SELECTION OF SUITABLE RESTORATIVE

MATERIAL
A dental restoration or filling: is a dental restorative material used
to restore the function, integrity and morphology of missing or damaged
tooth structure.

 The goal of research and development is to develop the ideal

restorative material.
Requirements for an ideal restoration:
1. It should stop further progress of the present lesion such as caries,
erosion, abrasion, attrition or fracture.
2. It should restore normal function of the affected tooth .
3. It should restore any speech defects due to missing parts of the hard
tooth structures.
4. It should restore normal esthetic.
5. It should restore and maintain the integrity of the dental arch and its
surrounding periodontium.
6. It should sustain the normal physiologic occlusal load without fracture
and it should protect the remaining hard sound tooth structures from
fracture.
7. It should protect and maintain pulp vitality.
8. It should maintain a constant relationship with the surrounding hard
tooth structures.

 According to the previously enumerated requirements, still none

of the available restorative material is ideal. For this reason, we
have to compromise and select the most suitable material for a
particular case.
 . The dentist must make this selection with great care because,
in future years, those restorations needing replacement will result in the
loss of increasing amounts of tooth structure. This sets up a cycle where
the increasing cavity size limits the selection of the materials that may be
used effectively.

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Factors influencing selection of the suitable restorative material:
I. Factors concerning the available restorative
materials.
II. Factors concerning the patient.
a- Factors related to the general condition of the patient.
b- Factors related to the oral cavity.
c- Factors concerning the tooth to be restored.
d- Factors related to the cavity to be restored.
III. Factors related to the operator.

I) Factors concerning the available restorative materials

The operator should have full knowledge about all available restorative
materials. This knowledge should include physical, chemical and biological
properties of each material. Furthermore, the operator should master
the manipulative techniques of these materials.

Available Restorative Materials:

They can be classified according to their durability and purpose of use
into permanent and temporary restorations. Then, dental restorations can
be further subdivided into two broad types: direct restorations and indirect
restorations.
Direct restorations:
This technique involves placing a soft or malleable filling into the prepared
tooth and building up the tooth before the material sets hard.
The advantage of direct restorations is that they usually set quickly and can
be placed in a single procedure. Where strength is required, especially as
the fillings become larger, indirect restorations may be the best choice.

Indirect restorations:
-This technique involves fabricating the restoration outside of the mouth
using the dental impressions of the prepared tooth.
- The finished restoration is usually bonded permanently with dental
cement. It is often done in two separate visits to the dentist.

Assessment of mostly used permanent restorations properties:

The ideal restorative material would be identical to natural tooth structure,
in strength, adherence and appearance. The properties of an ideal filling
material can be divided into four categories: biocompatibility, physical
properties, aesthetics and application. According to these categories
mostly used permanent restorations should be assessed:
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A- Biocompatibility:
Biocompatibility refers to how well the material coexists with the
biological equilibrium of the tooth and body systems. Since fillings are
in close contact with mucosa, tooth, and pulp, biocompatibility is very
important. Common problems with some of the current dental materials
include allergies, chemical leakage from the material, and pulpal irritation.
Remaining dentin thickness, state of the pulp, some of the byproducts of
the chemical reactions during different stages of material hardening need
to be considered.
 Metallic restoration can conduct thermal shocks to the pulp due to its
high thermal conductivity which could lead to pulp irritation.
 Amalgam restorations conduct thermal and galvanic shocks to the
pulp and its metallic ions may penetrate the dentinal tubules and
gingival tissues. Permanent discoloration of both tooth and gingiva.
Due to the known toxicity of the element mercury, there is some
controversy about the use of amalgams.
 Polymeric resin
- The volumetric contraction of polymeric resin and the relatively high-
coefficient of thermal expansion can create leakage space at the
 restoration-tooth structure interface and stimulate bacterial irritation
for the pulp.
- In addition to its monomer contents and to the heat produced during
polymerization that lead to chemical and thermal irritation to the pulp.
-On the other hand, tooth preparation of resin composite restorations
requires less tooth structure removal compared to preparation for
other dental materials such as amalgam and many of the indirect
restorations.
 Glass ionomer restorations are the best regarding biologic
compatibility.This can be attributed to their chemical bond with the
adjacent tooth structures, to their high molecular size of its acid
contents, fluoride release and recharge, minimal setting expansion and
preservative tooth preparation.
 Castable ceramic restorations are biologically compatible
due to their thermal insulation and their highly smooth glazed surfaces.
However, resin cement used for its lutting may cause pulp irritation.
The acid contents of some restorative materials and luting cements may
cause chemical irritation to the dental pulp particularly in deep cavities.

 Most of the previously mentioned irritational factors can be controlled

by using suitable cavity liner and/or base material. These materials
can protect the pulp from both chemical and thermal irritation of the
restorations.
B. Physical properties:
1. Indestructible and/or insoluble in the oral fluids such as saliva,
water,soft or hot drinks and juices. These fluids may alter the pH of saliva
according to their chemical contents.
 Metallic, ceramic and resinous restorative materials can resist
solubility in oral fluids.
 glass ionomer restorations cannot resist solubility so they are
intermediate restorations.
 luting cements such as zinc phosphate or zinc polycarboxylate
cements are relatively soluble in theoral fluids particularly in acidic
media.

2. Chemical adhesion with the surrounding hard tooth tissues or at

least, it should maintain intimate adaptation with the surrounding cavity
walls at the restoration – tooth structure interface.
-The importance of adhesion or adaptation is to provide marginal sealing to
prevent microleakage.Thus, post restorative hypersensitivity of dentin,
recurrent caries, pulp affections and discoloration of both restorations and
tooth structures will be prevented.
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 Amalgam: Adaptation of amalgam restorations increases by time due
to the presence of the corrosion products.
 Resin composite restorations do not adhere or adapt to the cavity
walls due to their hydrophobic nature, their polymerization shrinkage
and their different coefficient of thermal expansions. Thus, they
usually needed proper adhesive systems of high bond strength to
both enamel and dentin to produce successful sealed restorations.
 Glass ionomer restoration is the only restorative material that has a
self adhesive potential and bond chemically with the surrounding
tooth structures.
 Casted restorations suffer from marginal deteriration due to the
solubility or wear of their luting cements.

3. Withstand the functional forces without fracture

- it should protect the surrounding hard tooth structures from fracture.
- It should have high surface hardness to retain its smooth shiny surface
condition.
 Ceramic and gold restorations fulfill this property.
 Amalgam restorations suffer from low tensile and shear strength
(brittle) and creep.
 Glass ionomer restorations cannot resist wear.
 Resin composite restorations suffer from decreased wear resistance
compared to the amalgam, however, recent types had an increased
in its wear resistance given the restorations an average finite lifespan
7-8 years.

4. Maintain its dimensional stability inside the cavity.

- The restoration should be free from any volumetric changes after its
placement inside the cavity.
- If it expands, it may overhang producing premature contact, which may
fracture due to stress concentration. It may exert pressure on dentin and
create discomfort for the patient and may lead to pulp hyperemia or
pulpitis.
- On the other hand, contraction or shrinkage of the restoration inside its
cavity may cause marginal leakage with subsequent troubles or it may
lead to its looseness and displacement.
 Ceramic and gold restorations are stable inside their cavities.
 Amalgam restorations may contract inside their cavities during their
hardening. And, then, they may expand due to either excess mercury
or moisture contamination.
 Dental composite restorations shrink during their polymerization.
 Glass ionomer restorations has less dimensional changes compared
to the other restorations and they do not create marginal leakage due
to their chemical bond with the adjacent tooth tissues.

C- Aesthetic properties:

Aesthetic appearance (simulating the natural tooth)

The selected restoration esthetic’s properties should be very close to the
combined esthetic properties of both enamel and dentin.
 Porcelain restorations can provide perfect esthetic with that of the
natural tooth.
 Resin composite restorations provide superior esthetic. However, by
time, some resin composites restorations suffer from surface, marginal
and bulk discolorations. The rate of discoloration is changeable from a
person to the other according to the type of material, technique of
application and patient habits i.e. drinks and smoking habits.
 Glass-ionomers are tooth-colored, they vary in translucency. Despite
they can be used to achieve an aesthetic result; their aesthetic
potential does not measure up to that provided by resin composite
because their surfaces change to the chalky appearance as a result
of their solubility in the oral fluids.
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 Both gold and amalgam restorations have poor esthetic due to their
metallic colors. However, it is expected to find few patients enjoying
this metallic appearance of their teeth. These persons are most
probably technicians and butchers.

D. Other material properties:

1. It should have reasonable cost.
The restoration should be inexpensive either in its price or in its techniques
for production or manipulation.
  Amalgam is relatively cheaper than gold as a metallic restoration.
Construction of each gold restoration through the indirect technique
needs more costs than its construction with the direct technique.
 Porcelain restoration is the most expensive tooth-colored one.
 Composite restoration comes next to ceramic restoration regarding its
price.
 Glass ionomer restoration needs cost similar or near to that of
composite ones.

2. It should be convenient and easy in its manipulation.

The restorative material should not be sensitive to the human variables of
the operator. It should be produced easily without detailed procedures or
expensive special equipment.
 Amalgam restorations satisfy this property.
 Resin composite is a technique sensitive material;needs complete
isolation, and skillful manipulation.
 Glass ionomer restorations are easy in their manipulation by the
average operator.
 Cast gold restorations: dental technician participates in the
production of cast gold restorations.
 Castable ceramics :Some participation also can be observed in case
of castable ceramics.

In considering these properties of an ideal restorative material, it is

apparent that no single material can fulfill all of the clinical needs.
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CHAPTER 8
II) Factors related to the patient

A- Factors related to the general condition of the patient:

a. Patient’s age:
1. Young patient cannot stand long dental chair-side work. They cannot
follow post-restorative instructions carefully. They prefer esthetic
restorations wherever indicated.
2. Middle aged patient prefers ideal restorations.
3. Old patient cannot withstand long operations on the dental chair. He
prefers strong permanent restorations.
b. Patient’s sex:
1. Male patients prefer strong permanent restorations.
2. Female patients advocate esthetic.
c. Patient’s occupation:
1. Regular patients ask for restorations of reasonable price. They prefer
ideal restoration if possible.
2. Public personalities like esthetic restorations. Those are; politicians,
professors and teachers, spokesmen, television and movie stars,
diplomats and artists etc…158
3. Few technicians, butchers, fruit sellers, shoemakers and mechanics
advocate gold color in esthetic areas.
d. Physical condition of the patient:
1. Patients with normal physical fitness can stay on the dental chair for
the required time without creating any troubles.
2. Debilitated patients cannot tolerate long work on the dental chair. They
prefer cast restorations or short term restorations.
3. Handicapped patients prefer short term restorations.
e. Educational and social conditions of the patient:
1. Educated patient advocate the most suitable restoration according to
their satisfaction.
2. Less educated persons prefer esthetic restoratives.
3. Uneducated patients agree with the operator selection for the suitable
restoration.
f. Mental condition of the patient:
1. Normal persons can easily be satisfied with the most suitable restoration
according to the knowledge introduced by the dentist.
2. Psychic patients cannot withstand treatment for long time and prefer
esthetic restorations.
g. Patient’s habits:
1. Patients with smoking habit suffer from stains on rough surfaces in the
oral cavity and from acidic saliva.
2. Alcoholics always suffer from solubility of dental cements.
3. Persons with bruxism need strong restorations with high surface
hardness.
h. Economic condition of the patient:
1. Wealthy persons select the best restoration whatever it costs.
2. Ordinary people should be informed about the expenses before starting
the restorative procedures.
3. Poor patients prefer amalgam in posterior teeth and glass-ionomers for
esthetic restorations.

B- Factors related to the condition of the oral cavity:

a. Oral hygiene:
1. Oral hygiene is the practice of keeping the mouth clean to prevent
dental problems (mainly tooth decay and gum disease) and bad breath.
2. Patients with good oral hygiene are ideal candidates for all types of
permanent restorations and should be instructed to maintain this
condition after restoration of the tooth defects.
3. Patients with poor oral hygiene should improve and maintain
their mouths clean before the restorative procedures to decrease
periodontium inflammation that may affect restorations placement and
to decrease the acidity of saliva which may affect the success of the
restoration.
b. Caries incidence:
1. Selection of suitable restorations for patients with high caries incidence
should be done cautiously to prevent failure of the restorations due to
recurrent caries.
2. Teeth with rampant caries are better to be treated with glass-ionomer
restorations as intermediate restorations until the condition subsides.
Short-term regular check up is important to discover any progress of
caries to be treated early.

c. Condition of occlusion:
1. Normal occlusion has no troubles in the selection of the suitable
restorations.
2. Conditions of malocclusion such as anterior or posterior cross bite,
severe overlap, plunger cusp and tilted teeth have to be treated before
the selection of the suitable restorations.
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d. Presence of metallic restoration:
1. The present metallic restoration is leading for the selection of the future
metallic restoratives. Presence of different metallic restorations may
lead to galvanic shocks.
C- Factors concerning the tooth to be restored:
a. Position of the tooth:
1. Anterior teeth are better to be restored with esthetic tooth-colored
restorative materials.
2. Teeth that appear during smiling should be restored with esthetic
materials. However, few patients prefer gold color to appear during
smiling.
3. Teeth, which may act as abutment for fixed bridge, can be restored with
amalgam or resin composite or reinforced glass-ionomer restorations.
4. It is advisable to restore them with zinc free amalgam or cast gold
restorations.

c. Form of the tooth:

1. Hutchinsonian teeth or peg-shaped lateral incisors should be restored
with full coverage esthetic restorations.
2. Mulberry molars should be corrected occlusally with cast gold
restorations or even full metallic or ceramic crowns.
3. Normal teeth should be restored with the suitable restorative material
through their suggested designs.
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d. Condition of calcification:
-Hypocalcified tooth or teeth with friable enamel should be restored with
strong restoration to protect their cavity margins. These teeth indicate the
use of cast gold or ceramic restorations and contraindicate application of
forced condensable restorative materials.
e. Size and condition of the remaining coronal portion:
1. In regular condition the remaining tooth structures of the crown can
confine the restoration.
2. If the remaining coronal portion cannot confine the restoration and
are greatly destructed so that extra means of retention or indirect
restorations are advisable.
f. Vitality of the pulp:
1. It is advisable to preserve pulp vitality.
2. In deep cavities, apply calcium hydroxide then suitable base material
in deep areas to protect the pulp from thermal, chemical or traumatic
irritation of the restorative material or its technique.
3. Teeth with hyperemic pulp should be restored with a suitable temporary
restorative material until the irritational condition is relieved and then
restored permanently with a suitable restoration.
D- Factors related to the cavity to be restored:
a. Size of the cavity:
1. Relatively small cavities can be restored with amalgam, resin composite,
glass ionomer restorative materials.
2. Medium size cavities are better restored with amalgam, resin composite
or glass ionomer restorations.
3. Large cavities should be restored with indirect restorations.
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b. Location of the cavity:
1. Occlusal cavities should be restored with metallic or ceramic restorations
 to withstand occlusal loads.
2. Mesial cavities in anterior teeth and premolars should be restored with
esthetic restoratives.
3. Distal cavities bicuspids and molars can be restored with metallic
restorations.
4. Labial cavities and cervical cavities of anterior teeth should be restored
with esthetic restorative materials.
5. Cervical cavities of posterior teeth may be restored with amalgam, resin
composite or glass ionomer restorations.
6. Subgingival cavities are better to be restored with cast gold or ceramic
restorations or glass-ionomer restorations.
c. Accessibility to the cavity:
1. Wide mouth opening provides sufficient accessibility. However, small
mouth opening creates difficulty in cavity preparation and restoration.
2. Anterior teeth, premolars and first molars are more accessible than
second and third molars.
III- Factors related to the dentist (operator):
1- Dentist should know full information about population needs.
2- He should have sufficient information about all available restorative
materials.
3- He should have sufficient skill for manipulation and handling of
restoratives.
4- He should use the material within its indications.
5- He should provide his patients with sufficient post-restorative
instructions.
6- Successful dentist should satisfy his patients.