Incisal1 2007FINAL Rev
SELF-STUDY COURSECLINICAL UPDATE: FLOWABLE COMPOSITE RESINSIntroductionSince the introduction of adhesive bonding, the types of dental resins have increased along with the number of uses. Theearliest composite resins were usually quartz-filled with reasonably large filler particles, making restorations difficult topolish. Due to recent innovations, resins are now availablewith smaller filler particles forbetter polishability. A number ofnew product types have alsoemerged in response to needsexpressed by practitioners.FIGURE 1: Fissurotomy burs (SS White Burs,Lakewood, NJ).FIGURE 2: Thin and narrow diamonds for minimally invasive cavity preparations.FIGURE 3: Pit and fissure caries on the occlusalsurfaces of the first and second maxillarypremolars.Composite resins are polymermatrix filled, tooth-coloredrestoratives that derive theirphysical properties and handling characteristics fromloading with reinforcing fillerparticles and the viscosity ofthe resin matrix. Compositeresins can be classified by fillersize and per cent filler loading,as well as by the viscosity ofthe composite. With theexpanded categories of composite resins, they can also beclassified by their uses.The majority of direct restorative composite resins fall intoone of the following categories:hybrid, nano-filled or micromatrix hybrid, microfill, packablecomposites and flowable composites. What characterizes acomposite resin are its resinmatrix and filler particles. Oneof the primary reasons for theincreased loading of fillers incomposite resin is to improvephysical properties and resistance to functional wear. As fillerloading increased, so did composite resin viscosity. Most directrestorative composite resins havea putty-like consistency.While the putty-like consistency of composite resins wasa desirable characteristic formost clinical uses, there was aFIGURE 4: Preparation of the occlusal lesionswith air abrasion.6207 incisal edge1desire to have a less viscous composite resin but not onethat was as runny as dental sealants. For this reason, anew class of composite resins was introduced to thedental profession in late 1996. These flowable composites had as their principal characteristic a viscosity thatallowed them to be injected into a cavity preparation.(1)Most manufacturers packaged these flowable composites in small syringes that allow for dispensing with verysmall gauge needles (usually 20 gauge). Two manufacturers provide their flowables in unit dose packaging intubes with either a needle end (VersaFlo, Centrix,Shelton, CT) or a small canula end (Tetric Flow,Ivoclar/Vivadent, Amherst, NY). For practitioners withsmall hands, or skeleto-muscular difficulties, e.g.,arthritis, these small tubes can be inserted into a dispensing gun, making application of these resins easier.The application of flowable composites through smallneedles or canulas made them ideal for use in smallpreparations that would be difficult to fill with moreconventional composite resins.Why use a flowable composite?The development of flowable composites was basedupon its flowable viscosity and not any clinical evidenceof success for specific applications. At first glance, flowable composite resins are not highly filled and are moresusceptible to wear in stress-bearing areas. Dependingon the type of filler used, the majority of flowables arefilled between 41-53% by volume which translates into56-70% by weight.(2) Most manufacturers will citefiller content by weight because the number is alwayshigher. Some of the manufacturers are using fluoridecontaining glass fillers and can make the claim that theycontain fluoride. The availability of the fluoride is questionable. Table 1 lists many of the more popular flowable composite resins. While the earliest uses cited werefor small, conservative Class I preparations of pits andfissures (preventive resin restorations), today there havebeen case reports on expanded uses of flowable resincomposites.These uses include: preventive resin restorations (minimally invasiveocclusal Class I) pit and fissure sealants base or liner small, angular Class V abfraction lesions sealing ditched amalgam margins repair of small porcelain fractures in non-stress-bearing areas surfacing ribbon-reinforced composite resin splints repairing temporary restorations and adding to mar-
CLINICAL UPDATE: FLOWABLE COMPOSITE RESINSgins of temporaries fabricated using bis-acrylcomposite resinsinner layer for Class II posterior composite resinplacement in sealing the gingival margin to avoiddeficienciesenamel defect repairrepair of crown marginsrepair of composite resin marginsluting porcelain and composite resin veneersroutine Class I restorationssmall Class III restorationsbinedadhesive-compositeresin-sealant technique that he named preventive resinrestoration, or PRR.(3) Laterreports demonstrated theclinical success of these con servativerestorations. (4) Today, with the introduction of less viscous, wear resistant composite resins (i.e. flowable composite resins), the PRR can be accomplished in aRestoration of posterior teeth using flowablemore simplified restorativecompositestechnique.(5, 6) Flowable comMinimally invasive Class I - preventive resin restorationsposites offer the advantage of(PRR)needle tip placement into theIn 1978, Simonsen described a minimally invasivesmall, conservative preparapreparation using small burs and restored with a comtions of PRR's. Flowablecomposite resins donot have the sameTABLE 1: Partial Listing of Flowable Composite Resinsdepth of cure as otherNAMEMANUFACTURERrestorative compositeresins. They requireFiltek Supreme Plus Flow3M-ESPEincremental placementFlowTECBenco Dentalat a thickness of 2 mmand light curing of 10VersaFloCentrixseconds with a quartzSynergy FlowColtène/Whaledenthalogen curing light orLED curing light withVirtuoso FlowableDen-Mata light energy emissionDyract FlowDenstplyof600mW/cm 2.Plasma arc (PAC) curEsthet-X FlowDentsplying lights should have aGradia Direct FloGC Americacuring time of 5 seconds.(6)Gradia Direct LoFloGC AmericaUnifil FlowGC AmericaVenus FlowHeraeus-KulzerFour Seasons FlowIvoclarTetric FlowIvoclarHeliomolar FlowIvoclarPoint 4 FlowableKerr-SybronRevolution Formula 2Kerr-SybronWaveSouthern Dental IndustriesWave HVSouthern Dental IndustriesWave MVSouthern Dental IndustriesPermaFloUltradentSELF-STUDY COURSEFIGURE 5: Completed preparations.FIGURE 6: Single component, 5th generationadhesive applied to preparations.FIGURE 7: Completed restorations with flowablecomposite resin.Since the main use ofFIGURE 8: Pit and fissure caries in the maxillaryflowables is to restoresecond premolar, first and second molars.occlusal surfaces ofposterior teeth as a preventive resin restoration,one could be skeptical about the benefit ofchanging to a less wear-resistant, less filled composite resin. Actually, flowable composite resinsare an excellent choice as a preventive resinrestoration. By definition, preventive resinrestorations are very small preparations of isolated areas of caries in pits and fissures restored withcomposite resin. After restoration of the isolatedpreparations, the entire occlusal surface is sealedwith a sealant. For billing purposes, these areone-surface posterior composite resins, butbecause these restorations require multiple mate-07 incisal edge163
SELF-STUDY COURSECLINICAL UPDATE: FLOWABLE COMPOSITE RESINSrials—etch, prime, adhesive, hybrid composite resin,sealant—they can be time-consuming and relativelyexpensive to do. With a flowable composite resin, theadhesive technique is the same but only one restorativematerial, the flowable composite, is necessary, and it iseasier to place in these mini-preparations using needletip dispensing. In fact, with those flowables that areless runny, e.g. Gradia Direct LoFlo (GC America,Alsip, IL) and FlowTEC (Benco Dental, Wilkes-Barre,PA) you can build contours to the restoration byFIGURE 9: Initial preparation with NTF MicroNarrow Tapered Fissurotomy bur (SS WhiteBurs, Lakewood, NJ).FIGURE 10: Completed preparations.adding small increments and light curing instead ofoverfilling and using a finishing bur to carve the contour and anatomy. This translates into less occlusaladjustment.It is important that flowables not be used to merely sealthe pits and fissures as a sealant replacement with a thinapplication. Thin applications of flowable resin composites will fracture in function and be less durable. If aflowable resin composite is desired, some preparation ofthe tooth is necessary to increase the bulk of the composite to improve durability and resistance to fracture.When using sealants for the preventive sealing ofocclusal pits and fissures where there will be no preparation, their success is based upon their flexural modulus making them less susceptible to fracture. In fact,even with sealant placement you must apply at least athickness of 0.3-0.4 mm to achieve longer clinical success in sealing the occlusal surface from caries. Sincemost patients having sealant placement are childrenwith a transitional dentition, the addition of sealant tofunctional occlusal surfaces is not a problem. Thisthickness will allow the sealant to be maintained in a pitand fissure as the sealant wears in function.Flowable composite resins have demonstrated a usefulness for being matched with the use of air abrasion forcavity preparations .(7) Also, minimally invasive cavitypreparations can be accomplished with tooth preparation using a YSGG (Yittrium Scandium Gallium6407 incisal edge1Garnet) like Waterlase or Biolase for preparation ofenamel, dentin and carious tooth structure(8) or aVersaWave (Hoya ConBio) for oral use, which is notonly for hard tissue applications but also for soft tissueand endodontic applications. In many cases there is noneed for local anesthetic when performing these preparations. They are ideal for the pediatric patient. Theseminimally invasive cavity preparations created with anair abrasion unit or a laser can be controlled to be narrow and deep into pits and fissures on the occlusal sur-FIGURE 11: Restoring the minimally invasivepreparations with flowable composite.face and thus are more difficult to fill with the moreheavily filled, putty-like composite resins. However,precision needle placement with a flowable compositeassures a well adapted restoration. Bear in mind that theclinical success of preventive resin restorations is basedupon a minimal thickness of composite resin in order toresist both wear and fracture. Therefore, the use of airabrasion and the laser allow adequate room for sufficient thickness of the flowable composite resin restorative material.If you do not want to use an air abrasion system, yetwant to prepare minimally invasive conservative cavitypreparations as preventive resin restorations (PRRs),then site specific burs can be used.(9) These smallertipped burs have been introduced to both diagnose andtreat enamel lesions and to evaluate the extension ofcaries. Originally, smaller burs such as the #330, #½round, #1 round, and #33½ inverted cone were recommended for preparing PRRs. Recently, a new class ofburs that are thin enough to allow easy penetration intopits and fissures was introduced (Fissurotomy burs, SSWhite, Lakewood, NJ).(10-12) In some cases, the surfaceof the pit or fissure appears to be intact and relativelyhealthy with only some slight discoloration or stainingof the pit and fissure. Use of these burs allows the clinician to prepare the pit or fissure, in many cases withoutanesthesia due to the small surface area of the tip. Oncethe preparation access has been opened and the cariesexplored, decisions for further extensions can be made.
CLINICAL UPDATE: FLOWABLE COMPOSITE RESINSFissurotomy burs are available in three different configurations: Fissurotomy original (1.1 mm wide/2.5 mmlong), Fissurotomy Micro NTF (0.7 mm wide/2.5 mmlong) and Fissurotomy Micro STF (0.6 mm wide/1.5mm long).(Figure 1) Other manufacturers have developed thin diamonds to mimic the Fissurotomyshape.(Figure 2)SELF-STUDY COURSEsive before light curing. The adhesive was light curedfor 10 seconds. A flowable composite resin was placedinto the preparations and light cured for 20 secondswith a quartz halogen curing light. The restorationswere finished and polished using conventional techniques. The completed restorations were wellsealed.(Figure 7) The dam was removed and theocclusion was checked and adjusted.Case reports for use of flowable composite forClass I carious lesionsUse of site-specific burs and flowable compositeFlowable composite matched with air abrasion techniquesWith a diagnosis of caries, the treatment of the occlusalfissures on the maxillary premolars was initiated.(Figure 3) A dental dam was placed. When using an airabrasion device, the dental dam provides a better meansof controlling and evacuating the fine abrasive powderthat is used during cavity preparation. Since the lesionswere expected to be minimal with only slight extensioninto the dentin, local anesthetic was not administered.If the lesions became more extensive, the patient understood that local anesthetic would be used.A patient presented for treatment with a past history of not having dental treatment for five years. Themaxillary first and second molars and second premolar were diagnosed with caries. (Figure 8) Bitewingradiographs did not show the extent of the caries.After anesthesia was administered, a dental dam wasplaced. In order to gain access to the distal portionof the maxillary second molar, a W8AD wingless distal extension rubber dam retainer (Hu-Friedy,Chicago, IL) was used. While the occlusal surfacefelt hard to an explorer, when the teeth were transil-FIGURE 12: Completed restorations.FIGURE 13: Radiographic evidence of mesialcaries in mandibular second premolar.Using a setting of 70 psi, with a powder flow of 2grams/minute set on pulsed mode with a 0.014" nozzle, the aluminum oxide air abrasion device preparedthe occlusal surfaces.(Figure 4) Santos-Pinto andcoworkers found that different tip designs and diameters of the air abrasion nozzle produced differentcutting patterns. (13) Smaller diameter tips producednarrower, more controlled cuts. Narrow cutting follows the conceptual preparation parameters ofocclusal surfaces of preventive resin preparations. Thepreparations were evaluated for complete cariesremoval. (Figure 5) The cavity preparations wereetched for 15 seconds with a phosphoric acid etchant,then rinsed for 10 seconds with an air-water spray anddried. A single component, 5th generation adhesivewas applied to the preparations with a microapplicator. (Figure 6) An air stream was used to evaporatethe solvent from the adhesive and air-thin the adhe-FIGURE 14: Completed cavity preparation.luminated the caries appeared to be more extensive.The first and second molars were entered with aFissurotomy bur (SS White, Lakewood, NJ) and afterthe caries was better visualized, the teeth were prepared using a #245 bur. The mesio-occlusal pit of thefirst molar and occlusal pit of the second premolar hadminimal caries. The decision was made to do a preventive resin preparation using a NTF Micro NarrowTapered Fissurotomy bur. (Figure 9) The NTFFissurotomy bur allows the fissure to be explored withminimal tooth removal to evaluate the extent of thecaries and to complete the preparation. The outline ofthe preparations was dictated by the extension of thecaries. (Figure 10)The cavity preparations were etched for 15 seconds witha phosphoric acid etchant, then rinsed for 10 secondswith an air-water spray and dried. A single component,07 incisal edge165
SELF-STUDY COURSEFIGURE 15: Placement of flowable compositeresin as first increment in proximal box.FIGURE 16: Completed restorations.FIGURE 17: Periodontally compromisedmandibular anterior teeth with incisal wear ofthese anterior teeth.FIGURE 18: Preparation into the dentin to adepth of 1.0 mm of the incisal edges of themandibular incisors.FIGURE 19: Completed restorations and fiberreinforced periodontal splint.6607 incisal edge1CLINICAL UPDATE: FLOWABLE COMPOSITE RESINS5th generation adhesive wasapplied to the preparations witha microapplicator. An air streamwas used to evaporate the solvent from the adhesive and airthin the adhesive before lightcuring. The adhesive was lightcured for 10 seconds. The largerpreparations were restored byplacing increments of packablecomposite resin into the preparations with preloaded tips. Theminimally invasive preventiveresin preparations in the firstmolar and second premolar wererestored with flowable composite resin. (Figure 11) As statedbefore, flowable compositeresins are perfectly matched tofissurotomypreparationsbecause they can be placed witha needle tip and the materialadapts to the small conservativesized preparations. The restorations were finished and polishedusing conventional compositeresin techniques. The rubberdam was removed and occlusionverified. (Figure 12)ration was completed (Figure 14). After the adhesiveprocedure, an initial increment of a flowable compositewas syringed into the proximal box (Figure 15) toassure complete adaptation of the composite resin at allaspects of the gingival margin. The flowable compositeresin was not light cured until placement of the firstincrement of the packable composite. Once placed, theflowable and packable composite resins become sandwiched together and are then light cured. Tung andcoworkers evaluated packable composite resin placement with and without a flowable composite resin.They found that there was significantly less microleakage in teeth restored with the flowable composite resinas the first increment in the proximal box.(15) Leevailojand others also showed less microleakage at the gingivalmargin of Class II preparations.(16) These findings havebeen confirmed by other research at New YorkUniversity School of Dentistry.(17) Figure 16 shows thecompleted Class II restoration.Flowable composites forClass II preparationsThe use of a flowable composite resin as a liner has beencontroversial. (21) While many clinicians have beenachieving success at reducing postoperative sensitivitywith the use of flowable composite resin as a liner,(18)clinical research shows no difference in postoperativesensitivity between using an adhesive alone compared tousing a flowable composite as liner.(21) Also, anecdotally, the use of self-etch systems have been reported todecrease postoperative sensitivity with posterior composite resins that are not supported by clinical trialscomparing total etch and self etch adhesive use withposterior composites.(22) The final conclusion of thisresearch study was that postoperative sensitivity is clinician specific.For conservative preparation ofClass II interproximal carieswith only initial caries on theproximal surface and no carieson the occlusal surface, a facialapproach for the cavity preparation will leave the marginal ridgeintact.(14) Flowable compositeresins are also ideally suited forthe restoration of a facialapproach Class II cavity preparation. Another use for flowablecomposite resins is in conjunction with placement of viscouspackable composite resins.For this case, the diagnosis ofproximal caries can be seen inthe bitewing radiograph(Figure 13). The cavity prepa-Flowable resins used as a base or linerBases and liners have been traditionally used as pulpal protection when the dentin is thin over the pulp, to build-up cavitypreparations and to block out undercuts. It has been reportedthat flowable composite resins have been used as a base andliner in clinical applications. In recent years, there has beeninterest in using flowable composite as a liner that parallels theincrease in postoperative sensitivity reported by clinicianswhen placing posterior composite resins.(18-20)Due to the techniques they are using, some practitioners tend to see increased postoperative sensitivity.(22)When using flowable composite resins as liners, increasethe curing time for conventional quartz halogen andLED lights to 20 seconds. The depth of cure of flowablecomposite resins when compared to hybrid compositeresins is less due to increased light scatter created by the
CLINICAL UPDATE: FLOWABLE COMPOSITE RESINSfiller particles and opacity of flowable compositeresins.(23) Also note that in future radiographs, flowablecomposites may appear less radiopaque than the packable composite resin placed with them. There are variances in the radiopacity of different flowable composites.(24, 25) If used as the first increment for a Class IIrestoration or as a liner to prevent sensitivity, they mayappear as a gap or less radiolucent under a moreradiopaque hybrid composite resin that you typicallyuse to restore teeth. The clinical appearance of the radiograph may mimic recurrent caries. It is important thatyou verify intact margins with your explorer. If using aflowable composite as a liner to prevent postoperativesensitivity, a good recommendation is to make a radiograph of your chosen flowable placed in an extractedtooth to mimic the placement of a liner in a routinecavity preparation and then restore that tooth with yourchosen restorative composite resin. This will provideyou with a baseline. The restored tooth can now be usedas a reference to the radiographic appearance of theflowable within the cavity preparation.Restoration of Class V preparations with flowablecompositesSmall, angular Class V non-carious lesions have beenassociated with abfraction. (26) These lesions, which arecaused by flexure of the tooth once it has beenrestored with stiff hybrid composite resins, have beenassociated with a clinical success rate of only 70%. (27)It was assumed that the stiffness of the compositeresin contributed to this high failure rate. By using aflowable composite resin with a lower biaxial flexuralstrength than traditional hybrid composite resins, itwas assumed that clinical success of adhesive restorations for these Class V lesions would improve. Afterone year, a Class V clinical study using a flowablecomposite resin demonstrated that all restorationswere intact. (28) This study also reported no sensitivity after one year. This correlates to in-vitro microleakage studies of flowable composites that have demonstrated good marginal sealing at enamel and dentinmargins with an adhesive technique using a flowablecomposite resin. (29,30) Use of a flowable compositeresin with an adhesive technique for non-cariousClass V lesions has merit.restoration with a flowablecomposite resin is indicated.(1,31) For this case, the teeth wereperiodontally compromisedwith mobility.(Figure 17) Thepatient's chief complaint wasdiscomfort when biting intofood due to the occlusal trauma on the anterior teeth andshe was unhappy with theappearance of the worn incisaledges.A minimally invasive preparation with a depth of 1 mm wasmade using a 329 bur. (Figure18) The mandibular anteriorteeth were splinted with anadhesive fiber reinforced composite resin and the incisaledges restored with a flowablecomposite resin. (Figure 19)The lingual surface of thefiber splint was covered withflowable. When using fiberreinforcement ribbon for periodontal splinting, the use of aflowable composite resin tosmooth the lingual surface ofthe splint has been demonstrated to be useful.(32, 33) Also,there has been an increasingnumber of young patientswith the "cupping out" of thecusp tips on the maxillary andmandibular first molars.(31)(Figure 20) These are prepared with either a 329 or 330bur to a depth of 1 mm.(Figure 21) The depth of 1mm improves the durablilityof these restorations.(31) Usingeither a total etch or self-etchadhesive, these are thenrestored with a flowable composite resin. (Figure 22)SELF-STUDY COURSEFIGURE 20: "Cupping" of cusp tips of mandibularfirst molar due to wear.FIGURE 21: Preparation of cusp tips to depth of1.0 mm.FIGURE 22A: Cusp tip preparations restored withflowable composite.FIGURE 22B: 7-year recall of restorations (note thewear of the flowable as a sealant over the pastseven years.Other applications for flowable compositesBesides the primary uses for flowable composite resins thathave been stated, other uses for flowable composite resinshave been described. In clinical situations where there aresmall areas of incisal wear into the dentin, a small preparation with a 329 bur to a depth of 1.0 mm and an adhesiveOther uses for flowable composite include the repair ofamalgam margin defects toextend the life of an amalgamrestoration. (34) With theFIGURE 23A: . Preoperative view of overlappingmaxillary central incisors.07 incisal edge167
SELF-STUDY COURSECLINICAL UPDATE: FLOWABLE COMPOSITE RESINSReferences1.2.3.4.FIGURE 23B: Minimally invasive preparation of themaxillary incisors5.6.7.FIGURE 23C: Completed LUMINEERS porcelainveneers bonded using a flowable composite resin.8.9.increased usage of auto mix BIS-acrylcomposite resins as provisional restorations, the need to repair margins hasbeen a problem. Methylmethacrylaterepairs have been unsuccessful.However, the use of a flowable composite resin has been shown to be a reliablemethod of repair for BIS-acryl composite resin provisional restorations.(35) Theflowability of these composites havemade it useful for placement of porcelain veneers(2) (Figure 23), reattachmentof a tooth segment(20) and for repairing composite resin and crown marginal defects (2, 37).ConclusionWhen flowable composite resins werefirst introduced, they appeared to beone- dimensional restorative materialswith very limited uses. Over the last fewyears, the usefulness of flowable composite resins has been demonstrated.When choosing a flowable compositeresin, pick one that works well in yourhands. Most flowables have a variety ofshades to manage most esthetic clinicalsituations. There is variability in theviscosity of these restorative materials;choose the viscosity that will best suityour needs.6807 incisal edge110.11.12.13.14.15.16.17.18.19.20.Moon PC, Tabassian MS, CulbreathTE. Flow characteristics and film thickness of flowable resin composites.Oper Dent 2002; 27:248-253.Bayne SC. et al. A characterization offirst-generation flowable composites. JAm Dent Assoc 1998; 129:567-77.Simonsen RJ. Preventive resin restorations. Quintessence Int 1978; 9:69-76.Simonsen RJ, Landy NA. Preventiveresin restorations: fracture resistanceand 7 year clinical results. J Dent Res(Special Issue) 1984; 63:175, abstractno. 39.Moon PC, Tabassian, Culbreath TE.Flow characteristics and film thicknessof flowable resin composites. OperDent 2002; 27:248-253.Strassler HE, Goodman HS. A durableflowable composite resin for preventiveresin restorations. Dentistry Today2002; 21:116-121.Hamilton JC, Dennison JB, StoffersKW, Welch KB. A clinical evaluation ofair-abrasion treatment of questionablecarious lesions. A 12-month report. JAm Dent Assoc 2001; 132:762-9.Freedman G. On the cutting edge oflasers. Dentistry Today 2004;23(11):148-156.Strassler HE. Easy-to-place packableposterior composite resin.Contemporary Esthet Rest Pract 2000;3(10):44-48.Goff, S. Less is more. Dental ProductsReport May 2004:18-26.Hudson P. Conservative treatment ofthe Class I lesion. A new paradigm fordentistry. J Am Dent Assoc2004;135:760-4.Strassler HE, Park S. Easy-to-placepackable composite resin, ContemEsthet and Rest Pract 2000; 4(10):4448.Leibenberg WH. A useful evacuationaid for intraoral air-abrasive devices.Quintessence Int 1997; 28:105-108.Strassler HE. Predicatable and successful posterior packable Class IIcomposite resins. Am Dent Instit for CE2001; 75:15-23.Chuang SF, et al. Effects of flowablecomposite lining and operator experience on microleakage and internalvoids in class II composite restorations.J Prosthet Dent 2001; 85:177-83.Leevailoj C, et al. Microleakage of posterior packable resin composites withand without flowable liners. Oper Dent2001; 26:302-7.Tung FF, Hsieh WW, Estafan D. In vitromicroleakage study of a condensableand flowable composite resin. GenDent 2000; 48:711-5.Christensen G. Preventing postoperative sensitivity in Class I, II, and Vrestoratations. J Am Dent Assoc 2002;133:229-231.Eick JD, Welch FH. Polymerizationshrinkage of posterior composite resinsand its possible influence on postoperative sensitivity. Quintessence Int1986; 17:103-111.Opdeam NJ, Feilzer AJ, Roeters JJ,Smale I. Class I occlusal compositeresin restorations: In vivo post-operativesensitivity, wall adaptation, .37.microleakage. Am J Dent 1998;11:229-234.Perdigão J, Anauate-Netto C, CarmoAR, Hodges JS, et al. The effect ofadhesive and flowable composite onpostoperative sensitivity: 2-weekresults. Quintessence Int 2004;35:777-784.Perdigao J, Geraldeli S, Hodges JS.Total-etch versus self-etch adhesiveeffect on postoperative sensitivity. J AmDent Assoc. 2003; 134:1621-1629.Strassler HE, Massey WL. Cure depthsusing different curing lights. J Dent Res2002; 81 (Spec Issue A): A-323,abstract no. 2567.Bouschlicher MR, Cobb DS, Boyer DB.Radiopacity of compomers, flowableand conventional resin composites forposterior restorations. Oper Dent1999; 24:20-25.Clinical Research AssociatesFoundation Newsletter. Flowableresins used as a base or liner. 2006;30(9):1-3.Heymann HO, et al. Examining toothflexure effects. J Am Dent Assoc 1991;122:41-7.McCoy RB, et al. Clinical success ofClass V composite resin restorationswithout mechanical retention. J AmDent Assoc 1998; 129:593-99.Estafan D, Schulman A, Calamia J.Clinical effectiveness of a Class V flowable composite resin system.Compend Contin Educ Dent 1999;20:11-5.Estafan AM, Estafan D. Microleakagestudy of flowable composite systems.Compend Contin Educ Dent 2000;21:705-8.Estafan D, Dussetschleger FL, MiuoLE, Kondamani J. Class V lesionsrestored with flowable composite andadded surface sealing resin. Gen Dent2000; 48:78-80.Strassler HE, Kihn PW, Yoon R.Conservative treatment of the worndentition with adheisve compositeresin. Contemporary Esthetics andRestorative Practice 1999;
and light curing of 10 seconds with a quartz halogen curing light or LED curing light with . prime, adhesive, hybrid composite resin, sealant—they can be time-consuming and relatively expensive to do. With a flowable composite resin, the . Fissurotomy Micro NTF (0.7 mm wide/2.5 mm long) and Fissurotomy Micro STF (0.6 mm wide/1.5 .
The Rt. Rev. George N. Hunt The Rev. Frederick K. Jellison The Rev. Dn. Ida R. Johnson The Rev. Michaela Johnson The Rev. Paul S. Koumrian The Rev. Canon Harry E. Krauss * The Rev. H. August Kuehl The Rev. Richard T. Laremore * The Rev. Donald A. Lavallee The Rev. Canon John E. Lawrence The Rev. Dr. Gary C. Lemery * The Rev. Dn. Betsy Lesieur *
NACE Rev. 1.1 (ISIC Rev. 3) codes are often linked with more than one NACE Rev. 2 (ISIC Rev. 4) code. For example, 323 NACE Rev. 1.1 is linked with 261, 263 and 264 NACE Rev. 2 codes; 261 NACE Rev. 2 is linked with only one part of 311, 312, 313, 321 and 323 NACE Rev. 1.1 codes. Thus, it is not possible to obtain full codes of NACE
1912-1914 Most Rev. Edward Joseph Hanna 1939-1948 Most Rev. Thomas Arthur Connolly 1947-1962 Most Rev. Hugh Aloysius Donohoe 1948-1950 Most Rev. James Thomas O’Dowd 1950-1969 Most Rev. Merlin Joseph Guilfoyle 1637-1969 Most Rev. Mark Joseph Hurley 1967-1979 Most Rev. William Joseph McDonald 1970-1974 Most Rev. Norman Francis McFarland
Unión Pentecostés de Iglesias Locales Internacional, Incorporadas BOARD OF TRUSTEES Rev. Dr. Santiago "Jimmy" Longoria, Jr. Rev. C. Isaac De Los Santos D.Th Rev. Dr. John V. Carmona Rev. Josué B. Sánchez Rev. Roy Faragoza Rev. Becky Tafolla Rev. Salomon Munoz COMISIÓN DE ARTÍCULOS CONSTITUCIONALES Rev. Josué B. Sánchez
16 Rev. Michael Keller 1983 17 Rev. Cyril McDonnell 2000 19 Rev. Thomas Foudy 2019 21 Msgr. David Bushey 1994 21 Rev. Jose Izquierdo SJ 1997 22 Rev. Julian Bastarrica, OFM 1990 23 Rev. Harry Ringenberger 2016 29 Rev. John Lama 1994 Eternal rest grant unto them O Lord, And may perpetual light shine upon them.
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