Chapter V

BASIC PRINCIPLES OF TOOTH

PREPARATION

Learning Objectives

Needs & Objectives

The needs for preparing the tooth structure and the objectives of
these preparations should be discussed in details to draw the rules,
requirements and criteria of proposed preparations. This should clarify that
operative dentistry is not a drill and fill policy.

Biology & Mechanics

The student should be aware that we are dealing with a respectful
living structure that should be biologically considered. Also, we are
working in a complex mechanical environment of the oral cavity that
should be considered in different restorative treatments of the tooth
structure.

Variations
A complete understanding of the variations of the characters of
different preparations and properties of available restorations should be
developed.

DR. YASSER ALI AL-MORTADA AL-WASIFI

By LECTURER OF OPERATIVE DENTISTRY
AIN SHAMS UNIVERSITY
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T
he displine of operative dentistry harbors the essential knowledge of basic
tooth restoration, which is of utmost importance to dental practitioner.
This basic knowledge must not be constructed as simply treating a tooth, but rather
in context of treating a person. The physiologic and psychologic aspects of the
patient must be given proper consideration. In the sense of local treatment, biological
and mechanical factors regarding care of the tooth tissues and contiguous oral tissues
are paramount.

In the past, most restorative treatment was due to caries (decay), and the term
“cavity” was used to describe a carious lesion in a tooth that had progressed to the
point that part of the tooth structure had been destroyed. Thus, the tooth was
cavitated (a breach in the surface integrity of the tooth) and was referred to as a
“cavity”. Likewise, when the affected tooth was repaired, the cutting or preparation
of the remaining tooth structure to best receive a restorative material was referred to
as a “cavity preparation”.

Now, many indications for treatment for teeth are not due to caries and
therefore, the preparation of the tooth is no longer referred to as “cavity preparation”
but as “tooth preparation”, and the term “cavity” is used only as a historical
reference.

DEFINITION
Tooth preparation is defined as, any alteration of the defective, injured or
diseased tooth in order to best receive a restorative material which will re-establish a
healthy state for the tooth including esthetic correction where indicated, along with
normal form and function.

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NEEDS AND OBJECTIVES OF RESTORATIVE INTERVENTION

Teeth need restorative intervention for a variety of reasons:
1. Repair a tooth after destruction from carious lesion.
2. Another often-occurring need is the replacement or repair of restorations with
serious defects.
3. As previously mentioned, esthetic demands of patients is a reason for placing
and replacing restorations.
4. Restorations are also required to restore form and function.
5. For restoration of occlusion.
6. Repair of fractured tooth.
7. Lastly, a tooth may be restored in a preventive sense.

In general, the objectives of tooth preparation are:

1. To remove all defects and give the necessary protection to the pulp.
2. Locate the margins of the restoration as conservatively as possible.
3. Form the cavity so that the tooth or the restoration will not fracture under forces
of mastication and the restoration will not be displaced.
4. Allow for the esthetic and functional placement of the restorative material.

PRINCIPLES OF TOOTH PREPARATION

There are some general and fundamental principles, which must be realized in
preparing cavities for the reception of restorative materials. These principles are
essentially discussed under biologic and mechanical forms.

The biological concept aims to preserve the tooth vitality and function and
protect the supporting structures. This is performed by following definite steps
during cavity preparation to minimize irritation to vital tooth structure. These steps
are:

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a) Pulp protection against mechanical, thermal and chemical irritation during cavity
preparation.
b) Prevention of caries recurrence.
c) Working in a completely aseptic field.

The mechanical concept is primarily concerned with the preservation of the

structural integrity of both the tooth and restoration and retaining the restoration
inside its corresponding preparation. This can be achieved through a correct
mechanical cavity design as follows:
1. The cavity should be designed to decrease the magnitude of the destructive
stresses acting on the remaining tooth and the restoration.
2. The cavity design should decrease the deleterious and damaging effect of tensile
stresses created within the tooth as a result of defect.
3. Provision of adequate means of retention to prevent displacement of restoration
under functional forces.

As stated earlier by G.V. Black, the mechanical concept is performed by

following tooth preparation procedure which is divided into several steps. Each
should be thoroughly understood and each step should be accomplished as perfectly
as possible. There are occasions, however, when the sequence is altered, but this is
the exception and not the general rule.

These steps are:

a) Obtaining the outline form.
b) Performing resistance and retention forms.
c) Convenience form.
d) Removal of any remaining infected dentin.
e) Finishing of enamel and external cavity walls.
f) Cleaning and toileting.

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Remember that
The biological concept aims to The mechanical concept is primarily
preserve the tooth vitality and function and concerned with the preservation of the
protect the supporting structures. structural integrity of both the tooth and
restoration and retaining the restoration
inside its corresponding preparation.
The steps followed to perform the According to G.V. Black, the steps
biological concept are: followed to perform the mechanical concept
a) Pulp protection against mechanical, are:
thermal and chemical irritation during a) Obtaining the outline form.
b) Performing resistance and retention
cavity preparation.
forms.
b) Prevention of caries recurrence. c) Convenience form.
c) Working in a completely aseptic field. d) Removal of any remaining infected
dentin.
e) Finishing of enamel and external cavity
walls.
f) Cleaning and toileting.

I. BIOLOGICAL CONCEPT OF TOOTH PREPARATION

I-A) PULP PROTECTION:

1) Against mechanical irritation:
To perform pulp protection against mechanical irritation during cavity
preparation, the following precautions should be considered:
” Avoid direct traumatic injury of the pulp.
” Avoid unnecessary pressure and wrong direction of instruments.
” Avoid cutting across the recessional lines of the pulp chamber.
” Avoid over cutting of dentin and weakening of the tooth structure.
” Avoid sharp line angles within the cavity, which act as stress concentration
areas.

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2) Against thermal irritation:

To perform pulp protection against thermal irritation during cavity
preparation, the following precautions should be considered:
” Avoid heat generation during cavity preparation.
” Avoid working without coolant.
” Avoid long time working.

3) Against chemical irritation:

To perform pulp protection against chemical irritation during cavity
preparation, the following precautions should be considered:
” Avoid using of chemicals and caustics for toilet of the cavity.
” Avoid using air jet for long time.

I-B) PREVENTION OF CARIES RECURRENCE:

To decrease the incidence of caries recurrence after cavity preparation, the
following precautions should be considered:
” Removal of all carious enamel and dentin.
” The cavity outline should be extended to include all pits, fissures and vulnerable
areas to caries
” Proper extension of cavity margins to self-cleansable areas.
” Removal of all undermined enamel. Undermined enamel is that not supported
by sound dentin, which may fragment under force leaving a marginal ditch that
leads to food accumulation and recurrent caries.
” Proper inclination of CSA suitable with the type of restoration to provide
support to the restoration and enamel at cavity margins that prevents their
fragmentation and recurrence of caries.

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I-C) WORKING IN A COMPLETELY ASEPTIC FIELD:

It is unwise to treat a tooth and infect the patient with a dangerous systemic
disease that could be transmitted via the dental office. This constitutes a horrible
issue to most of the dental patients allover the world. To reduce the risk of cross
infection, the followings should be considered:
” Use sterile instruments.
” Use disposable tools as much as possible.
” Application of rubber dam to keep the fields clean and dry, and decrease the
chance of droplet infection.
” Follow the instructions of ADA and WHO to control infection in dental office.

II. MECHANICAL CONCEPT OF TOOTH PREPARATION

II-A) OBTAINING THE OUTLINE FORM:

Definition:
Outline form of prepared cavity is defined as the external shape of the
completed cavity boundaries, i.e. the shape or pattern of CSA of the prepared cavity.

Fundamentals of outline form:

To obtain ideal outline form, the following cardinal rules should be considered
(Fig. 5-1):
1. All the circumference of carious lesion must be included within the outline.
2. All pits, fissures, grooves and retentive areas must be included within the outline.
3. The cavity margins should be extended to sound tooth structure without
undermined enamel and in a self-cleansable area.
4. All carious and undermined enamel must be included in the prepared cavity.
5. The outline must be in the form of harmonious sweeping curves, in order to:
a) Prevent caries recurrence.
b) Avoid stress concentration areas.

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c) Obtain better esthetics.

6. Cavities approaching each other must be connected to avoid leaving a weak ridge
between them which is liable to fracture.
7. Extension for prevention or cutting for immunity.

Fig. 5-1: Designing the outline form for pits and fissures lesion. A, The carious
lesion should be included. B, Also the weakened unsupported enamel is included.
C, The outline form includes all defective pits, fissures and grooves. D, The
outline of the cavity should be extended to area self-cleansable. E, The final shape
of the outline form for Class I carious lesion.

Extension for prevention (Cutting for immunity):

Definition:
Extension of cavity margins to a self-cleansable area to decrease the possibility
of caries recurrence.

Factors affecting extension for prevention:

1. The extent of surface involvement in enamel.
2. The lateral spread of caries at DEJ, i.e. degree of undermining.
3. Esthetic demands necessitate the use of special outline with minimal extension.

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4. Oral hygiene; the better the oral hygiene, the lesser will be the extension.
5. Patient age; the older the patient, the lesser will be the extension due to tooth
attrition.
6. Force of mastication; the more to be ideal, the lesser will be the extension.
7. Restorative material as different extensions is used with different restorative
materials.

Technique:
1. Extending the occlusal outline up to 2/3 of the cusp inclined plane.
2. Extending the proximal outline up to the axial line angles of the tooth in direction
bucco-lingual.
3. Extending the gingival floor below the health gingival margins.
4. Extending the outline of cervical buccal and lingual cavities (Class V) up to above
the maximum height of contour and below the healthy gingival margin.

Adverse effects of extension for prevention:

1. Weakening of the sound tooth structure.
2. Increased irritation to the pulp.
3. Increased liability for gingival and periodontal problems in compound cavities.
4. Increased liability to recurrent caries.

Factors modifying the outline form:

1. Contact area in proximal cavities:
Location, dimensions and tightness of contact area determine the isthmus
outline of compound class II cavities to ensure the cavity outline is located in area
self-cleansable, i.e. the embrasures.

The isthmus outline will follow one of the Ingerham′s lines according to the
width of the contact area.

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These lines may be (Fig. 5-2):

” Straight; for cases with open or too small contact between teeth
” Uniform or universal; for cases with moderate touch or plus contact between
teeth.
” Reverse curve; for cases with tight and broad contact between teeth.

Fig. 5-2: To ensure proper freeing of the contact area and

placing the cavity walls in the embrasures, the outline
form will follow one of the Ingrham’s lines. A, Straight
line of small contact area. B, Uniform curve in case of
moderately sized contact area. C, Reverse curve in case
of wide contact area.

Remember that
• The reverse curve outline is always required in the buccal wall rather than the lingual
as the contact area is always shifted toward the buccal rather than lingual.
• The reverse curve outline could only be performed in the lingual wall when the caries
extension is far lingual at the isthmus portion.
• The reverse curve outline provides the adjusted required CSA at 90º and also conserves
much more tooth structure.

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2. Age of the patient:

Young aged patient shows increased liability for caries recurrence. So, the
outline should be well extended to insure all carious lesion and retentive area. At the
same time conservative due to increased liability to remake the cavity as a result of
caries recurrence.

3. Oral hygiene of the patient:

Patients with good oral hygiene, ultra conservative outline form could be
performed. While in cases with bad oral hygiene, all caries susceptible areas must be
included in the cavity outline and the cavity should be extended to area self-
cleansable.

4. Physical properties of the restorative material:

Brittle materials are in need for depth bulk with minimal width to decrease the
surface of restoration exposed to occlusal force and to increase their strength. So, the
outline width should be minimal as much as possible. In case of ductile materials, no
bulk depth or width specifications are needed.

5. Technique of construction of restoration:

Indirectly constructed restorations, such as cast gold restoration or esthetic
inlays, require further widening of the outline to allow easy and accurate
manipulation of the impression, wax pattern and casting of the metal.

6. Esthetic needs:
The outline extension may be affected by the location of the cavity. In anterior
teeth ultra conservative outline form should be performed in order to preserve the
natural esthetic appearance of the tooth structure as much as possible. So,
undermined labial enamel wall of Class III cavities could be left to preserve the
natural tooth appearance.

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For esthetic demands, the gingival margin of Class V cavity preparation should
be hidden subgingivally and the incisal wall is just limited to the defect in case of
tooth colored restorations in the anterior region and the incisal wall is given the
shape of a graceful curve for maximum esthetics. Graceful curve is performed by
cutting the incisal wall parallel to the curvature of the labial height of contours.

7. Convenience:
Areas of inaccessibility do hinder proper instrumentation and restoration. So,
slight extension of the cavity outline is indicated.

II-B) PERFORMING RESISTANCE & RETENTION FORMS:

Definitions:
Resistance form is defined as that form given to prepared cavity to prevent
fracture of remaining tooth structure or/and the restoration.

Retention form is defined as that form given to prepared cavity to prevent

displacement or dislodgement of the restoration out of the prepared cavity.

Remember that
• Resistance and retention forms are two distinct but yet, inseparable and interrelated
steps.

Factors affecting stress response of tooth structure and restoration:

For proper designing of the resistance features of the prepared cavity, a detailed
understanding of the stress response of both the remaining tooth structure and the
restoration should be obtained.

The stress response of the remaining tooth structure and the restoration is
affected by 3 major factors, which are:

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a) The occlusal loading force.

b) The cavity design.
c) The physical properties of the restorative material.

a) The occlusal loading force:

Occlusal loading force affects the stress response of tooth and restoration
through its magnitude, direction and character.

1. Magnitude: That differs from patient to another according to the action of the
mastication muscles, type of occlusion and inter-cuspation, type of food, age and
sex. Also, it varies from location to another in the same patient and also from
time to another.
2. Direction: It may be directed as compressive, tensile or shear and this depends on
the form and shape of the loaded surface as well as the inclination of the cavity
walls at which the stresses transmitted will be analyzed
3. Character: It may be a static force in centric occlusion, dynamic in eccentric lateral
movement and cyclic and repetitive during masticatory function.

We can conclude that cyclic force with different magnitudes and directions are
present during mastication producing fatigue of the restorative material and enhance
its fracture.

b) The cavity design:

1. Walls and floors: Should be either parallel or perpendicular to the long axis of the
tooth to decrease the analysis of force into destructive tensile components (Fig. 5-
3). Also, they should be flat and smooth to avoid stress concentration and to
provide equal distribution of occlusal stresses.

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Fig. 5-3: Flat pulpal floor. A, Correct

angulation of pulpal floor parallel to
the occlusal plane and at right angle to
the occluding force. B, Flat pulpal floor
but with incorrect angulation.

2. Cavity width and depth: Both of them are responsible to provide bulk to the
restoration. Increasing the bulk of the restoration especially brittle ones, increase
the strength of the material and its resistance to fracture. But, it was proofed that
it is better to provide bulk to the restoration through depth (within limits to
avoid pulpal irritation) rather than width. Increasing the width will weaken the
remaining tooth structure and the restoration as it leads to increased surface area
of the restoration exposed to occlusal force. It is recommended to get a cavity
depth of 0.5 – 1mm beyond the DEJ and a cavity width of 1/4 - 1/3 the inter-
cuspal distance (Fig. 5-4).

Fig. 5-4: Minimal cavity width 1/4 - 1/3 the intercuspal

distance will decrease the exposed area of restoration
to occlusal loading force.

3. Conservation: Maximum conservation of remaining sound tooth structure as

much as possible is recommended to avoid their fracture.

4. Line angles: All axial line angles of the prepared cavity should be rounded in the
form of sweeping curves to avoid stress concentration. For compound cavities,

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rounding of the axio-pulpal line angle is recommended as it leads to decreased

stress concentration and adds bulk to the restoration (Fig. 5-5).

Fig. 4-5: Rounding the axio-pulpal line angle to reduce

stress concentration on the restorative used.

5. Cavo-surface angle: It should have a correct angulation suitable with the physical
properties of the restorative material and the direction of enamel rods. For brittle
materials such as amalgam CSA should have 90 º angles to get the strongest
enamel wall and provides strength to amalgam at margins. Any deviation from
correct angulation may lead to fracture or tooth structure or restoration at margin
(Fig. 4-6). For ductile materials such as gold, it should be 135º to allow burnishing
of the gold over the enamel margin that provides protection.

Fig. 5-6: The cavo-surface angle with brittle

restoratives should be adjusted to the best
compromise between the tooth and restoration.
A) An acute CSA strengthens the margins of
brittle restoratives but undermines the inner
ends of enamel rods and grossly weakens the
enamel margin and therefore is absolutely
contraindicated. B) An obtuse CSA protects
the outer ends of enamel rods and strengthens
the enamel margins but grossly weakens the
margins of brittle restoratives. C) The best
compromise is obtained with a 90° CSA, which
results in a sound enamel margin with no
undermined rods and a strong restoration
margins.

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6. Amount of retention: Adequate amount of retention for each part of the cavity
increases the stability of the restoration under stresses. In compound prepared
cavities, each part should have its own ample independent retention to avoid
fatigue and fracture of the restoration at the isthmus area.

7. Weak cusp: Weak cusp is that which have its base smaller than its heights that
may lead to cusp splitting under loading force. Such a cusp should be reduced to
decrease the height in relation to its base. This is called cusp tipping in case of
using amalgam to cover this cusp and should be for at least of 2 mm to provide
strength to the amalgam. It is also called cusp coverage by performing counter
bevel in case of using cast gold restoration to protect such a cusp, i.e. In-onlay.

c) The physical properties of restorative material:

The tensile type stresses are the significant stresses for the brittle substances as
amalgam, cements and porcelain because they have high compressive but very low
tensile and shear strength values. These substances are especially sensitive to tensile
stresses, i.e. they cannot withstand high tensile stresses without fracture and cannot
be finished to thin margins otherwise ditching will occur.

On the contrary to the strong and ductile gold this is utilized for protection of
the weakened tooth structure.

Forms of resistance:
The design features of cavity preparation that enhance primary resistance form
are:
1. Relatively flat floors.
2. Box shape, which provides the following advantages:
” The seat of the restoration (pulpal and gingival wall) is placed at a distinct
right angle to the direct of functional stresses.

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” The tendency to split the buccal and lingual cusps of bicuspids and molars
by forces transmitted through the restoration is greatly diminished since
the inverted truncated cone shape prevents the wedging action of the
restoration inside the tooth (Fig. 5-7).
” It provides retention by friction due to relative parallelism of the axial
walls
” It allows access to and easy visualization of the interior of the cavity,
which allows for an easier and better instrumentation and filling.
” Restorative materials tend to adapt better against its plane surfaces.
” It allows the employment of retention features in dentin
3. Inclusion of weakened tooth structure
4. Preservation of cusps and marginal ridges
5. Rounded internal line angles
6. Adequate thickness of restorative material
7. Seats on sound dentin peripheral to excavations of infected dentin (creation of
dentin ledges).
8. Reduction of cusps for capping when indicated.

Fig. 5-7: Box form cavity will provide flat pulpal floor, A) that will prevent
restoration movement, whereas rounded pulpal floor, B) is conductive to restoration
rocking action producing a wedging force, resulting in splitting of tooth structure.

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Types of retentive features:

a) By utilizing dentin:
1. Mechanical undercuts; through converging the cavity walls occlusally (Fig. 4-8a).
2. Frictional wall retention; between parallel opposing cavity walls (Fig. 4-8b).
3. Gripping action of dentin; due to its visco-elasticity, stress relaxation of dentin
will grip the restoration. This will occur only with gold foil restoration.
4. Pin retention.

Fig. 5-8: A) Basic primary retention form

in Class II cavity preparation for
amalgam with longitudinal external
walls of proximal and occlusal portions
converging occlusally and B) for cast
inlay with similar walls slightly
diverging occlusally.

b) By modifying the cavity outline:

1. Dove tail lock; in compound proximal cavities (Fig. 5-9).
2. Occlusal lock; in compound proximal cavities.
3. Buccal and lingual extensions; to prevent proximal displacement.
4. Extension for retention; performed by extension to the other side of the cavity.

Fig. 5-9: Occlusal dove tail that adds retention and

prevent tipping of the cast restoration.

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c) By modifying cavity design:

1. Proximal axial grooves; in amalgam cavity, it extends from gingivo-axial line
angle up to the axio-pulpal line angle, along the axio-buccal and axio-lingual line
angle with undercut. In gold cavity, it extends up to CSA without undercut (Fig.
5-10).
2. Grooves in dentin line angles.
3. Reverse gingival bevel at the gingival floor with gold inlay. It prevents proximal
displacement and rotation around axio-pulpal line angles (Fig. 5-11). It could not
be used with amalgam cavities as it will lead to stress concentration and mercury
accumulation at axio-gingival line angle resulting in excessive weakening of
amalgam.

Fig. 5-10: Cutting proximal axial grooves to provide lateral retention should be in
expense of buccal and lingual walls rather than axial wall to provide lateral
retention and avoid pulp exposure.

Fig. 5-11: Reverse gingival bevel cut with GMT

of tapered fissure.

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d) Special retentive features:

1. Adhesive systems for composite restoration.
2. Dowel pin retention, i.e. post inside the root canal.

Factors affecting selection of retentive form:

1. Type of restorative material.
2. Available amount of remaining tooth structure.
3. Esthetic demands.
4. Amount of retention needed.
5. Pulp vitality; for non vital pulp will not provide gripping action of dentin due to
excessive dehydration.
6. Type of occlusion; abnormal occlusion increases the magnitude of stresses.

Remember that
• Stability is mean prevention of restoration displacement towards the center.
• It is gained by:
1. Definite cavity walls.
2. Flat pulpal floor.
3. Definite and slightly rounded line angles.
• Retention means prevention of restoration displacement towards the periphery.
• It is either:
1. Axial; against vertical displacement.
2. Lateral; against lateral displacement.

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II-C) CONVENIENCE FORM:

Definition:
Convenience form is defined as that shape given to the cavity to make it easily
seen, reached, instrumented and restored.

Convenience features:
1. Accentuation of point and line angles.
2. Slight extension of cavity outline to facilitate insertion and condensation of the
restorative material.
3. Roundation of axial line angles.
4. Beveling of enamel wall with gold restoration to provide room for burnishing the
gold to protect marginal enamel. It is also performed with composite resin cavity
preparation to increase surface area for acid etching.
5. Selection of smaller specially designed instruments that enable the operator to
prepare surfaces which are difficult to reach.

II-D) REMOVAL OF REMAINING CARIOUS DENTIN:

Definition
It is the process of removing decay and decalcified enamel and dentin; and
determining the prepared cavity depth.

Caries pattern:
Caries in enamel follows the direction of enamel rods in a triangular pattern
with its base toward the DEJ. The caries then shows a lateral spread at DEJ then
follows the direction of dentinal tubules of dentin.

The routine cavity depth:

The routine cavity depth should be extended 0.5 – 1mm beyond DEJ in order to:
1. Avoid cutting at this sensitive area; i.e. DEJ.

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2. To get sure that there is no undermined enamel resulted from the lateral spread
of caries at DEJ.
3. To detect lateral spread of caries at DEJ.
4. To provide sufficient bulk of the restoration.
5. To add retentive features.

Conditions at routine cavity depth:

Three conditions may be found at the routine cavity depth.
a) Hard sound viable dentin:
It is considered as the best condition. Finish enamel walls and apply either
varnish in case of amalgam or calcium hydroxide liner in case of composite.

b) Hard discolored dentin:

It is considered as sound dentin but the discoloration is due to the
chromogenicity of microorganisms. In posterior teeth, it could be left and the final
restoration could be placed. In anterior teeth, it must be removed as it appears from
enamel affecting esthetic.

c) Soft dentin:
Which is painful, denoting presence of viable protoplasmic processes, and
which may be discolored (chronic caries) or not (acute caries). This layer constitutes
the floor of deep and moderately deep cavities. Such soft dentin must be removed
since it is carious and if left will extend to involve the pulp.

If still soft, caries should be removed selectively forming dentin ledge and the
cavity will be deep that needs sub-base and base before placing the final restoration.

If there is still soft caries, it must be evaluated, either acute or chronic caries. If it
is an acute caries, it could be left and sub-base and base are placed before placing the

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final restoration. Only apply calcium hydroxide as indirect pulp capping, as the last
layer is sterile. If it is a chronic caries, it should be removed even pulp exposure
occurs, as the last later is infected.

Acute caries Chronic caries

Acid penetration occurs before

Acid penetration coincides with
bacterial invasion, so the last
bacterial invasion, so the last
Histology layer is sterile, it is just
layer is both infected and
decalcified; i.e. Affected and
affected.
not infected.
Could be left, only apply
Could not be left and must be
calcium hydroxide to neutralize
Last layer removed even if leads to pulp
acidity, i.e. indirect pulp
exposure.
capping.

Patient age Young, less than 20 years. Old, more than 40 years.

First molar teeth and lower

Site Anywhere.
anterior teeth.

Duration Short by months. Long by years.

Color Yellow. Dark brown.

Consistency Soft and removed in flacks. Harder and removed in debris.

Pulp reaction Hyperemia. Degeneration and necrosis.

Instruments used to remove caries:

1. Hand instruments:
Excavators with different shapes and sizes could be used in a direction parallel
to the pulp horns from the cavity periphery to the center with scooping motion. It
provides no heat generation.
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2. Rotary instruments:
Large round bur with low speed and without pressure.
Remember that
• Dentin ledge is a three-dimensional form in a level pulpal to the cavity. It impairs the
resistance form, so it should be lined with sub-base and base to the proper level of the
pulpal floor.
• Dentin bridge is the thickness of dentin protecting the pulp.

II-E) FINISHING OF ENAMEL WALL:

Objectives:
1. To give the CSA its correct inclination.
2. To remove any undermined enamel.
3. To produce smooth enamel walls that increases adaptation of the restoration.
4. To keep the rounded and convenient outline with proper cusp contours.

Requirements of enamel wall:

According to NOY’S rules for keeping strong enamel wall at margins:
1. Enamel wall must rest on sound dentin.
2. Enamel rods which form the CSA must have their inner ends resting on sound
dentin.
3. The outer ends of enamel rods must be covered by the restorative material and
inner ends rest on sound dentin. This establishes the strongest required enamel
wall. This had done by beveling the enamel rods and using a strong ductile
restorative material, e.g. Gold inlays.
4. The enamel walls and margins should be finished smooth, free from short, loose,
friable or undermined enamel rods.
5. The enamel wall must take the same inclination of enamel rods.
6. The enamel wall must have an inclination suitable with the physical properties of
the restorative material.

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7. The enamel wall must be beveled in case of using high strength restorative
material.

Factors affecting inclination of CSA

1. Direction of enamel rods.
2. Location of the cavity wall.
3. Friability of enamel.
4. Degree of marginal strength of the restorative material. CSA 90° for brittle
material as amalgam and CSA 135° for ductile material as gold.
Remember that
• Undermined enamel is only left in the labial surface of class III because of:
” Esthetic needs.
” It is subjected to minimal force produced from lip musculature.
” The destructive force is away from it as it is in a palato-labial direction.

Beveling of enamel wall:

Definition:
Beveling means increasing CSA inclination more than 90°.

Types:
1. Short bevel involving part of enamel thickness.
2. Long bevel involving the full enamel thickness up to DEJ.
3. Full bevel including enamel and dentin up to the pulpal floor.
4. Counter bevel made against enamel rods of the cusp to make inlay with cusp
coverage, i.e. in-onlay.

There is only one bevel made in dentin, which is the reverse gingival bevel for
retention of Class II gold inlay.

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Functions of bevel:
1. Protection of weak enamel rods.
2. Facilitate burnishing of ductile materials.
3. Protection of cement line from solubility.
4. Protection of weak cusps → counter bevel.
5. Making the enamel wall parallel to the direction of enamel rods.
6. Increasing surface area for acid etching needed for retention of composite
restoration.
7. Better esthetic and decreased demarcation of composite restoration.
8. Add retention → reverse gingival bevel.

Instruments used for finishing of enamel wall:

1. Hand instruments; Chisel and hatchets are the instruments of choice with no heat
generation.
2. Rotary instruments; Cutting fissure bur.

II-E) TOILET OF THE CAVITY:

Definition:
The process of removing all debris from the prepared cavity, e.g. cut chips,
blood, saliva and bacteria.

Objectives:
1. Increasing adaptation of the restoration to cavity walls.
2. Prevents contamination of the restorative material.
3. Enables the operator to examine properly all steps.
4. The cavity should be clean and dry before insertion of the filling material.

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Technique:
1. Phenol; but it leads to pulp necrosis.
2. Silver nitrate; but it leads to:
” Discoloration of tooth structure.
” Irritation to the pulp.
” Tarnish of amalgam.
3. Alcohol; leads to:
” Dehydration of dentin.
” Pulp irritation.
4. Hot air blast; leads to dehydration of dentin.
5. Hydrogen peroxide 3%:
” Highly effective through its effervescent action.
” Should be washed immediately with warm water to avoid thermal pulp
shock.
6. Water spray:
” The best as it is not a medicament.
” Cotton pellet to dry the cavity to reduce the use of air stream.
” Removal of remaining water by air for short time.
Remember that
• Adaptation is the maximum degree of proximity between the restoration and the tooth
structure.
• For proper adaptation:
” The tooth surface should be smooth, dry and clean.
” The restoration should be properly constructed.

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