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Living in a Composite World by Dr. Lee Ann Brady

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by Lee Ann Brady

In 1988 when I graduated from dental school, composite was a material reserved for conservative anterior restorations. In my practice today, composite is the only direct restorative material we use. The goal of restorative dentistry is to replace missing or damaged tooth structure with a material that has similar, ideally identical properties as the natural tooth structure. The properties we attempt to mimic in our restorative materials are biologic, physical and functional in nature.

Composite resins occupy the largest percentage of our direct restorative materials today because they allow us to restore the natural dentition conservatively, aesthetically and predictably. Composite can be used for anterior and posterior restorations from Class I to Class V, large and small alike. The versatility of composite is one of the reasons it has become the direct restorative material of choice in many offices. Additionally, it offers us a highly aesthetic, functional material with acceptable longevity. Lastly, composite is unique in its ability to be used with minimally invasive preparation techniques and allow the conservation of natural tooth structure.

I will say that my relationship with composite has been a long time coming as I moved from being a skeptic to a fan. Changing my paradigms about the placement, appearance and function of direct restorations was a process. So why have I gone exclusively to composite as my direct restorative material?

Composite resins are all, at their heart, similar in composition. They are a compilation of resin matrix, filler particles and coupling agents. We discuss composites or divide them into categories based on the nature of their filler particles and its percentage compared to the matrix. Composite materials from micro-filled to nano-hybrid are on the market today and chosen by the clinician when the material properties match the intended clinical outcome. The properties of the filler particles and the resin matrix are what create properties such as wear resistance, polishability, fracture resistance and optics. Material advances are being made all the time as we improve both the filler particles and the resin matrix and maximize the properties we value in a restorative material.

Conservative Preparations
The trend in dentistry is moving away from the traditional construct of tooth preparation toward minimally invasive procedures. Being able to conserve tooth structure has been facilitated by the development of new techniques and materials. A key ingredient has been our ability to adhesively place restorative materials. Unlike many of our restorative materials, composite does not require minimum thicknesses for retention or strength. The classic clinical situation of incipient occlusal caries is a perfect example of how composite allows dentistry to be more conservative. The depth of preparation when using composite will be determined by removal of the affected tooth structure, not a mandatory 1.5mm of reduction. With the improvement in dentin adhesives and increasing bond strengths, we no longer have to remove tooth structure to create a “retentive” prep.

Cusp Reinforcement
Cracked teeth have traditionally been treated by a process we call “containment.” The tooth is prepared so that restorative material will be around the tooth circumferentially and contain the cracked pieces, holding them together and preventing progression of the crack. The placement of a crown or onlay removes a significant amount of tooth structure and increases the risk of post-operative pulpal death. Adhesive dentistry and composite materials can be used as an alternative because of their ability to reinforce the remaining tooth structure. Studies show that teeth with MOD preparations and restorations exhibit much lower cuspal flexure when the restoration was bonded into place using an acid-etch adhesive technique.1,2

Aesthetics
There is no question that restorative materials that mimic the appearance of natural teeth add aesthetic advantage over metal-based materials. Modern composite comes with a variety of light-reflective properties. It is common to encounter teeth with dark secondary dentin or staining from previous restorative materials. The addition of .5-1mm of an opaque composite will obscure the darkened tooth structure and return the base of the preparation to the color of dentin. The final layer of composite can be built with translucent or opalescent composites to add the warmth and reflective characteristics of natural teeth. At the discretion of the operator, we can chose to restore a tooth with a single increment of composite or layer in materials with differing value, hue, chroma and translucency to add depth and character of a natural tooth into the restoration.

Materials Development
Advances in materials science occur every day in dentistry. The vast majority of these are focused in adhesive dentistry to improve our ability to interface with the tooth surface or improve the properties of the restorative materials themselves. Our newer materials are addressing the challenge of placement of composite materials. New advances in the chemical initiators and catalysts along with changes to the resin matrix are increasing the depth at which we can achieve optimal light polymerization. This increased depth of cure decreases the placement time and can increase the cost effectiveness of placing composite.

Longevity
There are numerous articles that have looked at the longevity of composite restorations. For posterior applications the debate is waning but many practitioners still express some concern over the longevity of composite. In 2004, the Buonocore Memorial Lecture was a “review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition.” The review surveyed studies that looked at survival of both indirect and direct Class II and Class III restorations since 1990 and compiled the data. Given the difference in the length of the variety of studies, the researchers converted the results into annual failure rates. The annual failure rates for a few common materials were as follows: amalgam at three percent, direct composite at 2.2 percent, and 7.2 percent for regular glass ionomer.3

Given all that we know and the current trends in restorative dentistry, I understand why composite has taken over the direct restorative market. It allows me to offer my patients an aesthetic, durable and functional restoration that can be placed conservatively.

References
  1. J Dent Res. 1984 Aug;63(8):1075-8., Cusp reinforcement by the acid-etch technique. Morin D, DeLong R, Douglas WH.
  2. PEDIATRICDENTISTRY/Copyrightht 1988 by The American Academy of Pediatric Dentistry Volume10, Number2, Cuspal reinforcement in primary teeth: an in vitro comparison of three restorative materials Kevin James Donly, DDS, MSThomas Wild, DDS, Mark E. Jensen, DDS,PhD
  3. Oper Dent. 2004 Sep-Oct;29(5):481-508. Buonocore Memorial Lecture. Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition. Manhart J, Chen H, Hamm G, Hickel R. Department of Restorative Dentistry and Periodontology, Ludwig-Maximilians-University, Munich, Germany.


Author's Bio
Dr. Lee Ann Brady earned her DMD degree from the University Of Florida College Of Dentistry. She lives in Phoenix, Arizona, with her husband, Kelly, and three children Sarah, Jenna and Kyle. She maintains a private restorative practice in Glendale, Arizona. Outside of her private practice, Dr. Brady teaches her own courses at meetings around the country, as well as provides a resource for dental professionals on the Web. When not focused on dentistry she enjoys time with her family, being outdoors, gardening and reading.
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