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[Music] hello my name is dr mario romero and i am the clinical director for romero dental seminars in this webinar i'm going to share with you important clinical information related to bulk fill restorative materials i hope you enjoy today we are going to talk about the bulk fill revolution in 2007 the american dental association published the results of a survey conducted between 2005 and 2006 of dental services rendered in the united states and found that the number of composite restorations surpassed the number of amalgam restorations placed on posterior teeth over 76 million resin composite restorations were estimated to have been placed in one year on posterior teeth for years we have been layering posterior composites with a high degree of success so the question is how can bulk fills help one of the known downsides to layering composite is controlling the thickness of each layer ideally each layer should not exceed the two millimeter thickness mark this is important since the degree of conversion of the monomer to a polymer during light polymerization is directly affected by this different studies have shown that it is difficult for us to control direct composite layer thickness in this study 60 dental students and 15 dental school faculty were chosen and divided into four groups they were given a 3d printed tooth model with a class one type of preparation they were told to restore the tooth using three two millimeter increments of composite they use light shade and dark shade composites so they could be differentiated during evaluation of the specimens the participants did not know the dimensions of the preparation nor did they have any measuring instruments once the restorations were completed the models were sectioned and observed under a microscope to measure the increments here you can see a diagram of the tooth model used the preparation had six millimeters in depth and there was a two millimeter ledge on the occlusal to serve as a stop for the tip of the curing light here are some of the section specimens where the range for the layer thickness is evident on the left side of the screen you can see a specimen with a small deviation from ideal but look at the specimens on the right side it is clear that the bottom layer thickness was overall affected the most in this chart we can look at the results of the study i would like to comment on the faculty group since this group has more clinical experience one critical aspect that needs to be evaluated is the layer thickness of the first increment since the bottom surface of that layer is furthest away from the curing light for the faculty group the bottom layer exceeded the two millimeter thickness target 60 of the times followed by the middle layer 47 percent of the times and finally the top layer 27 of the times wouldn't it be beneficial to use a bulk fill composite that requires no layering would it help clinically reducing the possibility of lack of degree of conversion so let's get to know bulk fills a little more how are they classified bulk fills can be classified by their viscosity or by the polymerization activation mode in regards to their viscosity they can be low medium or high it is important to mention that companies that fabricate low viscosity bulk fills normally recommend a final capping layer of regular micro hybrid composite since the amount of failure has been reduced to increase flow ability on the other hand the medium or high viscosity do not require this step in regards to its activation mode they can be light cured or door cured one of the benefits of dull cured bulk fills is that the depth of the restoration is not a concern as it is for the light cure bulk fills since the evidence has shown that the latter performs best at depths no greater than four millimeters philip from coltin is an example of a medium viscosity dual cure bulk fill composite other in vitro studies have looked at bubble formation and marginal adaptation of bulk fill composites in class 2 preparations in this unpublished in vitro study recently completed where we compared two commercially available bulk fill composites one high viscosity with philip medium viscosity from coltine we found that bubble formation within the high viscosity group seen on this slide was significantly higher than compared to the medium viscosity group a uniform bubble-free restoration could be seen in some of the specimens in this slide now let's look specifically into what considerations are needed in regards to bonding dough cure bulk fills like philip one of the things we need to consider is the ph of the dental adhesive the number to keep in mind is a ph of three when a universal dental adhesive has a ph lower than 3 which means that it is more acidic it could affect negatively the dual curing properties of the bulk fill one code 7 universal from coltine has a ph lower than three so if used in combination with philip you need to combine it with the one code activator this activator will increase the ph and thus allow the dual curing properties of philip to work properly to help you understand the clinical steps when combining these two products step number one would be to decide your etching strategy total edge selective edge or self etch step number two is to apply one to two codes of one code seven universal on the preparation step three is to mix one drop of each one coat seven and one coat activator and then apply one to two coats on the prepared tooth eliminate any excess and light cure now you are ready to restore using philip bulk fill dual cure composite another option would be to use the chemically cured adhesive system also made by coltin parabond the only thing you need to consider is that parabon requires a total edge technique this is a great adhesive system with multiple clinical applications now i am going to walk you through a step-by-step direct posterior composite clinical case using one code 7 universal and brilliant everglow i want you to pay close attention to the number of steps required so that we can then compare them to a bulk field like philip in cases where enamel is present i always recommend total edge or selective edge technique i choose the latter option when deep dentin is present after rinsing the acid i apply one to two coats of the universal adhesive to the dentin and the enamel with a rubbing motion followed by elimination of the solvent and the excess with a gentle stream of air from the air water syringe for the restorative technique i start with a horizontal layer as seen on the photo on the left followed by two oblique layers to restore the buccal and the lingual cusp inclines for more natural looking restorations i like adding the gold stain effect that is part of the mary's 2 restorative kit from coltin once occlusion is adjusted with multi-fluted carbide burrs polishing is achieved using the shapeguard two-step system now we are going to restore a class 2 preparation using philip do curing bulk fill universal shade after preparation is completed we place a retraction cord around the affected tooth to aid in rubber diamond version and ideal isolation of the tooth one of the things i like the most about philip is its delivery system this auto mix tip is long and thin enough to reach the bottom of any deep class 2 box dispensing the restorative material in an easy and predictable manner once hybridization is completed we simply fill up and cure here is a side-by-side photo of the before and after look at the chameleon effect properties of the universal shade as well as the smooth surface we were able to achieve after occlusal adjustment using shape guard system can we make restoring posterior teeth easier for this large class tool we are going to use philip bulgfill combined with parabon's self-cured dental adhesive system after removal of the fractured amalgam and carries dentin a 15 second total edge technique is completed we mix one drop of each parabon a and b and apply two to three coats to the dentin and enamel with rubbing motion we eliminate the excess and the solvent with a gentle stream of air for 5 to 10 seconds we fill up in one increment followed by finishing and polishing as you can see there are less steps and results are as good as with layering technique an added benefit to bulk fill composites like philip is that they can be used as core buildup materials not only is this a clinical benefit but an inventory benefit as well since it reduces the number of products a practice needs to purchase and store for clinical care my recommendation for this clinical application is to combine philip with parabon self-cured adhesive after root canal has been completed we place a toefl meyer band and wedges followed by total edge and adhesive application as per instructions previously discussed on the left side of the screen you can see the completed core buildup while on the right is the completed only preparation ready to be scanned once the restoration is milled stained and glazed we are ready to deliver using dual sim dual cured resin cement from coltin in this other case our patient presented with deep caries lesions on eight and nine in both cases it involved the pulp so we plan for root canal treatments and two full coverage ceramic restorations while the patient is being treated by the endodontist we wax the case up for fabrication of the temporary restorations once the root canal treatments were completed we proceeded with our core buildups using parabon and philip bulk fill in this photo you can see the final crown preparations with the red arrows showing the transition between philip bulgfill and the dentin the day of delivery using solo sem self-adhesive resin cement from colten this photo was taken immediately after cementation in this photo 30 days after note the natural appearance of the restorations and the healthy tissues surrounding them one more from a side view to evaluate the natural texture that the lab was able to reproduce on these ceramic restorations in summary bulk fill restorative materials like philip have gained popularity among clinicians for reasons like ease of use in a variety of clinical applications like large class 1 and class 2 preparations as well as a core build up material for partial and full coverage ceramic restorations [Music] [Music] [Music] [Music] [Music] [Music] [Music] [Music] i hope you found this information clinically relevant and useful for your daily practice don't forget to visit our webpage romerodentalseminars.com for more clinical tips thank you for [Music] watching