Conservative Dentistry: Lecture # 5:

This lecture is divided into 2 parts ( cavity preparation / amalgam restoration) Note: I dont have the slides, so I didnt include any pictures in the tafreegh.

Cavity preparation II :
So we are going to finish what we started last time.. In the previous lecture we talked about caries and caries removal..

When we do an ideal cavity preparation we assume incipient caries or early carious lesions, But if we have a large carious lesion (moderate large) we have to deal with it.

Sequence of caries removal:

1. Entry is made in conventional manner with a high speed fissure bur. We have a solid enamel, and this enamel is undermined by soft caries.. Enamel cannot be removed with a slow speed bur, so we use a high speed bur to access the cavity and remove the caries. 2. Ideal depth & width are established, ignoring the carious tooth structure. We have to establish an ideal depth & contour outline regardless of the caries.. I dont go to the whole depth of the caries.. I only go to the ideal depth which is 1.5 mm. We do not remove caries with the high speed burwith the high speed bur I only make (entrance, access, and I make the initial depth)

3. Caries extending beyond the limits of the ideal preparation is removed with the largest round bur that will fit into the area. -The excavation of caries is made by a slow speed large round bur, why?!! -To avoid early exposure of the pulp. 4. The caries removal process should begin peripherally in the DEJ areas. Then caries removal should start at the periphery, we start with DEJ Whether I was working on class I, II, V, we always start with the peripheries, then I go to the pulpal wall (axial wall) in case of class I and class II. 5. Caries in areas involving potential exposures, such as the axial and pulpal walls should be removed last. Sometimes, we can deal with the pulp (exposure of the pulp) without doing Root canal treatment..(procedures that youll learn later).. We can deal with that using restorations. So we make sure that the whole caries has been removed from the peripheries, then we go pulpally or axially 6. The criterion followed for caries removal is hardness which can be checked with spoon excavator.. Only those areas that are soft should be removed. The best indicator for caries is NOT the color, but the hardness.. So we stop when we feel that the tooth structure is hard, this means that we removed all infected dentine (soft dentine). 7. After all caries has been removed, the preparation is re-evaluated for undermined enamel, resistance form and retention form. Undermined enamel: is enamel unsupported by dentine. Undermined enamel should be removed because its weak and susceptible to fracture. 8. All undermined enamel areas should be removed with the high speed fissure bur and an attempt made to reestablish lost retention and resistance form. So again, why do I use the high speed bur? Because enamel cannot be removed using the slow speed bur. So the good cavity preparation should have: - No undermined enamel. - Good resistance and retention form.

9. The pulpal floor should be flattened only at ideal depth. The entire floor should not be reduced to include one isolated carious area.

You should not go beyond the ideal depth and remove sound (not sure of the word) dentine.. Because if we reduce the ideal depth we lose more tooth structure and more retention and resistance and will be closer to the pulp, and as we said the best protection to the pulp is dentine. The end of part 1

Part 2

Amalgam restorations:
We are going to take two lectures about amalgam restorations.. this lecture and next weeks lecture.. then the eid holiday, after that we have the exam.. so exams material is going to be till the end of amalgam.. Which means we have 6 lectures for the exam. In dental materials, You studied the part related to the chemical/physical properties of amalgam. But here, we are going to take the part that is related to the conservative dentistry..

Whats amalgam?! Amalgam = Tin-silver amalgam alloy + mercury So Tin-silver alloy mixed with mercury to form dental amalgam, we use the amalgamator to mix them together..so its a chemical set which means we have a limited working time. Thats why you should work efficiently because of the limited time.

Classification of dental amalgam:

Dental amalgam can be classified according to copper content into: This is the most common classification. 1- Conventional amalgam alloy (low copper alloy) 2- High copper alloy (used now)

Or can be classified according to particle size and shape into: 1- lathe-cut alloy 2- spherical 3- admixed You took this way in dental materials, and you learned how each shape is made.

Copper content: - The amalgam alloy consists of silver, tin, copper, zinc. - The conventional alloy contain 0-6% by weight, while - High copper alloy 12-30% by weight. - All what we use now in the clinic is high copper alloy, because all the physical properties increase as the copper content increases.

Conventional Vs High Copper Amalgam Alloy: High copper amalgam alloy have superior resistance to discoloration, corrosion, marginal breakdown, and creep compared to conventional amalgam. So all the physical properties were improved by the increase of copper in the alloy.

Particle size and shape: The shape of the particles will affect the setting time and condensation of the amalgam. 1- lathe-cut alloy: has sharp angles and irregular shape. 2- Spherical alloy: balls (spheres) in shape. 3- Admixed: mixture of the two, so it has properties intermediate between the two.

Spherical Vs Lathe-cut: Spherical alloy particles require less condensation pressure than lathe-cut fillings. Why? Because the irregular shape of the particles in lathe-cut require more pressure during condensation to condense the particles together, and the spherical requires less pressure.. If we use a small condenser with the spherical shape, the particles will escape .. so we have to use a large condenser when we have a spherical shape. Imagine that the spherical alloy as a box full with balls, if you press on one side the balls will escape to the other side. The same for the spherical if you press (condense) it, the particles will escape up and to the margins, so the spherical alloy requires care in condensation to get good contact. Again, the spherical shape requires less pressure, but it needs a larger condenser. And because of that, we dont use the spherical shape of amalgam in class II, because the contact with margins is better with the lathe-cut. spherical alloy particles have less mercury content since less mercury is needed to coat the particles during amalgamation (amalgam mixing), comparing to lathe-cut alloy which has irregular particles so it needs more mercury to cover all the particles.

Again: Spherical alloy: - Requires less pressure for condensation. - Needs less mercury to cover the particles. - Needs a larger condenser to have a good condensation. In class II we use admixed or lathe-cut alloy.. why? The spherical is not suitable for class II because it will not form a good contact. spherical high copper amalgam is the fastest in setting.. and admixed is the slowest in setting. It is important to know which has a faster setting time, because the setting time affects the working time, so if we have small cavity like class I we can use the one with short working time (spherical), but if we have a large cavity we have to use the one with longer working time to be able to condense and carve it.

Advantages of amalgam:
1- Strong. 2- Durable: lasts for a long period of time. Theres what we call longevity << how long the restoration will stay in the patients mouth>> For direct restoration (we compare direct restorations together: which we use directly in the clinic e.g. amalgam, composite, GIC) So amalgam has the highest longevity between direct restorations. Durable means that it can withstand forces, pressure, and stay in the patients mouth for a long time (longevity).

3- Relatively easy to use. If you compare amalgam to composite for example.. Compsite has many stages and its more complicated, whereas in amalgam, we make a cavity, put the amalgam and then condense it.

4- Low-technique sensitivity. Again, compared to composite for example, we need to do isolation, no water, no contamination, but in case of amalgam, its less sensitive. 5- Marginal sealing with time: amalgam is the only material that causes marginal sealing with time. You should know that always there is a gap between the restorative material and the tooth structure; we call this gap micro-gap (micro means in micrometers, very small). No material can fill this gap..even if you do a good adaptation, it will remain. But the only material that will seal with time is amalgam. This sealing occurs because of a process called corrosion to amalgam, the corrosion will seal this micro-gap with time. (Although this process considered as a disadvantage, it can be useful here). -So amalgam is the only material that causes marginal sealing with time. 6- Antibacterial properties: the bacteria cant attach to it compared with other materials like composite for example. Note: when we compare materials, we compare direct materials together and indirect together.

7- Wears at rate similar to that to tooth structure: wear: is the loss of tooth structure as a result of contact with another material (opposing material). Now if two teeth come in contact for long period of time they will take from each other in the same amount because they are the same material, what happen if we do a restoration to the opposing tooth? The rate will differ because the relation become tooth-restoration. But if this restoration is amalgam the rate will be similar to that if we have tooth. 8- Least time consuming and has the lowest cost.

Every material in dentistry has advantages and disadvantages.

Disadvantages of amalgam:
1- not tooth colored (silver in color). 2- susceptible to corrosion and galvanism.
although corrosion is decreased in high copper amalgam.. but still its susceptible to corrosion.

3- does not bond to tooth structure.

we need to have mechanical retention in amalgam.. which means we have to take more of the tooth structure to make mechanical retention..so this is a disadvantage.

4- contains mercury.

Indications: means where do we use amalgam, in which situations do we use it.

Where do we use amalgam?? 1- We use it in (class I, II, V ) restorations in posterior teeth..why?! we cant use it in class III or IV (anterior teeth) and its not aesthetic. 2- Base build-up prior to crown preparation. This when we have a broken tooth and we need to crown this tooth, so we need to build up this tooth first (because we dont make crown on a broken tooth) using amalgam, then we do the crown.

Properties:

Adaptation: 1- We said that there is a micro-gap between amalgam and restoration that causes microleakage (Its always there, whatever material we use, its always found) 2- Condensation of amalgam in the cavity should be done efficiently and promptly to minimize this micro-gap.. As minimum as possible.. why?
Because: 1) bacteria will accumulate there and cause recurrent caries, 2) Irritation to the pulp, 3) sensitivity

3- Amalgam does not strengthen the remaining tooth structure, as more tooth structure is lost the possibility of fracture increases. In comparison to composite it strengthens the remaining tooth structure because it binds to tooth structure..whereas amalgam doesnt bond, so it does not strengthen the structure. Amalgam bonding: There are attempts have been made to bond amalgam with adhesive resin liners (means make amalgam like composite ) Some of the studies found good result in increasing retention and strength of amalgam but most of them are laboratory studies.

setting dimensional changes: 1- there is a number of dimensional changes during setting of amalgam (expansion & contraction) 2- most of this dimensional changes occur in the first 6 to 8 hours after mixing. thats why we tell the patient not to eat for 8 hrs after making a restoration. 3- factors that contribute to expansion are: - undermixing - excess mercury - moisture contamination (water, saliva) (it can affect the setting of amalgam) 4- factors contribute to contraction are: - overmixing, - increased condensation forces - the use of smaller particles alloy.

5- high copper amalgam have less setting dimensional change than conventional amalgam. (remember; all the properties are better for high copper amalgam than the low copper (conventional)

 Strength: This is very important, we said that amalgam is weak, so the depth should be at least 1.5 2 mm..why?! Because of the tensile strength of amalgam. 1- Amalgam tensile strength (tensile force when we tense two thing from each other) is lower than its compressive strength (compressive force is the force on the long axis of the tooth) so the fracture of amalgam occurs due to tensile forces. 2- so amalgam should have sufficient bulk to compensate for this weakness. Sufficient bulk is obtained by 1.5 mm thickness. 3- all margins should be 90 to minimize marginal fracture . 4-Factors that contribute to increased strength of the amalgam is: a- Removal of excess mercury during condensation b- increase condensation force to eliminate voids (amalgam should be condensed in increments to avoid voids, if we have voids in the amalgam this means the thickness of the amalgam is less than 1.5 mm and that will affect the strength of the amalgam.) 5- decrease strength will result from undermixing or contamination during placement.

setting speed: This is important clinically, because we have limited time to work with the amalgam.. and this is related to the particles size. 1- The fastest setting time is the high-copper spherical amalgam.. We use this in small cavities, like class I. 2-the high copper admixture & the low copper spherical have intermediate setting time (we use it in moderate cavities) 3- the low copper lathe-cut amalgam is the slowest in setting. (if we have large cavity it is better to choose lathe-cut amalgam, because we need time for the condensation and carving)

4-the working time is related to the setting speed. The more the setting speed the less the working time. 5- manufacturers classification: - fast-set: usually it is high copper spherical. - regular-set: it is admixed high copper. - slow-set: it is high copper lathe-cut. 6-alloy that is selected should have appropriate working time.

Creep: It is deformation due cyclic load( force). As you know the forces inside the patients mouth are cyclic ( repeated for a long period of time) 1- The permanent deformation of set amalgam when it is subjected to mild, continuous or cyclic forces. 2- Can result in marginal or proximal extrusion of amalgam restorations. So these margins maybe subjected to break and produce open restoration. 3- High copper amalgam alloy has lower creep than conventional amalgam alloy..(as any other physical property) 4- Creep of conventional amalgam is influenced by - Increasing mercury. - Incorrect mixing time. - decreased condensation to a greater degree than is the creep of high copper amalgam.

Corrosion: 1- It is the slow deterioration of amalgam in the oral environment. 2- Initially can result in pitting and discoloration of the surface of amalgam. 3- If proceeds it can weaken & cause fracture of the amalgam.

4- One advantage of amalgam corrosion is the filling of the marginal gap with the corrosion products. the only advantage 5-Two types of corrosion chemical and electrochemical.

So, now this is a revision of what we took in the lab, its in the slides, and its included in the exam. Cavity preparation for amalgam:

Outline form: 1- The cavosurface outline should be continuous curved line, especially on occlusal surface. It is difficult to condense ,carve & burnish amalgam in sharp angles.
we said that the surface should be smooth and has no sharp angles.

2- The outline should be kept as conservative in width as possible (and as small as possible), removing only carious & potential carious pit & grooves. 3- The cavosurface margins on the proximal surface should not touch the adjacent teeth or restorations from all direction buccal, lingual & gingival. Resistance form: 1- the pulpal &axial walls should be in dentin. And the cavity should be box in shape with 1.5 mm depth and should be in the DEJ 2- the pulpal floor should be flat & smooth. The axial walls should be convex &follow the contour of the surface of the tooth. 3- Cavity depth and width should be enough to create sufficient bulk to the restoration. (1.5 mm pulpally, 1.5 mm proximally) 4- The opposing walls of the cavity preparation should be parallel or slightly convergent toward the surface of the tooth.

5- All cavosurface angles (the angle between the prepared and the unprepared tooth surface) should be approximately 90.. why 90? - Its important For the enamel and for the amalgam - For the enamel: to avoid formation of undermined enamel and breakage of enamel. - For the amalgam: If it was more than 90, the amalgam will not have enough thickness, and it may break.

You can find this part of the lecture in your book art & science

Forgive me for any mistake =)

The End Thank you!! :D

Done by: Katia Suleiman
No matter how hard life slaps you in the face, always say ALHAMDULILAH It's not the load that breaks you down - its the way you carry it!!=D When life puts you in tough situations, don't say "Why me", say "Try me". You're tougher than you think...