direct and indirect restoration

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GOOD MORNING
GOOD MORNING

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• Title: Clinical performance of Direct verses Indirect Composite Restorations
in posterior teeth: A Systematic Review
• Case report: Esthetic Restoration of Mandibular Molar by Indirect Composite
Restoration with Cusp Capping.
• Name of Presenter: Dr. Avneet Kaur
• Department: Department of Conservative Dentistry and Endodontics
MAHATMA GANDHI DENTAL COLLEGE & HOSPITAL
A unit of Mahatma Gandhi University of Medical Sciences & Technology

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Contents
 Introduction
 Direct composite technique
 Indirect composite technique
 Classification
 Case report
 Discussion
 Conclusion
 References

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Introduction
Today’s dental patient concerned about attractive restorations is looking
for a dentist who incorporates the newest and best techniques into
practice
In the past 5 years, many types of tooth colored inlays and onlays
have been introduced to the profession
Evolution of esthetic dentistry persist through innovations in
bonding agents, restorative materials, and conservative
preparation techniques

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• Patients’ concern for esthetic appearance, and dentists’ appreciation of the
additional strength of the restored tooth from acid etching and bonding have
generated interest in these restorations

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 There are different techniques for placement of composite resin
restorations.
Includes direct and indirect technique.

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 Increased strength
of remaining tooth
structure
 Potential for repair.
Improper contact and contours
Polymerization shrinkage
Marginal discoloration
Loss of marginal integrity
Postoperative sensitivity
Secondary caries
 Cusp flexure
 Technique sensitive
Advantages Disadvantages

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Indirect technique refers to fabrication of the restoration outside
the oral cavity in the laboratory following which it is luted to the
tooth with resin cement.
Indirect composite
restoration

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Definition
• The Class II inlay involves the occlusal and proximal surfaces of a posterior tooth and
may cap one or more, but not all of the cusps.
Sturdevant
• Inlay is defined as a fixed intracoronal restoration, a dental restoration made outside of
a tooth to correspond to the form of prepared cavity, which is then luted into the tooth
Rosensteil

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Classification Based on Evolution
First generation
 Introduced in the early 1980.
 These materials were developed in an attempt to overcome the
polymerization shrinkage and wear seen with direct composite
restorations.
 But these also had poor physical properties because of low filler
and high matrix load.
 Flexural strength (60–80
MPa)
 Elastic modulus (2–3.5 GPa)
 Resin volume more than 50%

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It was observed that the degree of conversion
increased up to 44%.
It was observed that supplementing conventional
photo-cure with additional cure increased monomer
conversion but did not improve physical properties.
J Conserv Dent. 2010 Oct-Dec;
13(4): 184–194.

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Second generation: they were introduced after mid 1990s so as
to have better properties than first generation indirect
restorations. which included microhybrid composites with fillers
of approximately 66% by volume.
This resulted in improved mechanical properties with flexural
strength in the range of 120–160 MPa and elastic modulus of
8.5–12 GPa.

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Improvements
occurred in three
areas:
• Structure &
Composition
• Polymerization
technique
• Fiber reinforcement
Pract Periodontics Aesthet Dent. 1998 May;
10(4):423-31; quiz 432.

14. Structure and composition
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The second-generation composites have filler with a diameter
of 0.04–1 µ.
By increasing the filler load, the mechanical properties and
wear resistance improved.
The new composite resins like Artglass® and belleGlass HP®
contain high amounts of filler content, which make them
adequate for restoring posterior teeth.

15. Polymerization techniques
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Light curing extra-orally did not efficiently improve
the degree of conversion.
Thus, specific conditions like heat, vacuum, pressure,
and oxygen-free environment are utilized for
polymerization of second-generation IRCs.
Ferracane JL, Condon JR. Post-cure heat
treatments for composites: Properties and
fractography. Dent Mater. 1992;8:290–5

16. Heat
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• Temperature usually used for IRC ranges from 120–140°C.
• This concept was first used by Heraeus-Kulzer.
• It was observed that the wear resistance increased by 35% on curing
with both light and heat when compared to curing with light only.
Nitrogen atmosphere
• Nitrogen pressure eliminates internal oxygen before the material
begins to cure.
• This influences the degree of conversion, esthetics, wear, and
abrasion.

17. • Belle glass HP
• Microhybrid composite having cured at a temperature of 138’C under 29 psi
pressure in nitrogen environment.
• high flexural and compressive strengths,
• Thus it can be an ideal material in cases of high occlusal forces.
• Variety of colors are available in this system .
The available commercial system for
fabrication
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• Art Glass
• Microhybrid polymer glass material having 78% inorganic filler
by weight.
• Having a 4-6 functional groups.
• More double bond conversion and increase cross linking.
• These are specially cured with xenon-stroboscopic light 320-
500nm

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Advantages
Improved physical properties
Wear resistance
More precise control of contours and contacts
Reduced polymerization shrinkage
Ability to strengthen remaining tooth structure
Biocompatibility and good tissue response

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DISADVANTAGES
Increased cost and time
Technique sensitivity
Requires two appointments
Wear of opposing dentition and restorations
Resin-to-resin bonding difficulties
Low potential for repair
Difficult intraoral polishing

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Esthetics Large
defects or
previous
restorations
Economic
factors
Class 2
cavity with
wide
isthmus
Good oral
hygiene
Indications of indirect
composite restoration

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Contraindi
cations
Heavy occlusal
forces
Inability to
maintain a dry
field
Deep
subgingival
preparations

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• C/C: Patient complained of food lodgement in
lower right back tooth region
• HOPI- Patient had no history of pain, sensitivity ,
swelling or pus discharge
• Intraoral examination- Mesioproximal caries irt 46
• Vitality test –Positive (cold test)
A 28 years old female patient reported to the Dept. of
Conservative Dentistry and Endodontics

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• Radiographic Examination : Radiolucency involving
coronal to middle one-third involving enamel and dentin
in mesioproximal region suggestive of mesioproximal
caries irt #46
• Diagnosis – class II (mesioproximal caries )irt 46
• Treatment plan – Indirect Restoration irt 46
Composite Inlay Ceramic Inlay

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Putty impression
Inlay with cusp capping
preparation
Cast try in

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Cementation
Post op radiograph Follow up

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DISCUSSION

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Tooth preparation
• No. 271 - Aid in development of
uniformly tapered walls
• Sides and end surface of the No. 271 bur
meet in a slightly rounded manner so that
sharp, stress-inducing internal angles will
not be formed in the preparation.
Armamentaria

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No. 169L - Dovetail Retention , Retention Grooves
No. 8862 - Development of marginal bevels and
secondary flares
Carbide bur or diamond
tapering instrument that
creates occlusally divergent
facial and lingual walls for
ceramic inlays.

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Patient should be anesthetized and the area isolated with rubber
dam
Compromised restoration (if present) is at this point completely
removed, and/or all the caries is excavated
Walls are then restored to a more nearly ideal form with a light-
cured glass-ionomer base or a composite restorative material
All margins should have a 90- degree butt-joint cavosurface
angle to ensure marginal strength of restoration
Cavity preparation for composite inlay

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 Initial cavity preparation should be done with the flat end tapered
carbide bur
 This result in facial and lingual walls that diverge occlusally
• Pulpal floor should be prepared 1.5 mm in depth and should be smooth and flat.
• Isthmus should be at least 1.5 to 2 mm wide to prevent inlay fracture.
• Axiopulpal line angle should be rounded to avoid seating errors and to lower
stress concentrations

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• Interproximal margins should be extended to allow at least 0.5-
mm clearance of contact with neighboring tooth
• Gingival margins in enamel are greatly preferred
• Carbide bur or diamond used for tooth preparation should be a
tapering instrument that creates occlusally divergent facial and
lingual walls

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Junction of the sides and tip of
the cutting instrument should
have a rounded design to avoid
creating sharp, stress-inducing
internal angles in preparation
2° to 5° per wall recommended
for cast metal inlays and onlays-
Divergence can be increased
because the tooth colored
restoration will be adhesively
bonded and because very little
pressure can be applied during
try-in and cementation

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Occlusal step should be prepared 1.5 to 2 mm in
depth- to decrease the possibility of fracture of the
restoration
Facial, lingual, and gingival margins of proximal
boxes should be extended to clear adjacent tooth
by at least 0.5 mm
For all walls, a 90-degree cavosurface margin is
desired because composite inlays are fragile in thin
cross-section
Gingival margin should be extended as minimally as
possible

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Bevels are contra-indicated because composite are brittle
and thin knife edge margins may easily fracture under
occlusal forces
Another school of thought advocates that placement of
hollow ground chamfer is preferable because it provides
more area for etching and hence better seal is achieved as
well as it improves aesthetic colour blending.

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Cusp capping
• When a portion of facial or lingual surface is affected by caries
or other defect, it may be necessary to extend preparation
around the transitional line angle to include the defect
• When extending through or along cuspal inclines to reach sound
tooth structure, a cusp usually should be capped if the extension is
two thirds or greater than distance from any primary groove to the
cusp tip

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• Centric holding cusps capping- Necessary to prepare a shoulder to
move facial or lingual cavosurface margin away from any possible
contact with opposing tooth, during functional movements
If cusps must be capped, they should be reduced 1.5 to 2 mm and
should have a 90- degree cavosurface angle.
Such contacts directly on margins can
lead to premature deterioration of
marginal integrity
• The axial wall of the resulting shoulder: deep to allow for adequate thickness of
restorative material
• Should have same path of draw as the main portion of preparation

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A provisional or temporary restoration is necessary when
using indirect systems that require two appointments.
 Direct Technique
 Indirect Technique
Provisional Restoration

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Place in the cavity with light pressure
Overcontoured proximal surfaces will
block the fit- then recontour
With mouth mirror evaluate the
fit
Use a floss at contacts to evaluate
tightness and position
Use Abrasive disks to adjust proximal
contour
Try-in and Cementation

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Indirect composite restorations are
bonded to tooth structure by :
Etching enamel to increase the
bondable surface area
Etching, priming, and applying the bonding
agent to dentin (when appropriate)
Etching (by hydrofluoric acid) and then
priming (silanating) the restoration
cementing the restoration with composite
cement(resin)
Applying hydrofluoric acid for 2min
to internal surface of composite
inlay. After rinsing and drying, etched
surfaces should have a "frosty" white
appearance.
Bonding and cementation of indirect composite
restoration

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A dual-cure composite cement is inserted into the preparation
and internal surfaces of the restoration
The inlay is immediately inserted into the prepared tooth,
using light pressure.
A ball burnisher applied with a slight vibrating motion is used
to seat the restoration
Excess composite cement is removed and light-cured 60
seconds in each direction

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• For indirect composite restorations, finishing may be started with 12-fluted
carbide finishing burs instead of diamonds.
• Interproximally, a No. 12 surgical blade: remove excess composite cement
when access permits
• Abrasive strips of successively finer grits: to remove slight interproximal
excesses
Finishing of indirect composite restoration

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• Slender flame shapes are used interproximally, while larger oval
or cylindric shapes are used on the occlusal surface
• 30-fluted carbide finishing burs are used to obtain a smoother
finish

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• The study concluded that indirect restorations have less surface roughness,
postoperative sensitivity, and soft-tissue irritation than direct restorations. The
clinical performances of the indirect restorations were more satisfactory than the
direct restorations.
Duke et al reached a 70.7% success rate 36 months after
placement and concluded that indirect composite resin
restorations represent a good choice for the therapy of severely
damaged teeth.

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Indirect composite restorations have superior surface texture, anatomic
form, occlusion, tooth integrity, lesser sensitivity and marginal
discoloration whereas direct composite restorstions have shown superior
restorstion integrity.

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Advances in composite, and adhesive technology have resulted in the
development of a variety of tooth-colored indirect restorations
These offer an excellent alternative to direct composite restorations, especially for
large restorations, and are more conservative than full-coverage restorations
However, because the clinical procedures are relatively technique-sensitive,
proper case selection, operator skill, and attention to detail are critical to success.
Conclusion

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References

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Case Gallery
Pre op
Inlay with cusp capping
preparation
Cementation Post op clinical picture
Cast try-in

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