Done By : Dr.

Mais Malol

This is a summary of what we have learned during 3rd year u may find it long but it is a very useful way to refresh your knowledge I used the slides and scripts of cons and dental materials courses hope u get benefit from it :D

Conservative Dentistry
Scope of Operative Dentistry Its The art & science of the diagnosis, treatment and prognosis of defects of teeth that do not require full coverage restoration for correction, also Prevention, preservation, interception & restoration. Diagnosis , by detecting of the lesion Treatment of the lesion Prognosis by knowing the outcome of our treatment (success or failure )

 Prevention by preventing the defects from happening preservation, by keeping the tooth healthy interception & restoration ,by interrupting the carious process and doing the restoration 90% of the defects of the teeth are caused by caries , but also we have other causes like trauma ,abrasion, erosion . We have two types of restoration Direct (intacoronal),which means putting the filling directly in the tooth (which will be covered in this course ) Indirect ,which means the full coverage of the tooth like crown ,bridges

Dental Caries

o o

Plaque with refined carbohydrates will result in demineralization At a certain point, the tooth is affected but it can be reserved by remineralization ,if the environment was suitable for reminerlization

If the carious process continues ,there will be a carious cavity and we need a restoration ( tooth is infected )

Classification of Dental Caries

Primary (initial) Caries: The process attacks the tooth surface for the first time, regardless of progression or extent. Secondary (Recurrent ) caries: The process attacks the tooth at the margin or margins of an existing restoration, regardless of extension or progression.

 Acute Caries: Involves a large number of teeth in the mouth, and destruction of tooth structure is usually quiet rapid.

Chronic Caries: Much lower progression of the lesion, and the average lesion size is smaller than in acute caries.

Active caries: Describe lesion that progressively destroys more tooth structure.

Arrested caries: Occurs when the active degradative process is interrupted or

ceases

Incipient caries: The lesion is confined to enamel and does not penetrate the DEJ.

Advanced caries: The lesion penetrates the DEJ.

Concentrate here

Location of the Lesion,

it can be

Pit & fissure caries: originates in developmental irregularities, most often in the occlusal surface of posterior teeth. Smooth surface caries: In smooth surfaces of crown of teeth. Root caries: Does not originate in crown of teeth, but rather on the root structure.

Classification of Cavities
Cavity: its the defect in the tooth, which is the result of caries.

Cavity preparation (prepared cavity): Is the result of specific operative procedure that has removed the caries or defect and shaped the tooth to receive and retain the restorative material.

Restorative material: That is used to restore the cavity, i.e. Amalgam,composite These restorative materials are direct,we prepare the cavity and put the restoration in the clinic

Restoration

Restoration=

The prepared cavity + the restorative material

Blacks Classification of Cavities Was put by J.V black the father of operative dentistry to form a common language between dentists . Class I Class II Class III Class IV Class V Class VI Class I Originate in structural defects of the tooth, such as pits and fissures. most probably pits and fissures occur in posterior teeth (premolars and molars ),but it can also affect the anterior teeth ,e.g. palatal pit in the upper lateral

when we say class I,

class I cavity

class I cavity preparation class I restoration

Class II Originate in the proximal surfaces (mesial or distal) of only posterior teeth molars and premolars. Again.. class II cavity class II cavity preparation class II restoration

Class III Originate on the proximal surfaces of anterior teeth ( incisors & canines) but do not involve the loss or removal of the incisal angle. Usually we use composite restoration for aesthetics class III cavity class III cavity preparation class III restoration

Class IV Involve the proximal surfaces of anterior teeth, and include the loss or removal of the incisal angle. Most of the times caused by fractures ,sometimes it may starts as class III and extends to Class IV ,and Usually composite restoration class IV cavity class IV cavity preparation class IV restoration

Class V Found in the gingival (cervical) third of the facial and lingual surfaces of the crown of any tooth. With the exclusion of cavities resulting from Class I pit or fissure caries For example .. On the buccal surface of the lower 6 we have the buccal pit if the caries are on this pit then its class I, but if the caries extend and spreads to the gingival it will be called class V class V cavity class V cavity preparation class V restoration

Class VI Its rarely happen Located on incisal edge of incisors & canines And on cusp tips of canines & posterior teeth.

Because we have some drawbacks to blacks classification, for example when we say class II we have to say Class II on the distal or Class II on the mesial so we have to be specific .. so we have other classification

Classification by Complexity
Simple: Involve only one tooth surface, Compound: Involve two tooth surfaces, for example in the picture occlusal and mesial Complex: Involve three or more tooth surfaces, for example in the picture mesial ,occusal, distal and lingual

Classification by Surface
Its the most specific Prepared cavities or restoration take the name of that surface or surfaces.

One Surface: i.e. O (occlusoal) Two Surfaces: i.e. MO, DO (mesio occlousal,desto occlusal) Three Surfaces: i.e. MOD (involve mesio occlusal and distal )

Components of Prepared Cavity

When we do cavity preparation ,each wall has a name Wall: The inclosing side of a prepared cavity that takes the name of the adjacent surface of the tooth , i.e. M, D. For example ,this is class I from the occlusal view(the first picture) ,when we prepare a cavity like a box inside the tooth ,This prepared cavity has inside walls from inside the cavity ,this internal wall is named according to the external wall of the tooth For example The wall at the buccal side is called buccal wall but we are talking about the wall from the inside(look at the arrows) ,so here at the same picture we have distal wall, lingual wall, mesial wall ,buccal wall and the plupal floor towards the pulp.

Only in class I the wall towards the pulp is called pulpal floor but any other its called axial In the second picture (class V) ,its different we have occlusal wall , mesial wall , distal wall ,gingival wall towards the gingival , and axial towards the pulp

The Dr said Here you have to imagine ,if you dont understand dont worry you will understand it later ..
this is a cross section from the proximal surface (mesial) of class II and there is a part of class I Class II .. has two components , occlusal part that extends toward the occlusal and proximal part (between the teeth either in the mesial or distal ) Look at the picture the occulsal part we call it the same .. for example in the picture distal ,facial .. class II the proximal part , there is facial ,lingual ,gingival and the one toward the pulp is called axial

 Line angle: The line, or angle formed when two walls of a prepared

cavity meet. It is named by combining the names of intersecting walls, i.e. Linguopulpal line angle(the meet of the lingual wall and pulpal floor), pulpoaxial line angle(the meet of the pulpal floor and axial wall) ,mesiopulpal line angle (the meet of the mesial wall and pulpal floor)

Point angle: The angle or corner formed by the junction of three walls of a prepared cavity. It take the name of the three walls that join to form it, i.e. Linuoaxiogingival point angle.( the meet of the axial wall ,gingival wall ,lingual wall) This picture is a proximal view of class III

 Cavosurface angle: The line or angle formed by the junction of a cavity wall with the unprepared surface of the tooth(you have just to know the definition and later on you will know more about it)

Principles of Cavity Preparation

1234Outline form & initial depth Primary resistance form Primary retention form Convenience form or old restorative material if indicated.

5- Removal of any remaining enamel pit or fissure, infected dentin

6- Pulp protection, if indicated. 7- Secondary Resistance & Retention Forms 8- Procedures for Finishing the External Walls of the Tooth Preparation 9- Final Procedures: Cleaning, Inspecting, and Sealing:

1-

The initial outline form: The borders of our cavity preparation.

When we drill the cavity we dont go to the full depth (the base) of the carious legion right away, instead we establish an initial depth. (Here the initial depth is 0.2 mm inside DEJ occlusally, 0.5 mm cervically), this means 0.2 mm inside the dentine occlusally and 0.5 mm cervically, and this is due to the variation of the enamel thickness. Occlusally the enamel is thicker; this is why we go less into the dentine, only a 0.2 mm would give us an initial depth of 1.5 mm in enamel and dentine. While cervicaly the enamel thickness is less so more depth is needed in dentine to establish the initial depth.

2. Primary resistance form:

"The shape & placement of the preparation walls that best enable both the restoration and the tooth to withstand, without fracture, masticatory forces delivered principally in the long access of the tooth" In other words, it is to prepare the cavity in a form that resists fracture of both the tooth structure and the restoration later on. In terms of the restoration we should prepare the cavity deep enough for the amalgam to be strong and resist fracture, so the depth should at least be 1.5 mm, consequently the amalgam thickness will be 1.5 mm, not less because the amalgam is weak in thin sections. But what about the tooth structure itself? How do we prepare the cavity in a way that resists fracture in the tooth itself? We keep the internal line angles of the cavity rounded, because stresses will become concentrated on those areas if they are sharp, leading to craze lines and fractures in the tooth.

The force we are trying to resist here is delivered principally in the long access of the tooth (Compression Forces).

Principles of resistance form: 1. Box shape with relatively flat floor: I should be able to distinguish the buccal and lingual walls, and the pulpal floor. In figure (A), the cavity is box-shaped, so the distribution of forces will be more even, however in (B) the distribution is not even, and can be more on one side than the other, which can cause the restoration to move leading to tooth fracture. Masticatory forces are directed along the long access of the tooth.

2. Keep the cavity as small as possible: Because the more tooth structure we remove, the less resistant the tooth is against fracture. So we should keep the cavity as

DEJ

small as possible, taking in consideration that all caries must be removed. This figure is a class 1 cavity preparation, upon doing this preparation, two principles must be applied:

Removing more tooth structure will: 1. Weaken the tooth. 2. Endanger the pulp because we are closer to it. 3. Cause irritation to the pulp because more dentinal tubules will be open causing mechanical and thermal conductivity to the pulp. 1. Maintaining a flat pulpal floor. 2. Removing the smallest amount of tooth structure as possible. The problem is that if I want to apply the first principle, I will have to remove a big layer of sound dentine that is not carious, because the caries are confined to a small area of dentine, so I sacrifice more tooth structure in order to keep the pulpal floor flat, this means that applying the first principle makes it impossible for us to apply the second one.

So how should I deal with this? I should make the pulpal floor flat by applying a liner or a base. In general I dont remove sound tooth structure to make the floor flat in such case. Pulpal & axial walls should be maintained just in dentin if at all possible: The initial depth in dentine should be maintained as small as possible (0.2 mm in dentine occlusally for example). If caries invaded the interjacent dentin, only the carious dentin should be removed.

3. Rounded well-defined internal line angles. Well-defined line angles aid in establishing uniform depth and prevent rotation of the restoration: the box shaped cavity has well-defined and rounded walls, with no sharp angles (Forces tend to be concentrated on those sharp angles and that makes the tooth more prone to craze lines and fracture). 4. Cap cusps or include weakened tooth structure within the restoration . (Will be explained later) 5. Provide enough thickness of restorative material to prevent its fracture. The restorative material may fracture if the cavity preparation is too shallow: because then the amalgam will not be thick enough to resist compressive forces. This is a class 2 cavity preparation: we need enough thickness of the amalgam proximally as we will discuss in details later. 6. To bond the material to tooth structure when possible. This is possible in composite filling for example. The resistance here will depend on the bonding of the composite to the tooth structure, so we will not concentrate on having well-defined rounded walls or box-shaped cavity, because composite will bond to the tooth structure increasing both the resistance of the tooth itself and the restoration against fracture. Factors Affecting Resistance Form: 1) Remaining tooth structure: Affect need and type of resistance form. 2) Type of restorative material: amalgam Vs composite.

3. Primary Retention Form:

The shape or form of the conventional preparation that resist displacement or removal of the restoration from tipping or lifting forces The resistance form is against compressive forces, other forces are resisted by the primary retention form, such as torsion, tension, shear and flexion. These forces can cause tipping or lifting of the restoration, but what we want is to keep the restoration inside the tooth structure, which is what retention means. Principles: (Depends on the restorative material) Composite Micromechanical bond: by acid etching & bonding: Acid etching creates a rough surface for the composite, and the resin will flow into these irregularities and lock itself there (micromechanically) when cured as we learned in dental material).

Amalgam: retention is mechanical, so we make the cavity in a way that resists the removal of the amalgam from the cavity. In most Class I and Class II, walls should converge occlusally: the retention comes from the buccal and lingual walls, which should be slightly convergent occlusally or parallel (slightly convergent is better).

(b > a) means that the base should be wider than the apex, so the amalgam will not be removed from the cavity. In class II, occlusal dovetail aid in retention: the dovetail should be made on the occlusal surface, and on the proximal surface the buccal and lingual walls should be parallel or slightly convergent occlusally. In Class V, walls diverge outward to provide strong enamel margin, retention obtained by grooves in the dentinal walls. 4. Convenience form: The form or shape of the preparation that provides adequate observation, accessibility and ease of operation in preparing & restoring the tooth 5. Removal of any remaining enamel pit or fissure, infected dentin or old restorative material if indicated. As mentioned earlier, we dont go all the way through the tooth and remove the caries from its base from the start, but we only reach the initial depth (0.2 mm occlusally in dentine, 0.5-0.8 mm cervically in dentine), then we deepen the cavity and remove all the caries in the final stage. Removal of remaining enamel pit or fissure Removal of defective old restorative material The walls shouldn't be: Too convergent Undermined enamel. Divergent Not retentive for amalgam.

Removal of infected dentin: All carious dentine must be removed, removing whats called the residual caries present on the DEJ, not leaving any caries on the DEJ, because it will eventually spread again and cause recurrent caries for sure. 6. Pulp protection, if indicated. Dentin is the best isolator against irritation to the pulp: No unnecessary tooth structure should be removed. When I remove more dentine and go closer to the pulp, I cause more dentinal tubules to be open, which will endanger the pulp even more. if you have deep caries, and your cavity is very close to the pulp, you need to protect the pulp by applying liners or bases. 7. Secondary Resistance & Retention Forms: when more tooth structure is lost due to fracture or caries (complex amalgam restoration for example), so these forms increase the resistance and retention of the restoration such as: A) Mechanical preparation features: 1. Retention locks, grooves, and coves 2. Groove extension 3. Skirts 4. Pins, slots, steps and amalgam pins B) Placement of etchant, primer, or adhesive on prepared walls (this concerns composite): 1. Enamel wall etching 2. Dentin treatment 8. Procedures for Finishing the External Walls of the Tooth Preparation:

The further development, when indicated, of a specific cavosurface design & degree of smoothness* or roughness* that produces the maximum effectiveness of the restorative material being used *Smoothness: needed with amalgam. *Roughness: needed with composite. Cavosurface angle: The line or angle formed by the junction of a cavity wall with the unprepared surface of the tooth. We have what we call enamel prisms, the optimum strength of the occlusal surface is obtained by having full enamel rods supported by short ones, while cervically the optimum strength is obtained by having full enamel rods only, and to achieve this arrangement of enamel prisms the cavosurface angle should be 90 degrees for both occlusal and cervical surfaces. The optimum cavosurface angle for amalgam is 90 degrees at both occlusal and cervical surfaces, and this is achieved by making the cavity walls (buccal and lingual) parallel or slightly convergent. If we make it A 90-degree cavosurface angle for amalgam is necessary for best resistance of both tooth structure and amalgam restoration. more convergent we will have weak enamel. If we make the angle more or less than 90 degrees we will cause problems; more than 90 degrees leads to having unsupported tooth structure and more susceptibility to facture (It's a bit confusing but when we explain class II cavities we will explain it more).

Objectives: 1) Create the best marginal seal possible between the restorative material and the tooth structure. 2) Afford a smooth marginal junction. 3) Provide maximum strength for both the tooth structure and restorative material. 9. Final Procedures: Cleaning, Inspecting, and Sealing: Cleansing and dryness of the cavity for inspection: Debris should be removed and cavity must be dried before putting the restoration. Sometimes, certain medicaments can be applied to the cavity prior to the restorative step: like sealers which are used when we have deep cavities, they close the dentinal tubules (sealers are not commonly used nowadays). Sequence of Caries Removal When we have caries on a tooth, there is a specific sequence that should be followed:1) Entry is made in a conventional manner with a high speed fissure bur. Enamel is hard; so a high speed fissure bur is required for entry, now we exposed the caries and this is what we call access to the caries. 2) Ideal depth and width are established, ignoring the carious tooth structure. Initial depth is established, and we dont go to the

base of the caries at this stage, because we are working with a high speed fissure which can cause pulp exposure before even removing the caries. 3) Caries extending beyond the limits of the ideal preparation is removed with the largest round bur that will fit into the area . (Using large slow speed round bur). The reason I dont use small round bur is that it may cause pulp exposure. 4) The caries removal process should begin peripherally in the DEJ areas. The direction of caries removal is from the peripheries to the center. For example, in class I we clean the walls (buccal, lingual, mesial and distal) of the cavity then the pulpal floor, and in class II we also clean the walls (buccal, lingual and gingival) then the axial which is toward the pulp.

5) Caries in areas involving potential exposures, such as the axial and pulpal walls should be removed last. 6) The criterion followed for caries removal is hardness which can be checked with spoon excavator. This is our criteria in removing caries from dentine; only infected (soft) dentine should be removed and affected dentine should be kept. The color is not the best indicator because affected dentine is discolored with bacterial stains but should not be removed! I use the spoon excavator here not the slow speed round bur, because the slow speed bur remove infected, affected and even sound dentine.

7) Only those areas that are soft should be removed. 8) After all caries has been removed, the preparation is re-evaluated for undermined enamel, resistance form and retention form. 9) All undermined enamel areas should be removed with the high speed fissure bur and an attempt made to reestablish lost retention and resistance form. 10) The pulpal floor should be flattened only at ideal depth.

11) The entire floor should not be reduced to include one isolated carious area.

Amalgam
Inexpensive Ease of use Proven track record >100 years Familiarity Drawbacks: Esthetics Mercury content

The basic component in the alloy are: Silver, Tin, Copper. All of these are mixed together then mixed with mercury. There also might be: Zinc, Indium, Palladium. All of these are added to improve properties,, to increase strength, to minimize corrosion. Classification of amalgam 1- Irregular ( lathe-cut amalgam) : usually they bring a block & start cutting it irregularly 2- Spherical amalgam (spherical alloy): they have the alloy in the melted state & they spray it in a chamber containing an inert gas ,,this cause the alloy to form a small balls (spherical shape) then itll solidify. 3- Admixed amalgam (admixed alloy): is just a mixture of two The setting reaction : Ag Sn + Hg Ag Hg + Sn Hg + un-reacted Ag-Sn

- Once the alloy (silver, copper, tin,..) is mixed with mercury a series of compound is produced. & they call them different names. The alloy itself ( un-reacted alloy) { Ag-Sn} is called Gamma () or gamma phase . when it reacts with mercury many things can form : part of alloy might remain un-reacted , silver may react with mercury & tin may react with mercury. Amalgam as a whole is composed many compound so its not totally composed of silver mixed with mercury for example. Its composed of unreacted part (Ag Sn) () , silver that reacts with mercury (1 ) & Sn that reacts with mercury (2) . So its a combination . Each material have certain properties for example the 2 phase leads to weakness to amalgam & susceptible to corrosion which its a chemical attack leads to breakdown. Newer amalgam is better,, 2 phase doesnt form a lot because they add more Copper. Copper will capture Tin (Sn) & prevent its reaction with mercury so it prevents the formation of 2 phase. And its called Copper Rich Amalgam , which its the amalgam we use it nowadays. This whole setting reaction take around 24 hours, although it becomes hard after initial set or maybe 10 min but U

cant work with it because the setting reaction hasnt finished yet,, the mercury is still reacting with alloy powder so no finishing or polishing before 24 hours. 1- Gamma phase () : silver tin is the strongest & the least material that is susceptible to corrosion 2- Gamma 1 phase (1) : silver mercury its strong but no as the & less susceptible to corrosion than 2 . 3- Gamma 2 phase (2) : tin mercury is the weakest & more susceptible to corrosion.
Three important terms to know about amalgam restorations Tarnish / corrosion / creep

Tarnish : which means oxidation of amalgam surface. Oxidation will attack the surface because of some chemical contact within the oral cavity like oxygen, chlorides, sulfide . All of these react only with the surface so no break down underneath,, only the surface will be changed & usually you can see it clinically when U see the filling becoming dark & dull . U should know that a tarnish filling isnt a weak one like corrosion, so U dont need to replace it >> all U do is finishing & polishing with certain instrument. But clinically a tarnish filling & corrosion look the same. Unless U start to examine it to see if part of it is broken down U cant really tell if its a tarnish or corroded filling. Both of them look similar < dark dull appearance > . Always when doing finishing & polishing U need to be careful because of the friction thatll result from finishing & polishing, it will produce heat & amalgam its a metallic filling which conducts heat which can harm the pulp. So you need to use water every now & then to prevent excess heat formation during finishing & polishing.
Note :

Now to minimize the chances of tarnish they can play with composition of material, by adding Palladium which prevents the oxidation reaction, so the composition can affect if the material is weak or not , if it susceptible to corrosion or tarnish or not

 Susceptible to corrosion : means to be broken down by chemicals,, usually this takes few years (doesnt happened very quickly) especially if the amalgam is copper rich & its used properly . Its a chemical reaction between the amalgam filling & oral environment ,, & this leads to break down & releasing its component in to oral cavity like tin & mercury, this weakens the filling & itll break off, then U should redo it again . Another thing might cause corrosion which is Galvanism & its defined as electric current between two opposing metallic fillings . & this lead to releasing of its component then oxidation >> which lead to weakness of the filling. So a corroded filling needs to be removed completely : U drill it >> remove it >> clean the tooth >> then place a new one. there is one benefit of these corrosion products. They close any space between the filling & the wall of the cavity. But again this isnt a solution, this is a problem called staining of dentine & enamel. & if U want to replace the filling U should drill more to remove the stained dentine & enamel >> this means U lost more from tooth structure. Creep : means plastic deformation, change the shape of the material due to continuous pressure. In the case of amalgam due to chewing, with time the shape of amalgam will change a little bit & it wont go back to its original shape so it needs to be replaced . ***** ideally when placing amalgam there should be no contact with saliva or blood. Older amalgam used to have zinc( now amalgam is zinc free),, if there is a moisture (saliva or H2O) zinc will react with oxygen & hydrogen will be released,, H2 is a gas so itll try to escape & causing expansion of the filling.

The amalgam capsule has two end ;one has powder (alloy or metal) the other contains the mercury (liquid) and between them there is membrane. Once the capsule start shaking in the amalgamator or the

machine this membrane will break off and mercury will be mixed with the powder. some types of capsule you have to activate which means these will be button at one end then press it to break the membrane and then place it in the machine . All of this are available in the instructions on the box containing the capsule. So either immediately in the amalgamator or sometimes you need to activate it first (press the capsule to break the membrane or the barrier between the mercury and powder) and then place it in the amalgamator . Regardless ,,, the powder in one end, liquid (mercury) in the other end and then placed in the amalgamator. Now the amount or size of the filling depends on the amount of mercury and powder placed on the capsule, one capsule can contain what we called a single mix or double or more depending on the size of your cavity. If you have small cavity u can use the capsule with single mix, so these are enough for one small cavity. If your cavity is large we use a large amount of amalgam. mix it for longer than the recommended time the amalgam will start to set quickly, mixed less than the recommended time the mixture will be dry (There wasn't enough time to mix the mercury with the powder to wet the powder with the mercury) giving crumbly, graining mix.

You need to know that the amalgam is placed gradually in the cavity layer by layer, so you don't take the mixed amalgam and place it as one mold in your cavity, it's placed in layers and condensed in layers. So if your working time is very short you won't have enough time to fill up the cavity because amalgam start to set, and we don't want the amalgam to become hard while we are still carving or still filling the cavity, we need it to be little bit soft so you can control it better (shape it) the way we want it it's easier to adapt it to the wall of the cavity and can fill any space that may exist and easier to carve to restore the morphology.

Placement and condensation : In general, there is an amalgam carrier or amalgam gun, you will see it in the lab, we use it to place layers of amalgam and condense them layer by layer vertical and lateral condensation to fill any space that might be present. The cavity should be over filled so that when we carve it, and the excess mercury is removed we make sure there's no spaces (micro leakage) left without being filled with amalgam. Q: In case of amalgam shortage do we add more amalgam or we do have to remove it and do it all over again? Answer: if you didn't over fill you cavity or over filled and carved a little bit more than you should. You have two choices depending on the state of the amalgam, if it's still soft you can add more, however if it started to set you can't add any more because amalgam doesn't stick to each other unlike glass ionomer cement for example which stick to each other. So a cavity with glass ionomer cement we can add more ever after setting but in case of amalgam we can't. Generally when you reach the point of carving and then you found out that part of it was deficient the amalgam had started to set already so you have to do it again.

Burnishing and carving : In the lab we were introduced to instrument including a burnisher which has ball, round end which is usually used before we start carving to remove excess from upper surface of amalgam filling and use it to burnish or make the surface shiny and smooth after the amalgam started to set, usually finishing and polishing is done after 24 hour.

We need to know that :

# Amalgam need to be placed in thick section not less than 1.5 mm. # Usually placed in layers and condensed vertically and laterally to adapt amalgam at the cavity wall. # Over fill the cavity so that no deficient areas are created. # Polishing and finishing after 24 hours.

Polishing is a very good step to do due to : 1/ minimize tarnish. 2/ increase smoothness. 3/ decrease plaque retention. 4/ decrease corrosion. 5/ more comfortable to the patient. They tried to produce amalgam that doesn't contain mercury so they replaced the mercury with "Gallium" however gallium didn't have good properties such as those found in mercury so it's not as strong and more susceptible to corrosion, so we don't use it.

Composite
The composite has four main components: Resin: (organic polymer matrix). Filler: (inorganic) particles. Coupling Agent: (silane). initiator/accelerator of polymerization

The organic phase is the resin and its made out of high molecular weight which can be something like Bis-GMA which stands for Biso-phenol Glycidyl methacrylate or UDMA (Urethane dimethacrylate). Now these molecules are very large and they need a help from another compound which is Triethylene glycol di methacrylate (TEGDMA) to help them increase the wetting ability.

The fillers particles provide strength for the organic matrix , they vary in size from less than 0.04 micron to over 100 micron . Common fillers are crystalline quartz : like silica and glass . why do we add fillers ?

Silane helps form a good bond between the resin matrix and filler particles during setting.

Composites contain initiators and accelerators that allow for light-, self-, and dualcure modes. For visible light activation, camphoroquinones start the free radical reaction using blue light in the 468 nm range.

Macrofilled resins (Conventional composite) : theyre 5-100 microns , the main disadvantage for them is that they cant be polished . Meaning that if you added a large piece of it and you want to trim it and then polish it you simply wont be able to . Theyre mainly used for posterior teeth Microfilled resins : theyre about 0.02 microns to 0.04 microns . Unlike the first one it can be highly polished but it cant bear mechanical loading . Theyre used in the anterior teeth. Hybrid composites ( Universal composites ): They can be used in both the anterior and posterior segment . Theyre a mixture of the first two types the macro and the micro. They have high polishability . And the full classification continues ( the dr didnt mention this ) : -particle composite

1. Esthetics. Some patients prefer all their teeth to be filled with composite which is tooth colored, unlike amalgam which is silver (unaesthetic). 2. Conservation and preservation of tooth structure. If we compare composite preparation to amalgam preparation we notice that in composite prep we are more conservative because we depend on the adhesion of the composite on the tooth structure by using the adhesive or bonding agent, while we need mechanical retention for the amalgam prep. - The prep tends to be shallower. For example in class V and class 2 the cavity can be shallower. - The prep tends to have narrower outline form. We dont need the retentive form or the mechanical retention like in amalgam. - Prep has rounder line angles. In amalgam we have definite line angles while in composite we have more rounded line angles. (Refer to slide 2) This is an example of a tooth that is prepared for composite, we have 2 one distal and one medial cavity and occlusal and buccal pit, for composite we can prepare these cavities separately but if we are going to prepare for amalgam we have to connect these cavity preparations together to make it like an MOD because we need more retention. So again for composite we have more conservation of tooth structure. 3. Another advantage is adhesion to the tooth structure. For amalgam we must remove all the undermined enamel because amalgam doesnt add to the strength of the tooth structure so we have to remove it because under occlusal forces the undermined enamel might fracture later on, for composite sometimes we can leave some undermined enamel tooth

structure because the composite strengthens the remaining tooth structure by binding to the enamel and dentin tooth structure. So the comp can strengthen the remaining tooth structure where as amalgam cant by the advantage of the bonging. 4. Low thermal conductivity. Amalgam can transmit heat for example while drinking hot drinks whereas composite has low thermal conductivity compared with amalgam. We compare composite to amalgam because they are both direct restorations, and also compare it to GIC to some extent. 5. Elimination of galvanic current. We said that this is an disadv of amalgam 6. Radio opacity. This means on the radiograph it appears white. Why is this important? To know that there is restoration, to detect for recurrent caries in margins, if we have open gap between the restoration and the tooth, or overhangs. Before they use to use microfilled composite which are not radio opaque so we cant tell if there is a restoration, they look like the tooth structure or like an empty area. But now all the available composites are radio opaque. 7. Alternative to amalgam. This is an adv, so now have more choices if we cant put amalgam we can put composite for post teeth.

Disadvantages: 1. Polymerization shrinkage. As we said in the last lec how when the composite polymerizes, the double bonds will become single bong leading to volumetric shrinkage, the volume of the composite will decrease, so when this happens it might affect the tooth, there will be a gap between the tooth and the restoration, because when we put the material its soft its not polymerized then we use the light to cure it, once the composite polymerizes the volume will decrease, we call this polymerization shrinkage. So there might be a gap, this gap will cause what >> (the 2nd and the 3rd disadvantages) 2. Secondary caries. 3. Post operative sensitivity. Because we have a gap now so the fluids can pass through the gap into the dentinal tubules leading to sensitivity. U should know that the polymerization shrinkage in the post teeth is more because your binding to more tooth surfaces (mesial, distal and so on) like when you bind to class 1 u bind to how many surfaces > 4, therefore there will be no relief of polymerization shrinkage, whereas in class 3 we bind to less surfaces. So the highest polymerization shrinkage is in class 1 and less in class 2 and it keeps decreasing in the other classes. Its not imp to know details its just imp to know that polymerization shrinkage is more in post teeth than in ant teeth and in class 1 more than in any other class. 4. Decrease wear resistance. When 2 materials come together one material will take from the other, this is what we call wear. Because on the occlusal surface of the post teeth, when we restore class 1 or 2 the force is more, so the wear is going to be more in the post but this is overcome with the new composites called universal composite and we can use it for both ant and post restorations. They still wear but to a lesser extent. 5. Other mechanical properties. You took them maybe in dental material, fracture toughness, high degree of elastic deformation, and CTE. All of

these have also improved with the newer composites because of the filler loading increase; like in nanocfillers, they have improved physical properties. Now the CTE in composite is very important because its different form the tooth structure, in GIC the CTE is similar to dentine but composite CET is higher, meaning if we have hot or cold the material will either contract or expand so because of this composite and dentin will expand and shrink at different degrees leading to cracking and crazing of the tooth which will cause tooth fracture later on (and also fracture to the restoration). But in GIC because the CTE is very close to dentine, so they used to call it a dentine replacement material because they expand and shrink at the same degree. 6. Water sorption. Composite can absorb or adsorb water, but this is also improved in the new composites. 7. Variable degree of cure. And this is more in the self cure than the light cure, during the mixing the two pastes. But now variable degree of cure in the depth of the composite and thats why we have to cure it in increments because the light does not exceed 1-2 mm of increment. 8. Inconsistent dentin boding (marginal leakage). Also this is important. Although composite adheres to tooth structure this is an adv, but the adhesion has some problems. 9. Technique sensitive. so we have to have moisture control , we have to be very delicate when we acid etch the dentine, too much water and too much dryness is not preferable, we have to have in between because it will affect the bonding this is what we mean by technique sensitive, and moisture control (no blood no saliva no water) during placement.

The acid etching technique was invented in 1955 by a Japanese scientist ( I couldnt hear the name ) . What are the advantages of acid etching ? It clears the enamel surface It increases the enamel surface area available for bonding

It produces micro-pores ( demenralztion of the minerals between the rods of the enamel in which resin interlocks ) . The enamel surface is etched with the ideal concentration of 37% phosphoric acid and the range of the correct concentration is 30% to 50 % . And the timing is 15 sec . It takes a longer time to etch fluoride treated teeth and primary teeth . I made micro-pored inside the enamel ( demenraliztion ) so that the dential tubulbes are now wide and open and I made a passage for the bonding agent .which is unfilled resin and itll go into these micropores inside the enamel and into the dentine tublubes between the collagen fibers in the dentine . BIS-GMA is thick it cant go easily inside these channels so I used what ? TEGDMA to increase the flowablity of this resin inside these micro-pores . So now the BIS-GMA is now in between the prismis in the enamel inside the micro-channels and around the collagen fibers and inside the dential tubules . The initiator di-ketone will absorb the light cure and thus initiating poly-maraziton . Now I apply the composite , the union between the composite and the dentine bonding agent is chemical . The tooth structure and the bonding agent is Micromechanical . The union between the glass incomer and the tooth structure is ? chemical Wash for 30 sec , when I dry I need to have a frosty appearance (good) , if I get a chalky appearance its wrong meaning that I over-etched . Someone might ask that if I accidently applied the acid etch in an area different to the cavity ( I put the acid etch in a sound area not where I want to put the composites ) you dont have to worry because as we said earlier its a dynamic process one where re-mineralization happens to de-mineralized surfaces (due to the minerals coming from the saliva ).

Each incremental layer shouldnt be more than 2 mm ( and why is that ? well if we added more than 2 mm there wont be curing ) . ~important

The light source should be 1 mm from the resin but not touching it . And allow exposure time of light for about 20-30sec for each increment and protect the eyes. You can use either cellulose strip or myloid strip (couldnt hear , correct please) ? For finishing we can use various tools : finishing strips , abrasive disks and finishing burs . What are the contra-inductions of using composite ? Bruxism Excessive wide preparations Inability to contact tooth structure Poor isolation
Class II composite restoration: - we have to Pre-wedging: it means that we put the wedge before preparing the tooth, and this has a lot of advantages. The most common issue that occur after doing a class II composite restoration is leaving a light or even a small proximal contact between the teeth, this result in food debris accumulation and may cause irritation to the gingival, so our goal is to keep a good tight proximal contact. This problem was solved in the amalgam restorations by condensing the amalgam against the matrix band - The matrix band we use is thick, so after applying the composite and removing the band it will leave a space between the two teeth caused by the thick matrix band. - So in pre-wedging, we put the wedge and the teeth will separate from each other, then we prepare the cavity while the wedge is there, then we put the matrix band and apply the composite with a little bit extra amount, then we remove the wedge and the teeth will come in contact. The result should not be a very tight contact or a light contact,, just something in between - The other advantage of pre-wedging is protecting the gingival from the bur in class II preparation. - And also protecting the adjacent tooth by separating it from the other tooth - The preparation of class II composite restoration should be limited to the carious tooth structure. - If there is two separate lesions on one tooth we work on each one separately because we are not depending on the mechanical retention. - Bevel placement on class II composite is a controvertible issue,, there is an arguments wither to do it or not. - The composite should be applied in the cavity by increments, because relatively we have a deep cavity so we are not sure if the light will pass through all the restoration and reach the bottom, also it helps in minimizing the polymerization shrinkage.

Matrix bands: There is two types of matrix bands we use in composite.. There is the metal one and the celluloid strips we have used in the anterior restorations, and each one have advantages and disadvantages. - The metal matrix bands is easier to handle and control , and this is opposite to the celluloid strips which is very hard to control it - The problem with the metal matrix bands that it does not pass light and this is solved by extra light curing the composite from Buccal and lingual areas after removing the bands. - We have another type of matrix band which we use in the private clinics: its called sectional matrix bands and ring, these bands have two advantages: & they are thinner than the metal band & the ring can do a little separation between the teeth and replace the wedge.

- We use a finishing diamond burs to remove the excess composite on high speed, also we use the strips for the inter proximal excess. - And for producing the detail anatomy we use a flame shaped diamond burs - Aluminum Oxide for smoothening.

GIC
A glass ionomer cement (GIC) is a dental restorative material used in dentistry for filling teeth and luting cements. These materials are based on the reaction of silicate glass powder and polyalkenoic acid. These tooth-coloured materials were introduced in 1972 for use as restorative materials for anterior teeth (particularly for eroded areas, Class III and V cavities). As they bond chemically to dental hard tissues and release fluoride for a relatively long period, modern day applications of GICs have expanded. The desirable properties of glass ionomer cements make them useful materials in the restoration of carious lesions in low-stress areas such as smooth-surface and small anterior proximal cavities in primary teeth. Results from clinical studies do not support the use of conventional or metal-reinforced glass ionomer restorations in primary molars, due to higher occlusal stress loads. However, use of glass ionomers in molar teeth is common as cementing, luting or basing materials may be used in temporary to intermediate term restorations in children and adults, particularly in difficult and dentally compromised cases and for medically compromised and elderly patients. GICs are commonly classified into five principal types:

Conventional glass ionomer cements (low- and high-viscosity) Resin modified glass ionomer cements (conventional with addition of HEMA) Hybrid ionomer cements (also known as dual-cured glass ionomer cements) Tri-cure glass ionomer cements

Metal-reinforced glass ionomer cements Setting time[

GlC sets within 68 minutes from the start of mixing, setting time is lesser for Type I materials than Type II materials. The setting can be slowed when the cement is mixed on a cold slab but this technique has an adverse effect on strength.

GIC Type 1: 57 minutes

GIC Type 2: within 10 minutes Manipulation] To achieve long lasting restorations and retentive fixed prostheses, the following manipulative considerations for GIC must be satisfied: 1. Surface of the prepared tooth must be clean and dry 2. The consistency of the mixed cement must allow complete coating of the surface irregularities and complete seating of prostheses 3. Excess cement must be removed at the appropriate time 4. The surface must be finished without excessive drying 5. Protection of the restoration surface must be ensured to prevent cracking or dissolution. The conditions are similar for luting applications, except that no surface finishing is needed.

Advantages]

Inherent adhesion to tooth structure High retention rate Little shrinkage and good marginal seal Fluoride release and hence carries inhibition Biocompatible Minimal cavity preparation required hence easy to use on children in and suitable for use even in absence of skilled dental manpower and facilities (such as in ART)

Disadvantages

Brittle Soluble Abrasive Water sensitive during setting phase. Some products release less fluoride than conventional GIC Not inherently radiopaque though addition of radiodense additives such as barium can alter radiodensity Less aesthetic than composite

The general use-based classification of GICs is as follows:

Type I: For luting cements Type II: For restorations Type III: Liners and bases Type IV: Fissure sealants Type V: Orthodontic Cements Type VI: Core build up Type VII: Fluoride releasing Type VIII: ART (atraumatic restorative technique) Type IX: Deciduous teeth

Additionally GICs may be also used for:

Intermediate restorations Adhesive cavity liners (sandwich technique) ART (atraumatic restorative technique) Restorations for deciduous teeth

Typical physical properties

Mixing time: 45 to 60 seconds Setting time: 2 minutes Working time: 2 minutes Total time: 4.5 minutes at 23 C

The end by Mais maloul ^_^