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Chapter 1: Introduction to Operative Dentistry
Objectives:
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Operative Dentistry
Definition:
It’s the art and science concerned with all procedures, whereby defects in hard tooth structures are
diagnosed, eliminated, treated, prevented and the lost tooth structures are restored.
A- Bacterial.
B- Mechanical.
C- Chemico-mechanical.
D- Endodontically treated teeth.
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A- Bacterial dental caries:
• Definition:
Caries could be defined as a chronic disease affecting hard structures (enamel, dentin or
cementum) characterized by demineralization of inorganic content and destruction of organic
structures by microbial fermentation of carbohydrates from the diet leading to dissolution of
hard tooth structure.
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3- According to location:
A- Primary caries:
First evidence of caries.
B- Secondary caries:
Recurrent caries.
• Spread of caries:
2- Smooth surface:
- Smooth surface cavities do not begin in an enamel defect. They occur in smooth
areas in surface enamel that are habitually unclean and are usually covered in
plaque.
- Caries spread also conical in shape. In enamel, the base is toward the outer
surface while the tip toward the DEJ. Again, there is lateral spreading of caries
along the DEJ. In dentin, the base is toward the DEJ while the tip is toward the
pulp.
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B- Mechanical:
1- Wear and attrition: the end result of rubbing teeth against each other or chewing hard
objects.
2- Abrasion: the end result of abrasive agent rubbing against teeth, leading to notches on
labial side of root surface it may occur from:
a- Improper brushing techniques.
b- Habit of holding pipe stem against teeth.
c- Tobacco chewing.
d- Vigorous rubbing between adjacent teeth.
3- Fracture: the loss of a part of the tooth due to an external blow or may split during loading
force when biting on a hard object.
C- Chemico-mechanical:
• Erosion: loss of hard tooth structure due to weak chemical force coupled with weak
frictional force.
- Causes:
1- Stomach acid.
2- Regurgitation habitual lemon suckers.
3- Ingestion of acid medicine.
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NOTES:
1- Self-cleansable areas:
Areas which are cleansed simply by the action of tongue and cheek movement and also due to
mastication.
Examples:
Areas buccal and lingual above the maximum height of contour occlusally.
Areas mesial and distal above the contact area occlusally.
Cusp tip and cusp inclined planes.
2- Stagnation areas:
The most liable to caries as it allows food retention.
Examples:
Areas buccal and lingual in a gingival position to the maximum height of contour.
Areas mesial and distal, gingival to the contact areas.
Pit and fissures on the occlusal surface.
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3- Less susceptible areas:
G. V Black proposed that restorations for smooth surface caries should be extended
to self-cleansing area to prevent recurrence of caries. Later, this concept was
broadened to include remaining enamel defects such as pits and fissures.
This practice has virtually been eliminated.
Enameloplasty refers to the removal of a shallow enamel developmental fissure or pit
to create a smooth, saucer-shaped self-cleansing surface.
Classification of cavities:
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3- According to G.V. Black classification:
a- Class I Restorations:
- All pit and fissure restorations.
- Restorations on occlusal surface of premolars and molars.
- Restorations on occlusal two thirds of the facial and lingual surfaces of molars.
- Restorations on lingual surface of maxillary incisor.
b- Class II Restorations:
- Restorations on the proximal surfaces of posterior teeth.
d- Class IV Restorations:
- Restorations on the proximal surfaces of anterior teeth involving the incisal
edge.
e- Class V Restorations:
- Restorations on the gingival third of the facial or lingual surfaces of all teeth
(except pit and fissure lesions).
f- Class VI Restorations:
- Restorations on the incisal edge of anterior teeth or the occlusal cusp heights of
posterior teeth.
Notes:
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Rule I:
The surrounding walls of the prepared cavity take the names of the adjoining or corresponding
tooth surfaces.
Rule II:
The floor of the prepared cavity occlusal to the pulp, and at a right angle to the long axis of the
tooth is called pulpal floor.
If the pulp is removed and the cavity is extended to involve the pulp, this floor is called sub-
pulpal floor.
The floor of the prepared cavity near the gingival tissues and lateral to the pulp is called the
gingival floor.
Rule III:
The wall in axial surface parallel to the long axis and approximates the pulp is called the axial
wall.
Rule IV:
All line angles are formed by the junction of two walls; or one wall and floor, and named by
combining the names of the sharing walls.
Rule V:
All point angles are formed by the junction of two walls and floor, and named by combining the
names of the sharing walls and floor.
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Tooth preparation terminology:
1- F = facial.
2- D = distal.
3- P = pulpal.
4- L = lingual.
5- M = mesial.
6- G = gingival.
7- A = axial.
8- DF = disto-facial line angle.
9- DP = disto-pulpal line angle.
10- DL = disto-lingual line angle.
11- Mf = mesio-facial line angle.
12- MP = mesio-pulpal line angle.
13- ML = mesio-lingual line.
14- DFP = disto-facial- pulpal point angle.
15- FP = facial- pulpal line angle.
16- MFP = mesio-facial- pulpal point angle.
17- DLP = disto-lingual- pulpal point angle.
18- LP = lingual-pulpal line angle.
19- MLP = mesio-lingual- pulpal point angle.
20- AFP = axio-facial- pulpal point angle.
21- AF = axio-facial line angle.
22- AFG = axio-facial-gingival point angle.
23- FG = facial-gingival line angle.
24- AG = axio- gingival line angle.
25- LG = lingual-gingival line angle.
26- ALP = axio-lingual-pulpal point angle.
27- AP = axio-pulpal line angle.
28- AL = axio- lingual line angle.
29- AGL = axio- gingivo- lingual point angle.
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Tooth preparation walls:
Internal wall: An internal wall is a prepared (cut) surface that does not extend to the external
tooth surface.
Axial wall: An axial wall is an internal wall parallel with the long axis of the tooth.
Pulpal wall: A pulpal wall is an internal wall that is perpendicular to the long axis of the tooth
and occlusal of the pulp.
External wall: An external wall is a prepared (cut) surface that extends to the external tooth
surface. Such a wall takes the name of the tooth surface (or aspect) that the wall is towards.
Floor (or seat): A floor (or seat) is prepared (cut) wall that is reasonably flat and
perpendicular to the occlusal forces that are directed Occluso-gingivally (generally parallel to
the long axis of the tooth). Examples are the pulpal and gingival walls. Such floors may be
purposefully prepared to provide stabilizing seats for the restoration, distributing the stresses
in the tooth structure, rather than concentrating them. This preparation increases the
resistance form of the restored tooth against post-restorative fracture.
Enamel wall: the enamel wall is that portion of a prepared external wall consisting of enamel.
Dentinal wall: the dentinal wall is that portion of a prepared external wall consisting of
dentin, in which mechanical retention features may be located
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Cavo-surface angle and margin:
The cavo-surface angle is the angle of tooth structure formed by the junction of a prepared
(cut) wall and the external surface of the tooth. The actual junction is referred to as the cavo-
surface margin. The cavo-surface angle may differ with the:
The cavo-surface angle is determined by projecting the prepared (cut) wall in an imaginary line
and the unprepared enamel surface in an imaginary line and noting the angle opposite to the
cavo-surface angle.
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Revision:
2- When caries occurs at the junction of a restoration and the tooth. It’s called:
a- Acute caries.
b- Incipient caries.
c- Secondary caries.
d- Arrested caries.
3- When a smooth surface carious lesion appears as opaque white, with a fairly hard and intact
enamel surface, your decision to treat such a lesion will be:
a- To try and remineralize the lesion since it is reversible.
b- To prepare and restore the lesion with appropriate restoration.
c- To seal the affected area with a sealant.
d- To monitor the lesion.
e- To perform prophylactic odontotomy.
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6- According to black's classification of cavities, a maxillary incisor may show the following classes:
a- I, III & V.
b- II, III & V.
c- I, IV &V.
d- I, III, IV, V & VI.
9- Cavities involving cusp tip 23& incisal edge 21 can be considered as:
a- Class III.
b- Class II.
c- Class V.
d- Class IV.
e- Class VI.
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d- Compound class III.
13- The principle bacterial agent involved in the caries process is:
a- Lactobacillus Acidophilus.
b- Streptococcus Sangvis.
c- Streptococcus Salivarins.
d- Streptococcus Mutans.
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Student Notes:
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Chapter 2: Principles of Tooth Preparation
Objectives:
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Tooth Preparation
Lecture Outline:
Objectives of tooth preparation.
Factors affecting tooth preparations.
Stages and shapes of tooth preparations.
The mechanical alteration of a defective, injured or diseased tooth to best receive a restorative
material that will re-establish a healthy state for the tooth, including esthetic corrections where
indicated, along with normal form and function.
Get the smallest possible cavity for demonstrable removal of all caries with water coolant.
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Essential of cavity preparation:
Remove all caries and defects and give the necessary pulp protection.
Locate the margins of the restoration as conservatively as possible.
Form the cavity so that the tooth and / or restoration won’t fracture and the restoration won’t
be displaced.
Restore form, function and esthetics to the tooth.
1- Diagnosis:
3- Patient factors:
Preservation of the vitality of the tooth by avoiding the application of poor or careless
operative procedure on the tooth.
Restorations should be made as small as possible.
Small tooth preparations result in restorations that have little effect on both inter-arch &
intra-arch relationships as well as esthetics.
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5- Restorative material factors:
Biological Principles.
Mechanical Principles.
Esthetic Principles.
Classification:
26
What are class I lesions?
Class II:
The lesions involving the proximal surfaces of the posterior teeth with access established
from the occlusal surface.
Class III:
The lesions involving the proximal surfaces of anterior teeth which may involve a labial or a
lingual extension but does not include the incisal edge.
Class IV:
The lesions involving the proximal surfaces of anterior teeth which include the incisal edge.
Class V:
The lesions involving the cervical third of all teeth, including the proximal surface of posterior
teeth where the marginal ridge is not included in the cavity preparation.
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Design and preparation of cavities:
The design and preparation of cavities are based on Black’s principles that have been determined
and re-applied with importance directed towards protection of tooth in preparation rather than
only on the material.
Each diseased tooth has an individual cavity form determined by caries involvement, morphology
of tooth and its location on the oral cavity leading to new conservative cavity designs.
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Stages and Steps of Tooth Preparation:
Initial Stages:
Final Stage:
Cavity margins placed in the positions they will occupy in the final preparation.
Initial depth is 0.2 – 0.5mm into dentin (in pit & fissure) and 0.2 – 0.8mm for extension onto the
root surface (and in smooth surfaces)
Notes:
We shouldn’t stop at the DEJ and we have to reach the dentin because the DEJ is very
sensitive (due to anastomosis of dentinal tubule).
The depth in smooth surface enamel (0.2- 0.8) is more than in pits & fissures (0.2 - 0.5)
because the thickness of the enamel is lesser in the pits& fissures.
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• General Principles:
• Factors to consider:
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II. Primary resistance form:
It is the shape and placement of the cavity walls that enable the tooth and restoration to
withstand Masticatory forces (along the axis of the tooth) without fracture.
1- Box shaped:
o All internal right angles should be rounded to prevent stress and rotation of the restoration.
o Flat floor.
o Restrict the extension of the external wall.
2- Cap weak cusps and envelope weakened tooth structure to prevent fracture.
3- Provide the right thickness according to the type of material.
4- Bond the material to the tooth structure when possible.
Note: we must be conservative thus only the carries should be removed.
NOTE:
Dentin Bridge: Thickness of dentin from the pulp to the floor of the cavity
Dentin Ledge: depression in dentin to remove the caries done by round large bur, low
speed & minimal pressure or by spoon excavator.
• Minimal thickness of restorative materials for adequate wear and resistance to fracture:
Amalgam 1.5 mm
Gold 1 mm
Porcelain 2 mm
Composite variable
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III. Primary retention form:
It's the shape or form of the cavity preparation that can resist displacement or removal of the
restoration from tipping or lifting forces e.g. gum.
NOTE:
• Types of restorations: Retention includes: slots,
retentive grooves & dovetails
1- Direct restoration:
Used in the clinic e.g. Amalgam & Composite.
We need to make an occlusal convergence.
A- Amalgam:
Class II &III: mechanical retention with converging walls.
Class V: retention grooves.
B- composite:
Mechanical retention with enamel/dentin bond.
2- Indirect restoration:
In the clinic and lab.
Diverging wall with taper \__/
• Types of retentions:
1- Macro mechanical means of retention: retentive groves, Convergence e.g. Amalgam and
Metallic.
2- Micro mechanical means of retention: by the usage of acid itching to make selective pores
and bonding e.g. composite.
3- Frictionary retention (both amalgam and composite).
Notes:
Retentive grooves are used in class II & class V.
The restoration is most susceptible to displacement in class II & class IV.
NOTE:
Caries detection is done by:
• X-ray
• Vision (discoloration)
• Pain (if under restoration)
• Consistency by prop
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IV. Convenience Form:
It is the shape or form that the cavity preparation allows for adequate observation, access and
ease of operation in preparation and restoration of the cavity.
Extension of proximal and or buccal or lingual wall to access deeper parts of the cavity.
Occlusal divergence on cast restoration (class II preparation).
Extending proximal preparations beyond the contact area.
Mechanical features e.g. locks, groove, cover, extension, skirt, beveled margins, pins, slots,
Amalgam pins
Cavity wall conditioning features:
o Acid itching enamel wall.
o Placing bonding agents or glass Ionomer on dentin walls.
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VIII. procedures for finishing the external walls:
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Amalgam vs. Composite
Amalgam Composite
Outline Form Include fault, break proximal & Include fault, break gingival
gingival contacts, include all contact, seal suspicious areas
suspicious areas
Pulpal depth Uniform 1.5 – 2mm Remove fault, not always
uniform
Axial depth Uniform 0.2 – 0.5mm into DEJ Remove fault, not always
uniform
Cavo-surface angle 90 degrees buccal and lingual >90 degrees buccal and lingual
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Revision:
2- The mesial & distal walls in class I cavity preparation for amalgam must diverge occlusally to
satisfy:
a- Outline form.
b- Resistance form.
c- Retentive form.
d- Convenience form.
5- According to black's classification of cavities tooth #25 may show the following classes:
e- I, II & V.
f- II, III & V.
g- I, IV &V.
h- I, III, IV, V & VI.
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6- The best geometrical design of the prepared cavity to resist fracture under masticatory forces:
a- Converge wall cavity design.
b- Diverge wall cavity design.
c- Saucer-shape cavity design.
d- Box-shape cavity design with relatively flat floor.
9- Conservative cavities modified form Black’s principles have the advantages of:
a- Decreasing fracture vulnerability & less display of restorations.
b- Decreasing fracture vulnerability of restorations.
c- Less display of restorations.
d- Being cheap.
11- It is the shape or form that is given to the cavity to allow for adequate observation, access and
ease of operation in preparation and restoration of the cavity:
a- Resistance form.
b- Convenience form.
c- Retention form.
d- Outline form.
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12- Oblique ridge in maxillary molars should be preserved, unless:
a- Caries.
b- Undermined.
c- Fissured.
d- None of above.
e- All of above.
15- Dentin ledge is proposed in deep caries to fulfill the requirement of:
a- Outline form.
b- Resistance form.
c- Retention form.
d- b & c.
e- b & a.
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Student Notes:
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40
Chapter 3: Instruments & Equipments of Operative Dentistry
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Operative Dentistry Instruments
Objectives:
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Operative Dentistry Instruments
The instruments that are used in Operative Dentistry are classified into:
1- Cutting instrument.
2- Exploring instrument.
3- Restoring instrument.
Cutting instruments:
Definition: They are the instruments used for cutting of the tooth structure.
Classified into:
A- Hand cutting instrument.
B- Rotary cutting and Rotary abrasive instrument.
C- Ultrasonic instruments.
1- Shaft which is grasped by the hand of the operator and has the following features:
a- Usually standardized in size.
b- Usually serrated for better handling of instrument.
2- Blade which has the cutting edge.
3- Shank which connects between the Shaft and the Blade and usually
tapers from the shaft towards the blade.
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Contra angle hand instrument:
• Advantages:
1- Better stability.
2- Better accessibility.
1- Long handle instrument: shaft, shank and blade are one piece.
2- Cone, Socket instrument: Shank and blade are one piece and the shaft is another piece and
they are screwed together by a screw.
• Disadvantages:
1- Less stable.
2- Limited to mirror.
I. Instrument Nomenclature:
G.V black described a way to name the hand instruments according to its name:
1- The Order: denotes the PURPOSE of the instrument e.g. excavator, scalar.
2- The Suborder: denotes the POSITION and MANNER of the use of the instrument e.g. push,
pull.
3- The Class: describes the FORM of the blade e.g. hatchet, chisel.
4- The Angle (Sub-Class): denotes the NUMBER of ANGLES in the shank e.g. bin-angle, triple
angle.
N.B. Naming of the instrument usually moves from 4 to 1 e.g. bin-angle hatchet push
excavator.
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II. Instrument Formula:
1- Ordinary formula:
The bevel (edge of the blade) is perpendicular to the long axis of the blade.
Consists of 3 figures:
2- Special formula:
The bevel (edge of the blade) is not perpendicular (acute) to the long axis of the blade.
Consists of 4 figures:
Example: -----15 (1) -----95 (2) -----8 (3) -----12 (4) -----
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III. Bevels:
To use the hand cutting instrument it has to have a bevel and is named according to the
number of bevels e.g. it is called uni-bevel when it has 1 bevel, bi-bevel when it has 2 bevels on
opposite sides or it can have a circular (or oval shaped) bevel (all around the blade) and is called
circumferential bevel.
A. Excavators.
B. Chisels.
C. Special forms of chisels.
1- Excavators:
Are designed for the excavation and removal of carious dentine and for shaping the internal
parts of the cavities.
• Types of Excavators:
1- Hatchet Excavator:
Used for the removal of HARD decay.
Used for the shaping of the internal part of
the cavity.
Bi-bevel.
The blade is in one line with the long axis of the shaft.
2- Hoe Excavator:
Used for the removal of HARD decay.
Used for the shaping of the internal part of the cavity.
Uni-bevel.
The blade is perpendicular (at right angle)
with the long axis of the shaft.
If the bevel is away from the shaft it is distal
and if the bevel is near the shaft it is mesial.
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3- Spoon Excavator:
Used for the removal of SOFT decay.
The blade is oval (or semi-circular) in shape and has
concavity.
Has circumferential bevel (around the edge).
Lateral cutting instrument.
“Double ended instrument” one end to the right and the
other to the left.
Made in pairs.
2- Chisels:
• 4 Types:
1- Straight chisels:
Have straight blade in line with the handle and shank.
The cutting edge is on one side only with the bevel of the
blade making a right angle with the long axis of the shaft.
Uni-beveled.
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4- Triple angle chisel:
Similar to straight but blade has 3 angles.
• Types:
1- Enamel hatchet:
The cutting edge is in the form of a bevel
parallel to the shaft.
Used for splitting or cleaving undermined
enamel for buccal and lingual wall in proximal
cavities.
3- Angle formers:
Like straight but the edge of the blade makes an acute angle (nearly
80 degrees).
Used to cut line and point angles.
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V. Instrument grasp:
1- Pen grasp.
2- Inverted pen grasp.
3- Palm and thumb grasp.
4- Modified palm and thumb grasp.
1- Pen grasp:
The same as the pen grasp but the hand is rotated so that the palm is facing
upwards.
Usually used in upper teeth.
The handle of the instrument is in contact with tips of the 4 fingers on one side
and the hand is half closed. The thumb is used for resting.
Not frequently used.
Permits greater freedom of movement.
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VI. Rests:
VII. Guards:
Restoring Instruments:
1- Condensing instruments:
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2- Carvers:
3- Burnishers:
Types:
a- Round.
b- Egg or ovoid.
Functions:
a- To make smooth surface.
b- Compacting.
c- To bend cast gold near the margins.
Types of explorers:
1- Straight, for occlusal surface.
2- Curved or sickle shape, for proximal surface.
3- Briault’s, for proximal surface.
4- Right angle, for proximal surface.
Mixing surface:
1- Glass slab used for mixing cements.
2- Paper pad used for mixing calcium hydroxide and composite.
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Dappendish:
Small glass, plastic or metal dish.
Has large depression in one end and small depression in the other end.
Has several colors.
Used to hold pastes, liquid and alcohols.
Mirrors:
Size ranges from 3/4 to 1 5/8 inch.
Is cone-socket instrument.
Types:
1- Plain.
2- Magnifying.
Uses:
1- Indirect vision.
2- Retraction of lips and cheeks.
3- Illumination of dark areas.
Tweezers:
Has two blades and handle.
It may be locked or unlocked.
Used to grasp materials and cottons.
Rotary tools:
For removal of tooth structure.
Types:
A. Burs, which are rotary cutting tools that have a bladed cutting head.
B. Stones which are abrading tools.
C. Discs.
Diamonds:
o Are sometimes called burs but are correctly named diamond abrasive point.
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Dental cutting burs:
Types of burs:
• According to their mode of attachment to the hand piece, dental burs can be
classified as either:
1- Long.
2- Short.
3- Regular.
1- Cutting burs:
Have 6-8 blades and are separated by clearance spaces.
2- Finishing burs:
Have 12-40 blades and are condensed to each other – no spaces.
3- Polishing burs:
The head is completely smooth.
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• According to their shape and size they may be classified as:
1- Round burs:
They are numbered from ¼, ½, 1, 2, to 10.
They are round in shape and used for initial tooth preparation,
placement of retentive grooves and removal of caries.
2- Wheel burs:
They are numbered from 14 to 15.
They are wheel shaped, used for placing grooves and for gross
removal of tooth structure.
• According to materials:
1- Steel bur:
Has low melting point.
Has low hardness.
Limiting its use for cutting dentin and with low speed.
2- Carbide bur:
Has high melting point.
Has high hardness.
Used for cutting enamel and with high speed.
Brittle.
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ISO numbering system:
In 1986, a new numbering system was approved by ISO International Organization for
Standardization the system covers all sizes and materials of the bur.
1st number: material of the head.
2nd number: type and length of the shank.
3rd& 4th numbers: shape of the head.
5th number: size of the head.
a) Bur tooth.
b) Rake angle.
c) Land.
d) Clearance angle.
e) Tooth angle.
f) Flute or chip space.
A. Rake angle:
The angle between the face of the bur tooth and a radical line from the center of
the bur to the blade. It’s either -ve, +ve or 0 (radical).
Radius
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B. Clearance angle:
The angle between the back of the tooth and the work.
If a land is present :
i. Primary clearance (<the land make with work).
ii. Secondary clearance (<between back and work).
C. tooth angle:
It is the ability of the bur to remove a maximum amount of tooth tissue with a minimum of effort
and time involved.
1- tooth angle:
The angle between the face &the back.
↓tooth angle ↑ efficiency.
2- rake angle:
+ve rake angle ↑ effective cutting (better with carbide).
Radial rake angle effective cutting (less than +ve).
-ve rake angle effective cutting (less than +ve& -ve).
3- Chip space:
Space between two successive teeth.
↑ Chip space ↑ cutting efficiency.
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4- Clearance angle:
The angle between the back &the work.
↑ Clearance angle ↑ cutting efficiency &↓ dulling of the bur.
5- Land:
The plane surface following the cutting edge.
Bur with land ↑ effective cutting.
7- Shape of blade:
Cross cut bur:
o More effective than plane cut specially with low speed.
o Increase chip space & less clogging.
8- Type of blades:
Straight blades less cutting than spiral.
10- Run-Out:
It refers to the eccentricity or maximum displacement of the bur head from
its axis of rotation while the bur turns.
Average clinically acceptable run out is about 0.023mm.
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12- finish of the flutes:
Burs should be well finished during manufacturing for better cutting
efficiency.
1- Friction:
Heat production due to friction between moving parts of hand piece specially
turbines.
↑ Friction ↓ cutting efficiency.
2- Torque:
Ability of a tool to withstand the lateral cutting without decreasing speed. It
depends on the type of bearing used.
↑ Torque ↑ cutting efficiency.
3- Vibration:
Eccentric movement that occurs during cutting by the bur which may be due to:
o Binding of the bur.
o Badly constructed bur.
o Wearing of hand piece part.
↑ Vibration ↓cutting efficiency.
C. Speed:
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D. Tissue to be cut:
E. Time:
F. Temperature:
Cleaning of teeth.
Removing of hard caries with round bur.
Smoothing of cavity preparation.
Finishing & polishing of restoration.
Margination of the gold restoration.
Finishing procedure.
Cavity preparation.
Placement of retentive grooves and bevels.
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Revision:
3- When approaching caries close to the pulp in deep cavity rotary cutting instrument should be
applied for caries remove and cavity preparation refinement in the range of:
a- Ultra high speed.
b- High speed.
c- Medium speed.
d- Low speed.
5- If you are using a low speed hand-piece, then you would be using:
a- Friction grip shank burs.
b- Friction latch shank burs.
c- Latch straight shank burs.
d- Latch type shank burs.
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6- A discoid is used for:
a- Removing undermined enamel.
b- For hard carious dentin.
c- For the excavation of soft caries.
10- Rotary cutting instrument should be applied for caries remove and cavity preparation
refinement in the range of:
a- Ultra high speed.
b- High speed.
c- Medium speed.
d- Low speed.
11- The type of instrument grasp with the greatest power is:
a- Pen grasp.
b- Palm & thumb grasp.
c- Modified palm & thumb grasp.
d- Palm thrust grasp.
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12- Chisels are used mainly to cut:
a- Enamel.
b- Dentin.
c- Cement.
d- Carious dentin.
16- The ideal instrument for beveling the enamel margin of gingival walls is:
a- Enamel hatchet.
b- Gingival marginal trimmer.
c- Enamel chisel.
d- Sharp spoon excavator.
17- Which hand instrument effectively planes the enamel of buccal and lingual walls of class II
cavity preparation:
a- Gingival marginal trimmer.
b- Straight chisel.
c- Enamel hatchet.
d- Hoe excavator.
e- Angle formers.
62
18- Retention grooves in class II amalgam cavity preparation are prepared using:
a- Inverted cone bur.
b- Long tapered fissure bur.
c- Pear shaped bur.
d- Cylindrical fissure bur.
21- If the working end of cutting dental instrument is right angle to the long axis of the handle the
instrument most probably:
a- Hatchet.
b- Chisel.
c- Spoon.
d- Hollenback carver.
e- Burnisher.
22- If u decided to use the high speed hand piece to do your operative project the one you pick is:
a- Friction grip bur.
b- Latch type bur.
c- Friction-latch type.
d- Straight hand piece bur.
e- None of the above
63
23- If the working end of the cutting dental instrument is not at right angle to the long axis of the
handle the instrument most probably:
a- Hatchet.
b- Chisel.
c- Spoon.
d- Hollenback carver.
e- Gingival Marginal Trimmer.
26- The average range of the low speed hand piece is:
a- 10,000-25,000.
b- 20,000-25,000.
c- 10.000-35,000.
d- 15,000-35,000.
e- 500-15.0000.
27- If u are holding your pen to answer these Q. using your thumb and index which tip of your
finger rest on top of your pen then this grasp is called:
a- Pen grasp.
b- Modified pen grasp.
c- Thumb grasp.
d- Palm thumb grasp.
e- Index thumb grasp.
64
Student Notes:
65
66
Rubber Dam
67
Rubber Dam
Rubber Dam:
Advantages:
68
Disadvantages:
69
1. Rubber Dam Material:
100% Latex-Free.
Powder-Free.
No rubber scent.
Tear resistance similar to latex.
Color reflective.
Minimum 3-year shelf life.
Hygenic brand – 6x6 inches, Medium (.010 inch [.025mm]) - .010 inches.
70
2. Rubber dam punch:
Ainsworth-type punch.
Ivory-design punch.
71
3. Rubber Dam Clamp (Retainer):
Winged Clamp:
The “wings” are placed into the hole in the dam first, and then both are placed on the tooth
together.
Provide extra retraction of the R.D.
Allows attaching the dam to retainer.
They interfere with placement of matrix band.
Wingless Clamp:
This type of clamps is placed on the tooth first, and the dam stretched around it.
‘W’ = Wingless.
‘A’ = Designed for partially erupted teeth.
‘D’ = Distal Extension
72
Commonly used R D Clamps:
As a General Role: For limited isolation, include one tooth posterior & 2 teeth anteriorly to the
operating tooth & bow must be distal to the tooth.
Heavy RD.
Facial placement of the hole.
Lingual jaw is 1st placed under cingulum then facial 0.5- 1 mm gingival to cervical line.
Clamp Ligature:
Ligature: An important safety step that makes it possible to retrieve a clamp should it accidentally
become dislodged and then inhaled or swallowed by the patient.
73
Anchors (other than retainers):
Waxed dental floss or tape (ligature) to anchor the anterior one or more teeth with short
clinical crown (no need to clamp).
Interproximal retainer (wooden wedge, small piece of RD, elastic cord Wedgets.
Low –fusing modeling compound, sometime used to secure the retainer to the tooth and
prevent its movement during operative procedure specially class V.
Anterior anchor interproximal retainers, while posterior anchors clamps.
Stabilizes and stretches the dam so it fits tightly around the teeth and out of the operator's
way.
Available in plastic and metal frames.
Young’s frame (U-shape metal frame).
Nygaard-Ostby plastic frame.
Woodbury plastic frame.
74
6. Rubber Dam Napkin:
7. Lubricant:
75
Revision:
3- The rubber dam materials used have different color according to:
a- Type of procedure.
b- Patient preference.
c- Dentist eye comfort.
d- Thickness needed.
76
Student Notes:
77
78
Management of Proximal Contacts
Objectives:
79
Management of proximal contacts
Definitions:
Proximal contact area: it denotes the area of proximal height of contour of mesial or distal
surface of the tooth that touches its adjacent tooth in the same arch.
Contour: the vertical curvature of the buccal (facial) and lingual surface.
According to the general shape of contours and contacts teeth can be divided into
three types:
1- Tapering type.
2- Square type.
3- Ovoid type.
Types of Contours:
1- Under contoured.
2- Over contoured.
3- Normal contour.
Matricing
80
Functions:
1- It serves as a temporary wall (or walls) of resistance during condensation of plastic restorative
materials. Necessary force of condensation can be applied safely against walls to produce
adaptation.
2- Establishes optimal contacts and contours to the restoration and prevents marginal over hangs.
3- It maintains restoration form until it hardens.
4- It keeps the gingival tissues and rubber dam away from the cavity margins during restoration.
5- It provides an acceptable surface texture for the restoration.
Parts of matrix:
1) Band:
A piece of metal or polymeric material used to support and give form to the restorative
material during its insertion and hardening.
Materials used are: Stainless steel – cellulose acetate [cellophane] – cellulose nitrate
[celluloid] – Polyacetate [Mylar].
Dimensions:
o Width = 3/6inch, 1/4inch, 5/16inch.
o Thickness = 0.001-0.002 inch.
81
2) Retainer:
This is a device by which the band be maintained in its designated position and shape, the
retainer may be a mechanical device, dental floss, a metal ring or impression compound.
Ivory no.1
This matrix consists of a stainless steel band which encircles one
proximal surface of the tooth.
Indications:
Ivory no. 8
This matrix consists of a band that encircles the entire crown
of the tooth.
Tofflemire matrix
Indications:
Advantages:
1- Ease of use.
2- Produces good contact and contour for most amalgam
restorations.
3- Rigid and stable.
82
Disadvantages:
1- Does not provide optimum contact and contour for posterior composite restorations.
2- Not useful for extensive class II restorations.
Assembly of Tofflemire:
Indications:
Advantages:
T-Band Matrix
This is a PREFORMED T SHAPED stainless steel matrix band without a retainer.
83
Precontoured Matrix
It consists of small, precontoured dead soft metal matrices ready for application to the tooth.
They are selected according to the tooth to be restored &wedged to adapt the gingival contour.
Following this the band is held in place by a flexible metal ring called Bitine ring.
Indications:
1- For class II cavities involving one or both proximal surface of a posterior tooth.
2- For both amalgam and composite restorations.
Advantages:
1- Ease of application.
2- The metal ring affords slight tooth separation.
3- Provide better proximal contours for posterior composite restorations.
Disadvantages:
Expensive.
Indications:
1- For badly broken down teeth especially those receiving pin-amalgam restorations.
2- For complex situation like class II cavities with large buccal or lingual extension.
Advantages:
84
Disadvantages:
Time consuming.
Auto Matrix
The auto matrix is a retainer-less matrix system.
Indications:
For complex amalgam restoration where one or more cusps are to be replaced.
Advantages:
1- Convenient to use.
2- Improves visibility due to lack of interference from a retainer.
3- Auto-lock loop can be positioned facially or lingually rapid application.
Disadvantages:
85
Transparent Cervical Matrix
These are commercially available transparent plastic crown forms.
They are available in various sizes &contours for anterior teeth.
A suitable crown form can be selected for the prepared tooth & trimmed to fit 1 mm past the
prepared margins.
Proximal Wedges:
Introduction:
Wedges: devices that create rapid separation during tooth preparation and restoration.
Made of wood.
Different types & sizes.
Wider base towards gingiva.
Customize.
Functions of wedges:
Types of wedges:
A. Wooden wedges:
Are made from soft wood like pine or hard wood like oak.
Usually preferred as they:
1- Are easy to trim.
2- Adapt well.
3- Absorb moisture and swell to provide adequate stabilization to the matrix band.
B. Plastic wedges.
C. Light transmitted wedges.
86
Special situation:
Contact location:
87
Hazards of faulty contact size and location
88
Revision:
1- A patient with 36 OD prepared amalgam cavity with a tight mesial contact, the best type of
matrix retainer to be used is:
a- Tofflemire matrix.
b- Ivory no. 1.
c- Ivory no. 8.
d- Automatrix.
3- The correct sequence of removing a Tofflemire system after finishing an amalgam restoration
is:
a- Wedge, retainer and then the band.
b- Wedge, the band and then retainer.
c- The retainer, the band and then the wedge.
d- The retainer and the band are removed as one piece, followed by the wedge.
e- Wedge first then retainer and the band are removed as one piece.
89
6- The slot of the Tofflemire head should be facing:
a- Occlusal direction.
b- Mesial direction.
c- Distal direction.
d- Gingival direction.
e- The opposite diagonal quadrant.
90
Student Notes:
91
92
Chapter 4: Dentist Posture & Patient Position
93
Dentist Posture & Patient Position
Balanced home operating position:
The inter-relation of the jointed segments of the body of the operator.
Position:
The way a person holds him/herself:
1- Upright- while standing or moving on the feet.
2- Seated- at work or at rest.
3- Supine- at rest.
Operating benefits:
1- Superior instrument control.
2- Increased accuracy.
3- Improved perception.
4- Superior concentration.
5- Fewer distractions.
6- Fewer operating decision during procedures.
7- Increased efficiency.
94
Operating posture:
1- Thighs parallel to the floor.
2- Feet flat on the floor.
3- Neck and back relatively straight.
4- Forearms parallel to the floor.
5- This result in an operating distance of roughly fourteen inches.
6- The lower visual eye fields should be used in an effort to offset the strain usually felt in the neck
when the head is continually tilted forward.
Patient position:
Total body support.
Patient should have direct access to the chair.
o Chair height should be low.
o Backrest should be upright.
o Armrest elevated to allow the patient to get into the chair.
The headrest cushion is positioned to support the head and elevate the chin slightly away from
the chest.
o In this position, neck muscle strain is minimal and swallowing is facilitated.
The most common patient positions are:
1- Supine position: patient head, neck, knee and feet are approximately on the same level.
2- Reclined 45 degrees.
Advantages of comfortable patient position:
1- Less muscular tension.
2- More capable of cooperating with the dentist.
95
General consideration:
When operating on maxillary teeth, maxillary occlusal surface should be directed perpendicular
to the floor.
When operating on mandibular teeth, mandibular occlusal surface should be directed 45
degrees to the floor.
The face of the operator should not come in close proximity to that of the patient.
The teeth being treated should be at the same level as the operator's elbow.
The operator should not hesitate to rotate the patient's head backward or forward or from side
to side to accommodate the demands of access and visibility without sacrificing the good
operating posture of the dentist.
Maintaining an appropriate working distance from the patient is important for the operator to
master.
Minimize body contact with the patient. The operator should not rest his forearms on the
patient.
The patient's chest should not be used as an instrument tray.
Instrument grasp:
Modified pen grasp:
1- The instrument is held with the same fingers as the pen grasp except that the pad of the middle
finger is placed on the top of the shank of the instrument with the index finger.
2- Provides more control and strength in some procedures.
3- Decrease operator fatigue.
4- It's used to hold instruments that have angled shanks.
96
Revision:
97
Student Notes:
98
99
Chapter 5: Cavity Preparations for Dental Amalgam
100
Class I Cavity Preparation for Amalgam
Objectives:
101
Class I Cavity Preparation for Amalgam
Indications:
Contraindication:
Esthetic areas.
Small to moderate cavities which can be well isolate.
Small class VI lesions.
Class III, IV and V in anterior teeth.
Characters of caries:
• It may be:
102
Clinical technique / tooth preparation: Outline form:
Outline form:
• Should include:
• Should be:
• Bucco – lingually:
Should not extend beyond the inter–cuspal line except if there is caries.
Minimal width of the cavity about 1/4 – 1/3 the inter–cuspal distance.
• Mesio – distally:
Should be extended midway between the triangular fossa and the crest of the marginal
ridge.
103
Resistance form:
Retention form:
Only against axial displacement, in the form of mechanical undercuts in dentin, by converging
the cavity walls.
Create walls that are parallel to each other, or slightly convergent in an occlusal direction.
Convenience form:
No need for convenience in class I cavity preparation as it is easily seen and instrumented.
The enamel wall should take the same direction of enamel rods without undermining.
CSA should be 90 degrees.
Buccal and lingual wall will be converging occlusally.
Mesial and distal will be diverged occlusally.
Remove all unsupported enamel rods.
Enamel rods forming CSA must be full length rods resting on sound dentin or shortened rods
resting on sound dentin and covered and supported by the restoration (Noy’s principles)
Place cavo-surface margins so that amalgam can be adequately carved and finished.
104
Features of prepared cavity:
Outline of the cavity is placed equidistant from the center of the groove.
Bucco-lingual width of 1.5 mm through central groove.
Bucco-lingual width of 1 mm through other extensions.
Pulpal floor is placed 1.5 mm from the enamel surface.
Pulpal floor is flat :
o Parallel to the occlusal plane of the tooth.
o Perpendicular to the long axis of the tooth.
Extremities of facial and lingual grooves and walls adjacent to mesial and distal marginal ridges
are prepared at 95 degrees to the pulpal floor, this results in a slight flare in these areas.
Cavity preparation:
105
2. Class 1 extension cavity:
Indications:
Resistance form:
Retention form:
Convenience form:
106
Finishing of enamel wall:
The mesial and distal walls of the extension will be completely parallel to each other and to
the long axis of the tooth.
The gingival floor will be slightly slanting gingivally to be in the same direction as the enamel
rods.
Note: class I extension can be: with step or without step (done in practical)
107
Revision:
1- The axio-pulpal line angle in class I facial cavity extension must be rounded, this is referred to
as:
a- Outline form.
b- Resistance form.
c- Retention form.
d- Convenience form.
e- Finishing enamel & dentin wall.
3- The mesial & distal walls in class I cavity preparation for amalgam must diverge occlusally to
satisfy:
a- Outline form.
b- Resistance form.
c- Retentive form.
d- Convenience form.
108
Student Notes:
109
110
Class V Cavity Preparation for Amalgam
Objectives:
111
Class V Cavity Preparation for Amalgam
Characters of caries:
Starts as white or chalky line near the center of the gingival third.
o (Persisting white chalk = CARIES, NOT INCIDEOUS!)
Marked sensitivity.
Tendency to spread mesially and distally near the axial line angles of the tooth.
Teeth with marked convexity are more susceptible.
Less frequent than other types of caries.
Usually affects multiple teeth.
More frequent among old aged patients and is called “senile caries”.
Outline form:
Usually described as trapezoidal outline, which may be modified by an added box extension to
involve proximal caries.
o (Class V has 4 point angles + 8 line angles)
Occlusal wall: Parallel to the occlusal plane and placed at or just occlusal to the height of
contour.
Gingival wall: Straight and parallel to the occlusal plane placed just beneath the gingival
margin.
Proximal walls: Straight and parallel to the direction of the corresponding proximal placed at
the line angles of the tooth.
Axial wall: 1 mm beyond the DEJ convex mesio-distally and straight occluso-gingivally.
Resistance form:
CSA 90°.
Bulk of restoration.
No need for additional resistance, as the force applied on this area is only the lip and cheek
musculature force.
112
Retention form:
Grooves in the occluso-axial and gingivo-axial line angles are placed in the expense of the
occlusal and gingival walls rather than the axial wall (axio-occlusal and axio-cervical line angles).
Convenience form:
CSA 90°.
Occlusal and gingival walls will be straight and parallel to the occlusal plane.
Proximal walls will be slightly diverging outwards to follow the enamel rods.
1- Access to dentin is gained by a round bur, then the cavity outline is extended using an inverted
cone bur to a trapezoidal shape of a width just enough to include the lesion.
2- The walls are flared and finished parallel to the enamel rods with a fissure bur. The floor is
made convex in all directions following the pulpal anatomy by an inverted cone.
3- An inverted cone bur is used to place incisal and gingival retentive grooves in dentin at the
pulpal line angles and below the DEJ.
113
Revision:
2- In class V cavities for amalgam, the axial wall must be convex mesio-distally so as to:
a- Remove all caries.
b- Receive equal thickness of amalgam.
c- Give means of retention.
d- Avoid undermining enamel.
e- Provide 95 degrees of cavo-surface margin.
114
Student Notes:
115
116
Class II Cavity Preparation for Amalgam
Objectives:
117
Class II Cavity Preparation for Amalgam
Definition:
It is a smooth surface cavity that occurs in the proximal surface of the posterior teeth.
1- Class II simple cavity (adjacent tooth is missing or there is a space between adjacent tooth).
2- Class II compound or complex cavity with proximal step.
3- Class II compound or complex cavity without proximal step (3rd molars distal surface).
It is composed of 3 portions:
1. Occlusal portion.
2. Isthmus portion.
3. Proximal portion.
118
A) Outline form:
1- Occlusal portion:
2- Isthmus portion:
- Definition:
The narrowest connection between the occlusal and proximal portions of class II compound
or complex cavity.
- According to:
The occlusal anatomy of the tooth.
Position and size of the proximal contact area.
Width of the embrasure.
- The isthmus outline form may follow one of the following Ingrham’s lines:
Straight: in case of small contact area.
Uniform: in case of normal sized contact area.
Reverse curve: in case of broad or wide contact area.
The width of the cavity at isthmus should be narrow bucco lingually as much as possible
about ¼ of the inter-cuspal distance.
119
3- proximal portion:
120
B) Resistance form:
1- Occlusal portion:
2- Isthmus portion:
3- Proximal portion:
Reverse curve approach in the buccal wall of upper premolars to remove all the
undermined enamel.
CSA 90°.
Gingival floor smooth, flat and parallel to the pulpal floor and the occlusal plane.
Axial wall parallel to the external proximal tooth surface and at 1.5 -2 mm away from the
DEJ, this will provide uniform bulk of the restoration.
Buccal and lingual walls parallel to the direction of the corresponding surfaces.
The proximal portion is in box form.
121
C) Retention form:
• Axial retention:
1- Mechanical under cuts by preparing the cavity walls slightly converging occlusally.
2- The inverted truncated cone shape of the proximal portion.
3- Proximal axial grooves.
4- Pin retention in extensive cavities placed in the gingival floor.
• Lateral retention:
1- Proximal dovetail:
In premolars, considered as extension for retention.
In molars, considered as extension for prevention that provides retention also.
2- Occlusal lock.
3- Proximal axial grooves.
4- Pin retention in extensive cavities.
- Convenience form:
Cutting an occlusal cavity is considered as a convenience form as it provides accessibility
to the proximal portion.
Accentuation of cavity walls and margins.
Roundation of line angles.
The axial wall should be parallel to the tooth long axis in occluso-gingival direction to
allow instrumentation up to the depth of the proximal portion.
Selection of suitable sized instruments.
122
D) Finishing of enamel wall:
1- Occlusal portion:
2- Isthmus portion:
3- Proximal portion:
The buccal and lingual walls are flared slightly outward to get CSA = 90°.
The gingival floor is slanted slightly gingivally to get CSA = 90°.
Reverse curve approach:
o In the buccal wall of the proximal portion of the upper premolars, after performing
reverse curve outline of the isthmus portion, the enamel of the buccal wall will be
undermined.
Beveling of the enamel of this buccal wall will provide:
a- Removal of all undermined enamel.
b- CSA = 90°.
Bin-angle chisel or enamel hatchet are the instruments used for this purpose.
Gingival marginal trimmer to trim the gingival wall.
Clinical considerations:
1- It is preferable to complete the proximal outline before breaking the marginal ridge and the
proximal enamel plate. This will provide:
a- A guide to proximal design.
b- Protection of the proximal surface of the adjacent tooth from rotary instrument.
c- Save time and effort.
d- Reduce heat generation as cutting in enamel produces much more heat generation.
123
2- The reverse curve outline will be followed in the buccal wall more than the lingual as the
contact area is much more shifted buccally, the reverse curve may provide:
a- Enamel wall in the direction of the enamel rods.
b- CSA = 90°.
c- Freeing of the contact area with maximum conservation of the tooth structure.
d- Increased bulk of the restoration which may provide lateral retention.
3- In large cavities, whenever a cusp is undermined or becomes weak it must be reduced and
covered with a minimum of 2mm thickness of the restoration and this is called cusp tipping or
cusp reduction. This is common in occluso-distal cavities in the lower first molars where the
distal cusp is easily weakened.
124
Revision:
1- In order to prevent isthmus fracture of dental amalgam restorations, the following line angle/s
should be rounded:
a- Axio-pulpal line angles.
b- Axio-gingival line angles.
c- Axio-pulpal & Axio-gingival line angles.
d- Axio-mesial line angles.
2- A patient has caries lesion occurred only in the mesial surface of his tooth #27, while his #26
was extracted. The prepared class II cavity preparation on this tooth is supposed to be:
a- Simple class II cavity preparation.
b- Compound class II cavity preparation.
c- Compound class II cavity preparation with facial extension.
d- Compound class II cavity preparation with lingual extension.
4- To achieve a proper resistance form, the gingival floor of class II cavities for amalgam should be
prepared:
a- Following the direction of enamel rods.
b- Parallel to the pulpal floor.
c- With flat dentinal floor and gingivally trimmed enamel floor.
d- With flat enamel floor and trimmed dentinal floor.
5- When restoring compound class II cavities, dental amalgam should be placed first in the:
a- Deepest areas in the proximal part.
b- Occlusal part.
c- Lateral walls.
d- Axial walls.
125
6- Optimum uniform depth of pulpal floor in class II cavity for amalgam is necessary to prevent:
a- Undermining of enamel.
b- Fracture of the tooth structure.
c- Fracture of the amalgam restoration.
d- Displacement of the amalgam restoration.
e- Pulpal involvement.
7- In class II cavity preparation for amalgam, axial grooves are made to prevent:
a- Gingival displacement.
b- Gingiva pulpal displacement.
c- Lateral displacement.
126
Student Notes:
127
128
Chapter 6: Direct Restorative Materials
129
Amalgam
Objectives:
130
AMALGAM
Definitions:
Dental Amalgam: mixing of mercury with solid particles of an amalgam alloy powder
(powder of Silver, Tin, Copper, Zinc, Palladium, Indium and Selenium.
Basic composition:
131
o S.expansion.
3- Copper (Cu): 0-30% by weight.
Increases:
o Strength.
o Hardness.
Decreases:
o Corrosion.
o Creep.
3. Additives:
1- Zinc (Zn): 0- 2%
Scavenger of oxides during manufacturing.
Provides better clinical performance.
Less marginal breakdown.
If contaminated with moisture during condensation:
o H2O + Zn = ZnO + H2
o Patient suffers from pain.
o Restoration deterioration.
o Roughness of the surface due to ditches and blisters.
132
3- palladium (Pd): 0.5 %
Increases luster.
Decreases corrosion.
INCREASE DECREASE
STRENGTH SILVER, COPPER, INDIUM TIN
CREEP SILVER, COPPER, INDIUM
SETTING TIME TIN SILVER
S. EXPANSION SILVER TIN
TARNISH SILVER
CORROSION TIN COPPER, PALLADIUM
HARDNESS COPPER
INCREASE DECREASE
SILVER STRENGTH, S.EXPANSION CREEP, SETTING TIME, TARNISH
COPPER STRENGTH, HARDNESS CREEP, CORROSION
TIN SETTING TIME, CORROSION STRENGTH, S.EXPANSION
CREEP, SURFACE TENSION, AMOUNT OF
INDIUM STRENGTH, AFFINITY TO Hg,
MERCURY, EMITTED MERCURY VAPOR
PALLADIUM LUSTER CORROSION
Amalgamation reaction:
The matrix holds the remaining un-reacted particles together as a coherent mass.
133
Symbols of phases:
1- Ɣ = Ag3Sn
2- Ɣ1 = Ag2Hg3
3- Ɣ2 = Sn8Hg
4- ε = Cu3Sn
5- η = Cu6Sn5
6- Different composition = AgCu
7- A silver-mercury containing filler particles of silver-tin.
8- Filler : Ag3Sn called gamma
9- Matrix:
Ag2Hg3 called gamma 1.
Cement.
Sn8Hg called gamma 2.
Copper Content:
Zinc containing:
Particle Shape:
Lathe cut:
Low Cu.
High Cu.
Irregular particles.
134
Spherical:
Low Cu.
High Cu.
Spheres particles.
Admixed:
Particle size:
Regular.
Fine.
Micro-fine.
Physical properties:
135
Dimensional change:
Mechanical properties:
Strength:
Creep:
Clinically: margins over extended from the cavity which lead to the restoration breakage.
Creep leads to:
1- Marginal breakdown.
2- Gingival overhangs: (by improper placement or creep) leads to food accumulation
caries.
3- Alteration of form & contours.
Tarnish:
136
Corrosion:
Advantages of amalgam:
High copper with high creep resistance can maintain proper anatomy, proximal contact
form and contour.
137
Disadvantages of amalgam:
Applications:
Selection of alloy:
Particle size:
Particle shape:
138
Spherical requires less Hg because it has less surface area.
• Lathe cut:
• Spherical:
- Advantages:
Hardens rapidly.
Needs lighter condensation.
Smoother polish.
Higher early strength.
- Disadvantages:
Difficult to achieve tight contacts.
Higher tendency for overhangs.
- Indication:
Pulp capping.
Pin retained restoration.
Multiple retentive means.
• Admixed:
- Advantages:
Easy to achieve tight contacts.
Ease of attaining contours and forms.
Good polish.
- Disadvantages:
Hardens slowly.
Lower early strength.
- Indication:
Large restoration to build up proper contour and contacts.
Cases which require recontouring.
Zinc + water = delayed excessive expansion pulpal pain in 3-7 days.
139
o Zinc free is used in cases with difficult moisture control (e.g. children)
because zinc + moist will cause excessive delayed expansion.
Capsules:
Several smaller mixes would be made at spread out times so the consistency of the mixed
amalgam remains reasonably constant during the preparation of the restoration.
Aims:
1- Select the proper amount of mix required to fill the cavity depending on:
Size of the cavity, which must be slightly overfilled.
The amount which could be condensed in 3-5 minutes.
2- To select the proper amount of Hg required to wet every alloy particle without affecting the
final properties of amalgam restoration.
Excessive Hg:
Excessive expansion.
Drastic loss of strength.
Increased creep.
Increased tarnish and corrosion.
140
Insufficient Hg:
Aims:
Aims:
141
To increase the homogenicity and plasticity of the mix ( mulling )
Technique:
1- Squeezing:
2- Mulling:
condensation of amalgam:
Procedure of packing of the freshly triturated amalgam into the prepared cavity through
homogenous manner.
Aims:
142
Pre-carving burnishing:
Using large sized burnishers with heavy pressure directed from the tooth to the restoration.
It provides the followings:
1- Increased adaptation of amalgam to cavity walls and margins.
2- During this, some frictional heat is generated which helps the excess Hg to be attracted to
the surface and easily removed with carving.
3- More cohesive amalgam.
4- Establishment of initial anatomy to be continued by carving.
Carving:
Post-carving burnishing:
Small sized burnishers with gentle strokes are used to smoothen the amalgam surface.
143
Checking of occlusion right after putting the amalgam polishing after 24 hours.
144
Revision:
1- Cavo-surface angle of amalgam cavities should be made 90 degrees because amalgam has:
a- Low compressive strength.
b- Low tensile strength.
c- Tendency to flow.
d- Tendency to creep.
5- An 18-year old patient came to the clinic with a deep class I carious lesion. Pulp capping was
required after caries excavation. Which one of the following is the best to be used:
a- High copper lathe-cut amalgam.
b- High copper spherical amalgam.
c- High copper admixed amalgam.
d- Low copper spherical amalgam.
145
6- Varnish should be used to improve the initial adaptation of amalgam. However, amalgam
adaptation improves with time due to creep.
a- First statement is TRUE, the second is FALSE.
b- First statement is FALSE, the second is TRUE.
c- Both statements are TRUE.
d- Both statements are FALSE.
8- After 4 days of placing Zn-containing amalgam in a sub-gingivally extended class II cavity, the
patient complained of pulpal pain. This is may be due to:
a- Premature contact.
b- Delayed expansion.
c- Galvanism.
d- Creep.
10- In a large amalgam restoration that requires proper contouring, which of the following should
be used:
a- Conventional spherical amalgam.
b- High copper admix amalgam.
c- High copper spherical amalgam.
d- Conventional lathe cut amalgam.
146
11- Admixed amalgam has the properties of fast hardening and attaining higher early strength. On
the other hand, spherical amalgam has properties of slow hardening and lower early strength.
a- First statement is TRUE, the second is FALSE.
b- First statement is FALSE, the second is TRUE.
c- Both statements are TRUE.
d- Both statements are FALSE.
12- In order to reduce setting time without greatly affecting the amalgam properties, it is advisable
to:
a- Increase the trituration time.
b- Decrease the trituration time.
c- Increase the Hg/powder ration.
d- Decrease the Hg/powder ratio.
147
17- Excessive delayed expansion occurs into zinc containing amalgam due to:
a- Contamination with saliva during insertion.
b- Contamination with saliva during carving
c- Contamination with saliva during checking of occlusion.
d- Contamination with humidity during storage.
18- An overextended cavity with many retentive means prepared to be restored with amalgam,
which of the following is the best to be selected:
a- High copper lathe-cut amalgam.
b- Low copper spherical amalgam.
c- High copper admixed amalgam.
d- High copper spherical amalgam.
19- In amalgam restoration, the angle between the cavity and the tooth surface is:
a- 90°.
b- Obtuse.
c- Acute.
20- Depth of amalgam cavities should be extended just below the DEJ in order to:
a- Remove all under mind enamel.
b- Give bulk to the restoration.
c- Place the restoration in dentin.
d- Get benefit from the gripping action of dentin.
148
Student Notes:
149
150
Finishing & Polishing of Amalgam Restorations
Objectives:
151
Finishing & Polishing of Amalgam Restorations
Burnishing:
a. It is the rubbing of the amalgam surface with a blunt instrument immediately after carving to
smooth the surface.
b. It improves margin adaptation and facilitate later finishing and polishing.
c. Types: Pre-carving & Post-carving burnishing.
1. It improves stress response of the restoration by elimination of surface roughness that causes
stress-concentration.
2. It increases corrosion resistance by increasing surface homogeneity and elimination of surface
dissimilarities that create galvanic cells.
3. It improves biocompatibility with soft tissues through provision of smooth surfaces that inhibit
plaque accumulation and preclude mechanical irritation.
4. It inhibits colonization of bacterial plaque and decreases vulnerability to caries recurrence.
5. It confers better esthetics and patient’s acceptance and thus, encourage better home-care.
The most commonly used rotary instruments are abrasive stone, disks and finishing burs.
The choice of abrasive stones, disks, and burs is dependent upon the size of the restoration,
the adaptability to the tooth surface, and the amount of amalgam to be removed.
152
Finishing:
Use small green & white stones for gross removal of excess amalgam and for dressing down
amalgam margins to remove all marginal excesses, or "flashs“.
Use finishing burs to refine the anatomy and contours of the occlusal surface and marginal
ridge areas.
Green Stones:
Finishing Disks:
153
Finishing Burs:
Polishing Agents:
Pumice and tin oxide are two commonly used polishing agents.
Other polishing agents are available in the form of abrasive-impregnated rubber points and
cups. They are to be used in the following order: Brownies, Greenies, and Super Greenies.
Note:
Brownies (coarse) and greenies (fine) are rubber abrasives points that can be used during the
finishing procedure.
If used, they should follow the use of finishing burs.
Be cautious during manipulation of these rubber points.
These popular silicone polishers are impregnated with high-quality polishing ingredients for
fast, brilliant polishing on precious metals and amalgam.
Polishing:
During polishing, use a wet slurry of polishing abrasives (pumice). The only abrasive
recommended for dry polishing is amalgloss (or tin oxide).
Rotate rotary instruments parallel to amalgam/tooth margins or from tooth structure to
amalgam.
Polishing abrasives should be used as needed in the following order: coarse pumice, fine
pumice, tin oxide (amalgloss).
154
Important Hints:
155
Amalgam Polishing Procedures:
This section will introduce one technique for polishing amalgam restorations. Each operator has
her/his own favorite equipment and technique for most effectively polishing amalgam restorations.
A step-by-step approach is offered so that the student may first become competent with this
method, and may then develop her/his own particular technique through practice activities. The
following armamentarium is needed for this procedure.
Step 3: Isolate
The primary objective of amalgam polishing is to achieve smooth, flush cavo-surface margins
which will resist plaque accumulation and contribute to the health of the tooth and surrounding
soft tissues. The margins can be smoothed easily by using a round bur. Choose #4 or #6 round
finishing bur—whichever will best fit the area you are working on. Place the side of the bur
against both amalgam and tooth surface. Use medium speed and light pressure to prevent
excessive reduction of the amalgam or cutting away tooth structure. Move the bur along all
cavo-surface margins. This procedure is not designed to reshape, rather it is to assure that the
blend of tooth structure to amalgam is perfect. Run the tip of an explorer back and forth across
the margins to ascertain if they are smooth and flush.
Further smoothing of the amalgam surface is accomplished with the use of a large round
finishing bur. Again, choose #4 or #6, whichever best fits the area you are working on. This step
is often times completed in conjunction with step 7. If marginal discrepancies are minimal, it is
possible to smooth the broad occlusal surfaces and marginal ridges while working on the cavo-
surface margins. Smooth the entire occlusal surface and marginal ridges, using the side of the
finishing bur.
Use light pressure and moderate speed as you move the bur back and forth across all surfaces.
156
Step 6: Smooth Proximal Cavo-surface Margins and Surface
Check the restoration frequently with the explorer to evaluate the integrity of the margins and
to determine the smoothness/roughness of the polished surface.
Smooth convex facial and lingual surfaces with finishing desks. Adapt the edge of the disk to
the margin of the restoration and, using a light sweeping stroke, move the disk toward the
occlusal surface of the tooth. Smooth the amalgam with a less abrasive (fine) disk. When a
concave area is involved, such as near the buccal or lingual grooves, use a finishing bur to
smooth the area.
The polishing phase consists of first removing the very light scratches remaining after use of the
finishing burs. It is achieved by using progressively finer abrasive agents and can be
accomplished by the use of a couple of different methods—or a combination of the two
methods:
Flour of pumice is mixed with water to form slurry. It is applied to all surfaces with a rubber
cup. Use fairly light pressure and sweeping strokes, adapting the cup to marginal ridges and
as far inter-proximally as possible. Replenish the moist pumice often since the pumice
should do the polishing—not the rubber cup. Rinse and evacuate all pumice from the area.
The amalgam should have a smooth, satin finish (dull luster). If deep scratches and
irregularities are present, return to the appropriate finishing bur.
Tin oxide may be used in a wet slurry or dry. It is applied in the same manner as the pumice.
If you do not change rubber cups after applying the pumice, be certain to wash the pumice
out of the cup to remove the coarser pumice particles before applying the tin oxide. Use a
light buffing motion and a slightly higher speed with the handpiece to create a shiny,
mirror-like finish.
157
B. Abrasive Points:
Adapt the Brownie abrasive point into the concavities of the occlusal surface and rest the
side of the cavo-surface margin. Using light pressure and low speed move the point over all
areas of the amalgam that is accessible. As with pumice, the surface should be a dull luster
after use of the brownie.
Using the same technique as described for the Brownie, use the Greenie. The surface will
become much shinier, but will not yet have a mirror-like finish. Repeat above steps using
the Super-greenie. It is the least abrasive of the three points (equivalent to tin oxide), and
it use should result in a mirror-like shine on the surface of the amalgam.
Rinse and evacuate all debris completely. Floss the interproximal surface with clean dental
floss just as though you were removing plaque from the area to help remove any remaining
abrasive from the interproximal space.
Evaluate all margins and surfaces of the restoration with the tip of explorer
Remove the rubber dam or cotton rolls and recheck the occlusion with articulating paper.
Standard Summary:
158
159
Revision:
2- Mulling of the dental amalgam mix can be done by rubbing of the mix against a piece of:
a- Cotton.
b- Rubber.
c- Gauze.
d- Cloth.
3- The operators choice for stones, disks or burs for finishing of amalgam restoration is dependent
upon:
a- Patient preference & cooperation.
b- Time elapsed after insertion of amalgam restoration.
c- Number of restorations need to be finished & polished per visit.
d- Size, location and adaptation of amalgam restoration.
160
Student Notes:
161
162
Amalgam Safety & Mercury Hazards
Objectives:
163
Amalgam Safety & Mercury Hazards
Mercury:
Mercury Uses:
Thermometers.
Electric Switches.
Fluorescent Lamps.
Batteries.
Insecticides.
Rat poisons.
Disinfectants.
Dental Amalgam.
164
Forms of Mercury:
Metallic - Hg - Stable/Unreactive
Ionic - Hg+ - Reactive/Not a HazMat
Salts - HgCl - Mercuric Chloride
Compounds - Amalgam
Methyl Hg - Reacted Toxic Form/Poison
Vapor - Detectable
Scientific Facts:
N.B: Once the amalgamation reaction is completed, only extremely minute levels of mercury can be
released and those are far below the current health standard.
165
Historical Issues:
First Amalgam War 1985 Huggins DDS “It’s All In Your Head”
1990 60 minutes Program “Poison In Your Mouth”
Anti-amalgamists
Anti-amalgam Claims:
Neurotoxicity.
Renal Dysfunction.
Birth Defects.
Arthritis.
Multiple Sclerosis.
Chronic Fatigue.
Etc, Etc, Etc...
Candida Infection.
Hodgkin’s Disease.
Mononucleosis.
Depression.
Ulcers.
Epilepsy.
Etc, Etc, Etc...
Sensitization (hypersensitivity)
Mercurialism (Symptoms)
166
Symptoms of Mercury Toxicity:
Insomnia
Physical weakness
Irritability
Loss of memory
Impaired vision
Nervous excitability
Headaches
Depression
Pregnant women: Mercury effects
Speech disorders
development of fetal brain and lead to:
Muscular tremors 1- Lowered intelligence.
2- Impaired hearing
Dental amalgam safety: 3- Impaired coordination.
It is known that mercury can cross the placenta form mother to fetus and can also be
detected in breast milk but this does not mean amalgam filling should be avoided
during pregnancy or breast feeding. There is no evidence of any link between
amalgam and mercury poisoning in infants and fetuses.
Threshold Limit Value ( TLV ) for Mercury Vapor is 0.05 mg (50 µg/m3):
(Very Important)
This concentration of mercury vapor represents the maximum level of mercury vapor in which a
person can work for 40 h/week without demonstrable health risks.
Mercury Toxicity:
Although the hazard is present, there have been NO REPORTS OF MERCURY VAPOR TOXICITY IN
DENTAL OPERATORIES
167
Factors Affecting Mercury Leakage of Amalgam Capsules: (Very Important)
Winding adhesive plaster around Capsule trituration inspection of the sticky surface of the
plaster for mercury droplets.
Materials:
a- CadiumSulphide.
b- Palladium Chloride.
c- Gold film.
168
Evaluation of Mercury Exposure Levels:
In biological fluids:
1- Gold Foil.
2- Gallium.
3- Thermite Glass Ionomer (silver reinforced glass Ionomer).
Shouldn’t I?
Many people want to replace their silver fillings because they have heard that there is
medical risk from the mercury in the silver fillings.
There are no clinical studies to prove that there is any risk in having a silver filling, so this
should not be a reason for their replacement.
Ethics:
Unless new and compelling evidence is presented to the contrary, dentists cannot
ethically tell patients that dental amalgam is a health hazard or that removal of amalgam
restorations will benefit their health.
When clinical research demonstrates that tooth-colored restoratives are as economical
and effective in the long-term as dental amalgam, switch.
169
Dental Mercury Hygiene Recommendations (ADA):
Conclusions:
Amalgam Restrictions:
170
Revision:
6- The most probable way of inhalation mercury in the dental office is:
a- During condensation.
7- One of the future concerns that might discourage the use of amalgam is:
a- Environmental concerns.
171
Student Notes:
172
173
Cavity Sealers, Liners & Bases
Objectives:
174
Cavity Sealers, Liners & Bases
Definitions:
Cavity sealer: Seals all of the cavity preparation, acts as a barrier to leakage.
Cavity liners: A cement or resin coating of minimal thickness(less than 0.5mm), acts as a
physical barrier.
Cavity bases: Materials used to replace missing dentin, used for bulk build-up, acts as a
thermal barrier.
Cavity sealers: Provide a protective coating for freshly cut tooth structure of the cavity
preparation. E.g.
o Varnishes.
o Adhesive sealers.
Cavity Sealers:
Varnishes:
Copal varnish.
Apply just before amalgam.
Apply with cotton pellet.
2 thin layers.
Air dry between layers.
Will provide a short-term seal, corrosion of amalgam (gamma 2 phase) will then form a seal.
Adhesive sealers:
Acid etch 15 seconds, rinse, leave tooth slightly wet, apply bond resin, air dry, apply 2nd
coat, air dry, light cure 10-20 seconds.
175
Cavity liners:
A liner is a material applied to dentin to act as a barrier against irritation from the final
restorative material and/or the effects of acid etching. A liner is approximately 0.5mm thick.
Liners are placed with minimal thickness, usually less than 0.5mm, provide a seal, adhesion to
tooth structure and antibacterial action. E.g.
o Calcium hydroxide.
o Glass Ionomer.
Calcium hydroxide:
Mix equal amounts of catalyst and base, apply sparingly with applicator, (self-cures in 2-3
minutes), cover with G.I.
Glass Ionomer:
Mix liquid and powder to give a “Dycal-like” consistency, apply with applicator, light cure 20
seconds.
Always follow the manufactures instructions. With glass Ionomer cements you may vary the
powder/liquid ratio slightly with significantly altering the physical properties.
With GI mix the powder and liquid all at once, not in gradual amounts.
Calcium hydroxide is very weak and dissolves over time so use just enough to cover a direct
exposure then cover the calcium hydroxide with a layer of glass Ionomer to protect it and
seal it in place.
Chemical-cured calcium hydroxide takes about 5 minutes to set in the mouth.
176
Cavity bases:
• G.I: Mix according to manufacturer’s instruction and pack in place or apply in a number of
thin layers curing each layer.
When mixing Zoe you will find that the liquid will absorb a large volume of powder. Mix
enough powder into the liquid to produce a consistency that may be rolled into a ball but
still be moist enough to stick to the tooth surface to provide a good seal.
Zoe is an excellent short-term temporary restorative material as it sedates the pulp as well
as providing a good seal.
To place the ZOE in the tooth preparation, dip your plugger in dry zinc powder to prevent
the slightly sticky mix from sticking to the instrument. You will have to do this often during
placement.
When mixing light-cured Ionomer cement dispense the recommended amount of
powder/liquid and mix all the powder into the liquid at once. If the mix is a little too thick to
apply with a Dycal applicator you may mix a small amount of excess liquid to give it the
desired consistency. Just remember the thinner the mix the weaker it is.
177
Approximate thickness of liners and bases:
E/D: 0.0015-0.0022
Zoe: 0.001
ZnPh: 0.003 NOTES:
Resins: 0.005-0.0008 The difference between Liners
Amalgam:0.04-0.06 & bases is the thickness of the
Gold: 0.75-1.10 material not the material.
It is better to over-fill rather
Liners and bases compressive strength: than under-fill the cavity as
you can remove excess
G.I: 20,000 psi + cement easily with a bur or
ZnPh: 17,000 psi diamond point.
PCA :10,000 psi
ZOE: 2,000 psi
Ca(OH): 500-1500 psi
Strong. NOTES
Fluoride releasing. When using cement as a base,
Relatively kind to the pulp. make sure you leave enough
Adheres to dentin. depth for a strong restoration.
Good thermal protection. G.I. is next to impossible to
Chemical and light-cured. remove, Polycarboxylate
Easy to handle. cement chips off easily.
178
Guidelines for basing, lining & sealing:
179
Revision:
2- The best liner used if the Dentin is less than 1.5 mm is:
a- Glass Ionomer or CaOH.
180
Student Notes:
181
182
Temporary (Provisional) Restorations
Objectives:
183
Temporary (Provisional) Restorations
Definition:
It is a short term restoration designed to replace the missing portion(s) of the tooth structure till
arrangement for placement of the final (permanent) restoration.
184
Rampant Caries:
Advantages:
Disadvantages:
185
Requirements of ideal temporary restoration: (Important)
A- Indirect technique.
B- Direct technique.
A- Indirect technique:
• Advantages: (Important)
1- Better marginal accuracy than the direct technique, less pulpal irritation, good oral hygiene
& good periodontal health.
2- Better visibility & accessibility to block and correct the undercuts on prepared & adjacent
teeth.
3- Avoid possibility for irritation from acrylic resin monomer.
4- Checking & adjustment of the preparation before final restoration (or impression?)
186
• Technique of fabrication:
1- Preoperative alginate impression after filling of large defects with utility wax.
One or two teeth = Quadrant impression.
More than two teeth = full arch impression.
o Keep the impression aside after wrapping in a wet paper towel.
2- Post-operative alginate impression is taken & poured in fast-set plaster.
3- Block the voids with utility wax & remove positive blebs with sharp knife if present!
4- Remove undercuts at gingival & soft tissue areas.
5- Try the plaster cast in the pre-operative impression.
6- Mix the tooth colored AR following the manufacturer instructions.
7- Pour the AR at the preparation area at the impression.
8- Seat the plaster cast in the impression.
9- Wrap the impression & cast with rubber band to avoid distortion & let it set in warm water.
10- With suitable bur (no. 271) or acrylic stone, trim any excess AR and Try the temporary on
the cast.
11- Try it on the tooth at the patient mouth, make the fine adjustment &occlusal correction
then finish & polish it!
12- Keep it aside for cementation with temporary cement after final impression is taken.
B- Direct technique:
• Advantages: (Important)
1- Quick.
2- Less steps & materials required.
• Disadvantages: (Important)
187
• Technique of fabrication:
188
Revision:
189
Student notes:
190
191
Glass Ionomer Restorations
Objectives:
192
Glass Ionomer Restorations
Definition:
Glass Ionomer: “glass” refers to the glassy ceramic particles and the glassy matrix (non-crystalline)
of the set material, while “Ionomer” refers to ion-cross linked polymer.
History of Development:
United Kingdom
Poor esthetics.
Rough surface.
Prolonged setting reaction.
Poor wear resistance.
Vulnerable to hydration extremes.
Handling difficulties.
193
Modifications:
Refined formulation:
o Addition of Tartaric acid.
o More reactive acids.
Improved packing.
Metal modification.
Addition to resin.
Advantages:
Disadvantages:
194
Indications:
Direct restorative:
o Class V.
o Root caries.
o Class III.
o Pediatric dentistry.
Resin modified version
o Tunnel preparations.
o Atraumatic restorative treatment (ART).
Luting agents.
Liners.
Caries control.
Core block-out.
Occlusal sealant.
Contraindications:
Physical properties:
195
Chemical composition:
A- Powder:
o These powders are combined and fused at a temperature 1100- 1500°C for 2 hours
in the presence of fluoride as flux to reduce their fusion temperature.
o The molten gas is poured on steel tray to fragment it.
o The fragments are crushed, milled and powdered in particle size range 20 –50
microns.
o For cementation purpose, a particle size of 13 – 19 micron is optimal.
B- Liquid:
1- itaconic acid:
196
2- polymeric acid:
3- Tartaric acid:
C- Water:
• Water gain:
• Water loss:
1- Surface micro-cracks.
2- Increase opacity.
3- Increase staining and micro-leakage.
4- Poor esthetics.
5- Weakened restoration.
197
Classification according to compositional forms:
A- Water mixed:
• Benefits:
C- combination:
A- Type I (luting):
198
B- Type II (restorative):
I. Lining:
199
Setting reaction:
Three phases:
Ion-Leaching phase.
Polysalt-Gel phase.
Hydrogel.
Material-Related Variables:
A. Fluoride release.
B. Adhesion.
C. Biocompatibility.
D. Optical properties.
Re-charging strategies:
200
Properties:
Adhesion: is the force that causes unlike materials to adhere to each other.
o A full 80% of the ultimate bond strength of the GIC to tooth structure develops within
the first 15 minutes following placement.
o GIC chemically bonds to enamel and to a lesser extent to dentine and cementum.
o GI, inter-diffuse to dentin and establish a micromechanical bond with collagen fibrils
following hybridization principle.
o Chemical bonding by ionic interaction of carboxyl groups of polyalkenoic acid from GI
with Ca of hydroxyapatite.
o Adhesion is initiated by the polyalkenoic acid when freshly mixed material contacts
tooth surface.
o Phosphate ions are displaced from appetite by carboxyl groups.
o Each phosphate ion takes Ca ion with it to retain electrical neutrality.
o An ion enriched layer firmly attached to the tooth structures is formed & called (Ca-
phosphate polyalkenoic crystalline structure)
Biocompatibility:
All soft tissues have a favorable response to GI, It is resistant to plaque. Bacterial plaques
(especially mutans streptococcus) fail to survive on the surface of GI due to the presence of
fluoride. It is biocompatible with tooth tissues, although it is acid containing, because:
1- Its acids are weak and have high molecular weight, so has less diffusion through dentinal
tubules to the pulp.
2- It has minimum temperature rise compared to other materials.
3- It is ion exchange adhesion that prevents micro-leakage and so it is valuable in isolation
of active carious lesions.
In case of deep preparation, CaOH is applied to the area next to the pulp before GI
application because of the low surface PH of traditional GI in the first 60 minutes of setting.
201
Post-Operative Sensitivity (Luting cements):
Optical Properties:
Most GI is more radio-opaque than dentin and several GI are more radio-opaque than
enamel in its insertion but its radio-opacity decrease after a period of time due to solubility.
Early GI was extremely radio-opaque because of their higher fluoride content which was
necessary to improve their handling properties.
Translucency generally improves over the first 24 hours but does not reach a maximum until
at least a week after placement of GIC restoration.
Most opinions consider GIC sensitive to moisture during the first 24 hours (till the formation
of stable less soluble Al Polycarboxylate).
Others recommend that GIC is protected from moisture for the 10-30 minutes after initial
placement.
Early contamination prevents Ca & Al ions from leaching out of the aqueous cement phase
and are prevented from forming Polycarboxylates, this causes the matrix to turn chalky &
erode easily to produce a rough surface& decrease surface hardness.
Cavity design:
202
Manipulation:
The mixed material should be transferred to disposable syringe for positive placement in
the cavity.
Placement technique:
1- The cavity is conditioned by acid 10% for 10 seconds then Polyacrylic dried without
dehydration and washed, isolated.
2- The restoration is then hand mixed or mechanical mixed.
3- Place restoration into the depth of the cavity first and continue expelling it while
withdrawing the syringe.
4- Apply the matrix for final positive placement.
5- Allow the restoration to set.
6- Remove the matrix and cover the restoration with a layer of sealant which may be light
cured bonding agent or 2 layers of cavity varnish.
7- Trim the excess restoration while the sealant is still liquid by a sharp blade or by slowly
rotating the bur in a direction from the restoration to the tooth.
8- If the sealant is disturbed during contouring then apply a second layer.
9- Trim any excess sealant.
10- Contouring & polishing is done after 24 hours under air / water spray with fine diamond in
the beginning then aluminum oxide discs for finishing.
203
Metal Reinforced Glass Ionomer:
On the expense of amount, fluoride release & bond strength to tooth structure.
1- Silver alloy admix: in which silver amalgam alloy is mixed with type II GI powder.
Composition:
A- Powder:
B- Liquid:
C- And / or water.
204
Matrixes:
1- Acid-Base Matrix: mixing the powder and liquid initiates the acid-base reaction of
conventional glass Ionomer that hardens and strengthens the formed matrix (responsible
for fluoride release and bonds with tooth structure).
Types of cure:
205
Compomers:
Setting reaction:
Compomers in Dentistry:
Direct restorations:
o Restoratives.
o Flowables.
Cements.
Advantages:
206
Disadvantages:
Indications:
Esthetics.
Areas of lower stresses:
o Class V.
o Class III.
o Pediatrics.
Conservative class I & II.
Contraindications:
Giomers:
207
Properties:
As GI:
o Fluoride release. (long term release was lower than that of other material )
o Fluoride recharge.
As composite:
o Excellent esthetics. (If polished with soflex disks, had smoother surface than GI )
o Easy polish-ability.
o Biocompatibility.
Particles are made of fluorosilicate glass that has been reacted to Polyacrylic acid prior to
being incorporated into resin.
The pre-reaction can involve only the surface of the glass particles (called surface pre-
reacted glass Ionomer or S-PRG).
Giomer are similar to Compomer and resin composite in being light activated and requiring
the use of a bonding agent to adhere to tooth structure.
No chemical bond to tooth structure.
More research needed.
Only one Giomer is commercially available “Shofu”.
Indications of Giomers:
1- Class I & V.
2- Cervical erosion.
3- Root caries.
208
Revision:
2- The common acid between glass Ionomer and Polycarboxylate cement is:
a- Polyacrylic acid.
209
13- The sandwich technique is:
a- Glass Ionomer below composite.
14- Glass Ionomer bond to enamel better than dentin due to:
a- Higher Inorganic content in enamel.
17- Which application that needs advantage of mechanical adhesion of glass Ionomer the most:
a- Class V.
b- Liner.
c- Base.
d- Cement.
18- Which application that needs advantage of fluoride release of glass Ionomer the most:
a- Base.
b- Liner.
c- Root treatment.
d- Shy filling material.
210
Student Notes:
211
212
Composites
Objectives:
213
Composites
What is a composite?
Materials with two or more distinct substances e.g. metals, ceramics or polymers.
A continuous polymeric or resin matrix in which an inorganic filler is dispersed. The strong bond
between the organic resin matrix and the inorganic filler is achieved by coating the fillers with a
Silane coupling agent.
Composition:
1- Resin matrix:
Monomer.
Initiator.
Inhibitors.
Pigments.
2- Inorganic filler:
Glass.
Quartz.
Colloidal silica.
3- Coupling agent.
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Monomers:
Bis-GMA:
• Extremely viscous:
Freely movable.
Increases polymer conversion.
Increases crosslinking.
Increases shrinkage.
Shrinkage:
2-7%.
Marginal gap formation.
Filler particles:
Crystalline quartz:
Larger particles.
Not polishable.
Silica glass:
Barium.
Strontium.
Lithium.
Pyrolytic.
o Sub-micron.
215
Functions of inorganic filler:
Increasing strength.
Reducing the liner coefficient of thermal expansion.
Filler particles:
35 to 71 % by volume.
50 to 86% by weight.
Strength.
Abrasion resistance.
Esthetics.
Handling.
Increases strength.
Reduces solubility and water absorption.
Visible-light activation:
Camphorquinone:
216
Classification system:
1- Traditional.
2- Micro-filled.
3- Small particle.
4- Hybrid.
Traditional (Macro-filled):
217
Micro-fills:
Small particle:
Hybrids:
Popular as “all-purpose”:
o Aka universal hybrid, micro-hybrids, micro-filled hybrids.
0.6 to 1 micron average particle size.
o Distribution of particle size:
Maximizes filler loading.
o Micro-fills added:
Improve handling.
Reduce stickiness.
Strong.
Good esthetics:
o Polishable.
Suitable:
o Class I to V.
Multiple available.
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Nano-filled composite:
Composite variants:
Packable.
Flowable.
Flowable composites:
• Marketed for:
Reduces viscosity.
Disadvantage:
o Have inferior physical properties such as low wear resistance and strength.
Advantages:
o Good wet ability and handling properties.
219
• Uses:
Packable composites:
Increase in viscosity:
o Better proximal contacts.
o Handle like amalgam.
Shape.
Size.
Particle distribution.
Affords a “feel” upon insertion, similar to amalgam (but some displacement of matrix
band is possible).
220
Packable Vs. Hybrid composites:
Similar:
o Mechanical properties.
o Wear properties.
o Curing depths.
o Proximal contacts.
Drier, denser feel.
Another classification:
1- Homogenous.
2- Heterogeneous (precured composite).
1- Chemical cured.
2- Light cured:
Longer working time.
Better color stability (less voids).
3- Dual cured (mainly luting cements).
Indications:
221
Contraindications:
Advantages:
1- Esthetics.
2- Conservative tooth structure removal.
3- Less complex when preparing the tooth.
4- Insulative, having low thermal conductivity.
5- Used almost universally.
6- Bonded to tooth structure resulting in:
o Good retention.
o Lower micro-leakage.
o Minimal interfacial staining.
o Increase strength of the remaining tooth structure.
7- Repairable.
Disadvantages:
222
Important properties:
1- Linear coefficient of thermal expansion (LCTE) dimensional change of a material per unit change
in temperature.
o The closer the LCTE of material to that of enamel, the less the chance there is for
creating openings at tooth-restoration interface when temperature changes.
2- Water absorption.
o Affected by amount of matrix.
3- Wear resistance:
o Affected by filler particle size, shape, content and occlusal relationship.
4- Surface texture.
5- Radio opacity.
6- Modulus of elasticity:
o Flexibility may perform in class V.
7- Solubility.
Polymerization of composite:
Polymerization shrinkage:
Can’t be avoided.
Main disadvantage of composite.
Results in creation of polymerization stresses.
1- Transferred to the tooth and causes deformation, may result in enamel fracture.
2- Gap between resin and cavity walls post-operative sensitivity, micro-leakage and recurrent
caries.
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Polymerization shrinkage factors:
• Tooth:
Location.
Size.
C-factor
Factors related to tooth:
o C-factor: cavity configuration and stress development, it is the ration between
bonded and un bonded surfaces
o Flat surfaces.
o Shallow cavities.
• Composite:
Formulation.
Technique of insertion.
Factors related to material:
o Filler content: increase in filler content decrease in polymerization shrinkage.
o Nano-filler technology.
o Resin formulation.
o Degree of conversion of monomer into polymer: increase in degree of
conversion increase stress, however enhances mechanical properties.
o Water sorption: decreases stress, however it deteriorates mechanical
properties.
• Bonding agent.
• Curing technique:
224
Polymerization techniques:
Restorative techniques:
Incremental filling:
o Decrease polymerization material volume.
o Reduce bonded to un-bonded surface ratio.
o Minimal contact with cavity walls.
Facio-lingual layering (vertical).
Gingivo-occlusal layering (horizontal).
Three site technique.
Wedge shape layering (oblique).
Bulk technique.
Centripetal technique.
Polymerization strategies:
The idea is that we try to delay gel point (point of transformation of composite paste into solid)
to allow some stress relaxation.
225
Mode of curing:
Chemical cured composite resins offer less polymerization stress due to slower rate of curing.
A- Pre-insertion Steps:
1- Isolation recommendations:
- Enamel Composition:
o Primarily inorganic:
Hydroxyapatite.
226
- Enamel Bonding:
o Developed by Buonocore-1955.
o Etching:
Various acids:
• Traditionally phosphoric acid.
creates micro-pores:
• 5 – 50microns deep.
Increases surface energy.
Increases wettability.
- Dentin Structure:
o Dentin composition.
o Dentinal tubules.
o Changes in dentin structure.
o Smear layer.
o Dentinal wetness.
- Dentinal tubules:
o Radiate from pulp.
o Largest near pulp.
2.5 microns at pulp.
0.8 microns at DEJ.
o Concentrated near pulp:
45,000/mm2 at pulp.
20,000/mm2 at DEJ.
- Tubule Composition:
o Peritubular dentin:
Surrounds tubule.
Hypermineralized.
o Intertubular dentin:
Between tubules.
Less mineralized.
o Odontoblastic process.
o Dentinal fluid.
227
- Changes in Dentin Structure:
o Sclerotic:
Normal aging.
Abrasion.
Erosion.
o Reparative:
Caries.
Dental procedures.
o Hypermineralization.
o Less receptive to bonding.
- Smear Layer:
o Produced by instrumentation.
o Composition:
Cut dentin debris.
Bacteria.
o Reduces dentin permeability:
86%.
o Thickness:
0.5 - 5microns.
o Will not wash off.
o Weak bond to tooth:
2 – 3MPa.
o Very soluble:
Weak acids
- Dentinal Wetness:
o Increases:
Dentinal depth.
Removal of smear layer.
Historically, more difficult to bond
- Dentin Bonding:
o Development:
Seven generations.
Chronologic Classification.
228
Currently available generations:
• Fourth Generation:
• Fifth Generation:
• Sixth Generation:
Two-step Self-etch.
One-step Self-etch:
o Mix.
• Seventh Generation:
One-step Self-etch:
o No mix
Conditioner.
Primer.
Adhesive resin.
229
- Conditioner:
Chemical alteration of surface:
o Acids: Phosphoric, Citric, Maleic, Nitric.
Removes dentinal smear layer:
o Exposes collagen fibrils.
Simultaneous enamel etch.
Rinse:
o Keep moist.
- Primer:
Bifunctional monomer:
o Link:
Hydrophilic collagen.
Hydrophobic resin.
o Example:
HEMA.
- Adhesive Resin:
Unfilled or lightly-filled monomers:
o Equivalent to enamel bonding.
o Bis-GMA, UDMA, TEGDMA.
Stabilize the hybrid layer.
o Fills up remaining pores.
Resin tags.
Links primer to composite resin.
- Hybrid Layer:
Conditioner demineralizes dentin.
Inter-diffused with low-viscosity monomer:
o Displaces water.
o Bifunctional.
Resin mechanically interlocks
collagen.
230
• Etch & Rinse (Two-Step):
Conditioner.
Combined primer and adhesive:
o Higher technique sensitivity:
Higher solvent-to-monomer ratio.
Risk of applying too thin.
Apply multiple layers.
• Self-Etch (Two-Step):
• Self-Etch (one-Step):
Combined:
o Conditioner.
o Primer.
o Adhesive.
• Resin-modified Glass-Ionomer:
Two-step:
o Weak conditioner.
o Mix and apply glass Ionomer
adhesive.
Fluoride release.
Matrix system:
1- Darway, Incorporated.
2- BiTine Ring and BiTine.ii Ring.
3- Sectional matrix sizes.
4- Standard matrix: 0.002inch.
5- Mini-matrix: 0.0015inch.
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• Automatrix II System:
Wedging:
B- Post-Insertion Procedures:
• Finishing Procedures:
- STEP 1:
12-Fluted carbide burs:
o 7406: occlusal anatomy.
o 7901: marginal ridge, proximal embrasure.
o 7801: refine occlusal anatomy.
Use these burs dry, low-end of high speed range
with light touch.
Minimize cavo-surface margin contact.
Sof-flex discs: interproximal areas.
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- STEP 2:
Intermediate finishing:
o Bonded elastic or rubber abrasives.
Enhance finishers: minimally abrasive to adjacent enamel.
Aluminum-oxide bonded abrasives: used dry with light to
moderate pressure and air to clear the field and dissipate heat buildup.
- STEP 3:
Aluminum oxide-containing composite polishing paste.
Prisma-gloss (Dentsply/Caulk) or Enamelize (Cosmedent).
Use Enhance polishing cups and dry/wet technique.
Proximal Areas: disc-shaped felt devices.
Super Snap Buff Disc (Shofu) or Flexibuff (Cosmedent)
• Finishing Procedures:
Raptor.
Profin.
Brasseler.
• Polishing procedures:
233
Revision:
234
13- Composites with filler particles:
a- Macrofilled.
14- When high occlusal stresses and esthetic is of prime concern, we use:
a- Hybrid composite.
235
Student Notes:
236
237
Chapter 7: Cavity Preparations for Dental Composite:
238
Class I Composite
Objectives:
239
Class I Composite
Definitions:
Class I composite: Pit and fissure caries restored with composite restoration.
Indications:
Contraindications:
Advantages:
Esthetic.
Conservation of tooth structure.
Reinforce weakened tooth structure.
Can be re-bonded.
Eliminate galvanic current.
Eliminate mercury toxicity.
Low thermal conductivity.
240
Disadvantages:
Shade selection:
When restoring the occlusal surface of a posterior tooth there are three possibilities:
o Occlusal sealant.
o Preventative resin restoration (PRR).
o Tradition class I restoration.
Class I preparation:
241
Class I preparation/restoration:
Pulpal protection:
o Calcium hydroxide.
o RM-GIC .
Acid etching:
o Start applying the etchant to enamel margins then into dentin.
o Rinse and wash with water, leave the tooth moist.
Class I:
Adhesive:
place composite:
Incremental placement.
Horizontal or vertical increment Hori.
242
Rebonding:
Rebonding: the application of a low-viscosity resin called “surface sealers” to the finished
surface and margins of a restoration.
Finishing and polishing procedures are inherently destructive to the restoration surface.
Finishing can exacerbate the marginal gaps formed during polymerization.
Technique:
Apply etchant to the marginal areas for 10 seconds then rinse and dry.
Apply rebonding resin then thin with a brush.
Light cure for 20-40 seconds.
Class I restoration:
243
Student Notes:
244
245
Class V Composite
Objectives:
246
Class V Composite
Definition:
Cavity located in the gingival 1/3 of facial & lingual surface of all teeth.
Indications:
1- Caries.
2- Sensitivity.
3- If the lesion is esthetically objectionable.
4- If notched defect.
1- Abrasion:
2- Erosion:
247
3- Idiopathic:
Due to flexure of the cervical area under heavy occlusal stresses. This process is called
Abfraction.
A- Amalgam:
B- Glass Ionomer:
C- Composite:
When esthetic is of prime importance and maybe used with or without glass Ionomer
(sandwich technique):
a- Is the most esthetic restorative material.
b- Has good wear resistance and longevity.
Contraindication:
248
Before cavity preparation:
Cavity preparation:
• Indications:
Lesions that extend into the root surface, no enamel on all margins of the preparation.
249
• Cavity preparation:
• Indications:
A large new carious lesion that has a part in enamel incisally (occlusally), possibly mesial
& distal margin in enamel as well, and the cervical part will have gingival retention
groove.
o Many of these preparations will be a combination of beveled enamel margin
(incisally) and 90° root surface (non-enamel margin) with root surface has groove
retention.
o Combined bevel conventional & conventional preparation
• Groove retention:
Is not indicated when the peripheries of the cavity preparation is located in enamel.
1- Increased retention due to the greater surface area of etched enamel afforded by the
bevel.
2- Decreased micro-leakage due to enhanced bond between the material & the tooth.
3- Decreased need for groove retention form and consequently less removal of tooth
structure.
250
• A gingivo-axial groove is indicated in the root surface because:
• When large class V carious lesion is extended into the root surface:
• Cavity preparation:
Prepare outline form before expect the depth is only 0.2mm. in dentin when groove is
unnecessary.
Remove any infected dentine.
Apply Ca(OH) liner or base.
Prepare gingival groove if:
1- The gingival margin is located on root surface.
2- If the preparation is large enough to warrant groove retention form.
Enamel margin is beveled using coarse flam shaped diamond instruments angled 45° to
external tooth surface and prepared to width 0.25mm to 0.5mm.
When decalcified area extend mesially from cavitated class V lesion.
A completed beveled conventional class V and prepare a conservation mesial extension
by round diamond instrument in enamel only.
• Indications:
Small enamel defect or small cavitated lesion that is largely or entirely in enamel. These
include decalcified & hypoplastic areas located in the cervical third. The objective is to
restore the defect or lesion as conservatively as possible.
251
• Cavity preparation:
Finishing:
Note:
Removal of excessive composite by finishing bur. We use the transparent
Aluminum oxide disk (softless disk). cervical matrix for contouring,
Fair diamond bur. smoothening & polishing the
White stone/rubber cup with polishing paste. surface.
252
Revision:
253
Student Notes:
254
255
Class II Composite
Objectives:
256
Class II Composite
Diagnosing class II caries:
B- Digital way, by using RPG, by analyzing the density of Ca in the normal & affected dentin.
Amalgam Composite
0.5 to 1 mm into dentin. 0.5 mm into dentin.
No cavo-surface bevel. Cavo-surface bevel buccal and lingual of
proximal.
Contact 0.5 mm proximal clearance. Contact can be left.
Isthmus 1/3 between cusps. Isthmus according to caries.
No gingival bevel. No gingival bevel.
Occlusal dovetail. Dovetail if needed.
257
Class II composite preparation:
Bur selection:
258
Student Notes:
259
260
Class III Composite
Objectives:
261
Class III Composite
Definition:
Lesions initiating in proximal surface of all anterior teeth, not involving incisal angle.
262
Preparation lingual access:
Facial access:
Cavity is rarely completely in the root surface but mainly it has a portion in the root surface and
a part in the crown.
263
• The root surface portion:
For replacing defective existing restoration in the crown portion of the tooth.
Restoring large carious lesions.
In this case I can’t put the composite directly in the deep cavity because it’s irritant, so I
have to:
1- Protect the pulp by placing Glass Ionomer below the composite (sandwich technique).
2- Acid etch by using 35% of phosphoric acid (gel or solution) or 10% maleic acid in the
enamel & GI.
3- Use bonding agent.
N.B. the matrix that is used in composite is the plastic matrix.
264
Revision:
265
Student Notes:
266
267
Class IV Composite
Objectives:
1- Be acquainted that the preparation will stimulate dealing with a fracture anterior tooth as well
as the situation where a large class II lesion has progressed to include loss of incisal angle.
2- Know how to avoid undermining and weakening of incisal angle in large class III.
3- Be able to list and identify different outline forms.
4- Know the proper esthetic forms of composite resin of class IV.
5- Compare between different conservative cavities.
6- Identify the proper retentive features used in class IV cavity for composite resin by skirting
bevel all over the fracture angle and that the retention will be through micro-mechanical
retentive mean.
7- Describe the technique of insertion of composite resin restoration.
8- Recognize the problem with neglecting to do beveling.
268
Class IV Composite
Definition:
Indications:
1- Enamel only.
2- Enamel and dentin without pulp involvement.
3- Enamel and dentin with pulp involvement.
269
Types of bevels:
2- Long bevel: Entire enamel is beveled at 45 degree to 75 degree by flame shape bur.
3- Full bevel: Enamel and dentine are beveled (full wall length).
4- Hollow ground bevel: About 2/3 of enamel thickness is ground in concave manner by round
bur.
5- Scalloped: May be used with short or long bevel to increase surface area for bonding.
6- Skirting (mini chamfer): When enamel is the main retentive feature for the restoration.
Advantages of bevel:
Technique:
Anesthesia:
270
Preparation:
Design 1:
Chamfer 1mm long or half the length of the fracture and half the depth of enamel on labial
and lingual surface.
Design2:
Use of pins:
Composite restoration:
271
Composite placement:
The crown form should be trimmed to cover 1mm above the margins of the preparation.
In case tied contact pre wedging must be done.
• First technique:
It may be filled with composite and placed over the preparation and wedged in place.
Excess material is removed with explorer or inter-proximal carvers.
Light curing for 60 seconds for facial and 60 seconds for lingual.
• Second technique:
Use only the lingual and proximal part of the crown form leaving the labial aspect open for
incremental building of composite for better esthetic.
The bulk of the restoration is built with hybrid composite to provide strength and the final
layer is veneer of micro-filled composite for smooth and glossy appearance.
272
3- Layering technique:
• Technique:
1- Anesthesia.
2- Long bevel 2-3mm according size of fracture.
3- Alginate impression poured in stone model.
4- Waxing up to the desired shape.
5- Putty matrix fabricated overt the wax up.
6- Accurate shade guide before tooth could dehydrate.
7- Etching and bonding.
8- Building composite in layering technique.
9- Finishing and polishing.
• Layering sequence:
1- Lingual shell.
2- Dentin layer.
3- Translucent layer.
4- Opaque layer.
5- First enamel layer.
finishing of composite:
273
Revision:
2- Advantages of Skirting:
a- Esthetic and more retention.
3- Function of beveling:
a- Expose the dentinal tubules.
274
Student Notes:
275
276
Chapter 8: Pit & Fissure Sealants and Preventive Resin
Restorations
Objectives:
By the end of this lecture, the student should:
1- List treatment Options for pits and fissure decay sequentially (starting with monitoring and
ending with restorations for frank cavitations).
2- Explain what are the objectives of placing sealants.
3- Describe the anatomy of pits and fissures and explain difficulties of cleaning and sealing such
areas.
4- Identify reasons behind limited used of sealants.
5- Give reasons of dentists’ hesitations and reluctance to use sealants.
6- List indications of using sealants and identify situations when presented with clinical cases.
7- Discuss sealants effectiveness regarding caries prevention citing a minimum of 3 studies.
8- List factors affecting retention rates of sealants.
9- Explain possibility of placing sealants by auxiliary staff.
10- Discuss cost-effectiveness of using sealants in populations with different caries status.
11- List and compare different ways of cleaning teeth before placing sealants.
12- List different approaches for preparing teeth for sealants placement (e.g. Air abrasion,
Enameloplasty).
13- Compare ways of preparing the teeth for sealant placement and identify the best approach.
14- Explain the technique of Enameloplasty and whether or not it should be a routine approach.
15- Describe effect of topical fluoride on sealants.
16- Name the types of acids used for acid-etching of enamel, its percentage, and clinical
significance of using different types. The student should also identify different forms of acids
(liquid or gel), and clinical implications of using either type.
17- Recall the appropriate duration of etching for primary and permanent teeth.
18- List types of sealants (resin-based, GIC, filled or not, opaque etc).
19- Identify components of resin-based sealants.
20- Discuss possibility of harmful effects of sealants due to estrogenicity issue (Olea work and later
work).
21- Recognize problems with GIC sealants.
22- Explain clinical implications of using filled and unfilled sealants.
23- List advantages and disadvantages of using colored and clear sealants.
24- Discuss the use of fluoride in sealants.
25- Discuss the use of intermediate bonding layer and its advantages and disadvantages.
26- Name at least one new development of sealants.
27- Sequentially describe the technique of placing the sealant.
28- Identify reasons for sealants loss and explain how to avoid them.
29- Explain what is PRR and what types of restoration is used in different clinical situations.
30- List advantages of PRR, indications and contraindications.
31- Explain the steps of PRR, identifying the equipment died restorations needed.
277
Pit & Fissure Sealants
Introduction:
Traditional caries management has consisted of detection of caries lesion followed by immediate
restoration. In other words, caries was managed primarily by restorative dentistry. However, when
the dentist takes the bur in hand, an irreversible process begins. Because this is the start of a
restoration cycle in which the restoration will be replaced several times.
Therefore, before restoration, a group of certain questions has to be asked:
Is the caries present?
If so how far does it extend?
Is the restoration required or could the process be arrested by preventive treatment?
o The modern dentistry & with the introduction of adhesive dentistry, the dentists are
allowed to seal the susceptible areas & make smaller preparations. Thus preserving hard
dental tissues.
Definitions:
Is a thin plastic coating placed in the pit and fissures of the teeth to
act as a physical barrier to decay.
278
Rationale:
Pits & fissures provide a sheltered environment in which dental plaque can develop so that
these areas are liable to decay.
Almost over 85% of children (5-17 years old) have caries in the pits and fissures.
Since it is difficult to diagnose decay “demineralization” in its early stages & fissures are
susceptible sites, the dentist may decide to fissure seal susceptible teeth as soon after
eruption as possible.
Fluoride is least effective on pit and fissures.
15 year study – 68% of sealed teeth were caries free vs. 17% of unsealed control group.
Indications:
When active fissure caries has been diagnosed or if a high risk has been established and fissures
have susceptible morphologic characteristics, sealants are indicated.
Deep fissures.
Incomplete or ill formed pits.
Newly erupted teeth.
High caries rate.
Children.
Molars.
Incipient Caries:
Incipient Caries Studies have shown that sealants can be placed over incipient caries which
arrests the caries process. Most dentists choose to use air abrasion, a bur, or a laser to remove
the caries before the sealant is placed.
279
Contraindications:
Shallow fissures.
Well coalesced pits.
Fluoride rich enamel.
Low caries rate.
Occlusal or proximal caries.
Adults.
Types of sealants:
According to composition:
• Resin sealants:
“autopolymerization”
Composed of:
o Base and catalyst.
o Monomer & Initiator +Diluted monomer &5% Organic Amine accelerator = Sealant.
280
• Visible light cured sealants:
“photopolymerization”
Composed of:
o Pre-mixed Dimethacrylate + Diluent + Activator + Light = Sealant.
• Advantages:
• Disadvantages:
• Advantages:
• Disadvantages:
281
According to shade:
Clear.
Tinted.
Opaque.
• Clear sealant:
Has the advantage of being able to see the tooth beneath it to detect any color change
that may indicate leakage and development of a carious lesion.
Has the advantage of being able to see the partial loss of the sealant and then the
sealant may be repaired.
• Recently:
Fluoride-releasing sealant.
Non-fluoride containing sealants.
Filled sealants.
Unfilled sealants.
• Unfilled sealants:
They are less viscous and better able to penetrate into fissures than filled sealants.
Consequently:
o Tend to be better retained.
282
o Suffer less leakage.
o Offer rapid loss of any occlusal interference.
Strength and Viscosity Characteristics Viscosity:
• Viscosity:
The thicker the sealant the less likely to penetrate to depth of fissure.
• Wear of Sealants:
Considerations for wear – less filler, more wear and vice versa.
Selection of cases:
Considerations:
Patient age.
Oral hygiene.
Caries risk.
Diet.
Fluoride history.
Tooth type.
Morphology.
Manipulation:
Sealant Kits:
Cavity Indicators.
Drying agent (optional).
Acid etch.
Sealant material.
• For sealants:
283
Sharp explorer to clean out debris.
Rinse.
Air abrasion.
Bur.
Laser.
Check occlusion:
Avoid placing acid etch and sealant on marked areas from articulator paper.
Isolate tooth/teeth:
15-20 seconds.
Use blue micro tip or brush tip.
Apply only in pit and fissures.
For liquid – dab but do not rub.
Re-etch 10 seconds if there is any saliva NOTE:
contamination. DO NOT use explorer
N.B. Etch longer in the following cases: after etching.
o Deciduous teeth.
o Saliva contamination.
o Air abrasion or prophy jet used.
o Highly mineralized teeth.
Rinse tooth/teeth:
284
Dry tooth/teeth:
Acid etching and Primadry (alcohol based) allows enamel to be easily “wetted”.
Active ingredient of Primadry is ethyl alcohol.
Use explorer.
285
Tooth should be smooth but not soft.
Re-apply sealant, if necessary. (Remove uncured sealant with wet cotton roll).
Check occlusion:
Articulating paper.
Ask patient how it feels.
Dentist can adjust with bullet-shaped finishing bur or polishing stone.
N.B. If using unfilled composite sealant the bite will self-adjust in 2-3 days.
>90% retention.
No caries.
286
Causes of sealant failure:
Loss of Sealant:
A contaminated site from faulty technique will likely result in complete or partial loss of the
sealant within 6-12 months.
Early loss means less retention of the resin.
The main cause is moisture contamination.
Repair of sealant:
287
Preventive measures:
288
Student Notes:
289
290
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ﻻ ﺗﻨﺴﻮﻧﺎ من دﻋﺎﺋﻜﻢ
ﻭﷲ اﻟﻤﻮﻓﻖ
291