Posterior Composite Revisited

Introduction

Posterior composite technique not fully accepted in our profession Recent advances have improved adhesives, composites and light curing But composite wear, less than ideal bonding to dentin .polymerization shrinkage, cost and technique sensitivity still exist. THIS ARTICLE To review the key aspects of the posterior composite technique, with emphasis on controversial, clinically related topics

Indications
American Dental Association Statement endorses use of posterior composites in Small and moderately sized restorations Conservative tooth preparation Areas of esthetic importance {Class I and Class II, replacement of failed restorations and primary caries}

Contraindications
The ADA Statement does not endorse the use of composite Teeth with heavy occlusal stresses Sites that cannot be properly isolated Patients who are allergic or sensitive to resin bonded material

Consideration

Esthetics of prime consideration In non esthetic areas : - Bucco Lingual width 1/3rd the intercuspal distance - Placement of the gingival margin - most critical in terms of marginal adaptation and microleakage - Direct composites for building cusps not recommended

No sign of excessive wear resulting from clenching or grinding .

Tooth should be amenable to rubber dam isolation .

How long do composites last?

The more conservative the restoration, the longer it survives.

Most clinical perfomance studies linear correlation between the size of restoration and the number of failures

Why do composites fail?

Most common reasons Secondary caries Fracture Marginal deficiences Wear Studies show that restorations with marginal deterioration were 5.3 times more likely to have failed . Resistance to wear has improved due to improvement in material itself better posterior composite technique improved light curing technique

Matrix Systems

Composites are plastic ,noncondensable materials , generating tight proximal contact with composites is a challenge. Proper selection and placement of matrix systems is essential

Recent studies show that restorations placed with sectional matrices and seperation rings stronger proximal contact

Bulk filling technique

Single increment composite placement requires high-intensity light curing which has elevated shrinkage stress and margin problems Bulk placement results in more marginal gap
Incremental placement allows: To maximize curing To minimize polymerization shrinkage To develop proper anatomy

Polymerisation Shrinkage

Polymerisation shrinkage can result in : Stress development at the tooth restoration interface when light cured Post operative sensitivity Marginal enamel fractures Premature marginal breakdown Staining

Polymerisation shrinkage can be affected by Total volume of the composite material Type of composite Polymerization speed Ratio of bonded \ unbonded (c factor)
Not possible to avoid polymerization shrinkage But a careful insertion and curing technique can minimize the stress

Flowable Composite

Hybrid composites with a high matrix /filler ratio.

Weak materials with elevated shrinkage rates . In small increments - reduced gingival margin leakage . Used in preventive resin restorations and pit and fissure sealant.

Resin Modified Glass Ionomers (RMGI)

Bonds well to dentin

Used as dentin replacement materials deep preparations Used as liner under posterior composites stress breaker to minimize polymerization shrinkage

Used as liner under composite in root surface reduce potential microleakage ,gap formation and recurrent caries .

Postoperative Sensitivity

Posterior composite has very low prevelance and only transient postoperative sensitivity Postoperative sensitivity can be triggered by: Preoperative pulp status Tooth preparation technique Lack of irrigation during instrumentation Residual caries Restorative technique Improper placement of materials Inadequate curing technique High occlusion Highly related to C-factor-due to polymerization stresses

Critical predators : Preparation depth Existence short term pulp complications Postoperative sensitivity minimized by: Proper clinical protocol Use of liners and bases as pulp protection materials when RDT is less than 1mm.

Advantages

Esthetic
Conservation of the tooth structure No need for the extension for prevention and retention Preparation has rounded internal line angle Decrease stress concentration Enhance resin adaptation Adhesion to tooth structure Seal the margin of the restoration Reinforce the remaining tooth structure against fracture

Low thermal conductivity Decrease post operative sensitivity

Elimination of galvanic currents Radiopacity

Allow the practitioner to evaluate the contours and marginal adaptation

Alternative to amalgam

Disadvantages

Polymerization shrinkage Secondary caries Postoperative sensitivity Decreased wear resistance Abrasion Attrition Restoration is technique sensitive

White fillings will stain and discolor over time.

Conclusion

Posterior composite can be used : Cases are well selected Adhesives and composites are properly applied