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Bien Air Optima Lecture Isolation, Con’t

KNOW Ratio is: - Nose breathing difficulty


Motor rotations: Bur rotations - Psychological issues
- Both motor and bur rotation is • Tips for Rubber Dam Isolation
ATTACHMENT dependent - Isolate 5 teeth, including 1 DISTAL to tooth
• High Speed: 1:5 ratio being prepped
- Red dot 5X handpiece X Max 40,000 motor = - More isolated teeth = larger field of vision and
200,000 RPM operating filed
- 500-200,000 RPM range - Clamp most distal tooth being isolated
• Slow speed: 2:1 ratio - Ligate/clamp most mesial tooth being isolated
- Blue dot - Invert dam to prevent fluid leakage
13,333 slow speed Intro to Operative
6,666 caries removal Classification of Carious Lesions
- Pre-clinic: Max speed: 40,000 X 1/2= 20,000 • Class 1 – pits and fissures
RPM • Class 2 – proximal surfaces of posterior teeth
- 50-20,000 RPM range • Class 3 – proximal surfaces of anterior teeth
Prophy on a slow speed • Class 4 – proximal surfaces of anterior teeth
(Green dot) 5:1 ratio, 2,000 RPM including incisal angle
• Straight Handpiece: 1:1 ratio • Class 5 – smooth facial and/or lingual surfaces in the
- Blue band gingival 1/3
100-40,000 RMP range • Class 6 – incisal edge or cusp tip pits
• Quiz Question: • Quiz Question
- Which operative handpiece removes tooth - What surfaces are involved in a class 3
structure at a faster rate with less pressure and restoration?
vibration? Proximal of anterior teeth
High speed Restorative Instruments
- If the handpiece ratio is set up at 2:1, then it • Hand Instruments
means: - Stainless steel used today b/c of sterilization
The motor rotates twice and the bur • Non-Cutting Instruments
rotates once - Mirror: indirect vision/reflect
Ergonomics (1 question) light/retract/ergonomics
• Quiz Question: - Explorer: caries detection, smoothness, check
- Number one cause of early retirement for margins of restorations
dentists? - Periodontal probe
Musculoskeletal disorders - Cotton Forceps: place/remove cotton
Isolation (2-3 questions) rolls/wedges/cord/picking up small objects
• Isolation is important for - Hemostatic Forceps: more rigid/lock in place
- Moisture control - Articulating Paper Forceps: hold art. paper
- Visibility and access - Plastic Instruments: place/shape composite
- Patient protection - Amalgam instruments:
• Methods of isolation -Carriers: Carry amalgam from well to prep
- Rubber Dam -Condensers: condense amalgam into prep
UNLV always uses Rubber dams if -Burnishers: contour matrix bands/final
NOT contraindicated condensation of amalgam/shape occlusal
Used 100% of the time in sim surface of amalgam restoration/smooth
- Absorbents (cotton rolls, dry angles) amalgam surfaces after carving
- High Volume Evacuator - Spatulas: mix/carry cements and liners
- Retraction Cord • Cutting Instruments
- Isolite - Tooth cutting
• Rubber Dam Advantages -Hatchets, chisels, hoes, gingival margin
- Dry, clean operating filed trimmers, spoons
- Improved access and visibility -Have STRAIGHT cutting edges and designed
- Potentially improved properties of dental to plane enamel and dentinal walls in
materials shaping cavity preps; especially, in areas
- Protection of patient and operator of prep that CANNOT BE REACHED W/ A
- Operating efficiency BUR
• Rubber Dam Disadvantages -spoons remove carious dentin/debris
- Time - Carvers
- Patient objection -Cleiod-discoid: carve occlusal amalgam surface
- Partially erupted teeth -Hollenback: carve occlusal/proximal/axial
- Mispositioned teeth -Interproximal: carve proximal amalgam surf.
Restorative Instruments, Con’t Restorative Instruments, Con’t
• Basic Elements of Hand Instruments Rotary Instruments
• Classified by speed range and angle
- Contra-angle: high speed, slow speed
-High Speed
- A – Blade 100,000-200,000 RPM; used for gross
To cut (nib in non-cutting) tooth reduction
- B – Shank Advantages: removes tooth structure
To connect handle to blade; bends allow faster w/less pressure/vibration
better control of instrument/distribution of Disadvantages: high heat – should be used
forces/access w/water and air spray
By bringing cutting edge to w/in 2mm of -Slow Speed
central axis of the handle it creates better 50-20,000 RPM
balance of instrument Advantages: used for caries removal and
- C – Handle/Shaft prep refinements and finishing/polishing
To hold Disadvantages: creates vibration; “skips”
-Straight Handpiece
Limited use in operative dentistry
(removable prosthodontics and lab
procedures)
Electric Handpiece Air Driven Handpiece
• Factors Affecting Control of Hand Instruments -More expensive -Less expensive
- Greatest control of a hand instrument is gained -Larger and heavier -Smaller and lighter
when it has: -Higher torque -Less torque
-Less vibration and noise -More vibration and noise
-Large blade
-Minimum number of bends in shank -More efficient cutting -Less efficient cutting
*we use these!*
-Cutting edge is in DIRECT axial alignment
w/shaft or handle (remember the 2mm) • Bur Design
• Operative Cutting Instrument Formulas - Series of metal cutting edges called
- 3 Number Formula (cutting edge at a RIGHT blades/teeth or flutes
angle to LONG axis of blade) - Instrument should be harder than substance
-1st number: width of blade in .1mm being cut (enamel is hardest body tissue)
-2nd number: length of blade in mm - Development of tungsten carbide helped
-3rd number: angle of blade to shaft in degrees overcome this problem
centigrade -Better than stainless steel, esp. at high speed
• Parts of a Bur
- Shank – fits the handpiece
-Straight, latch-type, fiction grip
- Neck – connects head to shank
- Head- working part of instrument

- 4 Number Formula (cutting edge is NOT at a • Bur Blade Design


right angle to long axis of blade) - Generally designed to cut when rotating
-1st number: width of blade in .1mm CLOCKWISE
-2nd number: angle of primary cutting edge - - Each blade has 2 SIDES and 3 ANGLES
makes to long axis of handle -2 Sides:
-3rd number: length of blade in mm Rake/Tooth Face: surface of blade that
-4th number: angle of blade to shaft makes contact
w/tooth structure
Clearance Face: opposite side of rake face
-3 Angles:
Rake Angle: angle made by face of blade
and radial line from center of
bur PERPENDICULAR to surface
being cut
Most burs have a neg. rake
angle which INCREASES the life
expectancy of the bur
Restorative Instruments, Con’t Restorative Instruments, Con’t
Edge Angle: angled formed by rake face
and clearance face
Increased angle provides greater
resistance to blade fracture
Clearance Angle: angle made by BACK of
blade (clearance face) and
surface being cut
Eliminates friction
Allows clearance space for tooth
debris

- Carbide finishing burs: bevel/smooth enamel;


finishing composite. Inc. number of flutes =
DECREASED efficiency but SMOOTHER cut
- Mounted Stones: polish
amalgam/gold/smooth enamel; Green stones =
silicon carbide; White stones = Aluminum
oxide
- Diamonds: 3 parts: 1. Metal Blank 2. Powdered
diamond abrasive 3. Metallic bonding material;
most diamond shapes PARALLEL those of burs
Coarse (125-150um)
Medium (88-125um)
Fine (60-74um)
• Bur Terminology
Very fine (38-44um)
- Flute Space
Finishing (10-38um)
Space btw successive teeth in the bur
- Lasers = Light Amplification by Stimulated
- Concentricity
Emission of Radiation
Measures how closely a SINGLE CIRCLE
can be passed through the tips of all the
blades of the bur. Measures if one blade is • Quiz Questions:
longer/shorter than another - Which instrument would be used to remove
- Runout small enamel projections?
Measures ACCURACY blade tips pass Hatchet
through a single point when the - Which operative handpiece removes tooth
instrument is rotated. structure at a faster rate with less pressure and
Measures concentricity but also accuracy vibration
with which the center of rotation passes High speed
through center of head of the bur - On a carbide bur, a GREATER number of cutting
i.e. A concentric head will exhibit runout if blades results in:
the head is off center on the axis of the LESS efficient cutting and a smoother
bur (bur neck is bent; bur not held straight surface
in the handpiece; etc) - In a 4-number instrument formula, what does
Runout is MORE SIGNIFICANT than the 4th number represent?
concentricity b/c it is a source of Angle of the blade to the shaft in degrees
VIBRATION centigrade
- It is generally believed that the more a joint
• Specific Bur Designs
derivates from neutral position, the greater the
- Round: 1/16-11; removes caries/places
chance of injury?
retention cuts “ends” and “sides”
True
- Inverted Cone: 30-series; smooths prep floors
- A DO two surface restoration on tooth #29 is
and retentive undercuts, cut“ends” and “sides”
best described as:
- Straight and Tapered Fissure: Straight:50-
Class II
series; Tapered: 70-series; cuts enamel well at
- Carbide finishing burs generally have how
high speeds’ well-cut prep walls
many flutes
- Cross-cut Fissure Burs: cross-cuts provide good
16
flow-away for debris; leave rough cut surface;
straight 550-series; Tapered: 700-series
- Pear Shaped/Elliptical burs: “pear” shaped;
330
Dental Amalgam Dental Amalgam, Con’t
• Dental Amalgam • High-Cu Admixed Amalgam Reaction
- Contains amalgam alloy and liquid mercury - The initial rxn is the same as the low Cu amalgam
-Amalgam alloy: - In the 2ndary slow rxn, Cu from the Ag-Cu
Silver spherical alloy preferentially reacts with the Sn of
Tin gamma 2, forming Cu6Sn5 – thus, eliminating
Copper gamma 2 (Sn7-8Hg)
Sometimes: Zinc, palladium, or indium - More gamma 1 is formed
• Amalgam is used to restore POSTERIOR restorations *Because of the higher copper content – NO
- Class 1, 2, 5 and 6 gamma 2 (Sn7-8Hg) is formed!*
• Advantages of Amalgam (listed TWICE!) • Advantages of Admixed Amalgam
- Easy to insert, not overly technique sensitive - Particle shape
- Maintains anatomical form Good adaptation to cavity walls
- PREVENTS/minimizes MARGINAL LEAKAGE after a Easy to obtain good interproximal contact
period of time – due to CORROSION products - High Cu content *THIS IS ASKED ON BOARDS!*
- Adequate resistance to fracture Medium to high strength
- Relatively long service life Good to excellent corrosion resistance
- Fairly inexpensive Reduced marginal ditching
• Disadvantages of Amalgam (listed TWICE!) Increased longevity of restoration
- Marginal breakdown; less conservative prep • Spherical HIGH-COPPER Amalgam
- Poorly bonded to tooth structure - Known as “unicompositoinal”
- Color doesn’t match tooth structure - Advantages:
- BRITTLE and less tough than desirable (>1.5 mm) High strength, esp. early
- Subject to CORROSION and GALVANIC action 10% LESS mercury
- Biological/environmental concerns (acceptable risk Small particles, therefore, SMOOTHER
to benefit ratio w/proper use) SURFACE and EXCELLENT CORROSION
• Amalgam requires adequate bulk for strength RESISTANCE
Manufacture of Alloy Powder No gamma 2, either!
Lathe-cut Spherical Admixed *Gamma 2 is ONLY found in LOW Cu amalgam!*
-Elements are -Elements are -Alloy contains at *High-Cu amalgam and resin have SIMILAR strength values, with
heated, cast into heated to least 12% copper resin being slightly LESS STRONG!*
ingots and slowly MOLTEN STATE, and are mixtures *SnO CORROSION products SEAL MARGINS of amalgam*
cooled sprayed into a of 25-60%
-Ingots are cut on large chamber spherical and 40- • Amalgam Insertion Steps
lathe to create w/inert gas and 75% lathe-cut 1. Proportioned capsuled
fillings solidify -The first HIGH 2. Trituration (mixes alloy and liquid Hg together)
-Fillings are ball -Particles may be COPPER *We use the Caulk ProMix Triturator at UNLV and either a
milled to reduce spherical or containing 2 spill (Grey/Aqua - 600mg) Ionosphere 8-12 sec or
size slightly irregular amalgams (>6%) 3 spill (Aqua - 800mg) Ionosphere 12-16 sec
Advantages: Advantages: Advantages: ADMIXED PARTICLE AMALGAM – IONOSPHERE at a
-Resists -Require LESS Hg -DECREASED slow/turtle speed (3700 cpm) KNOW! *
condensation to wet the alloy creep percentage 3. Transfer to cavity
more than surfaces -INCREASED 4. Condensation
spherical (more -Sets rapidly and compressive 5. Carving
viscous) has greater early strength 6. Adjusting occlusion
-Adapts well to strength -LESS marginal
cavity walls -Smoother surface ditching Trituration Mistakes
-Easier to obtain and probably LESS -The 1st admixed UNDER Trituration OVER Trituration
good CORROSION alloy was
interproximal “Dispersalloy”
contacts
• Creep
- Permanent deformation under static load – ADA
Spec. 1
- Now, corrosion is thought to be the major reason -Excessive wrinkles or -Mixture CANNOT be tapped
for DITCHING separate particles out of capsule and sets
quickly
Dental Amalgam, Con’t Dental Amalgam, Con’t
• Hardening of Amalgam • Delayed Expansion
- Influence of mixing SPEED on setting rate of High- - If amalgam contains ZINC and is contaminated
Cu amalgam w/MOISTURE during placement may form ZnOH
and hydrogen gas

• Transfer to Cavity Prep - B/c of this: spherical amalgams do NOT contain


- Amalgam carrier is used to transfer amalgam zinc and admixed amalgams contain 1% or less
- For large preps, ENTIRE MASS may be carried to - A week later, the hydrogen may cause
the prep w/cotton forceps EXPANSION of the amalgam
• Condensation • Repair of Amalgam
- Compressing and directing amalgam into prep - New amalgam to old amalgam bond is LESS than
w/hand instruments called condensers/pluggers 50% of unrepaired amalgam
- Proper condensation: - Attempt only if area involved is subject to LOW
Adapts amalgam to cavity walls STRESS – not recommended for occlusal surfaces
Eliminates voids in direct occlusion
Reduces amount of residual Hg • Dr. Walker’s Outlook
- Amalgam condensed vertically and horizontally - Amalgam is LESS TECHNIQUE SENSITIVE and will
toward cavity walls likely be more successful of difficult access and
- Prep should be overfilled and condensed to isolation
reduce amount of Hg in the restoration - For routine restorations by meticulous operators,
- Force: there is not much difference in longevity btw
ADMIXED require 5-10 lbs of force amalgam and resin
Spherical amalgams require LESS FORCE and - For large restorations, resin may were at TWICE
LARGER CONDENSERS THE RATE OF AMALGAM, but that is still
• Carving acceptable
- Contouring amalgam to simulate tooth form and • Quiz Questions
accommodate occlusion - Which of the following is NOT an advantage of
- Have mental picture of outline form and carve to dental amalgam?
achieve that outline Helps retain tooth structure
- Carver should rest on enamel ADJACENT to prep - Which is NOT a common material used in dental
and be pulled PARALLEL to margin of prep amalgam?
- When carving perpendicular, carver should be Iron
pulled from ENAMEL to AMALGAM to avoid - Know difference btw over triturated and under
overcarving triturated amalgam via pictures
*Flash may lead to FRACTURE of amalgam and - Amalgam needs bulk at its margin because
DITCHING of the margin* It is brittle
• Check occlusion w/articulating paper and adjust as
needed Class I Amalgam Preparations
- Shiny spot: once amalgam initially sets and pt • Principles of Cavity Preparation
bites down leaving a shiny spot – usually means - Cavity prep is the mechanical alteration of
occlusion is high defective, injured or diseased tooth
- Can also check occlusion w/shim stock and - Should minimally impact the remaining tooth
hemostat; anterior and posterior to restored tooth structure and be as conservative as possible
• Polishing - Must gain access to decay/remove unsupported
- Produces a smooth surface that is MORE enamel/friable tooth structure
RESISTANT to CORROSION and PLAQUE - Provide access for restoration placement and
finishing
- *Restoration should reestablish a healthy state
including normal form and function*
Class I Amalgam Preparations Class I Amalgam Preparations, Con’t
• Direct Restoration - Cavosurface margin: junction of cavity prep and
- Preventative resin restoration EXTERNAL surface of the tooth
- Composite restoration - Cavosurface angle: the angle formed at the
- Amalgam restoration cavosurface margin btw the cavity prep and the
• Amalgam indications external surface of the tooth (should be 90°)
- Class 1, 2, 5 and 6 • Pit and Fissure Caries Diagnosis
- Where esthetics is NOT important - Visual
- Moderate-large size - Tactile w/explorer
- Heavy occlusal contact area - Radiograph
- Cannot be isolated well, more moisture tolerant - Transillumination
than composite - Diagnodent
- Extends onto root surface - Caries die
- As a foundation for a full coverage restoration • Pulpal Depth
“build-ups” - Remember, amalgam is BRITTLE and needs at
- In a tooth serving as an abutment for an RPD least 1.5mm thickness on occlusal
• Steps in Cavity Preparation - 1mm thickness is okay on B, L, M, D b/c no
*One’s Renal Retention Can Require Finding Toilets* occlusal forces
1. Outline form – outline of cavity prep on surface • Preparation Walls
No more than ¼-1/3 intercuspal distance, - Distinct rounded internal line angles w/smooth
minimum of 1mm wide; marginal ridges in tact walls
2. Resistance form* - Smooth pulpal floor
Shape of cavity prep to prevent: - M/D walls slightly DIVERGENT (resistance)
Fracture of restoration (needs bulk) Helps preserve marginal ridge
Fracture of tooth structure - B/L walls slightly CONVERGENT (retention and
LATERAL displacement resistance)
3. Retention form* *If these steps are not met, the tooth could FRACTURE or the
Shape of cavity prep to prevent: filling could LIFT OUT!*
VERTICAL displacement • Quiz Questions
4. Convenience form* - Which step in cavity prep helps prevent tooth
Extend the outline form to allow for: fracture?
Observation of all internal aspects Resistance form
of cavity prep - What is the cavosurface margin?
Access for instruments used in Junction of the external tooth surface and
removal of caries the cavity prep
5. Removal of caries – atraumatic to pulp; minimize - Class 1 amalgam prep of #19 retention is achieved
further removal of good tooth structure from?
6. Finish of the preparation – planning and Convergence of opposing buccal and lingual
smoothing walls/margins; removal of loose enamel walls
rods; smoothing rough edges of margins; bevel, - The initial pulpal depth of an ideal amalgam prep
chamfer, butt joint, etc. should be?
7. Toilet of the preparation – removal of debris from 1.5-2.0mm
cavity prep (air/water syringe); disinfection of
cavity prep (chlorhexidine, HEMA) Class 2 Amalgam Preparations
• Walls and Floors • For this class, we’ll be treating a class 2 carious region
- Walls – PARALLEL to long axis of tooth that has MINIMALLY reached into the dentin
- Floors – PERPENDICULAR to long axis of tooth • Walls and Floors
- Walls – PARALLEL to long axis of tooth
F, L, M, D and now AXIAL wall
- Floors – PERPENDICULAR to long axis of tooth
Now pulpal and GINGIVAL floor
- Now, axial-pulpal line angle
• Requirements for Class 2 Amalgam Preps
- 90° cavosurface margins
- Adequate depth for thickness of amalgam
- Adequate mechanical retention
- Outline form
Carious pits/grooves
Proximal/gingival contacts properly
- Line angles: intersection of 2 surfaces (walls or
extended (open UP TO 0.5mm, ~width of probe)
floors)
No more than ¼-1/3 intercuspal distance
- Point angles: intersection of 3 surfaces
Class 2 Amalgam Preparations, Con’t
- Resistance form
1.5-2mm pulpal depth
Slightly rounded internal line angles
90 degree cavosurface margins
Beveled axialpulpal line angle
Flat pulpal and gingival floors
Occlusal dovetails
- Retention form
B/L occlusal walls CONVERGE toward O
B/L PROXIMAL walls CONVERGE toward O
- Convenience form
0.5 separation of box from adjacent tooth
Insures all caries removed; aids in
restoring tooth
- Removal of Caries
- Finish of Preparation
Bevel axialpulpal line angle w/gingival margin
trimmer
- Toilet of the Prep
*Gingival floor of box is 1.2-1.5mm, axially!

• Quiz Questions
- The occlusal isthmus of a class 2 amalgam
restoration is MORE RESISTANT to fracture if the:
Axiopulpal line angle is rounded
- In the initial prep, the proximal box on a class 2
prep should extend axially how far?
0.2mm into dentin
- Interproximal caries tend to form where?
B (interpoximal, at CONTACT)

Polishing of Amalgam Restoration


• Prior to Polishing
1. Amalgam must have been set for at least 24
hours
2. Basic anatomy should be carved PRIOR to set
3. Restoration must NOT be in HYPEROCCLUSION
Occlusion should be on sound tooth
structure, if possible
No marginal ridge contact
Cusp/fossa relationship, if possible
Marginal ridge contour should be
anatomically correct
KNOW: Must FINISH BEFORE POLISHING!
• Necessities
- 16 flute finishing burs (round end taper; 7801)
- 30 flute round end taper finishing bur
- Round finishing burs (H41-018;H41-014)
• Procedures for Polishing
1. Refine occlusion if needed (use multi-fluted
finishing burs)
2. Refine anatomy
3. Finish to cavosurface margins of prep
4. Use WET PUMICE w/webbed prophy cup to
smooth roughness
5. Use TIN OXIDE with fresh webbed prophy cub to
achieve a mirror-like finish

*Time to complete polish: 12 minutes!*

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