1

“BEAUTY LIES IN THE EYE OF THE BEHOLDER”

 TOOTH COLOURED
RESTORATIVE MATERIALS
PRESENTED BY:
DR. ABHISHEK. M. A
FIRST YEAR POSTGRADUATE
 FLOWCHART

1. Introduction
2. Definition and terminologies
3. Treatment planning and case design
4. Coexistence of facial and dental esthetics
5. Importance of light in esthetics
6. Categorization of tooth coloured restorative materials
7. Silicates
8. Acrylates
4
 FLOWCHART

9. Composites : 10. Glass ionomer cements:

A. Evolution
B. Classification
C. Composition
D. Indications and contraindications
E. Advantages and disadvantages
F. Modifications and Recent advances
A. Evolution
B. Classification
C. Chemistry
D. Indications and contraindications
E. Advantages and disadvantages
F. Modifications and Recent advances

5
 FLOWCHART

11. Ceramics : 12. Comparison between direct and

A. Timeline indirect tooth coloured restorative
B. Background Science materials
C. Classification 13. Conclusion
D. Indications and contraindications 14. References
E. Advantages and disadvantages 15. Questions asked
F. Comparison between types of ceramics
F. Modifications and Recent advances 6
 INTRODUCTION

• The search for “beauty” can be traced to the earliest civilisations.

• Dental art has long been part of the quest to enhance the esthetics of the teeth and mouth.
• In the past, teeth were filled with a mixture—or amalgam—of different metals.
• Today that is changing as more natural-looking and metal-free dental fillings are becoming
the preferred approach.
• However, the change in trend from “need based dentistry” to “elective dentistry”, most of
which involves esthetic dentistry, has made a significant impact on all aspects of the dental
industry.

7
 INTRODUCTION
• Esthetic dental appearance of teeth is one of the patients’ demands.
• Although the functional aspect of every case should be the dentist’s primary consideration,
esthetics may well be the patient’s main concern. This helped in the evolution of tooth
coloured materials.
• These include crowns, restorations, veneers, orthodontic brackets, and recenty, tooth
coloured posts too.
• In the emerging demand for such esthetic materials, tooth coloured restorative materials are
most sought after as they camouflage amidst the natural tooth structures, and at the same
time, restore the function of the teeth.

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 DEFINITION AND TERMINOLOGIES

• Esthetics is a sub-discipline of value theory or axiology, which is a

branch of philosophy that studies art, the methods of evaluating art,
and judgments of art.

• Esthetic (cosmetic) dentistry is a discipline within dentistry in which

the primary focus is the modification or alteration of appearance of
a patient’s oral structures, in conjunction with the treatment and
prevention of structural, functional, or organic oral disease.

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 DEFINITION AND TERMINOLOGIES

• Restorative materials: materials used to replace oral

tissues in dentistry; e.g., amalgam, gold alloys, cements,
porcelain, plastics, and denture materials.

• TOOTH COLOURED RESTORATIVE DENTAL MATERIALS:

substances that are used to repair, replace, or enhance a
patient's teeth and mimic the appearance of the tooth.

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 TREATMENT PLANNING & CASE DESIGN
• Treatment planning is the process of gathering information and developing a plan to address
both - the dental disease and the patient’s chief complaint.
• Case design enables the clinician to develop treatment strategies and identify possible
difficulties and solutions.
• The case design process must include both esthetics and function. These two guiding
principles must be viewed as inseparable entities.
• The patient must be well informed about the difference between “the need” and “the want”
during the treatment planning process to arrive at an informed decision (Christensen 2000);
and the repercussions of such a decision.

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 COEXISTENCE OF FACIAL AND DENTAL ESTHETICS

• It is important to have a good understanding of the overriding ethical principles

as well as the elements of microesthetics and macroesthetics prior to
performing esthetic dentistry.
• A simple rule of thumb is to start with the large features and work towards the
smaller features. Look at the face, lips, and gingiva before individual tooth
assessments are performed.

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 IMPORTANCE OF LIGHT IN ESTHETICS
Direction of light
Movement of light
Colour of light
• By varying the contour and facets on tooth surfaces, we alter and affect the direction of
light reflection.
• The concavities and convexities of the enamel surface partly determine the surface texture,
which influences the intensity and character of the reflected light by the way the surface
absorbs or reflects light.
• Also, when taking the shade; hue, value and chroma should be differentiated and matched.
Final shade in mouth should be checked with the patient in dynamic action.

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Based on the material used: Based on location of use:
a) Silicates a) Anterior
b) Acrylates b) Posterior
c) Dental Composites
d) Glass Ionomer cement
e) Ceramics

CATEGORIZATION OF TOOTH COLOURED RESTORATIVES

Based on type of bonding: Based on method of placement:

a) Micromechanical a) Direct
b) Mechanical b) Indirect
c) Chemical
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 Early
20th
century
SILICATES Solubility
Shrinkage
Discolouration
Silicate glass
+ Phosphoric
acid

Marginal
leakage 
Erosion

15
 Quartz powder
1940’s Reduced
ACRYLATES shrinkage and
expansion
Reduced
stress

Polymethyl-
methacrylate High wear
Toothlike Curing
Insoluble shrinkage
Easy manipulation Marginal leakage
Low cost
16
COMPOSITES

17
GLASS IONOMER
CEMENT

18
CERAMICS

19
 DEFINITION
• Composite – in material science, a solid formed from
two or more distinct phases (e.g. particles in a metal
phase) that have been combined to produce
properties superior to or intermediate to those of the
individual constituents (Anusavice)
• Dental composite is defined as a highly cross-linked
polymeric material reinforced by a dispersion of
amorphous silica, glass, crystalline, or organic resin
filler particles and/or short fibers bonded to the
matrix by a coupling agent (Anusavice)
• Composite can be described as a dispersed filler
phase mixed into a continuous matrix phase.
(Sturdevant’s Art and Science of Operative
Dentistry)
DCNA (vol. 27; no. 4; 1983): A three dimensional
combination of at least two chemically different
materials with a distinct interface separating the
components.
DCNA 2007; Dental materials; vol. 51; July: Composite
is a multiphase material that exhibits the properties
of both phases where the phases are complimentary,
resulting in a material with enhanced properties.
DCNA 2007; vol. 50, Aesthetic and Cosmetic Dentistry:
A composite is a multiphase substance formed from a
combination of materials that differ in composition or
form, remain bonded together, and retain their
identities and properties. 20
EVOLUTION

21
 Self curing acrylic EVOLUTION OF COMPOSITES
resins were developed New initiation systems Polymer
by German Chemists based on benzoyl-
Hybrid nanocomposites in
Dr Walter Wright: Dr Rafael composites Ormocers; Ion releasing germanium derivatives solution by
Methyl L. Bowen: Flowable fiber reinforced polymer
Unfilled resins composites
methacrylate BisGMA composites; functionalization
advocated for
resin; unfilled Ceromer Controlled
esthetic fillings Microfilled
resins for crowns Mini hybrid shrinkage
composite composites composites
and bridges
1937 1941 1945 1962 1976 1981 1996 1998 2001 2002 2008 2010
1900 1948 1955 1972 1980 1995 1997 1999 2003 2004 2006 2009 2016 2017

Light cure Light cure Single

Sevitron was one
using UV crystal
of the filling using Nano-
rays modified
materials available visible light; Packable composites composites Self
in the market. Reinforcement
Indirect composites adhesive with silver
composites composites nanoparticles–
Dr. Michael Buonocore: Polyhedral oligomeric
laden
Acid etch silsesquioxane (POSS)-
hydroxyapatite
Compomer polymers
nanowires
Sahin et al:
Acidic
monomers
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CLASSIFICATION

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 TRADITIONAL / SMALL PARTICLE MICROFILLED COMPOSITES HYBRID COMPOSITES
CONVENTIONAL COMPOSITES
COMPOSITES
FILLER SIZE 8-12µm (upto 50µm) 0.5 - 3µm Appx. 0.04 µm to 0.4 µm 0.4 – 1 µm
FILLER LOADING 70-80 wt% 80-90 wt % 35-67 wt % 75 – 80 wt %
60-70 vol% 65-77 vol % 20-59 vol % 60 – 65 vol %
TYPE OF FILLER •Quartz •Mostly glasses •Fumed silica or colloidal silica •Macrofillers: Ground glass particles
•Newer Glasses with •Colloidal silica with heavy metals
heavy metals (~5 wt %) •Microfillers: colloidal silica particles
CLINICAL Stress bearing High stress, High Small, protected class III & Class V Anterior restorations, including class
CONSIDERATION areas, Class II, Class abrasion prone in IV sites and stress bearing
IV areas like class IV restorations
ADVANTAGES High mechanical Relatively smooth • Improved surface smoothness •Greater surface smoothness;
properties surface for •Less polymerisation shrinkage reasonably good strength and
anterior use and radioopaque.
Radiopaque
DISADVANTAGES •Rough surface •Glass fillers •High chance for fracture in class II •Strength less than that of small
•Abrasion & wear soften, hydrolyze class IV particle.
rate is high & leach. •Break down in wear prone areas
•Discoloration • Prone to wear •Chipping around margins
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•Radiolucent
25
COMPOSITION

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27
28
 EFFECTS OF FILLER LOADING ON COMPOSITE RESINS
Generally, the smaller the average particle size, the easier it will be to polish the resin.
Within practical limits, the greater the percentage filler content, the better the physical
properties because there is less matrix.
Coefficient of thermal expansion, water sorption, polymerization shrinkage decreases while
modulus of elasticity, tensile strength, and fracture toughness increase.
% Filler Volume
2

Fracture Toughness
1.5

0.5

0
0 28 37 48 53 6229
Cramer NB, Stansbury JW, Bowman. Recent advances and developments in composite dental restorative materials. J Dent Res.2011;90:402–16.
 Indications
&
contraindications

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 Indications
• Esthetic enhancement procedures
• Partial veneers and Full veneers
• Tooth contour modifications
• Diastema closure
• Class I, II, III, IV, V and VI restoration for
esthetically pleasing restorations
• Foundations or core buildups
• Sealants and conservative composite
restorations (Preventive resin restoration)
Cramer NB, Stansbury JW, Bowman. Recent advances and
developments in composite dental restorative materials. J Dent
Res.2011;90:402–16.
• Cements for indirect restorations
• Temporary restorations / provisional
restorations in teeth with doubtful
prognosis.
• Periodontal splinting.
• In a badly broken down tooth prior to
endodontic / orthodontic / periodontic
treatment.
• Areas of minimal masticatory loading.
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 Contraindications
• Improper isolation of operating site.
• When all occlusal contacts will be on composite material.
• Heavy occlusal stresses.
• Deep sub-gingival areas that are difficult to prepare or restore.
• Poor oral hygiene.
• High caries index
• Habits (bruxism)
• Operator abilities

Cramer NB, Stansbury JW, Bowman. Recent advances and

developments in composite dental restorative materials. J Dent 32
Res.2011;90:402–16.
 Advantages
&
Disadvantages

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 Advantages
• Esthetics
• Conservation of tooth structure
• Less complex when preparing the tooth
• Insulative
• Used almost universally
• Strengthening
• Bonded to tooth structure
• Repairable
• No corrosion

Cramer NB, Stansbury JW, Bowman. Recent advances and

developments in composite dental restorative materials. J Dent 34
Res.2011;90:402–16.
 Disadvantages
• Direct function of the amount of resin.
• Polymerization shrinkage • Stresses can exceed the tensile strength of enamel & result in stress
cracking and enamel fractures along the interfaces.
• Technique sensitive
• Light-cured resin composites generate higher polymerization
• Higher coefficient of thermal expansion shrinkage stresses than chemically-cured composites.
• Difficult; time consuming • Dentine bonding agents, Cavity liner, Incremental buildup; Intensity of
• Low modulus of elasticity curing light

• Increased occlusal wear

• Staining
• Costly

Cramer NB, Stansbury JW, Bowman. Recent advances and

developments in composite dental restorative materials. J Dent 35
Res.2011;90:402–16.
IMPORTANT PROPERTIES
&
CLNICAL SIGNIFICANCE

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 POLYMERIZATION SHRINKAGE
• Free volumetric polymerization shrinkage is a direct function of the amount of resin.
• This shrinkage creates polymerization stresses as high as 13MPa between composite &
tooth structure. These stresses can exceed the tensile strength of enamel & result in
stress cracking and enamel fractures along the interfaces.
• It has been demonstrated that light-cured resin composites generate higher polymerization
shrinkage stresses than chemically-cured composites.
TYPE OF COMPOSITE CURING SHRINKAGE (vol%)

Small-particle 2-3
Hybrid 2-3
Microfilled 2-3%
Packable 0.6 – 0.9%
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Schneider L. F. et al Shrinkage stresses generated during resin-composite applications: a review. J. Dent. Biomech. 2010,
 MEASURES TO REDUCE POLYMERIZATION SHRINKAGE

• Develop dentin bonding agents that are able to develop immediate bond strengths that are greater than
those developed by polymerization contraction & are equal to those obtained to acid-etched enamel.
• Cover the bonded dentin surfaces with an elastic cavity liner: shock-absorber & places a low modulus
material between the relatively rigid dentin & resin composite.
• Incremental buildup to reduce the volume of the resin that is shrinking during polymerization.
• The longer the pre-gel point time, the less the stress in the post-gel phase.
• High-intensity energy output light sources, such as plasma arc curing lights or laser curing lights, allow a
reduction in polymerization time by increasing the polymerization rate. This results in a decrease of the
pre-gel point time and may increase the shrinkage stress. Thus, use low/moderate intensity curing
sources.

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Schneider L. F. et al Shrinkage stresses generated during resin-composite applications: a review. J. Dent. Biomech. 2010,
 CAVITY CONFIGURATION FACTOR
• The most important consideration while
placing a restorative that shrinks on
setting, like composites, is the number of
opposing walls facing the restorative
since these margins can be opened when
the material shrinks.
• The C-factor (configuration factor) is a
term used for the ratio of the number of
walls bonded to unbonded.
• As the C-factor increases, ramp, step,
and pulse curing become effective ways
of reducing marginal openings and cuspal
strain from polymerization shrinkage.
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Schneider L. F. et al Shrinkage stresses generated during resin-composite applications: a review. J. Dent. Biomech. 2010,
 MARGINAL INTEGRITY/MARGINAL LEAKAGE
• Factors contributing to microleakage –
• Polymerization shrinkage
• Difference in CFTE between tooth and composite
• Modulus of elasticity
• To enhance the marginal adaptation & reducing the microleakage of composite
restorations:
• Acid etch technique
• Dentin bonding
• Cavity design
• Incremental technique
• Sealing the margins-unfilled resin/ low filler content resin
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Schneider L. F. et al Shrinkage stresses generated during resin-composite applications: a review. J. Dent. Biomech. 2010,
 FACTORS AFFECTING CURING IN LIGHT CURE
• Maximum intensity of the light radiation beam is
concentrated near the surface of a light cured
composite. As the light penetrates the material, it is
scattered and reflected and loses intensity.

• A number of factors influence the degree of

polymerization in light cure composites:
time, intensity, temperature, light distance, resin
thickness, air inhibition, tooth structure, composite shade,
filler type, accelerator quantity, heat, and room light.
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 FACTORS AFFECTING CURING IN LIGHT CURE
• Both filler content and particle size are critical to dispersion of the light beam.
• For this reason, microfilled composites with smaller and more numerous particles scatter
more light than micro hybrid composites with larger and fewer glass particles. Longer
exposure times are needed to obtain adequate depth of cure of microfilled composites.
• The tip of the light source must be held within 1 mm of the surface to gain optimum
penetration. More opaque shades reduce light transmission and cure only to minimal
depths (1 mm).
• A standard exposure time using most visible light is 20 seconds. In general, this is
sufficient to cure a light shade of resin to a depth of 2 or 2.5 mm. A 40 second exposure
improves the degree of cure at all depths and will give sufficient cure with the darker
shades.
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 WATER SORPTION AND SOLUBILITY
• The higher the concentration of organic matrix in a composite resin, the higher the tendency
for water sorption. Once a resin restoration is exposed to water, it may absorb the solvent
into the restoration, causing a volumetric expansion that partially compensates for
polymerization contraction.
• The water solubility of composites varies from 0.01 to 0.06 mg/cm2. Inadequately
polymerized resin has greater water sorption and solubility.
TYPE OF COMPOSITE WATER SORPTION (mg/cm2)
Traditional 0.5-0.7
Small-particle 0.5-0.6
Hybrid 0.5-0.7
Microfilled 1.4-1.7
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 STRENGTH
FLEXURAL COMPRESSIVE DIAMETRAL TENSILE STRENGTH
(Mpa) (Mpa) (Mpa)

NANOCOMPOSITE 180 460 81

MULTIPURPOSE COMPOSITE 80 - 160 240 – 300 30 – 55

MICROFILLED 60 – 120 220 – 300 25 – 40

PACKABLE 85 – 110 210 – 280 33 – 48
FLOWABLE 70 – 120 210 – 280 33 – 48
COMPOMER 65 – 125 180 – 250 25 – 40
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 BIOCOMPATIBILITY
1) Direct biological risk
•Post-placement tooth sensitivity
•Local immunological effects
•Apoptotic reactions
•Long-term pulpal inflammation
•Systemic estrogenic effects
•May elicit allergic reactions, or may possibly
•Even act as carcinogens

2) Indirect biological risk – Post-operative sensitivity, pulpitis, and secondary caries

resulting from microleakage/nanoleakage.
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 BIOCOMPATIBILITY

1) Minimizing direct biological risks 2) Minimizing indirect biological risks –

• Cavity preparation • Complete removal of microorganism
• Selection of adhesive system • Using disinfectants
• Conversion of monomers • Selecting an adhesive
• Long-term degradation • Control of polymerization stress

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 COLOUR AND COLOUR STABILITY
• Change of color and loss of shade match with surrounding tooth structure are reasons for
replacing restorations.
• Stress cracks within the polymer matrix and partial debonding of the filler to the resin as
a result of hydrolysis tend to increase opacity and alter appearance.
• Discoloration can also occur by oxidation and result from water exchange within the
polymer matrix and its interaction with unreacted polymer sites and unused initiator or
accelerator.
• Composites are susceptible to staining due to microleakage too.

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 COLOUR AND COLOUR STABILITY
There are three common explanations for a color that appears too light:
(1) the tooth was allowed to dehydrate before final shade selection,
(2)there was a disparity between the shade guide and the composite restoration, and
(3) the composite was not completely cured.
Composites lighten during curing because of color transformation of the camphoroquinones
that are activated during polymerization. Therefore, determining shade color based on a
partly cured composite is likely to yield a shade that is too light when the restoration is fully
polymerized.

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 EROSION
• Composites are susceptible to chemical erosion.
• All resin systems have some susceptibility to hydrolysis.
• Acidulated phosphate fluoride (APF) can dissolve the fillers and pit the surface of many
macrofilled composites.
• Laboratory studies show that composites filled with strontium glass and, to a lesser extent,
those filled with quartz are dissolved during normal applications of APF gels.
• Microfilled resins are the least affected by APF. It is therefore prudent to use non-APF
fluorides on patients with macrofilled composite restorations.

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 WHITE LINE MARGINS

• If a composite restoration has any thin, knife-edge margins, a white line at this margin may be
noticeable at placement. Microfills generally produce more white lines at the margins than do
more heavily filled materials.
• White lines seen immediately after placement are thought to be related to finishing techniques
that cause the enamel tags to tear as a result of the tension of polymerization shrinkage.
• Finishing burs cause the most white line margins, whereas micron diamonds and flexible discs
cause the least. The exact cause of white lines is not established.
• Research suggests that these margins stain. Because of the large disparity in the coefficient of
thermal expansion between the tooth and the restoration, staining at an unsealed edge is a
longlasting problem.
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 PITS
• Pits are caused by porosity or air incorporation.
• They are sometimes hard to detect during placement but become readily apparent at
recall, because they stain easily. Aging is another factor in pit formation.
• When composites get old, they sometimes dry out. This can result in pitting throughout a
restoration.
• Light-cured materials are the least porous. In general, highly viscous materials are more
likely to have voids during placement, owing to poorer adaptation during layering and
injection.
• Viscous autoset composites are highly porous as a result of air incorporation during
mixing. Powder-liquid systems are the most porous of the composite types; it is difficult to
achieve a consistently mixed paste.
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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 CHIPPING
• Chipping is common with larger composites, such as veneers.
• In general, microfills chip in large pieces when stressed, which can cause a shear failure.
• More heavily filled materials tend to chip in small increments that are easier to repair.
• The most frequent cause of chipping is excessive occlusion. Ideally, all composite
restoratives should be cleared of any occlusal forces, including protrusive and
parafunctional movements.

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
 COHESIVE FRACTURE
Cohesive fracture is more common with microfills than macrofills. Heavily filled
composites are the least likely to fracture and should be considered as replacements for
more lightly filled materials.

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Schweiz Monatsschr Zahnmed. 2010;120(11):972-86. Composite materials: composition, properties and clinical applications. A literature review. Zimmerli B
MODIFICATIONS
&
ADVANCES 54
MODIFICATIONS & ADVANCES IN COMPOSITES

55
FLOWABLE & PACKABLE
COMPOSITES

56
 FLOWABLE/ INJECTABLE COMPOSITES
• Lower filler contents (≤ 60 wt%)  Indications
• Decreased viscosity • Filling material in low stress bearing areas
• Higher polymerization shrinkage • Areas of difficult access – proximal box
• Class V lesions
• Lower mechanical properties (60-90% reduction)
• Repairing old composite, amalgam, crown
• Higher wear rates margins
• Porcelain repair
• Preventive resin restorations
• Pit & fissure sealant
• Tunnel restorations

 Contraindications
Cramer NB, Stansbury JW, Bowman. Recent advances and
developments in composite dental restorative materials. J Dent High stress bearing areas - Class I, II & IV
57
Res.2011;90:402–16.
 NANO-FILLED FLOWABLE COMPOSITES

• Utilizes nano-sized fillers.

• Flows readily
• Excellent aesthetics
• Low wear comparatively
• Available in capsules

58
Cramer NB, Stansbury JW, Bowman. Recent advances and developments in composite dental restorative materials. J Dent Res.2011;90:402–16.
 PACKABLE/CONDENSABLE/ MOULDABLE/ DENSELY
FILLED COMPOSITES
• Has the ability to be packed like amalgam:
 Better contact with the adjacent teeth
 Better occlusal form

• Utilizes different filler systems:

1. Fibers
2. Trimodal particle distribution (interlock at the time of packing)
3. Non-slumping fillers
4. Resin impregnated fillers

• But, the increased viscosity  ↑ incidence of void formation; ↓ adaptability

• Usually used in combination with flowable liners
59
Cramer NB, Stansbury JW, Bowman. Recent advances and developments in composite dental restorative materials. J Dent Res.2011;90:402–16.
COMPOMERS

60
COMPOMERS (POLYACID-MODIFIED COMPOSITES)
• Modified composite having the main
advantages of glass ionomer cement.

•Compositional modifications:
 Certain liquid monomer (HEMA) is
modified by polyacrylic acid grafts
 Filler particles similar to the powder of
glass ionomer cement (calcium- fluoro-
alumino-silicate glass) Drawbacks:
 Using bonding systems still mandatory
 Lower wear resistance than regular
Nicholson JW. Polyacid-modified composite resin
composites
(“compomers”) and their use in clinical dentistry. Dent  Insignificant release of fluoride
61
Mater 2007;23:615–622
Minimal shrink composites

62
 MINIMAL SHRINK COMPOSITES
The development of minimal-shrink composites was based on:
1. Increasing the filler load
• Using prepolymerized composite fillers
• Using nano-sized fillers (Tetric Evoceram, Ivoclar-Vivadent)

2. Using organic matrices with lower polymerization shrinkage

• Spiro-orthocarbonate, can produce composites with no setting contraction (Thompson et al
, 1979; Eick et al,1992)
• Oxy bis-methacrylates (bifunctional monomer) shows also a reduced rate of the
polymerization contraction
• Cyclopolymerizable monomers [Mathias et al, 1987; Stansbury et al, 1990]
• Oxirane and silorane-based monomers
Moon EJ, Lee JY, Kim CK, Cho BH. (2005). Dental restorative composites containing 2,2-bis-[4-(2-hydroxy-3-methacryloyloxy
63
propoxy) phenyl] propane derivatives and spiro orthocarbonates. J Biomed Mater Res Part B: Appl Biomater 73:338-346
SILORANE composites

64
 SILORANES
• Guggenburger and Weinmann (2000) Advantages:
• Siloxane + Oxiranes • Low shrinkage (1%)
• Siloxane backbone – hydrophobic nature • Better marginal integrity
• Ring opening monomers, cationic cure • Comparable mechanical properties
• High reactivity, high degree of
conversion
• Flexible Si-O-Si bonds, low viscosity- no
diluents
• Increased hydrophobicity
• Decreased water sorption and solubility
Weinmann W, Thalacker C, Guggenberger R. (2005). Siloranes in dental • Improved biocompatibility
65
composites. Dent Mater 21:68-74
GIOMERS

66
 GIOMERS
• Hybrids of glass ionomers and composites: INDICATIONS:
To overcome some drawbacks of compomers • Class I through V
• The filler particles are a kind of pre- • Cervical erosion
polymerized glass ionomer agglomerates
• Root caries
• Fluoride release, fluoride recharge
• Easy to polish, biocompatibility
• They show a true hybridization of glass
ionomers and composites as they have the
fluoride release and recharge of glass
ionomers and the aesthetics, handling and
physical properties of composite resins.
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OrMocERS

68
 ORMOCERS / ORMOSILS
• Wolter, Storch & Ott (1994) Advantages:
• Light cured inorganic-organic copolymers • High molecular weight (2,000-20,000)
• Methacrylate substituted alkoxy silanes • Low shrinkage – 1.88%
• SiO2 filler (backbone) modified organically by • Good abrasion resistance & hardness
methacrylates (photopolymerizable side chains) • Good aesthetics (various shades)
• Filler – 77% wt, 1-1.5 (0.7) μm ; 20-25% matrix • Condensable
• Silica partially replaced by Zr, glass fillers • Fluoride release
• Bonding
Disadvantage: • Biocompatible
Rough surface, difficult to polish (high inorganic Uses:
content)
Anterior & Posterior restorations
Recent Advances and Developments in Composite Dental Restorative Materials N.B. Cramer, J.W. Stansbury, C.N. 69
Bowman J Dent Res. 2011 Apr; 90(4): 402–416.
70
 FIBER
REINFORCED
COMPOSITES
71
 FIBER REINFORCED COMPOSITES
• Good alternative to all and metal-ceramic 1. Continuous/Whiskers
restorations.
2. Longitudinal/Random
• Preimpregnated/Impregnated (wetting by
resin) 3. Unidirectional /Bidirectional/ Woven
(mesh)
• Fibers bonded to resin via adhesive interface
• Enhance fracture toughness Indications: Individual restorations (inlay,
• Improved structural onlay, full veneer crown)
properties - • FRC endodontic post
crack stopper • Reinforcing denture bases
• Implant frameworks
Recent Advances and Developments in • Bases of orthodontic appliances
Composite Dental Restorative Materials
N.B. Cramer, J.W. Stansbury, C.N. Bowman
• Fixed prosthesis
J Dent Res. 2011 Apr; 90(4): 402–416. • Periodontal splints. 72
FIBER REINFORCED COMPOSITES
Advantages:
• Single visit immediate treatment
• Suitable for transitional & long term
replacement
• Suitable for young patients
• Metal free restoration
• Improved esthetics
• Frequently minimal / no tooth
preparation
• Less wear of opposing tooth as
compared to traditional composites
Disadvantages:
• Potential wear of overlying veneering
composite - parafunctional habits
• Excellent moisture control required
• Space requirement greater in
comparison to metal occlusal
surfaces
• May lack sufficient rigidity for long
span bridges.
• Uncertain longevity
Recent Advances and Developments in Composite Dental
Restorative Materials N.B. Cramer, J.W. Stansbury,
73
C.N.
Bowman J Dent Res. 2011 Apr; 90(4): 402–416.
 Commercial Product Fiber type Fiber architecture Manufacturer
A. Pre-impregnated, dental laboratory products
 FiberKor Glass Unidirectional Jeneric/petron
 Vectris pontic Glass Unidirectional Ivoclar-Vivadent
 Vectris frame & single Glass Mesh Ivoclar-Vivadent
B. Pre-impregnated, chair-side products:
 Splint it Glass Unidirectional Jeneric/Petron
 Splint it Glass Weave Jeneric/Petron
FIBER  Splint it Polyethylene Weave Jeneric/Petron
REINFORCED C. Impregnation is required, chair-side products
COMPOSITES  Connect Polyethylene Braid Kerr
 DVA fibers Polyethylene Unidirectional Dental Venture
 Fiber splint Glass Weave Interdental
 Fiber flex Kevlar Unidirectional Distributor
 Class span Glass Braid BioComp
 Ribbond Polyethylene Leno weave Glasspan
D. Pre-impregnated, prefabricated posts
 C-Post Carbon Unidirectional Bisco
 FiberKor Glass Unidirectional Jeneric/petron
74
SMART COMPOSITES

75
 SMART COMPOSITES
It releases fluoride, hydroxyl and calcium ions, when the
pH in areas adjacent to the restoration drops down (e.g.
plaque accumulation)

Recent materials are based on alkaline glass fillers.

The release of alkaline ions helps in:

1. Inhibiting bacterial growth
2. Buffering the acids produced by bacteria
3. Reduce the incidence of recurrent caries (Reduce the
demineralization)
Recent Advances and Developments in Composite
Dental Restorative Materials N.B. Cramer, J.W.
Stansbury, C.N. Bowman J Dent Res. 2011
76
Apr; 90(4): 402–416.
Antibacterial
compositeS

77
 ANTIBACTERIAL COMPOSITE
A. Alteration to the resin component Advantages:
• Soluble agent  1% Chlorhexidine (Jedrychowski • No effects on mechanical properties
et al) • Long lasting antibacterial effect (3 months)
• Immobilized agent – MDPB (12- • Maintained after immersion in water
methacryloxydodecylpyridinium bromide) (Imazato
et al) • Unaltered/enhanced curing behavior

B. Alteration to the filler component Disadvantages:

• Silver as a filler • Action only against bacteria coming in contact
• MDPB in Pre-Polymerized Resin Fillers (PPRF) • Mainly bacteriostatic – no penetration
(Ebi et al) • Less intense action
Mehhdawi I, Neel EA, Valappil SP, Palmer G, Salih V, Pratten J, et al. • Reduced efficacy by adsorption of proteins
(2009). Development of remineralizing, antibacterial dental materials. Acta
Biomater 5:2525-2539 • Color stability…? 78
 BIOACTIVE
compositeS

79
 BIOACTIVITY
• Biomaterial: Any matter, surface or • Biomimetics: Study of formation,
structure that interacts with biological structure or function of biologically
systems. produced substances and materials and
• Bioactive material: Material that has the biological mechanisms and processes for
effect or elicits a response from a living the purpose of synthesizing similar
tissue, organisms or cell such as products by artificial mechanisms that
induction of formation of hydroxyapatite. mimic natural structures.
• Bioinductive material: Material that has
the capability to induce a response in a
biological system.
BIO-MIMETIC MATERIALS IN RESTORATIVE DENTISTRY Supriya Malik,et
al Journal of Updates in Dentistry, July-December 2015;4(2) 20--23 80
BIOACTIVE COMPOSITES

81
 BIOACTIVE MATERIALS
Bioactive materials include:
• Ca(OH)2
• Mineral trioxide aggregate
• Calcium enriched mixture
• Biodentine
• Activa TM BioACTIVE
• Pulpdent (composites that release more fluoride than GIC)
• Tetracalcium phosphate
• Bioactive Glass
BIO-MIMETIC MATERIALS IN RESTORATIVE DENTISTRY Supriya Malik,et al Journal of Updates in Dentistry,
July-December 2015;4(2) 20--23 82
NANO-FILLED compositeS

83
 NANO-FILLED
COMPOSITES
• Nanos – dwarf
• 0.005-0.01um, 57% filler loading by
volume
• Nanomer (NM): discrete, non- • Strength of hybrid and polish of micro fill.
agglomerated particles, 20-75 nm
- nanosilica • Equivalent / better mechanical properties
• Nanoclusters(NC): loosely bound • Better polish retention
agglomerates, 2-20 nm - 0.6 um – • Below wavelength of visible light (0.4-0.6um) - No
zirconia/silica
scattering/ refraction
• Fit between polymer chains high
filler loading. • Translucent effect – range of shades & opacities
Soh MS, Sellinger A, Yap AU. (2006). Dental
• Universal restorative
84
nanocomposites. Curr Nanosci 2:373-381
INDIRECT compositeS

85
 INDIRECT POSTERIOR
• Polymerized outside oral environment COMPOSITES
• Luted with a compatible resin cement
• Curing – light, heat, pressure, combination

Advantages:
• Higher degree of polymerization
• Improved physical properties & wear
resistance
• Reduces the subsequent effect of the
polymerization shrinkage (i.e. weak
bonding, microleakage, improper contact)
• Less abrasive than ceramic inlays
Disadvantages
 Technique sensitive
 Require long term clinical studies
Recent Advances and Developments in Composite Dental
Restorative Materials N.B. Cramer, J.W. Stansbury,
86
C.N.
Bowman J Dent Res. 2011 Apr; 90(4): 402–416.
 Start with light or chemical-
curing inside the mouth.
Then apply post-curing heat
or light treatment
CHAIR-SIDE
Indirect composite
restorations
CAD-CAM composites

Cured with heat & pressure

or light & pressure on a cast

LABORATORY
Fiber-reinforced composites

87
GLASS IONOMER
CEMENT

88
 DEFINITIONS
• Glass-ionomer is the generic name for materials based on reaction of glass powder and
polyacrylic acid” -Kenneth J Anusavice
(Phillips’ Science of Dental Materials First South Asia Edition 2014)
• “Glass ionomer cement is a basic glass and an acidic polymer which sets by an acid-
base reaction between these components” JW McLean, LW Nicholson. AD Wilson (1994)

• Glass ionomer is a water based material that hardens following an acid – base reaction
between fluroaluminosilicate glass particle and an aqueous solution of polyacid. –
Davidson and Major

89
EVOLUTION

90
 EVOLUTION OF GIC
Wilson and Kent: Miller et al: Novel
developed GIC in GIC: Bioactive; metal
a lab in Lonodon Wilson: ASPA II McLean: Cermet Easy mix cation-free and
High viscosity GIC
(aluminosilicate cement and GIC Giomer magnesium free
polyacrylic acid) Sandwich technique RMGIC
was produced
and marketed
1969 1975 1985 1990 1995 2001 2002 2013
1900 1972 1982 1988 1994 2000 2007 2014 2017
Atraumatic
Wilson and Kent : Restorative Hook et al: Series of GIC
First ASPA cement and RMGI Fast setting GIC
Crisp and Wilson: ASPA II functionalized with
luting Chorhexidine
 Second generation; cements
+tartaric acids to control hexametaphosphate
‘Al’ deposition nanoparticles

Purton and Rodd: showed that GIC not Nanoionomer

only releases fluoride ions, but also
calcium and phosphate ions.

91
CHEMISTRY

92
 93
Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater. 2016 ;7:pii: E16
 Indications
&
contraindications

94
 INDICATIONS
1. RESTORATIVE MATERIALS: 3. OTHERS:
• Restoring of erosion / abrasion lesions without • Dentin substitute
cavity preparation.
• Repair of defective margins in restorations
• Sealing and filling of occlusal pits and fissures.
• ‘Minimal cavity preparations’ – proximal
• Restoration of deciduous teeth.
lesions – buccal and occlusal approach (tunnel
• Class III lingual approach. preparation)
2. FAST SETTING LINING CEMENT BASE: • Core build-up
• Lining of all types of cavities where a biologic seal • In patients with rampant caries and as well
and cariostatic action are required multiple caries lesions
• Replacement of carious dentin or the attachment of • Modified cavity designs – minimal invasive
composite resins using the acid etch technique dentistry
95
Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater. 2016 ;7:pii: E16
 CONTRAINDICATIONS
• Class IV cavities
• Lesions involving large areas of labial enamel where esthetics is of major
importance
• Class II with increase occlusal load
• Lost cusp areas.

96
Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater. 2016 ;7:pii: E16
RECAP – TOOTH COLOURED RESTORATIVE MATERIALS

• Treatment planning and case design D. Indications and contraindications

• Coexistence of facial and dental esthetics E. Advantages and disadvantages
F. Modifications and Recent advances
• Importance of light in esthetics G. Clinical Aspects
• Categorization of tooth coloured restoratives • Glass ionomer cements:
• Silicates A. Evolution
• Acrylates B. Chemistry
C. Indications and contraindications
• Composites :
A. Evolution
B. Classification
C. Composition
97
CLASSIFICATION

98
 CLASSIFICATION OF GIC – Wilson mclean
(1988)
Type I : Luting crowns, bridges and orthodontic
brackets

Type II: Restorative

Type II a : Aesthetic restorative cements
Type II b : Reinforced restorative cements
(Cermets, Amalgam alloy admix, Silver alloy admix)

Type III : Lining cements, Base

McLean J.W: Glass ionomer cements, British Dental Journal, Volume 164, 1988 99
 TYPES OF GIC – SMITH, WRIGHT AND BROUN
(1989)
TYPE I  LUTING (e.g: GC Fuji – I, GC Fuji Cem)
TYPE II  RESTORATIVE (e.g: GC Fuji – II, Ketac-Fil)
TYPE III  LINERS AND BASES (e.g: GC Fuji lining LC, Ketac-bond)
TYPE 1V  PIT AND FISSURE SEALANT (e.g: GC Fuji III)
TYPE V  LUTING FOR ORTHODONTIC PURPOSE (e.g: GC Fuji Ortho)
TYPE VI  CORE BUILDUP (e.g: 3M Vitremer, Ketac Silver)
--------------------------------------------------------------------
TYPE VII  HIGH FLUORIDE RELEASING COMMAND SET (e.g: GC Fuji VII)
TYPE VIII  HIGH STRENGTH ANTERIOR ESTHETIC MATERIAL (e.g: GC Fuji VIII)
TYPE IX  PEDIATRIC AND GERIATRIC RESTORATIVES (e.g: GC Fuji IX, FUJI
Ketac molar)
Smith, Wright, Brown: The clinical handling of dental materials. 1st Edition. Butterworth-Heinemann; 1989. 100
Literature GC Fuji VII, VIII, IX ; As of February 2nd 2015
 CLASSIFICATION OF GIC – MC LEAN
(1994)
1. GLASS IONOMER:
a. Glass polyalkeonates
b. Glass polyphosphonates

2. RESIN MODIFIED GLASS IONOMER

3. POLYACID MODIFIED COMPOSITE RESINS

McLean JW, Nicholson JW, Wilson AD : Suggested nomenclature for Glass ionomer
cements and related materials (editorial), Quintessence Int, 1994; 25:587-589101
 Advantages
&
Disadvantages

102
 Advantages
• Form a rigid substance on setting • Filler–matrix chemical bonding
• Good fluoride release (bacteriostatic, inhibit • Resistant to microleakage
caries) • Non irritating to pulp
• Low exothermic reaction on setting • Good marginal integrity
• Less shrinkage than polymerizing resins • Adhere chemically to enamel and dentin
in the presence of moisture
• Coefficient of thermal expansion similar to
dentin • Rechargeable fluoride component
• Good bonding to enamel and dentin
• No free monomers
• Dimensional stability at high humidity
103
Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater. 2016 ;7:pii: E16
 Disadvantages

• Susceptible to dehydration over lifetime

• Sensitivity to moisture at placement
• Poor acid resistance
• Average esthetics
• Less tensile strength than composites
• Technique sensitive powder-to-liquid ratio and mixing
• Cannot be used in stress bearing areas

104
Sidhu SK, Nicholson JW. A review of glass-ionomer cements for clinical dentistry. J Funct Biomater. 2016 ;7:pii: E16
MODIFICATIONS
&
ADVANCES

105
MODIFICATIONS & ADVANCES IN GIC
1. According to packability and viscosity: 4. Antibacterial Glass ionomers:
• Low – viscosity / Flowable glass ionomer cements (GC Fuji • Amino acid modified GI (proline containing)
II)
• Chlorhexidine impregnated GIC (CHX diacetate
• Highly viscosity GI (GC Fuji IX Extra) and/or CHX dihydrochloride – Sigma Aldrich)

2. According to reinforcements: 5. Others:

• Metal reinforced glass ionomer cements (GC Miracle mix • Smart GIC ( GC Fuji IX GP EXTRA)
capsule)
• Bioactive glass ionomer (Nexus GI)
• Cermet – ionomer cements
• Giomer (Beautifil Bulk)
• Zirconomer
3. According to resin modifications:
• Anhydrous Glass Ionomer (Medifil Aqua)
• Resin modified; Nano filled resin modified; Self hardening
resin modified GIC (GC FujiCem 2)
• Polyacid modified composite/Compomer (Dyract Xtra)
106
Khoroushi et al.: "A review of glass-ionomers: From conventional glass-ionomer to bioactive glass-ionomer." Dental research journal 10.4 (2013): 411.
 SANDWICH TECHNIQUE

Khoroushi et al.: "A review of glass-ionomers: From conventional glass-ionomer to bioactive glass-ionomer." Dental research journal 10.4 (2013): 411. 107
CERAMICS

108
DEFINITION

109
 CERAMICS
• Ceramic is an inorganic compound with non-metallic properties typically composed of
metallic (or semi metallic) and non-metallic elements (example AI2O3, CaO and Si3N4).
• Dental ceramic is an inorganic compound with non-metallic properties typically consisting
of oxygen and one or more metallic or semi-metallic elements (eg. Al, Ca, Li, Mg, K, Si, Na,
Sn, Ti and Zr) that is formulated to produce the whole or part of a ceramic based dental
prosthesis. (Phillips)
• The American Ceramic Society had defined ceramics as inorganic, non-metallic
materials, which are typically crystalline in nature, and are compounds formed between
metallic and nonmetallic elements such as aluminum & oxygen (alumina - Al2O3), calcium &
oxygen (calcia - CaO), silicon & nitrogen (nitride- Si3N4)

Anusavice KJ, Phillip’s Science of Dental Materials,, 2010, 11th Edition, 655-720. 11th ed.
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology,
110
2015, Vol. 3, No. 2, 19-26
TIMELINE

111
 WH Taggard 
Lost Wax
CERAMICS: A Timeline
technique Introduction of
Pressable glass
ceramic (IPS Concept of all
Pierre Fonzi  terro-metallic Fredrick Gardner empress) ceramic post & IPS empress 2:
Fauchard first porcelain teeth held in place core introduced. II gen pressable
Developed Taggart’s Introduction
to propose use of by a platinum pin/frame. technique of forming of Zirconia ceramic
porcelain in Peale Development 3 dimensional glass ceramics
dentistry of baking process in particles Adair and Celay copy
Philadelphia Grossman  Dicor milling system
1728 1808 1822 1907 1930 1980 1984 1989 1990 1992
1700 1789 1817 1825 1870 1900 1903 1963 1965 1971 1976 1983 1986 1994 1999 2000
Development of 1st 1st generation CEREC 1
De Chemant & 3nd generation
Brewster  commercial porcelain (Siemens CAD CAM)
Duchateau  2nd generation CEREC
introduced (Vita Zahnfabric Sopha system: First Mormann and
patented first Planteau  CEREC 1 (Siemens (Sirona CAD
porcelain inlay dental CAD/CAM Brandestin
porcelain tooth Introduced McLean and Hughes Francois CAD CAM) CAM)
porcelain for clinical milled and installed
material Used aluminous core Duret began
teeth to the use in a mouth.
ceramic : Significant to fabricate
US
Thomas Fletcher improvement in crowns with
Stockton fracture resistance optical
 First
Commercial impression
translucent
production
Fused porcelain began cement
McLean & Sced
was introduced Dr. CH Land  one developed the
for manufacture Dr. Andersson:
of the first ceramic platinum bonded
of teeth Procera 112
crowns to dentistry alumina crown
 Hint-ELs®:
intraroal scanner CERAMICS: A Timeline
called DirectScan 3Shape: Dental System™ 2016 MecSoft Corp
CAD software Visual CAD/CAM 2017
Lava CAD/CAM

2002 2007 2016 2017

2000 2006 2009 2012 2015 2017
Cadent: introduced Sescoi  WorkNC Sirona introduced the
its intraoral Dental: a CAD/CAM new powder-free E-manufacturing
scanner, iTero™, at software for automatic CEREC Omnicam solutions EOS
the ADA meeting 3 to 5-axis machining M 100 Direct
Metal Laser
Sintering System

113
 114

COMPOSITION

Ceramic materials in dentistry: historical evolution and current practice; JR Kelly, P Benetti; Australian Dental Journal 2011; 56:(1 Suppl): 84–96
BACKGROUND
CONCEPTS IN
CERAMICS
SCIENCE
BACKGROUND CONCEPTS IN CERAMICS SCIENCE
I] There are only three main classes of dental ceramics:
(1) predominantly glassy materials;
(2) particle-filled glasses; and
(3) polycrystalline ceramics.
II] Virtually any ceramic within this spectrum can be considered as being a ‘composite’.

Two examples of the utility of these concepts include these basic statements:
(1) highly aesthetic dental ceramics are predominantly glassy and higher strength
substructure ceramics are generally crystalline; and
(2) the history of development of substructure ceramics simply involves an increase in
crystalline content to fully polycrystalline.
Ceramic materials in dentistry: historical evolution and current practice; JR Kelly, P Benetti; Australian Dental Journal 2011; 56:(1 Suppl): 84–96 116
 EVOLUTION OF CERAMICS CROWNS

Ceramic materials in dentistry: historical evolution and current practice; JR Kelly, P Benetti; Australian Dental Journal 2011; 56:(1 Suppl): 84–96 117
 Advantages
&
Disadvantages

118
 ADVANTAGES
• Compared to metal ceramics, the advantages of all ceramic restorations
include:-

1. Increased translucency and esthetics

2. Improved fluorescence
3. Greater contribution of colour from the underlying tooth structure
4. Inertness
5. Biocompatibility
6. Resistance to corrosion
7. Low temperature / electrical conductivity
8. The advent of vacuum firing has reduced bubbles, producing a fine textured
restoration with improved translucency and increased impact strength.
119
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 DISADVANTAGES
1. Most all ceramic restorations are inferior to metal ceramics in strength.
2. The main problem with the all - ceramic crown is its fragility when cemented with
conventional cements.
3. The margin of the porcelain crown may not be as accurate as a cast margin and a
cement line of varying dimensions can form that tends to wash out and stain when
conventional cements are used. Therefore resin or resin ionomer type cements are
recommended.
4. Cervical shadowing or “black line” is caused by “disruption of the light harmony
between the root and crown” of the prepared tooth and the overlying soft tissues.
5. More expensive??

120
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 Indications
&
contraindications

121
 INDICATIONS

The all-porcelain crowns are indicated when:

• There is too little tooth structure to reduce the tooth sufficiently for
porcelain fused to metal with an all-porcelain occlusal surface.
• Obtaining the best esthetic result is the single most important
consideration.
• The patient is allergic to metal.

122
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 CONTRAINDICATIONS

• The natural tooth is not completely erupted.

• Preparation of all-ceramic crown would unavoidably cause pulpal
involvement.
• The patient participates in contact sports or has a parafunctional habit, such as pipe
smoking that involves heavy contact on small areas of the dentition.
• The patient habitually grinds or clenches the teeth.
• The patient requires a reinforced restoration, such as a posterior fixed bridge.

123
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
(Phillips’ Science of Dental Materials First South Asia Edition 2014) 124
 (Phillips’ Science of Dental Materials First South Asia Edition 2014) 125
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
Ceramic materials in dentistry: historical evolution and current practice; JR Kelly, P Benetti; Australian Dental Journal 2011; 56:(1 Suppl): 84–96 126
 (Phillips’ Science of Dental Materials First South Asia Edition 2014) 127
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 128
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 (Phillips’ Science of Dental Materials First South Asia Edition 2014) 129
Dental Ceramics: Part II – Recent Advances in Dental Ceramics: Datla et al; American Journal of Materials Engineering and Technology, 2015, Vol. 3, No. 2, 19-26
 MECHANISMS OF STRENGTHENING CERAMICS
Mechanisms that can lead to toughened or strengthened ceramics can be categorized as:

1. Crack tip interactions: These occur when obstacles in the microstructure act to impede the crack motion.
These are generally second phase particles and act to deflect the crack into a different plane so that it is no
longer subject to the normal tensile stress that originally caused its propagation.

2. Crack tip shielding: These are a result of events that are triggered by high stresses in the crack tip region
that act to reduce these high stresses. Transformation toughening and microcrack toughening are two
mechanisms that have been identified as leading to crack tip shielding.

3. Crack bridging: This occurs when the second-phase particles act as a ligament to make it more difficult for
the cracks to open.

Shenoy A, Shenoy N. Dental ceramics: An update. Journal of Conservative Dentistry : JCD. 2010; 13(4):195-203.
130
doi:10.4103/0972-0707.73379.
Ceramic materials in dentistry: historical evolution and current practice; JR Kelly, P Benetti; Australian Dental Journal 2011; 56:(1 Suppl): 84–96 131
132
 Survival of all-ceramic restorations
• It is very important to consider the available survival data for all-ceramic materials when
selecting a treatment strategy. This could be very challenging due to the numerous all-
ceramic systems available and the definition of failure that varies in the literature.
• It has been reported that survival rates of all-ceramic restorations range from 88 to
100% after service for 2-5 years, and up to 97% after 5-15 years.
• Long-term survival was related to the fabrication method of all-ceramic restorations.
• Restorations fabricated using the hot pressing technique had the highest long-term
survival.
• CAD/CAM ceramics had the next highest long-term survival.
• The lowest long-term survival was for restorations fabricated by powder condensation.
Review of the Current Status of All Ceramic Restorations: Laila Al Dehailan - IU School of Dentistry 2012 133
CENTION N

134
 CENTION N

• Cention N is a direct tooth-coloured, alkasite, radiopaque, self-curing

filling material (with light-curing option), which releases fluoride and
calcium ions.
• Available in tooth shade A2.
• It is suitable for use as a full volume replacement material in restorations
for class I, II and V cavities. As a dual-cured material it can be used as a
full volume (bulk) replacement material.
• Cention N can be optionally cured with light in the wavelength range of
400–500 nm.
Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 135
 CENTION N
• Cention N may however be used with or without an adhesive. No etching
with phosphoric acid is carried out when used without an adhesive.
• If without, then retentive preparation (with undercuts) similar to that
used with amalgam fillings is required and enamel margins should not be
bevelled.
• If it is used with an adhesive then the cavity is prepared according to
the modern principles of minimally invasive dentistry i.e. by preserving
as much natural tooth structure as possible and the corresponding
instructions for use followed as regards conditioning and application.

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 136

 CENTION N - COMPOSITION

• Cention N Liquid contains dimethacrylates, initiators, stabilizers and additives.

• Cention N Powder contains calcium fluoro-silicate glass, barium glass, calcium-
barium-aluminium fluoro-silicate glass, iso-fillers, ytterbium trifluoride, initiators
and pigments.
• Once mixed, Cention N contains 78.4 wt%, or 57.6 vol% of inorganic fillers.
• The particle size of the inorganic fillers ranges between 0.1 and 7 μm.

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 137

 CENTION N - TECHNIQUE

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 138

 CENTION N – ION RELEASE

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 139

 CENTION N

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 140

 CENTION N - ESTHETICS

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 141

 CENTION N - ESTHETICS

CENTION FUJI IX GP/GC KETAC MOLAR EASYMIX

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 142
 CENTION N - INDICATIONS

• Permanent restorations of classes I and II

• Suitable for use without an adhesive in class I and class II cavities
with retentive preparation
• Permanent restoration of class V cavities in conjunction with an
adhesive
• Restoration of deciduous teeth

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 143

 CENTION N - CONTRAINDICATIONS

The application of Cention N is contraindicated:

– if a dry working field cannot be established or the prescribed
application technique cannot be applied;
– if the patient is known to be allergic to any of the ingredients of
Cention N
– when used as a luting composite.

Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016 144

IDEAL REQUISITES OF TOOTH COLOURED RESTORATIVE MATERIAL
• Aesthetic • Non-technique-sensitive
• Adhere to enamel and dentin • Non existent post-operative sensitivity
• Bacteriostatic and cariostatic • Preventive chemistry
• Biocompatible • Properties of tooth structure
• Color – tooth colour • Radiopaque
• Low cost • React to temperature changes like
• Good handling and easy repair other tooth structures
• Innovative • Fast setting and long working time
• Insoluble • Smoothness
• Longevity • Strength
• Maintain marginal integrity • Low or no wear, shrinkage and stress
145
What is the ideal direct restoration: Paul L Chils Jr, Gordon J Christensen: Restorative feature July 2011
Comparative analysis

146
Direct restoratives

147
148
 GLASS IONOMER
FACTORS AMALGAM COMPOSITE RESIN MODIFIED GIC
CEMENT (GIC)
Mercury + silver alloy  Powdered glass ‘F’ containing ‘F’ containing powdered
GENERAL
self hardening metal filler + acrylic  powdered glass + glass filler + acrylic resin
DESCRIPTION
mixture self/light hardening organic acid  self/light hardening
Fillings; sometimes for
restoring portions of Esthetic dental
PRINCIPAL Small non–load-bearing fillings, cavity liners and
broken teeth; heavily fillings
USES cements for crowns and bridges.
loaded posterior and veneers.
restorations
Low leakage when Low leakage; recurrent
Low leakage when
properly bonded; decay is comparable
Moderate leakage; properly bonded;
LEAKAGE AND recurrent decay to other direct
recurrent decay is no recurrent decay is
RECURRENT depends on materials; fluoride
more prevalent than comparable to other
DECAY maintenance of the release may be
other materials. direct materials;
tooth material beneficial for patients at
fluoride release
bond. high risk for decay.
Good in small to
OVERALL Good to excellent in large Moderate to good in non–load-bearing
moderate size
DURABILITY load bearing fillings restorations; poor in load-bearing.
fillings
149
JADA, Direct and indirect restorative materialsVol. 134, April 2003
 GLASS IONOMER
FACTORS AMALGAM COMPOSITE RESIN MODIFIED GIC
CEMENT (GIC)
CAVITY Removal of tooth structure for
PREPARATION adequate retention and Adhesive bonding permits removing less tooth structure.
CONSIDERATIONS thickness of the filling.
Tolerant to a wide range of
CLINICAL conditions; moderately Must be placed in a well-controlled field of operation; very
CONSIDERATIONS tolerant to the presence of little tolerance to presence of moisture during placement.
moisture during placement.
WEAR
High Moderate Very low (chewing surfaces)
RESISTANCE

Brittle; subject to chipping on

FRACTURE filling edges; but good bulk
Moderate Low Low to moderate
RESISTANCE strength in larger high-load
restorations.

Dependent on Dependent on ability to

POST PLACEMENT Early sensitivity to hot and
ability to Low adequately bond
SENSITIVITY cold possible.
adequately bond
JADA, Direct and indirect restorative materialsVol. 134, April 2003 150
 GLASS IONOMER
FACTORS AMALGAM COMPOSITE RESIN MODIFIED GIC
CEMENT (GIC)

BIOCOMPATIBILITY Well-tolerated with rare occurrences of allergenic response

Generally lower; actual cost

RELATIVE COST TO Moderate; actual cost of fillings depends on their size and
of fillings depends on their
PATIENT technique.
size.
AVERAGE
One for direct fillings;
NUMBER
One 2+ for indirect inlays, One One
OF VISITS TO
veneers and crowns.
COMPLETE
Mimics natural tooth
Silver or grey metallic colour colour & translucency, Mimics natural tooth color, but lacks
ESTHETICS
does not mimic tooth colour. but can stain and natural translucency of enamel.
discolour over time.

JADA, Direct and indirect restorative materialsVol. 134, April 2003 151
Indirect restoratives

152
 FACTORS CERAMIC
Porcelain, ceramic
GENERAL
or glass-like fillings
DESCRIPTION
and crowns.
PRINCIPAL Inlays, onlays, crowns
USES and esthetic veneers.
Sealing ability depends
LEAKAGE AND on materials, underlying
RECURRENT tooth structure and
DECAY procedure used for
placement.
Brittle material, may
fracture under heavy
biting loads. Strength
OVERALL
depends greatly on
DURABILITY
quality of bond to
underlying tooth
structure.
JADA, Direct and indirect restorative materialsVol. 134, April 2003
METAL CERAMIC CAST GOLD ALLOYS BASE METAL ALLOYS
Ceramic is fused to Alloy of gold, copper Alloys of non-noble
an underlying metal and other metals metals with silver
structure to provide resulting in a strong, appearance resulting in
strength to a filling, effective filling, high-strength crowns and
crown or bridge. crown or bridge. bridges.
Crowns and fixed Inlays, onlays, crowns Crowns, fixed bridges
bridges. and fixed bridges. and partial dentures
The commonly used methods used for placement provide a good seal
against leakage. The incidence of recurrent decay is similar to other
restorative procedures.
High corrosion resistance prevents tarnishing;
Very strong and
high strength and toughness resist fracture and
durable.
wear.
153
 CAST GOLD
FACTORS CERAMIC METAL CERAMIC BASE METAL ALLOYS
ALLOYS
Including both ceramic and
Removal of tooth metal creates a stronger
CAVITY The relative high strength of metals in thin
structure for adequate restoration than ceramic
PREPARATION sections requires the least amount of
retention and thickness alone; moderately
CONSIDERATIONS healthy tooth structure removal.
of the filling. aggressive tooth reduction
is required.
CLINICAL These are multiple-step procedures requiring highly accurate clinical and laboratory
CONSIDERATIONS processing. Most restorations require multiple appointments and laboratory fabrication.
WEAR Highly resistant to wear, but ceramic can rapidly wear Resistant to wear and gentle to opposing
RESISTANCE opposing teeth if its surface becomes rough. teeth.
Prone to fracture when Ceramic is prone to
FRACTURE
placed under tension or on impact fracture; the metal Highly resistant to fracture.
RESISTANCE
impact. has high strength.
Low thermal conductivity
reduces the likelihood of High thermal conductivity may result in early post-placement
POST PLACEMENT discomfort from hot and discomfort from hot and cold.
SENSITIVITY cold.
Sensitivity, if present, is usually not material-specific.
JADA, Direct and indirect restorative materialsVol. 134, April 2003 154
 CAST GOLD
FACTORS CERAMIC METAL CERAMIC BASE METAL ALLOYS
ALLOYS
Well tolerated, but Well tolerated, but
some patients may some patients may
BIOCOMPATIBILITY Well-tolerated show allergenic Well tolerated show allergenic
sensitivity to base sensitivity to base
metals. metals.
Higher; requires at least
RELATIVE COST TO
two office visits and Higher; requires at least two office visits and laboratory services.
PATIENT
laboratory services.
AVERAGE Minimum of two; Minimum of two;
NUMBER matching esthetics matching esthetics of
Minimum of two.
OF VISITS TO of teeth may require teeth may require
COMPLETE more visits. more visits..
Ceramic can mimic
Color and translucency natural tooth
Mimics natural tooth color, but lacks natural
ESTHETICS mimic natural tooth appearance, but
translucency of enamel.
appearance. metal limits
translucency.

JADA, Direct and indirect restorative materialsVol. 134, April 2003 155
Ivoclar Vivadent - Scientific Documentation of Cention N; October 2016
 CONCLUSION
• With the advent of a range of esthetic tooth coloured restorative materials, achieving
desired function while maintaining the natural tooth like appearance has been the main
goal of esthetic restorative dentistry.
• Although the presently available materials serve the function of being a tooth coloured
restorative, maintaining a balance between the two properties of function and esthetics is
what we have achieved in the recent past.
• Success of a restoration depends on the clinician’s ability to select the appropriate
material to match intraoral conditions and esthetic demands.
• Future directions must be aimed at introducing a material with the ideal requisites which
mimics the tooth structure in every which way. Such a material requires diligent and
systematic research with scientific evidence of long term clinical performance.
157
Mjor, I.A. (1997) Selection of Restorative Materials in General Dental Practice in Sweden. Acta Odontologica Scandinavica, 55, 53-57. http://dx.doi.org/10.3109/00016359709091942
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 QUESTIONS ASKED
1. Discuss recent advances in anterior restorative materials & procedures [20M RGUHS 2009]
2. Define and classify dental composites. [20M RGUHS April 2008] Discuss in detail role of C Factor and
methods to overcome high C Factor [7M RGUHS Sept 2007. Add a note on recent advances. [10M
RGUHS April 2002; RGUHS Sept 2005]  [75M Nitte University April 2012]
3. Define and classify dental composites. Write in detail about its properties and newer modifications
[20M Nitte University April 2011]
4. Discuss limitations of composite resin restorations [10M RGUHS Sept 2007]
5. Discuss in detail about direct and indirect composites. [20M RGUHS 2004] Discuss about posterior
composite restoration. [10M RGUHS 2004] [10M RGUHS MAY 2007]
6. Condensable Composites [10M RGUHS 2002]
7. Discuss historical development of composite resins in dentistry. Add a note on its use as a posterior
restorative material. [20M Nitte University 2013] 165
 QUESTIONS ASKED
8. Discuss anterior and posterior composite materials disadvantages [20M RGUHS 2009]
9. Evaluate posterior composites critically. [20M RGUHS Nov 2011] Write in detail on evolution of
posterior composites. [100M RGUHS Oct 1998]  [100M RGUHS 2009]
10. Properties of dental composites [10M RGUHS May 2010]
11. Discuss recent developments in GIC and add a note on its biocompatibility. [20M RGUHS Sep 2007]
[25M RGUHS Sept 1999] [ 10M RGUHS Nov 2011]
12. Define and classify dental ceramics. Write about properties, advantages, disadvantages and
discuss strengthening of ceramics in detail. [20M Nitte University 2012]
13. Ceramics in restorative dentistry [100M RGUHS May 2010]
14. Recent advances in Ceramics [20M RGUHS 2000] [10M RGUHS 2009]
15. CAD CAM [7M Nitte University 2013]; CAD CAM CEREC [10M RGHUHS 2001]
16. What are Biomimetic substances? [10M RGUHS Sept 2007] [10M RGUHS Nov 2011] 166