMA ( Foster and Walker 1974 ) and modified UDMA


New monomers
NEW - monomers material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • reduce polymerization shrinkage/stress

    • SiloranesWeinmann et al 2005

    • modified UDMA – increased molecular weight egKalore ( GC ), Venus ( Kulzer)

      N’Durance ( Septodent)

    • Ormocerseg Definite ( Degussa )Wolter et al 1994


Microhybrid and nanohybrid cr
Microhybrid and nanohybrid CR material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • improved strength, handling & polishability

    Ritter 2005

    Watanabe et al 2008

  • reduced wear

    Yap et al 2004

    Yesil et al 2008


New modify fillers
NEW – modify fillers material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

Add

  • polymer nonofibers, glass fibres, fused silica fibres and titaniananoparticles

  • dicalcium/tetracalcium phosphate nanoparticles

  • antibacterial and remineralising agents

    eg fluoride, chlorhexidine, zinc oxide or

    quaternary ammmoniumpolyethyleneiminenanoparticles, MDPM monomer


NEW material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Nanocomposites

  • incorporate calcium fluoride nanoparticles into dental resins

    • high levels of calcium phosphate and fluoride release achievable at low filler particle levels due to high surface areas of nanoparticles

    • addition of nanoparticles do not affect mechanical properties of resin

      Xu et al 2010


Bulk fill cr
Bulk fill CR material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • high depth of cure (4-5 mm)

  • reduce incremental placement

    • less porosities

    • less time

  • use below the restoration (flowable) or as a restorative (sculptable) material


Bulk fill cr1
Bulk Fill CR material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Flowables

    • Surefil SDR Flow Dentsply

    • X-tra Base Voco

    • Venus Bulk Fill Heraeus Kulzer

    • FiltekBulk Fill 3M ESPE

  • Sculptables

    • Tetric N-Ceram Bulk Fill Ivoclar/Vivadent

    • X-tra Fil Voco

    • QuiXfil Dentsply

    • SonicFill Kerr


How did we achieve the reduction in polymerization stress
How did we achieve the reduction in polymerization stress? material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

ANSWER:

  • The kinetics of the radical polymerization is regulated

  • As the modulus development is slower less polymerization stress builds up.

  • Call it a chemical soft start polymerization if you like.


Perfect compatibility with metharylate based bonding and capping composites

Any (!) material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”cap composite*

SDR™

SDR™ Filling Technique

Perfect Compatibility with metharylate-based bonding and capping composites

* EsthetX HD, CeramX, Spectrum TPH 3, Filtek Supreme, Tetric EvoCeram, Artemis, Z100, Point4, Venus, Enamel HFO, Herculite, Premise, etc ... but not Filtek Silorane


Bulk fill cr2
Bulk Fill CR material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Flowables

    • Surefil SDR Flow Dentsply

    • X-tra Base Voco

    • Venus Bulk Fill Heraeus Kulzer

    • FiltekBulk Fill 3M ESPE

  • Sculptables

    • Tetric N-Ceram Bulk Fill Ivoclar/Vivadent

    • X-tra Fil Voco

    • QuiXfil Dentsply

    • SonicFill Kerr


Clinical study burgess munoz
Clinical Study material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”Burgess & Munoz

  • 3 year study

  • 170 Cl 1 and Cl 2 in 2 schools

  • 86 restorations at the end of 3 years

  • 6 fractures within capping agent and one restoration replaced

  • no post-op sensitivity, no recurrent caries


New resin infiltration
NEW – resin infiltration material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • use of infiltrative resin to arrest superficial carious lesions proximally

  • soak up the porous lesion body with a low viscosity resin and polymerized

  • block diffusion pathways for cariogenic acids and seal lesions

  • diffusion barrier created inside lesion

    Paris & Meyer-Lueckel 2007


Resin infiltration
Resin infiltration material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Indications

    • non-cavitated

    • enamel and outer 1/3 of dentine

  • Contra-indications

    • cavitated lesions

    • root caries

    • pit and fissure caries

    • erosion lesions


Methodology for resin infiltration material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • 15% HCl etching gel – 120 sec

  • wash off with air-water-spray – 30 sec

  • blow dry – 10 sec

  • apply ethanol – 10 sec

  • blow dry – 10 sec

  • apply infiltrant – 5 mins, blow dry and floss

  • light cure from buccal, occlusal and lingual – 1 min

  • repeat infiltration step – 1 min

    Paris & Meyer-Lueckel 2010


Clinical studies for resin infiltration
Clinical Studies for resin infiltration material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Ekstrand et al 2010 - combination of resin infiltration and fluoride varnish increased therapeutic effect > 35% compared to fluoride varnish alone

  • Paris et al 2010 - Caries progression was seen in 7% of the effect group and in 37% of the control group


Take home messages cr material
Take Home Messages material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”CR Material

  • development of nanocomposites has led to significant improvements in dental materials and clinical applications

  • still room for improvement for nanocomposites

    Chen 2010


DENTINE BONDING SYSTEMS material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”


Dentine bonding system
Dentine Bonding System material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • ETCHANT

  • PRIMER

  • ADHESIVE


Adhesion strategies
Adhesion Strategies material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • concept of exchanging inorganic tooth material for synthetic resin

  • done in 1 , 2 or 3 application steps

  • classified as

    • Etch - & - rinse ( E & R )

    • Self - etch ( SEA )

    • ( RM ) GIC


Self etch adhesives
Self – Etch Adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • do not require a separate etching step

  • contain acid monomers to ‘etch/condition’ & ‘prime’ at the same time


Acid monomers
Acid monomers material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Acids may be ‘mild’ ( pH > 2.0 )

    • dentine smear layer is usually altered

    • sclerotic and tertiary dentine , enamel not effectively etched

  • Unifil Bond (GC), Clearfil SE Bond

    (Kuraray), S/E Optibond Solo Plus (Kerr)


Acid monomers1
Acid Monomers material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Acids may be strong ( pH < 2 )

    • good for enamel bonding but poor

      dentine bonding

  • Optibond XTR ( Kerr ), Simplicity (Apex)


Self etch adhesives1
Self – Etch Adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • lower incidence of post-op sensitivity

    Perdiago et al 2003

    Unemori et al 2004

    Tay et al 2002


  • etching and priming occurs to the same depth of penetration material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • no guesswork with ‘how wet is wet’

    • less aggressive and more superficial interaction with dentine , tubules largely obstructed with smear layer which is altered and infiltrated by primer


2 step
2-step material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • inability to be self cured

  • requires a self cure catalyst activator for self cure /dual cure cements for indirect procedures


Summary for se systems
Summary for SE systems material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • use of etchant for ‘mild’ acid systems

  • inability to be self cured


Self etch adhesives2
Self – Etch Adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • 2 – step ( Etchant + Primer, Adhesive )

  • 1 – step ( Etchant + Primer + Adhesive )

    • two - component ( require mixing )

    • one - component ( no mixing )


One component se
one – component SE material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • ‘ all – in – one ’ adhesive

  • conditioning + priming + adhesive

  • do not require mixing


1 step se adhesives
1 step SE adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • user friendly

  • low bond strengths

    Inoue et al 2001, 2003

    Bouillaguet et al 2001

    Fritz & Finger 1999


1 step se adhesives1
1 step SE adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • simplify steps

  • time saving

  • make them more user-friendly

  • at the expense of quality or durability of resin bonds ?

    Tay 2002


1 step se adhesives2
1 step SE adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • increase permeability

  • less mechanical durability

  • chemical instability

  • require a self-cure activator for indirect procedures


Degradation of dentine adhesives
Degradation of dentine adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

deterioration in the strength and structural integrity of resin-dentine bonds created with total-etch (Armstrong et al 2004, Carrilho et al 2007 )and self-etch ( Sano et al 1999, Hashimoto et al 2000 )techniques over time.


Problems with current adhesive systems
Problems with current adhesive systems material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • earlier systems were too hydrophobic and recent adhesives tend to be overly hydrophilic, impairing adhesion

  • increasing acidity of adhesive systems

  • mixing of hydrophilic and hydrophobic components in 1 system


1 step se adhesives3
1 step SE adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

complex mixture of hydrophobic and hydrophilic components in an organic solvent ( acetone or ethanol )

  • phase separation

    in one-component HEMA – free SE adhesive

    Van Landuyt et al 2005

  • shelf life problems

  • a reduced bond strength

    Van Landuyt et al 2009 Sadek et al 2005


Problems with new dentine adhesives
Problems with new dentine adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • in-vitro data = clinical data ??

  • clinical validation ( if any ) : short term

  • quick turnover of products


Summary on dbs
Summary on DBS material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

“ None of today’s systems yet appears able to guarantee leakage-free margins for a significant amount of time, especially at the dentine site ”

Van Meerbeek et al 1998

De Munck et al 2003


Summary on dbs1
Summary on DBS material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

3 – step etch & rinse adhesives still perform best in laboratory and clinical research

Sunnegardh & van Dijken 2000

van Dijken 2000, 2001


A critical review of the durability of adhesion to tooth tissue
A critical review of the material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”durability of adhesion to tooth tissue

  • 3-step E & R adhesives remain the “gold standard ” in terms of durability

  • 2-step self - etch adhesive approach the gold standard

    Munck et al 2005


Dental adhesives
Dental Adhesives material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • In vitro study

    Bond strength of 11 adhesives to dentine

  • The 3-step total etch system had the highest bond strength > 2 step SE > 1-step SE

    Sarr et al 2010


Take home message bonding systems
Take Home Message material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”Bonding Systems

  • In vivo bonding to enamel when the substrate is etched with phosphoric acid for 30 seconds is adequate and reliable

  • Dentine

    • quality of bond is related to many variables

    • formation of hybrid layer is mandatory

    • not totally eliminated leakage

    • bond failures still a problem

      Ferrari and Garcia-Godoy 2002


Summary on bonding systems
SUMMARY on Bonding Systems material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

Etch and Rinse systems ..… perform better on enamel than Self-Etching systems which may be more suitable for bonding to dentin.

Milia et al 2012


The era of light polymerization
The Era of Light Polymerization material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • control of working time

  • sets in seconds

  • colour stability

  • posterior restorations

    effectively done


Type of curing light
Type of curing light material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • traditional halogen light

  • plasma arc

  • argon laser

  • lead emitting diode ( LED )


Light emitting diodes led
Light-Emitting Diodes (LED) material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Semiconductors

    • electrically-excited atoms

  • Gallium-nitride blue

  • Narrow emission spectrum

    • 430-490 nm

      • peak at 470 nm

      • near absorption max of camphorquinone

      • efficient


Led curing lights
LED Curing Lights material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

  • Long lasting light source

    • minimal aging

    • minimal decrease in output

  • Less lateral heat production

    • Fanned

      • larger size; continual operation; slight noise

    • Fan-less

      • smaller size; quiet; easier infection control; portability

      • may shut down temporarily with continual use

        • thermostat

  • No filters

  • Typically cordless

  • Duke, Compend Contin Educ Dent 2001


    Which lights cure all cr
    Which lights cure all CR material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    ?


    Requirements for curing
    Requirements for curing material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • Wavelength to match resin

      photoinitiator

      • CQ photo initiator: 430-480 nm

      • Proprietary: 380 – 480nm (broad spectra)

    • Enough power to cure resin

      • > 800mW / cm2 for regular curing (20 seconds)

      • > 1500mW / cm2 for fast curing (5 seconds)


    Polymerization of composite resins
    Polymerization of Composite Resins material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Initiators

    • camphorquinone ( CQ )

    • PPD ( phenylpropandione )

    • lucerin

  • radiation absorption spectrum =

    lamp emission spectrum


  • Led curing lights1
    LED Curing Lights material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • First Generation

      • high cost

      • > arrays was better

      • < 300 mW/cm2

      • did not cure all CR

    • Second Generation

      • use of chips

      • > output power

      • improved battery ( NiMH Energy )

      • did not cure all CR

    • Third Generation

      • broad band / multi spectrum


    How long to cure
    How long to cure material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    ?


    Depth of cure
    Depth of cure material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    For halogen

    At 3 mm layers, even at 800 mW/cm2 and 80 secs exposure, there was no adequate polymerization

    Rueggeberg et al 1994


    Depth of cure1
    Depth of cure material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    With LED ( 1500 – 2000 mW/cm2 )

    Curing time for 2 mm of CR can be reduced to 20 sec

    Ernst et al 2004

    Schattenberg et al 2008

    Kramer 2008

    Rueggeberg et al 2009


    Best mode of cure
    Best Mode of Cure material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    ?


    Soft start polymerization
    “Soft-Start” Polymerization material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • Slow increase or delay in irradiance

      Stepped

      • short, low initial burst

      • full intensity

        Ramped

      • gradual increasefrom initial low level

        Pulsed delayed

      • short, low level burst

      • delay for polishing

      • full intensity

  • Slow rate of shrinkage

    • reducing stress


  • Soft start studies
    “Soft-Start” Studies material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • Laboratory studies somewhat equivocal

      • many show benefit

      • some show no improvement

    • Clinical studies are limited

      • all show NO BENEFIT!

        • El Mahdy, J Dent Res 1999

        • Oberlander, Clin Oral Investig 1999

        • Brackett, Oper Dent 2002


    Heat generation
    Heat generation material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • problem when dentine is < 1 mm –

      rise of 5.60C

    • lower heat generation with LED ?

      • 93 % of total energy is still heat as intensity is up to 2,000 mW/cm2

        Asmussen & Peutzfeldt 2005


    Curing lights heat generation
    Curing lights – heat generation material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Park et al 2010


    Curing lights heat generation1
    Curing lights – heat generation material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • “ …exposure times with high intensity lights

      ( > 1200 mW/cm2 ) should be limited to short periods ( 15 secs ) to minimize potential biologic impact ”

      Park et al 2010


    . material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Summary statements

    with high-power LED units of the latest generation, curing time of 2 mm thick increments of resin composite can be reduced to 20 seconds to obtain durable results


    Summary statements
    Summary statements material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    polymerization kinetics can be modified for better marginal adaptation by soft-start polymerization; however, in the majority of cavities this may not be the case


    Summary statements material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    heat generation with high-power photopolymerization units should not be underestimated as a biological problem for both gingival and pulpal tissues


    Light curing

    Take home message material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Light curing

    • cure in layers of max 2 mm

    • keep tip close to restoration

    • impossible to “overcure”

    • maintain light tip and output


    Take home message
    Take home message material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • LED will be the light source for the next generation curing light

      • emits enough power for fast and adequate curing

      • correct wavelength

      • extended LED life

      • slow degradation

      • portability

    • heat management needs to be looked into


    Practice based research network
    Practice Based Research Network material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • large Cl 2 CR and amalgams

      ( 3, 4, 5-surface restorations )

    • restorations placed from 1983 – 2003, min 5-year followup

    • 1949 Cl 2 in 273 patients

      Opdam et al 2010


    Practice based research network1
    Practice Based Research Network material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • Restorations placed in the high caries risk group lower survival than restorations placed in the low caries risk group

    • Large CR > 12-year survival than large AR

      Opdam et al 2010


    Practice based research network2
    Practice Based Research Network material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • 12-year survival rate :

      • large amalgams = large composites

        ( high caries risk group )

      • large composites > large amalgams

        ( low caries risk group )


    Safety of cr bpa
    Safety of CR - BPA material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • Bisphenol A ( BPA ) found

      • in plastic products

      • dental sealants

      • composite resins ??

    • safety issues

      • estrogenic effects

      • affecting reproduction and

        development


    BPA material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • direct ingredient - rarely used as an ingredient in dental products

    • by-product of other ingredients in CR or sealants - CR formulated from bisGMA, bis-DMA can release very small quantities of BPA due to salivary enzymes acting on it

    • trace material –bisGMA formulated from BPA as a starting ingredient


    Us dept of health and human services 2007
    US Dept of Health and Human Services material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”2007

    “ Dental sealant exposure to BPA occurs primarily with use of dental sealants. This exposure is considered an acute and infrequent event with little relevance to estimating general population exposures.”


    Fda 2010
    FDA 2010 material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    “ recent studies provide reason for some concern about the potential effects of BPA on the brain, behaviour and prostate gland of fetuses, infants and children……., based on this conclusion, the FDA does not require testing of dental materials, medical devices or food packaging for BPA at this time. ”


    Ada 2010
    ADA 2010 material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    “ Based on current research, the Association agrees with the authoritative government agencies that the low-level of BPA exposure that may result from dental sealants and composites poses no known health threat. ”


    Prevention
    PREVENTION material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • remineralization

    • fluoride

    • minimal intervention

    • repair of defective restorations

    • patient education


    Minimally invasive dentistry
    Minimally Invasive Dentistry material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    “ ……loss of even a part of a human tooth should be regarded as a serious injury, never to be considered lightly, and the tooth is certainly worthy of the most careful restoration ”

    Markley 1951


    Avoid
    Avoid material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Death spiral of restorations

    Qvist 2008


    Possible risks of replacement
    Possible risks of replacement material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    Surface area increases

    Millar et al 1992 (CR)

    Brantley et al 1995

    Hunter et al 1995

    ( CR and AR)


    Possible risks of replacement1
    Possible risks of replacement material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • damage to adjacent teeth

    • 69% of adjacent permanent teeth

    • most common : depth of 0.5 – 1.0 mm scratches and grooves

    • restorations placed in 35% of these teeth after 1- 3.5 years

      Qvist et al 1992


    Possible risks of replacement2
    Possible risks of replacement material ( composite ), even when informed that the clinical longevity will be shorter than that of amalgam ”

    • destruction of tissue

    • possibility of endodontic therapy

    • cost

    • time


    “ The day is surely coming.... when we will be engaged in practicing preventive, ratherthan reparative, dentistry. When we will so understand the etiology and pathology ofdental cavities that we will be able to combat its destructive effects by systemicmedication.”

    Dr. G. V. Black 1896


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