composite fillings that keep falling out

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groker2009

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Assume that rubber dams aren't used and also assume that generic materials are used.

What are some tips for doing composite fillings that don't fall out?

Right after placing them, I sometimes notice composite fillings coming out when I remove the matrix band, check contacts with floss, or do occlusal adjustments.

Given that I don't have control over any bonding/composite supplies and instructions for how to use them, I arbitrarily insert acid etch into the prep, rinse the prep and air dry after 5-10 secs, apply bonding ( sometimes this is from one bottle; other times I have to mix a drop from two or three bottles ) to the prep using a microbrush in a rub back and forth motion, light cure for 5-10 secs, insert hard ( or flowable ) composite and light cure for 10-20 secs.

Please help. Thank you. I know that there isn't one way of doing dentistry but I certainly haven't learned any of this effectively.
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groker2009 said:
Assume that rubber dams aren't used and also assume that generic materials are used.

What are some tips for doing composite fillings that don't fall out?

Right after placing them, I sometimes notice composite fillings coming out when I remove the matrix band, check contacts with floss, or do occlusal adjustments.

Given that I don't have control over any bonding/composite supplies and instructions for how to use them, I arbitrarily insert acid etch into the prep, rinse the prep and air dry after 5-10 secs, apply bonding ( sometimes this is from one bottle; other times I have to mix a drop from two or three bottles ) to the prep using a microbrush in a rub back and forth motion, light cure for 5-10 secs, insert hard ( or flowable ) composite and light cure for 10-20 secs.

Please help. Thank you. I know that there isn't one way of doing dentistry but I certainly haven't learned any of this effectively.
Click to expand...
#1. Use a rubber dam, at least until you get better at placing composites.
 
aphistis said:
#1. Use a rubber dam, at least until you get better at placing composites.
Click to expand...

I'm not offered rubber dams. Couldn't it be my composite techniques that are responsible for poor retention and adhesion?
 
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Usually, if the composite is just popping out like that, it is due to saliva/blood finding its way in, so really there's no substitute for rubber dam, like Aphistis said. Something else I was taught, was that after etching, just rinse, then blot dry with a cotton pellet. Blowing air forcefully on the dentin can collapse the collagen giving less bonding area, although I would doubt that this would lead to the whole restoration just popping out. I also usually try to etch for a little longer (15-ish seconds). Anyway, if rubber dams really aren't available (where the hell are you practicing, Antarctica?) then just make sure to use LOTS of cotton rolls and try a svedoptor if you have one.
 
We're taught to etch 20 seconds (etching helps mechanical retention so 20 sec beats 10 sec in my book). I also light cure everything for 20 seconds and then the final layer for 30 seconds. Possibly overkill but I'd rather be safe than sorry.
 
Streetwolf said:
We're taught to etch 20 seconds (etching helps mechanical retention so 20 sec beats 10 sec in my book). I also light cure everything for 20 seconds and then the final layer for 30 seconds. Possibly overkill but I'd rather be safe than sorry.
Click to expand...

No, it's 15 second, etching excessively in dentin causes collapse of dentinal tubules, leading to poor bonding.

OP: if you're in a dental school, you should grab a competent and eager to teach attending/faculty and tell him/her that you're having this problem, and have him/her sit down and walk you through the whole bonding/inserting procedure while you assist. Composites are very technique sensitive and it's something you want to know inside and out.
 
tinman831 said:
Lots of cotton rolls and a good assistant. :thumbup:
Click to expand...

What if you're not always given an assistant? And where are the cotton rolls placed?

I'm not in dental school, where rubber dams were officially mandatory and the acid etch/bonding materials were from Ultradent. ( they make the best composite products ever ) Evidently I never had fillings fall out in dental school.

In the real world, I always see practicing dentists do composite fillings WITHOUT rubber dams and sometimes even WITHOUT assistants. And the acid etch/bonding materials are never or rarely from a brand-name manufacturer. Most ( in my experience, all ) clinics don't even give you rubber dams unless you're doing endo.

Maybe there's something I don't know about but I'm getting lots of composite failures in the outside world. Or maybe I'm a crappy dentist with a crappy job.
 
follow the directions that are on the package. Normally i etch dentin for 15 sec enamal for 30 sec. Then you should use a wetting agent, primer, after the etch. then one quick shot of air. then apply the bonding agent. When you say you use the microbrush at a back and forth method I would suggest a dabbing method. When you brush and scrub it you can also collapse the tubules. So i like to dab it on then give it a shot of air. Then cure the binding agent fro 15-20 sec. When you place the composite it, do it in increments no more than 1.5 - 2 mm thick and cure for 20 sec, because depending on the type of composite the sureing light doesnt penetrate fully. The method that i described is a three bottle system, etch, prime, and bond. This is the most technique sensitive in my opinion. So when you place composite you must focus on two things 1) keep it dry 2) dont collapse the dentin tubules. Also you should be placing a bevel on the enamel to increase surface area to get better bonding.
 
groker2009 said:
What if you're not always given an assistant? And where are the cotton rolls placed?

I'm not in dental school, where rubber dams were officially mandatory and the acid etch/bonding materials were from Ultradent. ( they make the best composite products ever ) Evidently I never had fillings fall out in dental school.

In the real world, I always see practicing dentists do composite fillings WITHOUT rubber dams and sometimes even WITHOUT assistants. And the acid etch/bonding materials are never or rarely from a brand-name manufacturer. Most ( in my experience, all ) clinics don't even give you rubber dams unless you're doing endo.

Maybe there's something I don't know about but I'm getting lots of composite failures in the outside world. Or maybe I'm a crappy dentist with a crappy job.
Click to expand...
You sound like you're getting abused, man. You aren't being given the equipment, materials, or help necessary to do a good job. I hope you're able to find a better practice environment soon.
 
I admit that it's best to do fillings under rubber dams. But is this really necessary?

Outside of dental school, how often do you really see practicing dentists use rubber dams for every fillings they place?
 
aphistis said:
You sound like you're getting abused, man. You aren't being given the equipment, materials, or help necessary to do a good job. I hope you're able to find a better practice environment soon.
Click to expand...

If you are unable to isolate the area properly to place composites, then do NOT place them. Choose alloy instead. If you are told to do it anyway then walk away from the practice. It ain't worth it when you get a investigative letter from the State Board for doing sub standard dentistry. DP
 
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groker2009 said:
I admit that it's best to do fillings under rubber dams. But is this really necessary?

Outside of dental school, how often do you really see practicing dentists use rubber dams for every fillings they place?
Click to expand...

It is best with rubber dam but if the area is assessible and proper isolation can be achieved with cotton rolls, gauze and with the help from a darn good assistant then no, it can be done without one. DP
 
How much composite are you packing in at a time?

If you refuse to use a rubber dam, at least instruct the patient to breath through his nose.

My guess is your bonding agent is defective. Troubleshoot: mount a tooth, drill it (several designs), fill it, then try to pry out the composite with a spoon or something. See how well it attaches.
 
DrJeff said:
Okay, we've hit on the rubber dam thing enough. How about some good "old school" mechanical retention grooves in your preps??
Click to expand...

First thing I thought. It does not matter what you have in your prep, composite fillings should not pop out even w/o using bonding. Mechanical retention is the primary, then bonding. Bonding is a must as well, and there may be many reasons your filling are failing. You seem to not know what bonding agent you are using! I would write the names down and look it up and follow the directions. Second, good isolation: cant bond in a contaminated field. I never use RDI for fillings and I am confident in my work. It is important, that you evaluate the prep before placing composite to insure it is free of contamination.
 
If you can't do anything about isolation, undercut your prep design with walls that converge towards the cavosurface. Try also prepping bevels at the cavosurface since composite bonding agents have a better hold to enamel rather than dentin.

If you're still having problems...well...I don't know.
 
Mechanical retention? If his bonding procedure is failing to the point where the fillings are actually falling out, that means (to me) that he's not getting an appropriate enamel bond. That means, regardless of whether the filling actually falls out or not, any pretense of a marginal seal is shot, and if these things stay in they're going to leak like a sieve.

Please, correct my dental student opinion if I'm wrong, but isn't this the sort of case we keep amalgam in our toolbox for?

OP, all the instruments and materials you need to place 50 rubber dams cost less then then the going rate for a single 1 surface composite filling...seems like it might be worth it.
 
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There are many reasons other than not using rubber dam or not having proper mechanical retention. You need to look at each reason and determine why it fails. The reasons include:

1. Inadequate isolation (no rubber dam used or the area is inaccessible to use one).

2. Inappropriate cavity preparation.

3. Incorrect operating procedures (application of too much/too little bonding agent, inadequate pressure when condensing the composite, too much material applied at one time...).

4. Improper choice of location ( subgingival, functional cusp areas).

5. Improper choice of material (trying to bond to dentin).

6. Hyperocclusion.

7. Parafunctional habits.

8. Material defects.

The list goes on and on... If you are unable to determine the cause for your failed composite restorations, then don't do them. DP
 
speaking of composite fillings, there's something that strikes my mind.

I see many older and experienced GPs who do Class II composite fillings on kids ( on primary teeth, not permanent ) without using a matrix, toffelmire, and wedge. Again, no rubber dams. They also check the contacts for overhangs or open margins. Since it would be a primary tooth, I think they're very tolerant of open contacts.

Class II fillings are some things I can't get a hang of at all without using a matrix band. Any idea how this is done?
 
groker2009 said:
speaking of composite fillings, there's something that strikes my mind.

I see many older and experienced GPs who do Class II composite fillings on kids ( on primary teeth, not permanent ) without using a matrix, toffelmire, and wedge. Again, no rubber dams. They also check the contacts for overhangs or open margins. Since it would be a primary tooth, I think they're very tolerant of open contacts.

Class II fillings are some things I can't get a hang of at all without using a matrix band. Any idea how this is done?
Click to expand...

*If* you've got some pedo spacing where you could get a plastic instrument (or whatever your favorite composite placing instrument is) interproximal to place/contour the uncured composite, then I could see it. But once again, isolation/moisture control becomes a major concern, especially if a rubber dam isn't being used (somehow I'd guess that if the GP isn't using a matrix badn that their also NOT using a RD :rolleyes:) Possibly doable without a band and too much moisture control concerns if your using glass ionomer as your "composite" material and also have the spacing.

Personally, about the only time that I'd really even consider placing a class II composite without a band, would be a maxillary 1st molar or maxillary pre-molar where I'm doing an MO on a very compliant adult where they're missing atleast the tooth immediately mesial to it(if not a couple teeth mesial to it) AND the finish line of the proximal box was atleast a millimeter supragingival. Other than that, let me place a band (either a traditional tofflemire or a sectional matrix band in a few seconds and make my job MUCH easier!
 
tinman831 said:
Lots of cotton rolls and a good assistant. :thumbup:
Click to expand...

I second that.

Most times if it's a posterior tooth, and isolation is an issue I'll just put an amalgam.

Otherwise...pack that mouth full of cotton rolls!
 
groker2009 said:
Given that I don't have control over any bonding/composite supplies and instructions for how to use them, I arbitrarily insert acid etch into the prep, rinse the prep and air dry after 5-10 secs, apply bonding ( sometimes this is from one bottle; other times I have to mix a drop from two or three bottles ) to the prep using a microbrush in a rub back and forth motion, light cure for 5-10 secs, insert hard ( or flowable ) composite and light cure for 10-20 secs.

Please help. Thank you. I know that there isn't one way of doing dentistry but I certainly haven't learned any of this effectively.
Click to expand...

We're taught 40 second cures for composite per increment in Melbourne.
 
Theillestill said:
We're taught 40 second cures for composite per increment in Melbourne.
Click to expand...

Cure time is TOTALLY dependent on the output of the light. What might take 40 seconds with a low output Halogen light may very well only take 5 seconds with a high output LED light. Also, light output does change with time, so regular checking of the output is imperative.

It's why initially folks may balk at the increased cost of a modern high output LED light, but if you're placing alot of composite restorations, those 30 or so seconds of time you save with a high output light add up over the course of a day, and as the saying goes, "time is money" :D
 
If you aren't able to create a good bond with the composite don't try to make up for it with mechanical retention. As another poster said the goal of a good restoration is the marginal seal, not just the retention of the restoration. If the restoration is still physically present but there is no marginal seal then the tooth will just continue to rot away until there is physically nothing left for the restoration to hold onto. Personally I would rather my restorations fall out so i know they need to be replaced than have them hang around for years until there is nothing left of the tooth. Oh yea, if you can't isolate the tooth then don't use a material that requires it, use a glass ionimer or amagam instead that is a little more tolerant of moisture.
 
Question: what are the causes of filings falling out within weeks or months of placement? I understand that fillings don't last forever, I had to replace my old fillings and get two new ones recently. I switched dentists so I could get insurance to cover part of the cost. So I had the fillings replaced and since then four fillings have fallen out; 2 have fallen out 4 times! I feel like an idiot going back to the same dentist (she keeps assuring me that I'm the only patient that is having problems). One of the fillings that has now fallen out a third time is on the lingual side of 14 where I have some major gum damage/recession due to trauma - are there areas of your tooth where composite shouldn't be used? I am really concerned that the fillings that haven't fallen out are kind of like bombs waiting to go off. when I floss I feel like I keep inadvertently slipping the floss between the tooth and the filling although its more likely a jagged edge or something like that.

Sorry to beg for free dental advice, I'm kind of a broke med student and I would really appreciate any insight you guys can offer.
 
Dazedinvt said:
Question: what are the causes of filings falling out within weeks or months of placement? I understand that fillings don't last forever, I had to replace my old fillings and get two new ones recently. I switched dentists so I could get insurance to cover part of the cost. So I had the fillings replaced and since then four fillings have fallen out; 2 have fallen out 4 times! I feel like an idiot going back to the same dentist (she keeps assuring me that I'm the only patient that is having problems). One of the fillings that has now fallen out a third time is on the lingual side of 14 where I have some major gum damage/recession due to trauma - are there areas of your tooth where composite shouldn't be used? I am really concerned that the fillings that haven't fallen out are kind of like bombs waiting to go off. when I floss I feel like I keep inadvertently slipping the floss between the tooth and the filling although its more likely a jagged edge or something like that.

Sorry to beg for free dental advice, I'm kind of a broke med student and I would really appreciate any insight you guys can offer.
Click to expand...
SDN is not the place to seek medical advice. You should consult with your dentist.
 
UKdent said:
follow the directions that are on the package. Normally i etch dentin for 15 sec enamal for 30 sec. Then you should use a wetting agent, primer, after the etch. then one quick shot of air. then apply the bonding agent. When you say you use the microbrush at a back and forth method I would suggest a dabbing method. When you brush and scrub it you can also collapse the tubules. So i like to dab it on then give it a shot of air. Then cure the binding agent fro 15-20 sec. When you place the composite it, do it in increments no more than 1.5 - 2 mm thick and cure for 20 sec, because depending on the type of composite the sureing light doesnt penetrate fully. The method that i described is a three bottle system, etch, prime, and bond. This is the most technique sensitive in my opinion. So when you place composite you must focus on two things 1) keep it dry 2) dont collapse the dentin tubules. Also you should be placing a bevel on the enamel to increase surface area to get better bonding.
Click to expand...

:thumbup: You pretty much summed up my last quarter of restorative class.
 
Dazedinvt said:
Question: what are the causes of filings falling out within weeks or months of placement? I understand that fillings don't last forever, I had to replace my old fillings and get two new ones recently. I switched dentists so I could get insurance to cover part of the cost. So I had the fillings replaced and since then four fillings have fallen out; 2 have fallen out 4 times! I feel like an idiot going back to the same dentist (she keeps assuring me that I'm the only patient that is having problems). One of the fillings that has now fallen out a third time is on the lingual side of 14 where I have some major gum damage/recession due to trauma - are there areas of your tooth where composite shouldn't be used? I am really concerned that the fillings that haven't fallen out are kind of like bombs waiting to go off. when I floss I feel like I keep inadvertently slipping the floss between the tooth and the filling although its more likely a jagged edge or something like that.

Sorry to beg for free dental advice, I'm kind of a broke med student and I would really appreciate any insight you guys can offer.
Click to expand...

you can always get a second opinion.
 
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