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Amalgam Restoration I [continue]

** First I want to point that the doctor spends most of the lecture reading from the slide, and she gives us only the handouts so I don't have the pictures in the slides. So I'm sorry but I did my best to make the lecture easy to study. ** This the last lecture in midterm exam material. All what we will talk about it in this lecture will be included in the mid exam which is in the Thursday 17\11. The doctor continue the rest of the last lecture which is [Amalgam Restoration I] and she said these two lectures which talk about amalgam is a repetition of what we took in the lab

Convenience Form
As always I say the cavity should be wide enough for instrumentation as we talk in cavity preparation; the cavity should be wide\ large enough for me to be able to see it and instrumented Instrumentation meaning: [cleaning or removal of the caries avoiding the pulp] and then making or placing the restoration. In proximal lesions, the access should whenever possible avoid extension beyond what is necessary to access the proximal lesion & the adequate retention form, so it will be a balance between resistance and retention and convenience form. So the cavity will be wide enough to be able to see it and instrumented but we should maintain a proper outline form convenience form and resistance form. If occlusal lesion is present, it should be treated separately whenever possible; suppose we have class I and class V for example I shouldn't connect them together unless it needed; if the caries are undermined or already connected whenever possible I should leave each cavity alone Unless we have minimal tooth structure between two cavities then I have to connect them together.

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Removal of Carious Dentin

Finishing the Enamel, all enamel margins should be 90 [the margin between the prepared tooth surface and unprepared tooth surface] In class II we talked about S curve we should have S curve to maintain 90 on order to maintain good tooth structure because if it less or more than 90 the tooth structure will fracture . So when we have here S shape on the buccal we will have 90 angle and we will have a good thickness of amalgam to give enough tooth structure to resist the fracture.

Student asked and the doctor said: If we draw a line parallel to unprepared tooth structure and another line parallel to the prepared tooth structure the angle between them should be 90 ok.

Class I Buccal Pit Amalgam Outline form: [we did already this in the lab]
All of pit area and any portion of buccal groove that is carious or potentially carious, outline form follow the caries. Sometimes buccal pit will be like triangle so the outline form should be triangle dimension the same the diameter 1.5 mm the depth [axial depth] 1.5 -2 mm. And if the outline form is a capsular shape so the cavity should have capsular shape
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So again according to the outline of the caries if it is round [as we suppose in the lab] the outline of the cavity should be the same.

Resistance Form
Mesial and distal walls are parallel or slightly divergent toward buccal wall this if the pit was large. Occlusal and gingival walls are parallel or slightly divergent toward the buccal surface, retention come from the occlusal and the gingival The axial wall depth is 1.5 mm or just inside the DEJ, the axial wall follow the external contour of the buccal surface of the tooth, the axial wall should be convex. Look here in the picture!!! There is a something in the gingival floor We have what we called retention groove some time if the buccal pit is large and we can't form the primary retention form for occlusal and gingival wall we add retention do you remember when we talk about the principle of cavity preparation we talked about something called auxiliary retention features; it's a retention groove made in the gingival floor to aid or to increase retention, sometimes if it is large the buccal pit it need extra retention so we add retention groove. And a gain the doctor is reading the slide but this time quickly!!

Retention Form
In ideal size buccal pit, no need for additional retention. In large size preparations, retention grooves can be placed in Mesial, Distal or gingival walls, but most commonly in gingival floor Class I Occlusal Amalgam [this is a repetition ,we already talked about this!! ]

Outline Form
Include mesial and distal pits. Central, buccal and lingual grooves. Free flowing outline form with no sharp corners or angels. All faciolingual width should be 1-1.25 mm except at the intersection of grooves.
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We have exception!! For example Class I in lower six it is one cavity but class I in the upper six is two separate cavities because of the oblique ridge So I have an exception I have two separate cavities and two separate restorations, these exception is: Mandibular first premolars we have triangular ridge here so I have separate cavities Maxillary molars we have one cavity mesially and one distally

Resistance & Retention Forms:[still talking about class I]

Pulpal floor should be at right angle to the long axis of the tooth. So when we prepared class one it should be parallel to the long axis of the tooth so I put the pair parallel to the long axis of the tooth to make a flat pulpal floor. Except of the mandibular first premolar (angled lingually). We know that always pulpal floor is at right angle [90] except in mandibular premolar why? because the pulp in the buccal is higher than the lingual so there is possibility if I make it the pulpal floor at 90 angle to expose or injuring the pulp because in the mandibular premolar the buccal cusp is more prominent in relation to the lingual cusp they are not in the same level but in upper premolar the cusps almost in the same level so the pulpal floor in angled plane as same as the occlusal plane, it is not at right angle . Pulpal depth: it should be 1.5-2 mm [half the length of the pair we use it in the lab] Buccal and Lingual walls are parallel or slightly convergent occlusally [ already we took this in the lab] Mesial and Distal walls diverge occlusally we said the retention in class I always come from the buccal and lingual walls. mesial and distal will not add a lot in the retention because they are small walls but always make them parallel or slightly divergent. Slightly divergent will make this angel 100 to avoid weakening of the marginal ridge or undermining the marginal ridges [as you did in the lab its ok you do it straight] So if we make it convergent that will weakening the marginal ridges

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I always tell you to let the thickness of the marginal ridge 1.5 mm to avoid the fracture of the marginal ridge [ this is also we talked about it in the lab]

Class I with Buccal Extension Outline form:

Same as Class I Buccal groove is extended to include buccal pit [we do it also in the lab] Depth pulpally:1.5-2 mm Depth axially:1.25 mm to 1.5 I will accept it.

Resistance & Retention Forms: [ also we already took this in the lab!
So it's a repetition] Pulpal floor should be at right angle to the long axis of the tooth Buccal and Lingual walls are parallel or slightly convergent occlusally in class I Mesial and Distal walls: On occlusal diverge occlusally. Those on facial extension are parallel so the retention here come from the mesial and distal Retention grooves: Grooves in Mesial, Distal walls if we have a large buccal extension and we don't have enough retention on mesial and distal wall sometime we put retention grooves here .

Class I with Palatal Extension [all this in the manual and we talked
about it in the lab]

Outline Form:
Mesial: Central pit, mesial pit, of buccal groove. Distal: L shaped preparation. Include distal pit and lingual groove. Pulpal depth: 1.5-2 mm Axial depth: 1.25-1.5 mm

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Resistance & Retention Forms as we talked previously

Buccal and Lingual walls: Parallel or slightly convergent Mesial and Distal walls: Mesial diverges. Distal wall is vertical Mesial and Distal walls of the extension: Parallel Retention grooves in the lingual box. In Mesial, Distal walls, from gingival to pulpoaxiall line angle. I will talk about this because we didn't take it before, again if it is large the palatal extension and there is not enough retention I can put auxiliary retention features so in the Mesial and distal wall I put retention grooves. Always the retention grooves should be in dentine not in enamel because in enamel will cause scratch we put it in the dentine from the gingival floor below the pulpoaxial line angel Retention groove: is a small groove we make it inside the DEJ from the gingival floor below the pulpoaxial line angle And by this we finished the previous lecture and now we will start with today lecture.

Amalgam restoration II
We will talk about: Class II amalgam restoration Class V amalgam restoration [usually you don't do it a lot in the clinic because we now put more esthetic restoration like composite and GIC so we don't do a lot of class V amalgam restoration and because of the lake of the time the doctor didn't put it in the lab but it is here in the lecture so we should know about it] Amalgam Mixing and Placement

Class II Amalgam Preparation

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This the definition : Cavity preparation for caries that originate in the proximal surfaces of molars and premolars.

As I said before because there is an adjacent tooth and we have to access the area below the contact and the only access available for us is the occlusal access for that we come from the occlusal on order to reach the caries and remove them. Why we do like step in class II?? In order to avoid the pulp and protect more tooth structure. Usually interproximal caries starts just below the contact point This is in incipient lesion [the early lesion] usually in the clinic we can't see it because the marginal ridge is intact so most of the time this can be seen only in the radiograph Sometimes it become larger and grayish discoloration of the marginal ridge is happened, the shadow of the caries will appear through the marginal ridge like grayish shadow because enamel is start to demineralize. later on when the caries extend to the DEJ the marginal ridge will breaks down and cavity will form so it easy to remove the caries because the marginal ridge already breakdown but in incipient caries the marginal ridge is still intact.

Occlusal outline form

If a groove is not carious, it should not be included in the outline. Faciolingual width is approximately 1 mm except at the intersection of grooves.Like what ? class I occlusaly will do what we called in the lab [dove tail] for more retention for class II

Proximal Outline Form [This the box]

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The cavity should be extended buccally and lingually to break the contact with the adjacent tooth. How much the dimension buccally and lingually or gingival? It depends on the adjacent tooth I can't say for example that from buccolingual this 2 mm gingivally 1 mm this is wrong I'm talked about class II in general; class II is a class II whenever it is in molar or premolar ,upper or lower. So for example if I'm doing class II on the mesial of the six it will be the same as distal to the six but the dimensional will be different why ? because the proximal adjacent mesialy is the premolar and adjacent distally is the seven[second molar] So extension buccally and lingually to break the contact with the adjacent tooth. The gingival wall should be extended gingivally to break the contact with the adjacent tooth . Why we do break to the contact ? to be able to place matrix band later on to do the amalgam restoration and be able to finish it. of curse the access is from the occlusal .. I will do class I first then I will do the box; we did this in the lab !! Buccal and lingual walls should be parallel. Retention for class II buccal and lingual should be parallel or slightly convergent toward the occlusal

Resistance Form
Buccal & lingual walls of the occlusal part should be parallel or slightly convergent occlusally, as the same as class I !! Well defined internal line angles. What we mean by this ? it mean it is not sharp there is a difference between well defined and sharp; well defined mean when I point to the cavity I said this the lingual wall this the buccal wall this the pulpal floor .. but it is not sharp . Occlusally should be about 1.5-2 mm ,1.25 -1.5 mm mesiodistally. Parallel or slightly convergent buccal and lingual walls of the box. Well defined internal line angles and point angles. Buccal and lingual proximal walls should meet the external portion of the tooth at 90. S shaped or reverse curve buccal outline. The axial wall should be just inside the DEJ, about 1.25 mm in depth, It should be convex to form the outer surface of the floor .
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The buccolingual contour of the axial wall should be parallel to the proximal surface of the tooth. This very important because the most fracture of amalgam in class II is happened here at the marginal ridge so you have to do Roundation for the pulpoaxiall line angle.

Retention Form
Retention form in Class II comes from Occlusal : [dove tail] sometimes it is large and I have to dot retention grooves to increase the retention. pointing to the picture in the slide !!this a retention groove and this a retention groove as we always say the retention groove should be inside the DEJ along the linguaxial and the buccuaxial line angels not on them why? Suppose that the caries is so deep that extend the axial wall is very close to the pulp so if I put my retention groove on the line angel there is a possibility in injuring the pulp so the groove should be inside the DEJ along[ mean parallel to] the linguaxial and the buccuaxial line angels The groove extends from the gingival floor to the pulpal floor. Not to the external surface of the tooth why ? Because it should be in dentine not in enamel because the enamel brittle so when I make groove, it will fracture. Retention is made in the buccal and lingual wall with (small) round bur, retention grooves aid in retention as well as strengthen the restoration

Class V Amalgam Preparation Outline Form

Let's talk a little pit about this because we didn't make it in the lab Usually determined by the extent of caries. We always as far said that the outline form follow the grooves and fissure when we do class I for example we follow the grooves but in class V the caries will be buccal or lingual we don't have grooves so we don't follow the grooves the outline depends on the caries the extension of the caries where there is caries I should follow them I should remove whole caries this why usually outline form determined by the extend of the caries or the lesion, so all carious

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lesion and decalcification that is not hard should be included in the outline form Occlusal cavosurface margin should be parallel to the occlusal table and gingival cavosurface parallel to the gingival floor. Generally speaking about 4 mm wide mesiodistally and 2 mm wide occlusogingivally,but remember always we should follow carious lesion.

Resistance Form
Mesial and distal walls are divergent toward the external tooth surface. Why? Because the direction of enamel prisms direct me. So I should let the mesial and distal wall divergent a little bit on order to give 90 cavosurface margin. Retention comes from the occlusal and gingival walls and they should be parallel to each other. The axial wall is: 1. just inside the DEJ, 1.5 mm deep at the occlusal wall, 1.0 mm at gingival. 2. convex follow the contour of the tooth parallel to the external surface of the tooth.

Retention Form:
Retention grooves in dentin should be made in the occlusal and gingival walls near the internal line angles. The grooves should not be placed in the mesial and distal walls ,because it will undermined enamel .

Amalgam Mixing and Placement

Mixing the Amalgam Trituration of the amalgame meaning: mixing the mercury with the alloy powder. Electric amalgam mixers (amalgamators), already we saw this in the lab Amalgam pellets and bottled mercury is still in use. We have previously amalgamator with tow containers we put the alloy in one container and
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mercury in one container then they mix them together, but the cpsule amalgam is better . Precapsulated amalgam alloy is recommended ; provide more consistent mix.[ the mix will be proper] Eliminate the possibility of mercury spills. Because of that we now use the amalgam capsule . The duration and speed of trituration of amalgam should be just enough to coat all the alloy particles with mercury. Over mixing of the amalgam will set prematurely and this will prevent enough condensation and adaptation of the amalgam. So we should avoid the over mixing of the amalgam we should use the recommended mixing time for example they put 7 or 9 or 11 seconds . But in the lab we change the time to give you more time to condense the amalgam more and finish it, but in the clinic it should be set according to the recommended mixing time [ from the manufacture]. Over mixed amalgam is dry and coherent. Under mixed amalgam is dry, but crumbly.[ is not one piece because there is excess mercury] Well mixed amalgam is shiny & coherent.[ mean Homogeneous] its one piece not dry or crumbly it should be one mixed smooth coherent and shiny. Mixed amalgam is placed in the amalgam well. Amalgam should be used directly after mixing. because we have limited working time so I told you in the lab that you should prepare your instrument before starting mixing the amalgam and prepare the cavity , clean the cavity , and then you ready to put amalgam Condensation of the Amalgam Condensing is: the process of compressing and directing the amalgam in the cavity with the amalgam condenser. Amalgam carrier: is used to carry the amalgam in increments to the cavity. We should not put the amalgam in one piece why? To avoid voids and when voids happen that mean the thickness of amalgam is not even all the way, and will this lead to amalgam fracture.

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The cavity should be overfilled and then carved back in order to eliminate voids and remove excess mercury. By the way when I remove the excess amalgam I usually remove the excess mercury. Amalgam should be condensed both vertically and laterally to adapt it to the walls. Especially on class II ,to avoid any deficiency in the buccal and lingual walls not only vertical but lateral condense it, you will notice you condense amalgam, carve it and remove matrix band then you discover that there is a deficiency on the buccal and lingual walls then you have to repeated the amalgam.

Condensation forces:
How much the forces I should put on the amalgam ? usually the force should be 2-5 kg for admixture & conventional amalgam. ? It result in slight movement of the patients mandible or head. So sometime I should support the patient mandible because I want to condense the amalgam very well and I don't want the head of the patient to move. Less condensation is required for spherical alloy. Small condenser should be used initially and in small areas larger condenser for overfilling of the restoration. There is something we call it Precarve Burnishing It is burnishing prior to carving with large burnisher., it's immediately after condensation. Heavy strokes in the mesiodistal & buccolingual direction. Produce denser amalgam at the margins of the restoration The first step in shaping the occlusal surface of the restoration.

Carving of Amalgam
Carving should create contours and occlusion that reproduce the missing tooth structure. The carver should rest on the enamel adjacent to the preparation and be pulled in a direction parallel to the margin of the preparation. This what I talk always about it you should put the tip of the carver in the center grooves and side of the caver should be on the amalgam to remove amalgam and carve tooth structure so the tooth structure will form a guide for me how much amalgam I should remove .
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Amalgam should not be over carved leaving the groove anatomy deep. Because I will take from the thickness of the amalgam and it will become susceptible to the fracture and it become more difficult for the patient to do oral hygiene. If the anatomy is shallow, it may affect occlusal masticatory function or create occlusal interferences. So the amalgam should be carve well not deep or shallow. Amalgam restorations should ideally have 75 to 90 degree amalgam margins. Ideally, carving should be completed within 6 minutes of amalgamation.

Placing amalgam in Class II cavities.

Types of retainer : The Universal Tofflemire Retainer Contra-angled Tofflemire retainer. Component of the Tofflemire Retainer 1. Set screw 2. Rotating spindle 3. Slide 4. Head 5. Band Matrix Band Ideal Properties of the Matrix Band : Easy to apply & remove. Extend the below the gingival margin. Extend above the marginal ridge height. Resist deformation during material insertion. Shapes of Matrix bands: look to the previous picture ! 1. Universal matrix band 2. Type # 2 (MOD) band. 3. [Type # 3] band. The most band we use it is the universal band 2 and 3 we use it when the caries extend very deep gingivaly then we have something to extend gingivaly

1 2 1 3

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Wedge: [we use it in the lab] it's like a wedge !! Obtain a tight proximal contact. Obtain proper interproximal contour. Prevent gingival overhang. [ excess amalgam gingivaly ] we should avoid it ? because any excess amalgam gingivaly will cause irritation to the gingival and periodontal problems later on. And another use is to protect the gingiva during preparation. Many different shapes and sizes of plastic and wooden wedges. Most commonly used is the triangular shape. Because the embrasure is triangle, the wedge is placed in the wider embrasure, usually the lingual. Correct Position of the Wedge: The wedge should be below the matrix band The base of the wedge should be gingival to the gingival margin. Incorrect Position of the Wedge Can cause concavity in the matrix, and this concavity can transfer to the amalgam.

Postcarve Burnishing [this is optional]

Light rubbing of the carved amalgam with a burnisher to smooth the surface of the restoration. The amalgam can be wiped with water-damp cotton roll for additional smoothening.
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Adjusting the Occlusion

Occlusion should be checked with an articulating paper. Ask the patient to very gently to tap the posterior teeth together. Interferences should be checked first in maximum intercuspation, and then in eccentric movements This when we finished the amalgam we should ask the patient if there is a high spot, if yes we have to use articulating paper. The exam will be until here, the last three slides are not included in the ex am . The exam will be online in the Thursday after the Eid 17\11 at the time of the lecture 9:15 am in 10H 3,4 and N2 Forgive me for any mistake ..

The End. Done By : Duaa Walid Abu Hmaid

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