Essentials of

Operative Dentistry

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 DVD Contents
1. Introduction
2. Manipulation of Dental Materials
– Amalgam Trituration
– Calcium Hydroxide Cement Manipulation
– Glass Ionomer Cement Manipulation
– Zinc Oxide Eugenol Cement Manipulation
– Zinc Phosphate Cement Manipulation
3. Hand Cutting Instruments
4. Rubber Dam Application
5. Class I Amalgam Restoration
6. Class II Amalgam Restoration
7. Class I Composite Restoration
8. Class II Composite Restoration
9. Class III Composite Restoration
10. Class IV Composite Restoration
11. Class V Composite Restoration
12. Temporary Restoration
13. Endodontics
– Maxillary Incisor Root Canal Treatment
– Mandibular Molar Access Cavity Preparation
14. Preclinical Tooth Model Exercise
 Essentials of
Operative Dentistry

I Anand Sherwood MDS (PhD)

Reader
Department of Conservative Dentistry and Endodontics
CSI College of Dental Sciences and Research
Madurai, Tamil Nadu, India

Foreword
L Lakshmi Narayanan

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Essentials of Operative Dentistry

© 2010, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any
form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author
and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any
dispute, all legal matters to be settled under Delhi jurisdiction only.

First Edition: 2010

ISBN 978-81-8448-779-4

Typeset at JPBMP typesetting unit

Printed at
 I want to thank my wife,
child (Aditya)
and
parents
for their cooperation and patience
during the preparation of this book
 Foreword
It is heartening to write the foreword for this wonderful textbook
authored by a youngster. The contents of this book will go a long
way in fulfilling the needs of a standard Textbook of Operative
Dentistry by an Indian Author. I complement Dr I Anand
Sherwood for his monumental contribution to the field of
Operative Dentistry.

Regards

Dr L Lakshmi Narayanan MDS

Dean
SRM Kattankulathur Dental College and Hospital
SRM Nagar, Kattankulathur 603203
Kancheepuram Dist.
Tamil Nadu, India
 Preface

The need of writing this book was felt when I was looking for various designs of tooth preparation for various restorative
materials. It surprised me that for each restorative material different books written by different authors were needed for
getting a grasp of various tooth preparation design and modification. The book is essentially a compilation of these
information being presented in an easily comprehendable manner so that an undergraduate dental student could find it
easier to learn.
The book contains about 1200 illustrations to depict various tooth preparation designs and fundamentals in operative
dentistry. The book has also been written keeping with the requirement of preclinical conservative students in mind who
have for long been facing the task of learning the more complex clinical books. The book sorted out this problem by
including chapters on preclinical exercises and also about basic tooth morphology which are required to be learned by the
undergraduate students in their 2nd and 3rd year syllabi.
The book starts out from explaining basic chapters like ergonomics in dentistry, instruments used in operative dentistry
to more advanced topics like bleaching, tooth colored inlays/onlays, etc. The main feature of this book is the manner by
which each chapter has been explained with easy point-to-point presentation of necessary details. Besides this, at end of
each chapter a section of Key Terms has been added to acquaint with terms relevant to that chapters. Also a section on
Questions to Think About at the end of each chapter should prepare the students for the possible questions that could be
asked in their university examinations.
The book will be a tribute to the great teachers under whom I did my undergraduation and postgraduation and learned
the basics of dentistry and more importantly how to lead a life as a human. The book I hope fulfill the need of undergraduate
and also postgraduate students of operative dentistry. At this juncture, I want to thank M/s Jaypee Brothers Medical
Publishers (P) Ltd., New Delhi, for designing this book.

I Anand Sherwood
[Link]@[Link]
 Contents

1. Introduction to Operative Dentistry ............................................................................................... 1

Definition
History
Scope of Operative Dentistry
Need for Operative Dentistry
Conservative Approach
Dynamics of Operative Dentistry

2. Basic Principles in Operative Dentistry ......................................................................................... 3

Ergonomics in Dentistry
Equipments in Dental Environment
Protection and Safety Precautions

3. Clinical Decisions in Operative Dentistry .................................................................................. 18

Examination of Dentition—Occlusion
Examination of Dentition—Dental Charting

4. Isolation of Operating Field ........................................................................................................... 57

Moisture Control
Local Anesthetics

5. Dental Anatomy, Physiology, Histology and Occlusion .......................................................... 66

Structure of Teeth
Enamel
Pulp-dentin Complex
Cementum
Dentitions
Incisors
Canines
Premolars
Molars
Occlusion
Tooth Alignment in Arches
Movement of Mandible
Tooth Contacts During Movement

6. Cariology ......................................................................................................................................... 114

Definition
Etiology
Pathophysiology
Classification of Caries
Caries Diagnosis and Preventive Treatment
 xii Essentials of Operative Dentistry

7. Fundamentals in Tooth Preparation .......................................................................................... 130

Definition
Need for Tooth Preparation
Objectives of Tooth Preparation
Terminology in Tooth Preparation
Classification of Tooth Preparation
Fundamental Steps in Tooth Preparation

8. Instruments and Equipment Used for Diagnosis,

Tooth Preparation and Restoration ............................................................................................ 155
Terminology
Development and History of Instruments
Classification of Instruments
Instrument for Diagnosis
Hand Cutting Instruments
Hand Instrument Techniques
Sharpening Hand Cutting Instruments
Rotary Instruments
Other Instruments for Caries Removal
Auxillary Instruments and Equipments

9. Infection Control ............................................................................................................................ 194

Environment in Dental Lab
Regulatory Body Stipulations
Overview of Asepsis Techniques
Sterilization
Dental Water Unit and Hand-pieces Sterilization

10. Preclinical Conservative Laboratory Exercises ......................................................................... 223

Fabrication, Care and Preparation on Plaster Models
Extracted Teeth for Operative Dental Procedures
Care and Disinfection of Extracted Teeth
Dental Simulators for Operative Dental Procedures

11. Amalgam Restorative Material .................................................................................................... 232

Alloy Composition
History of Amalgam
Metallurgical Phases and Amalgam Crystallization Reaction
Properties of Amalgam
Manipulation of Amalgam
Mercury Toxicity
Amalgam Waste Management
Recent Advances in Amalgam

12. Amalgam Class I Preparation and Restoration ........................................................................ 247

Preparation Sequence
Restoration
Designs
 Contents xiii
13. Amalgam Class II Preparation and Restoration ....................................................................... 259
Preparation Sequence
Restoration
Designs

14. Amalgam Class III Preparation and Restoration ..................................................................... 299

Preparation Sequence
Restoration
Designs

15. Amalgam Class V and VI Preparations and Restorations ...................................................... 304

Preparation Sequence
Restoration
Designs

16. Bonding ........................................................................................................................................... 310

Types of Bonding
Clinical Applications of Bonding
Enamel Etching and Bonding
Dentin Bonding
Philosophy of Dentin Bonding
Classification of Dentin Bonding Agent
Hybridization Amalgam Bonding
Ceramic Bonding Resin-metal Bonding
Biocompatability and Microleakage

17. Resin Composite Restorative Material ...................................................................................... 327

Evolution and History of Composites
Composition of Dental Composite Resin
Classification of Dental Composite
Curing of Composite
Reduction of Polymerization Stresses
Properties of Composite
Indirect Composite
Finishing of Composite
Biocompatability of Composite
Repair of Composite Restoration

18. Composite Restoration Class I to VI .......................................................................................... 342

Indications and Contraindications
Advantages and Disadvantages
Basic Preparation Design
Preparation Sequence

19. Direct Filling Gold Restoration ................................................................................................... 367

Direct Filling Gold Material Properties
Tooth Preparation Sequence and Design
Restoration
 xiv Essentials of Operative Dentistry

20. Pin Retained Amalgam Restoration ........................................................................................... 379

Types of Pins
Factors Affecting Pin Placement
Pin Retention in Dentin and into Restorative Material
Tooth Preparation and Pin Placement
Mishaps During Pin Placement and in Pin Retained Restorations
Alternative to Pin Retention for Amalgam Restoration

21. Class II Inlay Restoration ............................................................................................................. 393

Indications and Contraindications
Materials Used for Restoration
Tooth Preparation Sequence
Restoration

22. Cast Onlay Restoration ................................................................................................................. 421

Indications and Contraindications
Tooth Preparation Sequence

23. Tooth Colored Inlays and Onlays .............................................................................................. 425

Indications and Contraindications
Tooth Preparation Sequence and Design
Advantages and Disadvantages
Materials Used in Tooth Colored Inlays and Onlays
CAD / CAM Restorations

24. Glass Ionomer Restoration ........................................................................................................... 434

Glass Ionomer Cement
Clinical Application of Glass Ionomer Cement
Modifications in Cavity Design for Glass Ionomer Cement
ART Technique
Sandwich Restoration

25. Minimal Invasive Dentistry ......................................................................................................... 442

Introduction to Minimal Cavity Preparation
Cavity Design Principles
Newer Cavity Classification

26. Noncarious Cervical Lesions ....................................................................................................... 446

Types of Noncarious Cervical Lesion
Clinical Features
Diagnosis
Treatment Options
Restorative Materials Used in Noncervical Carious Lesion
Preparation Design

27. Esthetic Operative Dental Procedures ....................................................................................... 451

Veneers
Types of Veneers
Indications and Contraindications for Veneers
Tooth Preparation Design
Advantages and Disadvantages of Veneers
 Contents xv
Bleaching
Etiology of Tooth Discoloration
Tooth Color
Advantages and Disadvantages of Bleaching
History of Bleaching
Types of Bleaching
Constituents of Bleaching Agents
Alternatives to Bleaching
Microabrasion / Macroabrasion
Indications and Contraindications
Advantages and Disadvantages
Clinical Technique

28. Additional Considerations in Operative Dentistry ................................................................. 470

Dentinal Hypersensitivity
Definition
Etiology
Mechanism of Dentinal Hypersensitivity
Management in Dentinal Hypersensitivity
Management of Gingival Tissues
Indications for Gingival Management
Methods of Gingival Retraction
Newer Methods of Gingival Retraction
Comparison of Different Gingival Retraction Methods

29. Endodontics .................................................................................................................................... 479

Introduction to Endodontics
Root Canal Treatment
Indications of Root Canal Treatment
Incisors Root Anatomy
Steps in Root Canal Treatment
Access Cavity Preparation
Working Length Determination
Biomechanical Preparation of Root Canal
Obturation
Access Cavity Restoration

30. Endodontic Materials and Instruments ..................................................................................... 498

Pulp Capping
Root Canal Filling Materials
Root Canal Sealers
Post and Core
Root Canal Instruments

Suggested Reading ............................................................................................................................ 515

Index .................................................................................................................................................. 517
 1 Introduction to
Operative Dentistry

Definition many of the aspects of operative dentistry has become

specialty areas.
Operative dentistry is the art and diagnosis, treatment, • In early days dentistry was practiced by so-called ‘barber
and prognosis of defects of teeth which do not require full dentists’.
coverage restorations for correction; such treatment should • It was during late 18th century that GV Black who had
result in the restoration of proper tooth form, function, both medical and dental degrees who modernized
and esthetics while maintaining the physiologic integrity dentistry and he is rightly called as Father of Modern
of the teeth in harmonious relationship with the adjacent Dentistry.
hard and soft tissues; all of which enhance the general • First dental college established was Baltimore College
health and welfare of the patient. of Dental Surgery in 1840.

Functions and Purposes of Factors Affecting Operative

Operative Dentistry Treatment
Functions and purposes of operative dentistry are actually Indications for operative procedures are numerous.
derived from definition itself: They can be categorized into three primary treatment
• Diagnosis: Proper diagnosis of lesions is vital for needs:
treatment planning of restoration of tooth. 1. Caries.
• Prevention: Ultimate goal should be disease prevention. 2. Malformed, discolored, fractured teeth.
• Interception: Preventing further loss of tooth structure 3. Restoration replacement or repair.
by way of restoration.
• Preservation: Conservative approach while tooth
preparation is necessary to preserve as much of tooth Considerations
structure as possible.
• An understanding of and appreciation for infection
• Restoration: Ultimate goal of operative dentistry is res-
control to safeguard both health service personnel and
toration of health, this includes restoring form, function,
patients.
phonetics, esthetics and occlusal stability and also
• A thorough examination of not only the affected tooth
surrounding tissues and entire stomatognathic systems. but also the oral and systemic health of the patient.
• A diagnosis of the dental problem that recognizes
History the interaction of the affected area with other body
tissues.
• Historically operative dentistry was considered to be • A treatment plan that has the potential to return the
the entirety of the clinical practice of dentistry, today affected area to a state of health and function, thereby
 2 Essentials of Operative Dentistry

enhancing the overall health and well-being of the • This newer approach is a result of the reduction in
patient. caries incidence because of increased knowledge
• An understanding of the material to be used to restore about caries, increased preventive emphasis, use of
the affected area to a state of health and function, multiple fluoride applications, and proper sealant
including a realization of both the material’s limitations application.
and techniques involved in using it. The primary results of conservative treatment are retention
• An understanding of the oral environment into which of more intact tooth structure and less trauma to the pulp tissue
the restoration will be placed. and contiguous soft tissue.
• The biologic knowledge necessary to make the
previously mentioned determinations.
• An understanding of the biologic basis and function Development in Field of
of the various tooth components and supporting Operative Dentistry
tissues.
• An appreciation for and knowledge of correct dental • Development of high speed handpiece played a
anatomy. dramatic role in more conservative and efficient removal
• The effect of the operative procedure on other dental of tooth structure for restorative procedures.
treatments. • Mechanical bonding to tooth structure by etching
and dentin bonding has led to conservative bonding
techniques.
Conservative Approach • Increased knowledge about carious process and
beneficial effect of fluoride has laid emphasis on
• Although tooth preparations for operative procedures
prevention of caries.
originally adhered to the concept of “extension for
• Increased research on dental biomaterials has led to
prevention“, increased knowledge of prevention
vastly improved dental materials.
methods, advanced clinical techniques, and improved
restorative materials have now provided a more All these process have led to a more conservative and
conservative approach to the restoration of teeth. effective restoration of tooth structure.
 2 Basic Principles in
Operative Dentistry

Ergonomics in Dentistry Dental Chair (Figure 2-1)

• The dental chair is center of all activity.
• Ergonomics is defined as ‘the study of man in relation
• First dental chair was manufactured by SS white dental
to his working environment: The adaptation of
company called as “Harris’. First hydraulic operated
machines and general conditions to fit the individual
chair was manufactured in 1877 called ‘Wilkinson’
so that he may work at maximum efficiency’.
(Figure 2-2).
• The contemporary dental unit is a masterpiece of design
• Modern reclining dental chair were marketed from late
incorporating as many ergonomic features as possible
1960’s.
to enable the operator to experience the minimum of
• Dental chair should support entire patient’s body, in
stress and fatigue.
upright, supine and subsupine position.
• Dental chair is designed for operator and dental
Dental School and Practice Environment assistant to work on the patient in an efficient manner.
• The dental school environment is obviously very • Chair should be able to move up, down, recline and
different from general practice, although many features incline and controls for which will be present either in
are common to both. There is an entrance, which should foot control or on the side of chair.
be well signposted so that the patient knows where
to go.
• Other information, such as hours of opening and
arrangements for out-of-hours emergency treatment,
should be clearly shown.
• Everyone concerned with dental care should appreciate
that the hospital or practice, which seems so common-
place when one works in it everyday, is a new and
possibly frightening environment for patients.
• Dentists and staff should look critically at the
surroundings to see that they are as attractive and
welcoming as possible.
• Even more important is the personal touch: A friendly
smile from the receptionist and the prompt attention of
the dentist or student, or a genuine apology for
unavoidable delay, all help to transform what is often a
Figure 2-1: Dental chair. A—Suction unit, B—Operating light,
worrying experience for patients into a warm and
C—Spittoon/Sink, D—Dental delivery unit, E—Handpiece and
welcoming one. three way syringe, F—Foot control unit
 4 Essentials of Operative Dentistry

Figure 2-4: Delivery unit side of patient

Figure 2-2: Wilkinson dental chair

• The patient’s head should be at the top of the headrest,

so that the dentist does not have to bend forward
excessively to see into the mouth, and at the dentist’s
midsternum level, bringing the mouth to the correct focal
range of the eyes. The dentist’s knees will now fit under
the headrest (Figure 2-3).
• The dentist and dental nurse need work-surfaces
around them on which to place instruments and
materials. The dental nurse needs facilities for mixing
materials, and the dentist needs an area for the patient’s
notes and a viewing box for radiographs. Figure 2-5: Delivery unit in front of the patient
The dentist requires easy access to the handpieces
and hand instruments. These (dental delivery unit) may
be situated on the dentist’s (Figures 2-4 to 2-6).
1. Side of the chair
2. Over the patient, or
3. On the nurse’s side each one having advantage and
disadvantage. Usual dental delivery unit consist of
handpieces, scalars, suction units, electric motors,
light cure unit, etc.
• By having the instrument tray side of the chair or over
the chest of patient it will be difficult for dental nurse to

Figure 2-6: Delivery unit rear of the patient and operator

reach for the instruments and many patients are

claustrophobic of having instruments over their chest.
• If instrument tray is placed behind the dentists then the
instrument has to be transferred in front of the patient
and chances of dropping the instrument and causing
damage to patient is a possibility.
• Position of instrument delivery unit is individual choice
and in a dental school set up, students are required to
work on various set up systems to get accustomed to
Figure 2-3: Operator position in relation to patient various positions.
 Basic Principles in Operative Dentistry 5
• Dental chair consists of spittoon which may use by the
patient for washing the mouth and spitting, it’s usually
found on the dental nurse side of the chair.

The Operator’s Chair (Figure 2-7)

• This should be fully adjustable and mobile, provide a
broad, preferably anatomically contoured seat and give
support in the lumbar region.
• It should be adjusted in height to suit each individual
operator in order to distribute the weight equally
between the thighs and feet.

Figure 2-8: Operator seating positions

Figure 2-9: Working position for lower right quadrant

position

Figure 2-7: Operator’s chair

Operator’s Position
• The dentist will normally work within a range from the
12 o’clock to the 9 o’clock position relative to the
patient’s head. However, most operative procedures are
completed from, at, or near, the 12 o’clock position
(Figures 2-8 to 2-11).
• Although the dentist usually sits at 11 o’clock, some Figure 2-10: Working position for upper teeth
operators move round to the 8 o’clock position and
readjust the patient’s chair when working on the lower
right quadrant by direct vision. The base of the chair
should be lowered and the backrest raised slightly, the
patient’s head turned towards the dentist.
• For a right-handed dentist, the dental nurse sits on the
patient’s left-hand side, facing the patient. Her stool
should also have a backrest, but for her to be able to see
clearly into the mouth. She should be seated some 10
cm (4 inches) higher than the dentist; thus, her stool Figure 2-11: Working position for lower anterior lingual
may require a bar on which she can rest her feet and surfaces
 6 Essentials of Operative Dentistry

may have a backrest which can be swung round to the

front to support the dental nurse when she leans
forward towards the patient (Figure 2-12).
• During intraoral examination dental nurse will be
without gloves and charting will be by dental nurse
once operator starts working dental nurse wears gloves
(Figure 2-13).

Criteria for Proper Operator Position

• The operator is seated in an unstrained position with
back straight, feet flat on the floor, and thighs angled so
that the knees are slightly lower than hip level (Figure
2-14).
• The operator should position elbows close to sides, and
shoulders should be relaxed.
• The oral cavity should be positioned at the operator’s Figure 2-14: Operator’s back should be straight
and thighs should be parallel to ground
elbow height.
• The operator’s head should be positioned facing
forward with eyes focused downward.
• There are different zones in relation to operator and
dental stimulator or patient.
• The transfer zone is basically present only when
working on a patient with a dental nurse assisting.
Following is method of instrument usage and transfer
when working on a patient with dental nurse assisting:
• Different zones for a right-handed and a left-handed
operator are arbitrarily marked (Figure 2-15).
• An instrument is retrieved from the tray setup using the
thumb, index, and middle finger of the left hand.
• The used instrument is retrieved at the end of the handle,
or opposite end of the working end, using the last two
fingers of the left hand.
• The new instrument is transferred in the transfer zone
and positioned firmly into the operator’s grasps.
Figure 2-12: Dental assistant stool with
front arm support and foot rest Working on Patient with Dental Nurse Assisting
See Figures 2-16 to 2-18.

Transferring Some Basic Instruments

(by Dental Nurse)
See Figures 2-19 to 2-21.

Operator’s Vision
There are two types of vision (Figures 2-22A and B):
1. Direct vision
2. Indirect vision
Figure 2-13: Operator’s position in relation to patient with dental • There can be no doubt that any tooth is best visualized
nurse not wearing gloves during charting procedure by direct vision.
 Basic Principles in Operative Dentistry 7

Figure 2-18: New instrument is positioned in

operator’s grasp

Figure 2-15: Different zones of operating environment

Figure 2-19: Transferring mouth mirror

Figure 2-16: Taking a new instrument from tray set up by

dental nurse to be given to operator

Figure 2-17: Retrieval of used instrument from operator by

dental nurse Figure 2-20: Transferring cotton plier
 8 Essentials of Operative Dentistry

Phantom Head or Patient Position

(Figures 2-23 to 2-26)
• Initially, the dentist and patient need to talk to each
other, and this should be with both seated face-to-face
on the same level. If the dentist stands towering over
the patient or talks to the back of their head, communi-
cation is poor and the patient feels even more at a
disadvantage.
• Most common position in dentistry is almost supine or
reclined 45°, which can be called as ‘home position’.
• For working on lower teeth the phantom head or patient
could be brought forward 40°.
• The patient may also be asked to turn their head
towards or away from the dentist. For example, when
examining the buccal surfaces of teeth in the upper left
quadrant the patient’s head should be turned to the
Figure 2-21: Transferring hinged instrument right so that this area can be seen clearly by direct vision.
When examining lower teeth the patient should tip the
chin down. Conversely, when examining upper teeth
the patient should tip their head back.
• Depending on individual choice basic home position
could be modified but operator’s back and shoulders
should be straight and not drooping while working.

Figure 2-22A: Direct vision

Figure 2-23: Initial position where dentist is talking

to patient sitting and without gloves being worn

Figure 2-22B: Indirect vision

• Whenever possible, the line of vision is perpendicular

to the tooth surface.
• Clearly, those surfaces inaccessible by direct vision
must be visualized indirectly through a mirror. Figure 2-24: Home position
 Basic Principles in Operative Dentistry 9
• Switches on handpiece and high volume evacuator
system must move with minimal effort.
• Knurled or crosshatched surfaces require less force to
grasp.
• Syringe, such as air/water, impression, and even
anesthetic syringes must produce reduce stress on the
thumb and fingers.
• Lighting is critical to dentistry, used personal protective
eyewear.
• Personal protective equipment used to reduce the spread
of infection must also influence ergonomics.

Figure 2-25: For lower teeth working position Illumination

• Most of today’s dental unit are fitted with halogen unit
for illumination.
• In recent advancements fiber-optic working equipments
and instruments are available for better visualization
in operating field.
• If the operator should be able to perform in satisfactory
a well lit operating field is required.
• As a whole the dental operatory area or room should be
lit above normal requirement, so that there is not too
much contrast between surgical room area and operating
Figure 2-26: For lower right quadrant working field. There’s less strain on eyes to adapt.
• Operating light is situated above the patient’s head and
Some Ergonomic Facts
its direction could be varied (Figure 2-27).
Instruments should be easy to use in an ergonomically • The handles and on/off switch are covered with
efficient posture. barriers during procedures. The barriers are changed
• Instruments should be well maintained to ensure that between each patient.
moving parts are well lubricated.
• The force needed to operate and instrument should be
minimized.
• A handpiece should be used instead of a manual hand
instrument.
• Hoses on handpieces and evacuators should be in a
position that maintain an ergonomically sound
posture.
• Hose should be locked into position to prevent pullback
on the operator.
• The patient chair must provide support for the patient’s
entire body in every position. Figure 2-27: Operating light
• The chair back and headrest must combine strength
with thinness. Aspirating Equipment
• The patient chair should move automatically. • High-speed cutting instruments require water cooling,
• Handpiece should rotate and turn. and cavities must be washed, dried, and isolated from
• Retentive mechanism for holding a bur to remove and saliva. Thus, suction equipment to remove liquids from
replace easily. the mouth is essential.
• The diameter of a handpiece should be relatively larger • Suction unit mainly consists of a high volume evacuator
at the base. and saliva ejector.
 10 Essentials of Operative Dentistry

• Syringe which will deliver a jet of water or air, or a

spray mixture of the two—a three-in-one syringe (Figure
2-28).

Figure 2-28: Three way syringe: A—Handle, B—Air-water

control, C—Removable disposable tip

Dental Handpieces
• There are usually two dental handpiece; low and high
speed.
• The handpieces are attached to hoses that are part of
the dental unit. It is important that these hoses are not
bent or tangled.
• Each handpiece has two controls. First, the hose
attachment has on/off switch to prevent more than one
handpiece from running at once. Second, the speed of Figures 2-29A and B: Rotary vane dental compressor
handpiece is controlled by a foot pedal called a rheostat.
• The dental handpieces are removed after each patient’s
treatment and are sterilized. At the beginning and end Compressed air has disadvantages of:
of the day, the handpiece should be run for several • Oil for compressor coolant getting mixed with air.
minutes. Between patients, run the handpiece for at least • Compressed air has moisture contamination.
one minute to flush the system. But newer age compressor with better air dryers and
filters circumvent these problems.
Sink
The treatment room should be designed with sinks in Other Small Equipment
convenient locations for the dentist and the water controls Dental Curing Light (Figures 2.30A and B)
on the sink should be operated by wrist, foot, or knee
• It is basically used for polymerization of light cure
control. There are light and motion sensor devices that
composite.
turn the water on and off automatically when standing in
• It consists of a light source, a fan to dissipate heat,
front of the sink. The sinks should be easy to clean and
reflector, a band pass filter, fiber optic bundle to guide
have an area nearby for soap and towel dispensers.
the light to specified area.
• Commonly lamp emanate radiant power density of
Compressor (Figures 2-29A and B) approx 300-1200 mW/cm2 and it should be never less
• Power for air turbine handpieces is derived from than 300 mW/cm2 with wavelength of light between
compressed air generated by compressors. 400-500 nm.
• Most common dental compressors are of rotary vane Depending on source of light it can be of:
type, which has the advantage of silent running and a. Halogen light unit
better efficiency. b. LED light unit
 Basic Principles in Operative Dentistry 11

Figures 2-31A to C: (A and B) Amalgamators

and (C) Fully automatic amalgamator

Three basic motions of amalgamators are:

1. Back and forth
Figures 2-30A and B: Dental light curing unit
2. Figure of 8 motion.
(Halogen light)
3. Centrifugal motion.
c. Plasma arc light unit
d. Laser light unit. Magnifiers (Figure 2-34)
Most dental curing light have a beep sound for every • In today’s restorative dentistry which very much focuses
10 sec and correct exposure time for polymerization of on the preservation of tooth structure magnification
composites and bonding agents must be followed from becomes an essential part.
manufacturer’s instructions. • Magnification methods are varied from simple loupes
to sophisticated operating microscopes.
Amalgamator (Figures 2-31 to 2-33) • A magnification of 2.5 times seems adequate for
operative procedures.
• These are primarily used for triturating amalgam alloy
powder and mercury. Nowadays they have also been
used for mixing dental cements which are also available Close Support Dentistry
in capsules. • Earlier before 1950’s dentistry was practiced as
• Capsules (amalgam or cements) are placed on the standing dentistry. But with advent of high speed
reciprocating arm and covered by hood to prevent handpieces in mid 1950’s sitting dentistry was made
mercury spillage. popular, it was in 1954 Dr. Sanford S Golden an US
• An automatic timer or manual timer is set to activate army dentist who called for sitting dentistry to be
the amalgamator. practiced (Figure 2-35).
• Wide varieties of capsule systems are available. • Close support or four-handed dentistry are the terms
• Also amalgamators of different speed are available. used to describe systems of close cooperation between
12 Essentials of Operative Dentistry

Figures 2-32A and B: Centrifugal motion amalgamator

Figure 2-33: Amalgamator operation. 1—Pressing the amalgam capsule to activate capsule, 2—Select the
amalgamator and know about its functions, 3—Open the hood of the amalgamator, 4—Place the activated amalgam
capsule in the amalgamator, 5—Ensure that the arms of amalgamator is tightly adapted to capsule, 6—Close the
hood, 7—Know the correct time and speed required for selected amalgam alloy powder, 8—Set the speed and time
and activate the amalgamator
 Basic Principles in Operative Dentistry 13

Figure 2-34: Magnification devices

Figure 2-36: Dental nurse aspirates the fluid

and at same time clears the mouth mirror

Safety
• One of the foremost things achieved with four-handed
dentistry is unmatched safety of both patient and dentist.
• Even though it may seem patient in supine position is
vulnerable to aspiration of instrument, it has been shown
that tongue presses against soft palate in this position
Figure 2-35: Early standing dentistry to achieve a seal.
• In high-risk procedures where aspiration of
dentist and dental nurse in the actual dental treatment instruments is greater like in endodontics it’s mandatory
of patients. to work under rubber dam protection.
• Such cooperation is essential for maximum efficiency. • In all patients irrespective of what position, proper
• A principal role of the dental nurse in close-support airway protection is mandatory.
dentistry is to maintain a clear working field so that the • All patients, operator and dental nurse must be
patient is comfortable and the dentist can see the working protected by eyewear, and no instrument must be
area. This involves aspiration of water and coolant transferred over the face of patient.
spray, retraction of soft tissues, keeping the mirror free
of spray, and keeping the cavity clear of debris (Figure Methods
2-36).
• The concept of four-handed, ergonomic dentistry is open
• When cutting with the air turbine, the mirror surface
to varied individual approach. However, the under-
quickly becomes obscured by spray. The dental nurse
lying principle demands that all delivery, discard and
should keep the mirror clear by washing it with spray
transfer takes place in the area of safety and convenience
and blowing air over it.
around and below the chin – the so-called ‘transfer
• Each time the cutting stops, the dental nurse should
zone’. This practice demands maximal delegation to
wash and dry the cavity and the mirror so that the
the dental nurse and requires concerted effort and
dentist can see clearly.
understanding (Figure 2-37).
• The dentist’s hands should therefore remain whenever
Principles of Four-handed Dentistry possible in the transfer zone, instruments and materials
Delegation should be asked for, not looked for, and be received to
enable correct grasp with no risk of injury.
It is the transfer of any task to a person who is both quali-
• If both hands are free, instrument transfer is simple but
fied and capable. This greatly reduces workload of operator.
more commonly the task must be completed in one hand.
This method of instrument retrieval by the fourth finger,
Anticipation rotation of the wrist, and supply from thumb to first
Any experienced dental nurse will be able to anticipate fingers is easily mastered and is undoubtedly efficient
the operator’s requirement in advance of his request. (Figures 2-38A to D).
 14 Essentials of Operative Dentistry

opportunity to maximize the potential for a fulfilled

professional career.

Instrument Tray Set-up (Figure 2-39)

From left to right will be:
• Examination instruments
• Additional examination instruments
• Restorative instruments
• Accessory items.

Basic Tenets of Four-handed Dentistry

They are:
• Work simplification
• Elimination
Figure 2-37: Transfer zone and instrument is grasped by
little finger by dental assistant • Combination
• Rearrangement
Therefore, it is clear that when due attention is paid to • Simplification
basic procedural aspects and organization, the clinical • Equipment must be designed to minimize unnecessary
scenario is efficient, effective, enjoyable and professional. motion.
On the other hand, without such discipline, there is the • The operating team and patient are seated comfortably
potential for inefficiency, lower standards and a lost in ergonomically designed equipment.

Figures 2-38A to D: (A) The dental nurse is picking up a mirror and probe. Note that she grasps the non-
working ends, (B) The mirror and probe are placed firmly into the dentist’s hands. They are immediately
ready for use, (C) To exchange an instrument the dental nurse brings in the new instrument (a Briault probe
in this picture) parallel with the instrument that the dentist is using, (D) Exchange is completed by the dental
nurse taking away the old instrument with the little finger of her left hand while placing the new instrument
into the dentist’s hand
 Basic Principles in Operative Dentistry 15
Protection, Safety and Management of
Minor Emergencies
• There are inevitable risks in all operations and dentistry
is no exception. The dentist works in the limited space
of the mouth, a cavity covered by soft and mobile tissues,
and at the origins of the respiratory and alimentary
tracts.
• Sharp hand instruments, high-speed rotary instru-
ments, and the manipulation of small objects in
awkward positions provide opportunities for possible
injury and mishap.
• However, care and forethought will greatly reduce these
inherent risks.

Eye Protection (Figure 2-40)

• Eye protection by large spectacles is mandatory for both
patient, operator and dental nurse.
• No instrument transfer should take place over the face
of the patient.
Figure 2-39: Basic instrument set-up
• Patient’s eyes are protected from any debris, calculus
(Preset instrument tray)
that may be removed from patient mouth during cutting
Work Simplification to fly out and injure patients eyes.
• Operator’s and dental nurse eyes are protected
• Keep the basics of working on patient simple.
especially during removal of cast restorations and
• Utilization of preset instrument tray set up.
amalgam.
• Clinical ergonomics is practized.

Elimination
Working on patient can be lot simpler if unnecessary
instruments or instruments seldom used is removed from
tray set up.

Combination
Lot of time can be saved if instrument used is double ended
instrument, which can perform two functions.

Rearrangement
Have the instrument tray set up close to operator. Avoid Figure 2-40: Both patient and operator are
protected by eye wear
reaching out for instruments.
Airway Protection
Simplification • Another major consideration with a supine patient is
• Make clinical working simpler by eliminating frequent preventing the inhalation of small objects such as metal
need for transfer of instruments. restorations, pins, and small hand-held files used for
• Place the patient in supine position while working. cleaning root canals.
• Delegate as much of work possible like, bur changing • Complete protection against this type of accident is
to dental nurse. provided by a rubber dam, and for this reason its use is
• Select multipurpose dental instrument as much as highly desirable for many procedures, in particular
possible. endodontic treatment (Figure 2-41).
 16 Essentials of Operative Dentistry

• Most objects of dental origin inadvertently swallowed

can be relied upon to pass through the alimentary tract
without incident. Exceptions are sharp objects such as
endodontic files, which may become lodged and require
surgical removal.

Soft Tissue Protection

• Care must be taken to avoid injury from local anesthetic
(or other) needles. Not only can they cause physical
injury but they risk transmitting infection. Dental staff,
cleaners, and waste disposal personnel are all at risk
unless all needles and other sharp disposable
Figure 2-41: Rubber dam application
instruments are properly disposed of in a rigid, sealable
‘sharps container’. Needlestick injuries can occur when
re-sheathing a local anesthetic needle after giving the
injection. There are various designs of needle guards to
help avoid this (Figure 2-43).

Figure 2-42: Throat screen application

when patient has to close the mouth

• When fitting a restoration, such as an inlay or crown, Figure 2-43: A needle guard to prevent needle stick injuries
which may also be dropped, a rubber dam is not
appropriate because occlusion must be checked and • Skilful operating is of primary importance. The insertion
the rubber dam precludes this. Throat protection can be of sharp instruments to the correct point of application
given by throat screen made by gauze (Figure 2-42). and their withdrawal without touching lips, cheek, or
• First action is to lean the patient forward and ask them tongue is a basic requirement. The use of finger or thumb
to rinse and cough. Then the fauces and the sublingual rests at all times and insistence upon sharp instruments
and vestibular sulci should be examined thoroughly in is essential to good practice; blunt instruments require
that order. The tongue and palate should not be more force and are likely to slip.
disturbed too much because the object may be retained • Rotary instruments are another potential source of trauma
in the oropharynx for a short time before ingestion. to soft tissues. The tongue, lips, and cheeks should be
• Then the patient should be got out of the chair, as far as retracted gently but firmly with mirrors, flanged saliva
possible without remaining in the upright position for ejectors, or the flattened end of the aspirator tip, taking
too long, bent sharply at the hips and given one or two care to avoid pressure on the alveolar mucosa or excessive
firm slaps on the back to help dislodge the object from retraction of labial and buccal frena. A rubber dam is a
the oropharynx. reliable way of retracting soft tissue.
• The next step is a thoracic radiograph to localize the High-speed instruments are a source of risk, especially
foreign body in the esophagus or stomach or, more if they are bent or rotating eccentrically. The rules are as
seriously, in a bronchus. In the latter case, reference to follows:
an accident and emergency department or a thoracic • The shank must be firmly held in the chuck and be
surgeon is required because bronchoscopy and early incapable of working loose.
removal are necessary to avoid pulmonary collapse. • Bent instruments must be discarded immediately.
 Basic Principles in Operative Dentistry 17

Figure 2-44: Step 1—In incident of sharp injury remove the gloves to verify extent of injury, Step 2—Thoroughly wash the
injured area in clean water, Step 3—Dry the area with clean napkin, Step 4—Bandage the area with wash proof bandage

• Never attempt to restraighten a bent instrument because • Explain what has happened but do not be defensive or
this leads to sudden fracture and a high-speed projectile offer financial compensation.
is produced. • Make a careful record of the incident, at the time, in the
• Long-tapered diamond instruments are particularly patient’s notes.
prone to bending and therefore should be examined
before use. Protection from Infection
Soft tissue injury may occur due to caustic agents like • It is very important that patient, doctor, nurse are all
acid etchant, hot instruments used inside oral cavity. protected from cross-contamination and infection.
• Proper infection protocol, universal precautions and
Accidents and Injuries (Figure 2-44) personal protection barrier equipment be employed.
• If there any injury to doctor or patient from sharp
instruments, the inoculation injury site is cleaned and
washed in clean water.
Summary
• Injured site is dried with sterile napkin and an A thorough knowledge of these basic principles and ergo-
washproof dressing is given. nomics greatly improves operator efficiency and reduces
• Followed by antitetanus injection. physical strain of patient, operator and dental nurse.
• Patient must be examined for any potential infection
source like hepatitis B or HIV and necessary precautions Key Terms
be taken.
• Ergonomics
• All accidents and injuries are recorded.
• Dental chair
• Dental delivery unit
Avoiding Air Emphysema
• Dental assistant stool
• When using an air turbine or a three-in-one syringe • Operator position
near a breach in the mucosa or the orifice of an empty • Operator stool
root canal, surgical emphysema may be caused by the • Zones of different operating environment
compressed air. • Patient position
• This is important because of the possible spread of infec- • Operating light
tion into deeper tissue planes. The risk can be minimized • Compressor
by avoiding directing jets of air into these areas. • Dental curing light
• Amalgamator
Dealing with Accidents and Accident
• Close support dentistry
Reporting • Four-handed dentistry
However, accidents will happen occasionally and there • Tray set-up.
are some rules that should be followed:
• A student should inform the teacher immediately. Questions to Think About
• Provide whatever immediate treatment is needed (for
example, sutures) or arrange other investigations such 1. Define ergonomics in dentistry. What are the principles
as a thoracic radiograph. in four-handed dentistry?
• Show the patient by your attitude and sympathy that 2. Elaborate about protection and safety management in
you care for their welfare. operative dentistry.
 18 Essentials of Operative Dentistry

3 Clinical Decisions in
Operative Dentistry

Dentist when examining a patient is needed to make • For example, in caries diagnosis its essential that all
following decisions: above mentioned factors are mentioned in diagnosis to
• Diagnosis make a proper treatment plan.
• Prognosis
• Treatment options and treatment planning Prognosis
• Prevention of further disease.
• Is estimate of what will happen in the future both with
and without treatment.
Professionalism • Prognosis of early enamel caries is good if patient
compliance with preventive treatment plan.
• Professional-client relationship is special in that
professional people take upon duty of setting their
Treatment Options
clients interests above their own.
• It’s this professionalism that enables a patient to trust • It is a very important decision which affects the patient.
dentist and take his advice on treatment options. • It is taken from the judgement of above two decisions.
• Students starting to work on patients should understand
the ethical issues and legal issues in patient care. Preventive Treatment
• Students should be aware of two terms in patient care, • Long-term success of any treatment plan lies in the
i.e. duty of care and informed consent. preventive aspect of the disease.
• When making clinical decisions all information from • Initial treatment plan is to assess the disease condition,
patient is collected and collated to arrive at a decision, stabilize the disease and start preventive measures.
sometime judgement on part of clinician is necessary • Patient’s response to this initial treatment plan will be
when information collected is not sufficient. In these an important factor in planning subsequent care.
situations its clinician’s experience and his rationality Growing attention is paid in giving the most effective
should help. Students can take help from the experience and appropriate treatment to patients. Research is greatly
of their teachers. expanding our knowledge base of treatment options
available, which treatment best suits to patients. This
Main Decisions process of translating research into practice activities and
Four main decisions are following: enhanced care of patients is Evidence-based Dentistry.
Evidence-based dentistry is defined as ‘conscientious,
Diagnosis explicit, and judicious use of current best evidence in
making decisions about the care of individual patients’.
• Diagnosis is the recognition of the disease.
• In making clinical diagnosis just naming the problem
will not be sufficient, its location, extent and other Patient Visits
characteristics (e.g. severity) may be mentioned. There are following types of patient visit, they are:
 Clinical Decisions in Operative Dentistry 19
Routine Initial Visit and student to take medical history of patient before
Involves obtaining detailed information for treatment examination of patient.
planning.
Problem Oriented Treatment
Emergency Visit
Planning Model
Obtaining basic information and focussing on patient’s
chief complaint. There are two generally accomplished mode of treatment
planning:
Revaluation Appointment 1. Treatment oriented model
2. Problem oriented model.
Requires updating patient information and assessing
previous treatment.
Treatment Oriented Model
Recall Appointment Dentist examines the patient finds certain intraoral
conditions and mentally equates those problems to the
Assessing patient previous condition with current status.
need for certain forms of treatment.
Pretreatment assessment of patient must be thorough
and maintained as a patient record for any future reference.
Problem Oriented Model
• Examination of patient leads to the formulation of a list
Patient Assessment of problems. Each problem has a different treatment
options with its own advantage and disadvantage. Each
• This section deals with how to collect the information of its merits and demerits are weighed before a treatment
required for making clinical decision and how it should plan is formulated.
be recorded. • Problem oriented model is the suggested model, here
• Part of the skill of an experienced clinician is to decide clinician’s attention is to a systematic evaluation of
what information is needed, and to acquire it accurately patient, so no problems are overlooked.
and rapidly so that they are in the best position to give
good advice without undue delay.
There are basically two approaches: Problem List Formulation
1. Data gathering approach where questionnaire can be • Dentist initially evaluates the patient from a subjective
created and patient can be asked to fill it up, but its standpoint, first ascertaining chief compliant and
cumbersome. patient’s goal of treatment.
2. Other approach is discussing with patients which • Then medical and dental history is evaluated.
allows to patient to open up about the problem more. • Then objective portion of assessment begins with
Both these approaches are exclusive of each other but examination of vital signs (blood pressure, cardiac rate,
rather should be combined for effective information pulse, respiratory rate), then extraoral head and neck
collection (Figures 3-1A and B). examination and progressing to thorough intraoral
Questionnaire like this can be useful to certain extent examination.
whereby it can reduce chairside time and also divert the • Nonclinical portion of examination includes exami-
clinician attention to problem at hand. But these have nation of casts, radiographs and photographs.
disadvantages: • Objective of examination is to differentiate normal from
• Being too broad and not pertaining to complaint at abnormal findings and to determine which abnormal
hand. findings constitute problem requiring treatment.
• Patient can misunderstand the questions.
Before the examination and diagnosis of teeth,
periodontium, and orofacial soft tissues, attention is given
to infection control (IC), the patient’s chief complaint,
Treatment Sequencing
medical review, sociologic and psychologic review, dental This involves which problem to be treated first followed
history, and risk assessment. It is essential for clinician by which treatment.
20 Essentials of Operative Dentistry

Figure 3-1A
 Clinical Decisions in Operative Dentistry 21

Figure 3-1B

Figures 3-1A and B: Self administered questionnaire

Treatment sequencing as follows: Diagnostic Procedure

• Chief complaint Certain conditions may require additional diagnostic
• Medical/systemic care procedures which would not have been accomplished in
• Emergency care initial patient evaluation.
• Treatment plan presentation
• Diagnostic procedure
• Disease control phase
Disease Control Phase
• Re-evaluation phase Consists of treatment designed to arrest active disease.
• Definitive care phase
• Maintenance care. Re-evaluation Phase
Consists of a formal reassessment, during which the dentist
Chief Complaint decides if desired goal of initial treatment has been
achieved or not and whether there need for change in
Patient’s chief compliant should be addressed at the outset
treatment plan.
of treatment.

Medical/Systemic Care Definitive Care Phase

Phase includes aspects of treatment that affect the patient’s After the initial control of active disease specific conditions
systemic health. Problems addressed in emergency care are to be addressed like may be endodontic treatment,
phase involve head and neck infections which should be restoration of a badly broken teeth or orthodontic
attended before routine dental treatment. treatment.

Treatment Plan Presentation and Acceptance Maintenance Care

It should precede all nonemergency dental treatment. It is an ongoing phase designed to maintain the results
Depending on patients acceptance an alternative treatment of the previous treatment and prevent recurrence of
plan should also be ready. disease.
 22 Essentials of Operative Dentistry

About the Patient By discussing chief compliant at outset it accomplishes

two important goals:
This section mainly involves subjective evaluation and 1. Patient feels that his/her problem have been recognized
history taking, when taking history certain points need to and doctor-patient relationship is maintained.
be remembered: 2. By noting down chief compliant, it is assured that
• History taking is the first step in patient evaluation. patient’s chief compliant is not neglected, because in
• It should be done with patient sitting comfortably. certain patients who present with large number of
• Always introduce yourself to patient and accom- dental problems but chief compliant may be trivial. But
panying person and be cordial. by noting down chief compliant it is assured that it will
• Remember, patient is neither dentally or medically be addressed.
trained so plain speech without speaking down to them Patient may or may not give detailed explanation about
is necessary. present condition if not pertaining questions should be
• Questions are a key to history taking; make relevant asked, which forms the history of present illness.
questions to elicit required information.
The history of present illness is the course of the patient’s
chief complaint: When and how it began; what exacerbates
Name, Age, Telephone and Other Contact and what ameliorates the complaint (when applicable); if
Details (Biographic and Demographic and how the complaint has been treated, and what was
Information) the result of any such treatment; and what diagnostic tests
• This is important for identification and also for future have been performed. Direct and specific questions are
references. used to elicit this information and should be recorded in
• Address can reveal about certain local conditions the patient record in narrative form as follows:
prevailing like fluorosis. • When did this problem start?
• What did you notice first?
• Did you have any problems or symptoms related to this?
Age, Gender and Occupation
• What makes the problem worse or better?
• Patient’s age significance is very important as there very • Have the symptoms gotten better or worse at any time?
many dental conditions that are age specific and also • Have any tests been performed to diagnose this
developmentally tooth undergoes various stages in a complaint?
younger patient. • Have you consulted other dentists, physicians, or
• Patient’s gender usually has no bearing on treatment anyone else related to this problem?
outcome planned but it is needed for future reference. • What have you done to treat these symptoms?
But gender could be taken into consideration when
planning esthetic treatment. Review of Systems
• Occupation is noted as occupational hazards can
It is a comprehensive review of all systems based on
manifest in dental tissues like erosion, abrasion, etc.
subjective symptoms of patient (Table 3-1).
This comprehensive review alerts the clinician to any
Chief Compliant and History of Present hidden medical conditions that might not have been
Illness revealed in medical history.
• The patient should be encouraged and guided to
discuss all aspects of the current problem, including Medical Condition of Patient
onset, duration, symptoms, frequency, relieving factors Clinician has to identify certain medical conditions, they
and related factors. are:
• If pain is present; nature of pain, onset of pain, • Any communicable diseases (Table 3-2).
exacerbating factor for pain needs to be assessed. • Allergic manifestations or previous allergic episode.
• This information is vital to establish the need for specific • Systematic diseases and cardiac problems.
diagnostic tests and to determine the cause and • Any medication followed?
treatment of the complaint. If any of these is positive then patient may be required
Chief compliant is recorded in dental record in patient’s to send to a physician for a second opinion for his fitness
own words. for dental procedure.
 Clinical Decisions in Operative Dentistry 23
Table 3-1: Review of systems

Organ or system Symptoms

General Weight changes, malaise, fatigue, night sweats
Head Headaches, tenderness, sinus problems
Eyes Changes in vision, photophobia, blurring, diplopia, spots, discharges
Ears Hearing changes, tinnitus, pain, discharge, vertigo
Nose Epistaxis, obstructions
Throat Hoarseness, soreness
Respiratory Chest pain, wheezing, dyspnea, cough, hemoptysis
Cardiovascular Chest pain, dyspnea, orthopnea (number of pillows needed to sleep comfortably), edema,
claudication
Dermatologic Rashes, pruritus, lesions, skin cancer (epidermoid carcinoma, melanoma)
Gastrointestinal Changes in appetite, dysphagia, nausea, vomiting, hematernesis, indigestion, pain, diarrhea,
constipation, melena, hematochezia, bloating, hemorrhoids, jaundice
Genitourinary Changes in frequency, urgency, dysuria, hematuria, nocturia, incontinence, discharge,
impotence
Gynecologic Menstrual changes (frequency, duration, flow, last menstrual period), dysmenorrhea,
menopause
Endocrine Polyuria, polydipsia, polyphagia, temperature intolerance, pigmentations
Musculoskeletal Muscle and joint pain, deformities, joint sweelings, spasms, changes in range of motion
Hematologic/lymphatic Easy bruising, epistaxis, spontaneous gingival bleeding, increased bleeding after trauma,
swollen or enlarged lymph nodes
Neuropsychiatric Syncope, seizures, weakness (unilateral and bilateral), changes in coordination, sensations,
memory, mood or sleep pattern, emotional disturbances, history of psychiatric therapy

Allergic Manifestations Some Pertaining Questions in Medical History

• Any form of allergic manifestations to drugs or injection • Are you fit and well?
must be properly evaluated. • Have ever been admitted to hospital? If yes give details.
• Patients word is taken for allergic manifestations unless • Have you ever had any surgery? If yes give details.
and until its proven otherwise by appropriate tests. • Have you had any heart trouble or high blood pressure?
• Have you ever had any chest problem?
Systemic Disease and Cardiac • Have you had any other bleeding problem?
Abnormalities • Any allergic to penicillin or other drugs?
• Have you had any infectious disease like:
Cardiac conditions like valvular diseases, infarction
• Rheumatic fever
increase the chances of acquiring bacterial endocarditis if
• Diabetes
dental procedures are performed without proper antibiotic
• Epilepsy
prophylaxis (Tables 3-3 and 3-4).
• Tuberculosis
• Hepatitis.
Medications • Are you pregnant?
• All information regarding medication patient is taking • Any current prescription being followed?
should be recorded.
• This information can give vital clue to disorder patient
is suffering from or any other drug induced disorder Past Dental History
that patient might be prone to. • Consists of reviewing previous dental visits and
• Drugs taken by patient might adversely react with experiences.
dentists prescription and local anesthetics which • Frequency of dental care and perceptions of that care
should be guarded against. may be indications of patient’s future behavior.
 Table 3-2: Communicable diseases of concern in dentistry 24
Infectious agent Route of transmission Disease Clinical characteristics Treatment Comments

Herpes simplex virus (HSV) Congenital, oral (saliva), sexual, Oral/genital herpes Vesicles that rupture to form Acyclovir, penciclovir, or Lesions of HSV type 1 are usually
types 1 and 2 direct contact with lesions Primary herpetic gingivostomatitis multiple shallow ulcers, inflamed valacyclovir found above the waist, while
Herpes labialis gingival may be present; lesions Topical ointment those of HSV type 2 usually
Herpetic whitlow (finger) frequently recur when reactivated Systemic use in severe cases occur below the waist; herpetic
Keratoconjunctivitis (eye) by various stimuli (e.g. stress) infections may be severe and potentially
life threatening in newborns and
immunosuppressed individuals

Varicella-Zoster virus (VZV) Aerosols; respiratory droplets; Chickenpox or varicella (primary infection) Vesicular lesions associated with Acyclovir, penciclovir, valacyclovir, VZV infections may have serious,
direct contact with lesions Shingles or zoster (reactivates infection) chickenpox appear initially on the vidarabine, or famciclovir fatal consequences in neonates
trunk and scalp; shingles follow a Topical and systemic use and immunocompromised individuals
unilateral dermatome distribution

Human papilloma virus Direct oral or sexual contacts with Venereal warts, or Condylomata Flat or raised nodules that may Surgical or chemical removal Certain lesions may progress to
lesions acuminatum coalesce into cauliflower-like precancerous and cancerous growths
clusters; typically asymptomatic;
lesions frequently recur

Respiratory viruses Direct contact with respiratory Respiratory infections (e.g. cold, flu) Sneezing sore throat, fever, Prophylactic prevention for flu by Probably the most frequently transmitted
(e.g. rhinoviruses, respiratory droplets; aerosols headache, and malaise vaccination or treatment with diseases within dental practices
syncytial virus, influenza viruses) amantadine or rimantadine
Palliative treatment for colds

Paramyxoviruses Direct contact with respiratory Rubeola or measles Rubeola—cough, conjunctivitis Childhood vaccination and Serious infections may lead to life-
droplets; aerosols mumps fever, maculopapular rash, and palliative treatment threatening pneumonia
Koplik’s spots
Mumps—salivary gland enlargement,
headache, fever, and malaise

Togavirus Direct contact with respiratory Rubella or german measles Low-grade fever, sore throat, and Childhood vaccination and May cause congenital defects in
droplets; aerosols mild exanthematous rash of palliative treatment neonates, including mental retardation,
short duration heart defect, deafness, and retarded growth

Epstein-Barr virus (EBV) Direct contact with saliva Infectious mononucleosis Lymphadenopathy, fever, and None Infection is rarely serious
petechiae

Hepatitis B virus (HBV) Blood; sexual; perinatal; present in Hepatisis, cirrhosis of the liver, Fever, malaise, anorexia, gastroin- Vaccination and palliative care HBV infection is a serious occupational
all body fluids, including saliva hepatocellular carcinoma testinal distress, chills, and icteric Treatment of chronic hepatitis with hazard to unprotected dentists and
symptoms of liver damage α-interferon may be beneficial dental personnel
Essentials of Operative Dentistry

(e.g. jaundice, dark urine, pale stool)

Human immunodeficiency virus Blood; sexual; perinatal Opportunistic infections Acute—flu-like symptoms (early in No curative treatment is available HIV infection is a progressively
(HIV) Neoplastic lesions the illness), fever, weight-loss, Therapy with reverse transcriptase debilitating and ultimately fatal
(e.g. Kaposi’s sarcoma) chills, and lymphadenopathy inhibitors, protease inhibitors, illness that spans the clinical
Wasting syndrome Chronic—lymphadenopathy, intraoral and similar medications may spectrum of no symptoms
Acquired immunodeficiency syndrome lesions (e.g. herpes labialis), slow disease progression (asymptomatic period) to frank
(AIDS) hairy leukoplakia, candidiasis, AIDS
extreme weight loss, and HIV-
associated periodontal diseases

Mycobacterium tuberculosis Respiratory droplets; aerosols; Pulmonary tuberculosis (TB) Persistent cough, night sweats, and Multidrug chemotherapy (e.g. The incidence of TB is rising,
saliva; ingestion; direct contact dissemination to the intestines, loss of energy and appetite isoniazid and rifampin), rest, and largely because of poor sanitary
kidney, bones, meninges, lymph proper nutrition and living conditions, growing number of
nodes, and oral structures persons with AIDS, and reactivated diseases

Neisseria gonorrheae Sexual contact Gonorrhea (i.e. oral lesions; gonococcal Urethral or vaginal discharge, Penicillin One of the most prevalent sexually
arthritis; infections of the skin, eye, heart, pharyngitis and oral lesions (rarely) transmitted diseases
and meninges)

Treponema pallidum Sexual contact, congenital Syphilis, (i.e. oral lesions; disseminated Primary—lymphadenopathy and chancre Penicillin Syphilis has been nicknamed “the great
infections to other organs, including the Secondary—generalized rash, imitator” because of the varied clinical
central nervous system (CNS) and heart) bone lesions and red patches manifestations accompanying the infection
on mucosal membranes
Tertiary syphilis—gummas, involve-
ment of the CNS and circulatory system
 Clinical Decisions in Operative Dentistry 25
Table 3-3: Condition associated with high-risk of • What type of dental treatment you have had before and
endocarditis how was the experience (can give information on any
untoward incident that has happened and to an extent
• Prosthetic cardiac valve what can be expected)?
• Previous infective endocarditis
• Congenital heart disease
– Unrepaired cyanotic congenital heart disease, including Attitude and Motivation of Patient to
palliative shunts and conduits Dental Treatment
– Completely repaired congenital heart defect with
prosthetic material or device, whether placed by surgery This usually cannot be assessed by single question but
or by catheter intervention, during the first 6 months rather can be assessed by having conversation with patient,
after the procedure by his/her previous dental treatment exposure.
– Repaired congenital heart disease with residual defects
at the site or adjacent to the site of a prosthetic patch or
prosthetic device (which inhibit endothelialization) Diet
• Cardiac transplantation with subsequent cardiac
• Since diet plays a major role in caries development, brief
valvulopathy.
discussion about diet is necessary, but a detailed diet
• Patients tolerance to dental treatment should also be review is needed only after examination of patient and
reviewed. information on his/her current caries status is recorded.
• Diet also plays a role in tooth erosion.
Some Pertaining Questions in Dental History
• How often do you go to dentist (give information about Habits
motivation of patient)? About patients smoking, alcohol, brushing habits are
• When did you last see a dentist and what did he do needed as they certainly affect the existing dental condition
(gives information of clinical procedure done)? of patient and also successful outcome of treatment.
• How often you brush your teeth and how long (again
gives information about motivation of patient)?
• Do you bite your nails, thumb sucking, tongue Family and Social Background
thrusting, usage of tooth picks (gives information about • Certain conditions are inherited and other hidden
any deleterious oral habits)? systemic diseases are also inherited which could be
• How do you feel about dental treatment (give assessed by enquiring about family history.
information about anxiety factor in patient)? • Social background to a certain extent determines the
• How important do you think teeth is to your appearance disease state and also patients cooperation for treatment.
and well-being (again gives information about moti- • In this aspect the monthly salary should also be include
vation of patient and attitude towards dental treatment)? to evaluate the socioeconomic status of patient.

Table 3-4: Prophylactic antibiotic regimen for endocarditis

Dose (single, 30-60 min before procedure)

Patient group Antibiotic Adults Children
Able to take oral medication Amoxicillin 2g 50 mg/kg
Unable to take oral medication Ampicillin 2 g IM or IV 50 mg/kg IM or IV
or
Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Allergic to penicillins or ampicillin Cephalexin 2g 50 mg/kg
and able to take oral medications or
Clindamycin 600 mg 20 mg/kg
or
Azithromycin or Clarithromycin 500 mg 15 mg/kg
Allerging to penicillins or ampicillin Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
and unable to take oral medications or
Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
 26 Essentials of Operative Dentistry

Risk Assessment examination of the oral cavity, dentition, oropharynx,

• Few disease are caused by single known factor, most and adnexal structures, as customarily carried out by
of disease is caused and aggravated by a host of the dentist) should be carried out at least once annually
factors. or at each recall visit.
• Assessing these factors and assigning risk of a patient The tendency for the dentist to focus on only the tooth
to a particular disease is done in this procedure. or jaw quadrant in question should be strongly resisted.
• Though this step is still not perfected and as newer Examination of patient in dental office set up includes:
research data for diseases come about risk assessment • Registration of vital signs (respiratory rate, temperature,
can be a perfect procedure. pulse, and blood pressure).
• By assigning risk potential for a patient, treatment • Examination of the head, neck, and oral cavity, including
aggressiveness can be modified (Table 3-5). salivary glands, temporomandibular joints, and lymph
nodes.
Clinical Examination • Examination of cranial nerve function.
• Special examination of other organ systems.
• A thorough systematic examination of oral cavity and • Requisition of laboratory studies.
adnexal tissues prevent any conditions being
overlooked.
General Appearance
• For restorative treatment planning, the intraoral
examination includes assessment of periodontium, • Much of what you need to know about any individual
dentition, occlusion. patient can be obtained by watching them enter the
• Specific diagnostic tests such as radiographs, pulp surgery and sit in their chair and body language.
testing, etc. may be done as when it is necessary. • Note the general appearance of the individual and
• It is deemed necessary that systematic assessment is evaluate emotional reactions and the general nutritional
needed and every step be completed before commencing state. Record the character of the skin and the presence
on next step. of petechiae or eruptions, as well as the texture,
• Before commencing clinical examination of patients distribution, and quality of the hair. Examine the
universal precautions with regard to infection control conjunctivae and skin for petechiae, and examine the
are maintained properly. sclerae and skin for evidence of jaundice or pallor.
• The routine oral examination (i.e. thorough inspection, Determine the reaction of the pupils to light and
palpation, auscultation, and percussion of the exposed accommodation, especially when neurologic disorders
surface structures of the head, neck, and face; detailed are being investigated.

Table 3-5: Risk factor for caries

Factors High-risk characteristics

Nonoral
Age Less than 18 or more than 65 years old
Socioeconomic status Lower status
Medical condition Reduced salivation
Medications Reduced salivation
Fluoride history Lack of fluoride during tooth development
Dietary habits High intake of refined carbohydrates, tobacco and alcohol use
Genetic predisposition Family history of disease
General health Debilitation and decreased ability to give self-care
Oral
Tooth anatomy and composition Development fissures and low fluoride content
Oral floral/plaque High levels of mutans streptococci
Previous infections and restorations History of extensive restoration
Restorations Defective restorations
Oral hygiene (e.g. skills, knowledge, motivation) Poor oral hygiene
 Clinical Decisions in Operative Dentistry 27
Table 3-6: Vital signs

Normal Tachypnea
Respiratory rate 14-16 breaths/min > 20 breaths/minute
Oral Axillary Rectal Aural
Normal temperature 98.6°F/37.0°C 97.6°F/36.3°C 97.6°F/36.3°C 99.6°F/37.7°C
Bradycardia Normal Tachycardia
Pulse rate < 60 beats/minute 60-100 beats/minute >100 beats/minute
Regular Regular Irregular
irregular irregular
Pulse rhythm Evenly spaced beats. May Regular pattern with No pattern
vary slightly with respiration skipped beats chaotic

Vital Signs Table 3.7: Blood pressure value

• Respiratory rate, pulse rate, temperature and blood
Systolic blood Diastolic
pressure has to be recorded. pressure blood pressure
• It can reveal underlying disorder but this can also be Category (mm Hg) (mm Hg)
used as a reference if any untoward incident like
Nonhypertensive
syncope should happen (Tables 3-6 and 3-7). Optimal < 120 and < 80
Normal < 130 and < 85
Head, Neck and Oral Cavity Examination High normal 130-139 or 85-89
Hypertensive
To perform this examination procedure successfully, the
Stage 1 140-149 or 90-99
examiner needs the following (Table 3-8): Stage 2 160-179 or 100-109
• Adequate knowledge of the anatomy of the region to be Stage 3 >180 or > 110
able to recognize normal structures and their common
variations.
• A well-practiced technique for displaying all of the
Lymph Node Examination
skin and mucosal surfaces of the head, neck, and oral
Palpate for adenopathy. The superficial and the deep
cavity with minimal discomfort to the patient and a
lymph nodes of the neck are best examined from behind
routine that ensures the systematic examination of all
the patient, with the patients’s head inclined forward
the tissues that can be approached.
sufficiently to relax the tissues overlying the lymph nodes.
• Knowledge of the variety of disease processes that can
Look for distention of the superficial veins as well as for
affect the superficial structures of the head, neck, and
evidence of thyroid enlargement. Palpate any swellings,
oral cavity.
nodules, or suspected anatomic abnormalities and also
• The ability to succinctly record (in writing) both
presence of tenderness.
normal and abnormal findings noted during the
examination.
• Examination gloves, tongue blades or dental hand Examination of Temporomandibular Joint
mirrors, a dental explorer and periodontal probe, gauze • Deviations in the path of the mandible during opening
pads, a dental chair. and closing, as well as the range of vertical and lateral
movement. Palpate the joints, and listen for clicking
and crepitus during opening and closing of the jaw;
Extraoral Examination use a stethoscope to characterize and locate these sounds
Any facial asymmetry, swellings, outgrowth, pigmentation accurately. Note any tenderness over the joint or
of the face is noted. masticatory muscles.
 28 Essentials of Operative Dentistry

Table 3-8: Normal anatomic structures that may be identified by superficial physical examination of head and neck

• Head: Extraoral structures

• Face
• Skin
• Nose (alae, external nares, nasal mucosa)
• Eyes (pupils, palpebral and bulbar conjunctivae, irises, lacrimal caruncle, lacrimal glands and duct orifices, orifice of the
nasolacrimal duct, eyebrows, eyelashes commissures)
• Jaws (mandibular border, angle, symphysis, condyle and coronoid processes; malar process, maxilla, infraorbital foramen,
mental foramen, lingual notch, maxillary sinuses)
• Masticatory muscle (temporalis, masseter, buccinator)
• Parotid gland
• Muscles of expression (obicularis oris, depressor and levator anguli oris, orbicularis oculi)
• Distribution of branches of the facial nerve
• External carotid, lingual, and temporal pulses
• Scalp and cranium (frontal, occipital, and temporal bones; mastoid process; nuchal point; frontal sinuses; cranial aponeurosis;
insertion of temporal muscle)
• Ears (pinna, external auditory meatus and canal, tragus, helix)
• Neck (anterior, posterior, and submaxillary triangle; sternocleidomastoid; platysma; digastric and mylohyoid muscles; thyroid
and cricoid cartilages; trachea; wings of hyoid bone; thyroid gland; anterior and posterior cervical lymph nodes; submandibular
lymph nodes; sternal notch and clavicles; first cervical vertebra (atlas), carotid pulse)
• Relationships: Mesial, distal, anteroposterior, buccal, facial, labial, vestibular, lingual, palatal, coronal, sagittal, lateral,
interproximal, gingival, incisal, occlusal.
• Head: Intraoral structures
• Lips (skin and mucosal surfaces, vermillion border, commissures, oral vestibule, minor salivary glands, labial frenum)
• Cheeks (buccinator muscle, buccal fat pad, buccal frenum, occlusal line (linea alba), orifice and papilla of parotid gland duct
(Stensen’s duct), minor salivary glands, Fordyce’s granules, buccal vestibule)
• Tongue (dorsum (anterior two-thirds and posterior one-third); filiform, fungiform, vallate, and foliate papillae; foramen
cecum; lymphoid follicles of posterior one-third; ventral surface, including mucosa, fimbriated folds, superficial veins and
varicosities, anterior lingual glands (Blandin and Nuhn’s glands) and ducts)
• Floor of mouth (plicae submandibularis (sublingual folds), submandibular duct (Wharton’s duct), and orifice of submandibular
and sublingual gland ducts (sublingual caruncle); lingual vestibule; genial tubercles; mylohyoid ridge; lingual nerve)
• Palate (hard and soft palates, reflecting line, foveae palatine, maxillary tuberosity, pterygoid hamulus, tensor palate muscle,
anterior and posterior palatine canals, uvula)
• Gingivae (marginal gingivae, attached keratinized (alveolar) and nonkeratinized (areolar) gingivae, gingival sulcus,
interdental papillae)
• Retromolar region (retromolar pad, external oblique ridge, palatoglossal arch (anterior pillar of fauces), pterygomandibular
ligament, retromolar triangle, stylohyoid ligament
• Pharynx (palatine tonsils, palatopharyngeal arch (posterior pillar of fauces), tonsillar crypts, posterior pharyngeal wall,
lateral pharyngeal wall, orifice of Eustachian tube and posterior nares, larynx, pyriform fossa, epiglottis, internal pterygoid
muscle, Waldeyer’s ring, lingual tonsils, adenoids)
• Teeth: Chart the designation and name of each tooth.

• As most of procedures especially complex operative mucobuccal folds, the palate, the tongue, the sublingual
procedure require longer duration of mouth opening space, the gingivae, and then the teeth and their
from patient a healthy temporomandibular joint is a supporting structures. Last, examine the tonsillar and
prerequisite. the pharyngeal areas and any lesion, particularly if the
lesion is painful. Any noted asymmetry should be
Intraoral Examination investigated further.
• Completely visualize the smooth mucosal surfaces of
Soft Tissue Examination the lips, cheeks, tongue, and sublingual space by
• Examine in sequence the inner surfaces of the lips, the using two tongue depressors or mirrors. Perform a more
mucosa of the cheeks, the maxillary and mandibular detailed examination of the teeth and supporting tissues
 Clinical Decisions in Operative Dentistry 29
with the mouth mirror, the explorer, and the periodontal This examination is aided by the assessment of caries
probe. risk factor assessment.
• Have the patient extend the tongue for examination of It is important to recognize active caries lesion and
the dorsum; then have the patient raise the tongue to the restore it to prevent further progression of lesion.
palate to permit good visualization of the sublingual Prerequisite for caries diagnosis are:
space. The patient should extend the tongue forcibly out • Good lighting
to the right and left sides of the mouth to permit good • Clean teeth
visualization of the sublingual space and to permit careful • A three way syringe so that teeth can be visualized both
examination of the left and right margins. A piece of in wet and dry environment
gauze wrapped lightly around the tip of the tongue • Sharp eyes, if possible with magnification
helps when manually moving the patient’s tongue. • Radiographs (Bitewing radiographs)
Examine the tonsillar fossae and the oropharynx. • Knowledge of what to look for.
Examination should start from upper right quadrant
• Use bimanual or bidigital palpation for examination of
and going in clockwise direction finishing in lower right
the tongue, cheeks, floor of the mouth, and salivary
quadrant, covering the entire dentition.
glands.
• As clean teeth is mandatory for good diagnosis of caries,
oral prophylaxis could be carried out beforehand
Examination of Dentition provided patient is not in an emergency visit.
• On no account should intact surface of early enamel
Elements of Clinical Examination lesion be poked with an explorer as these lesions are
amenable to remineralization. Use of explorer should
• Evaluation of dentition
be done judiciously without injuring the patient
• Assessment of caries risk and plaque
(Figures 3-2A to C).
• Caries diagnosis
• Radiographs for examination should be of high quality.
• Evaluation of existing restorations
• In addition to clinical examination certain tests such as
• Assessment of pulp
percussion, palpation, radiograph, pulpal tests and
• Evaluation of occlusion and occlusal contours other diagnostic tests are employed as and when
• Assessment of additional defects required, these tests should have high positive
• Evaluation of esthetics predictive value and high test sensitivity and specificity.
• Evaluation of periodontium
• Assessment of disease activity
Pit and Fissure Caries
• Evaluation of structure and contour of bony support
• Mucoginigval evaluation • Both pits and fissure are areas where there is non-
• Evaluation of radiographs. coalesced enamel at the bottom. Therefore, they are
• Evaluation of diagnostic casts. susceptible to caries formation.
• These pits and fissures are found on occlusal surfaces
Plaque and Caries Risk of premolars and molars.
• Tactile examination with a sharp explorer into the
• An assessment of caries risk should be done this will be
fissure will give a catch or resistance to movement and
discussed in chapter on caries.
there will be softening at base of the fault. But this
• Plaque in patient can be evaluated using plaque technique has been shown to be unreliable.
disclosing solutions like triclosan red and utilizing In summary an occlusal surface caries can be detected
plaque index for scoring. by presence of one of the following:
• Determination of caries risk and plaque risk serves as a • Chalkiness or softening of the fault.
baseline value from which patient could be assessed on • Brown gray discoloration (Figure 3-3).
recall visits. It can also give about prognosis of treatment. • In radiograph, radiolucency beneath the occlusal
surface (Figure 3-4).
Caries Examination Carious pits on the buccal and lingual surface of molars
Dental caries is diagnosed by one or all of the following: and on lingual surface of maxillary anteriors can also be
• Visual changes in tooth surface and texture. detected by the same way as mentioned above.
• Tactile sensation when used with explorer. Sometimes, carious pit are also found on the cusp tips
• Radiographs. of posterior teeth.
 30 Essentials of Operative Dentistry

Figure 3-3: Gray discoloration of occlusal

enamel before breakdown of enamel

Figure 3-4: Bitewing radiographs for

detection of occlusal caries

Proximal Surface Caries

• Is usually detected by radiographs. Bitewing radio-
graphs are of paramount importance in this aspect
(Figure 3-4).
• By careful visual examination there may be chalky white
appearance or shadow under the marginal ridge before
breaking down of marginal ridge.
• Careful probing of proximal surface can detect proximal
surface breakdown.
• Tooth separating devices (more about this device in later
chapters) or orthodontic separators could be used to
move the teeth away from each other to visualize the
proximal surface (Figures 3-5 to 3-7).
• Transmitted light passing through the contact of two
Figures 3-2A to C: An intact enamel surface teeth can be used to detect proximal caries either
can be broken down by explorer tip light curing unit or dental operatory light could be
employed— Transillumination.

Smooth Surface Caries Smooth Surface Caries on Gingival

It mainly occurs on three locations, viz. Third of Crown
1. Proximal surface of posteriors and anteriors. • These are found on the facial and lingual surfaces of
2. Facial and lingual cervical 3rd of crown of teeth. teeth on the gingival third.
3. Root surface caries. • Earliest manifestation of this type of caries is white spot
These proximal surface caries is most difficult to detect. that is different from adjacent translucent enamel which
 Clinical Decisions in Operative Dentistry 31

Figures 3-5A and B: Usage of orthodontic separators

Figures 3-8A and B: Early enamel white spot

Root Surface Caries

• Usually occurs in geriatric patients occurring on
cemental surface of root (Figure 3-9).
• It can usually be detected by thorough clinical
examination.
• Sometimes gingiva may be covering the root caries
which is usually swollen and reddish.
Figure 3-6: Tooth separating devices

Figure 3-9: Root surface caries

Active Caries (Figure 3-10)

• Here patient’s caries risk is high.
• Lesion is highly retentive for food debris and plaque.
Figure 3-7: Careful use of interproximal explorer • Lesion is soft, with leathery dentin and deminera-
lization is progressing.
• Restoration is definitively adviced to stop progression
partially or totally disappears on wetting (Figures
of caries and reduce patients caries risk potential.
3-8A and B). Drying again causes it to reappear
(Distinguishing feature from enamel hypoplasia).
• Presence of this type of caries indicates patient has high Arrested Caries (Figure 3.11)
caries risk potential. • In a slowly progressing caries in a patient with low
• Advanced lesion presents discoloration and deminera- caries risk, darkening occurs overtime because of
lization and will feel soft on penetration by explorer. extrinsic staining and remineralization of hard tissue.
 32 Essentials of Operative Dentistry

Figures 3-12A and B: Diagnodent

Figure 3-10: Active caries lesion

Figure 3-13: Quantifying light induced fluorescence

Figure 3-11: Arrested caries lesion

Figures 3-14A and B: Electrical caries monitor

• Most of the time lesion is wide open with very little food
debris accumulation. Symptoms of Caries
• Dentin becomes eburnated and changes color to dark So far the clinical detection of caries has been discussed,
brown. but symptoms of caries are:
• Progression of caries is stopped and no further • Most of times when caries is experienced by patient it
progression is anticipated. will be at very later stage when caries has progressed
• Restoration is not indicated unless for esthetic purposes. into dentin or pulp.
• Patient may sometimes feel or experience a hole in the
Newer Technologies teeth.
• Where visual examination by magnifying loupes can • Caries in dentin per se also may or may not be painful
employed to detect mildest of changes. except for sensitivity to cold, hot or sweet things.
• Fiber-optic transillumination. • When patient seeks for treatment for pain in a caries
• Emitted fluorescence from carious lesion can be used tooth it would most probably would have affected the
(Diagnodent, Kavo) (Figures 3-12A and B). pulp resulting in pulpitis or necrotic pulp.
• Quantifying light induced fluorescence (Figure 3-13).
• Digital imaging fiber-optic transillumination. Assessment of Existing Restorations
• Electrical conductance measurement (Figures 3-14A This assessment should also be done under:
andB). • Good lighting.
• Caries detecting dyes are some of the newer technolo- • Clean dry field.
gies in diagnosis of caries. • A three way syringe for air and water manipulation.
Some of the caries risk factors are given in Table 3-9. • Sharp eyes.
 Clinical Decisions in Operative Dentistry 33
Table 3-9: Caries risk assessment

High-risk Low-risk
Social history
Socially deprived Middle class
High caries in siblings Low caries in siblings
Lower knowledge of dental disease Dentally aware
Irregular attendance Regular attendance
Ready availability of snacks Work does not allow regular snacks
Low dental aspirations High dental aspirations
Medical history
Medically compromised No medical problem
Handicapped No physical problem
Xerostomia Normal salivary flow
Long-term cariogenic medicine No long-term medication
Dietary habits
Frequent sugar intake Infrequent sugar intake
Fluoride use
Nonfluoride area Fluoridation area
No fluoride toothpaste Fluoride toothpaste used
Plaque control
Infrequent, ineffective cleaning Frequent, effective cleaning
Poor manual control Good manual control
Saliva
Low flow-rate Normal flow-rate
Clinical evidence
New lesions No new lesions
Premature extractions Nil extractions for caries
Anterior caries or restorations sound anterior teeth
Multiple restorations No or few restorations
History of repeated restorations Restorations inserted years ago
Multiband orthodontics No appliances
Partial dentures

• Good radiograph. • Restoration related periodontal health

And importantly knowledge of what to look for. • Occlusion and interproximal contacts
• Secondary caries
General Criteria Used to Evaluate • Esthetics.
Existing Restorations
• Structural integrity Structural Integrity
• Marginal opening • To determine whether a part or whole of restoration
• Anatomic form has fractured or missing.
 34 Essentials of Operative Dentistry

• Any fracture line present. A fracture line in isthmus of

restoration may be indicated for replacement of
restoration.
• If any void is present does it weaken the restoration or
acts as plaque retentive zones. If void is present and its
on the gingival one-third of crown then it might be
necessary to replace the restoration.

Marginal Opening
• Few restorations have perfect marginal seal.
• Point at which marginal opening present deemed for
replacement of restoration is difficult to determine. Figure 3-15: Improper anatomic contour and
• Marginal opening is determined by use of a sharp secondary caries around restoration
explorer.
• For amalgam restorations a marginal ditching will be Restoration Related Periodontal Health
closed by corrosion products and does not deemed to Problems commonly encountered in this aspect are:
be replaced. 1. Surface roughness of restorations
2. Interproximal overhangs
Amalgam Blues 3. Impingement on biologic width.
• Amalgam blues are often discoloration caused by • All these problems could lead to periodontal problem.
amalgam which may be due to leaching of corrosion • Rough or open margin restorations especially near
products or from color of amalgam showing through gingival one-third can lead to inflammation in perio-
unsupported enamel. dontal tissues. Rough margins or roughness in restora-
• Presence of amalgam blues does not indicate for tions is diagnosed visually and tactilely using explorers.
replacement of restoration. • Interproximal overhangs are diagnosed visually,
• But replacement could be done with view of esthetics. tactilely and radiographically. Tactilely explorer could
Marginal opening in resin composites are required to be moved through the interproximal region to see for
smooth transition between tooth structure and restora-
be replaced as these gaps cannot be filled up by corrosion
tion if explorer catches or it runs over the restoration it
products.
indicates overhangs. Dental floss can passed over the
Anticariogenic restorations like glass-ionomers with
contact into interproximal region, if the floss gets caught
marginal opening need not be replaced because of their
or shreds it indicates overhanging margins. This over-
fluoride release potential unless until frank caries has
hanging margin can lead to periodontal inflammation
occurred.
because of food trapment. Any interproximal overhang
restoration should be replaced and periodontal
Anatomic Form condition needs to be revaluated (Figure 3-16).
Anatomic form refers to degree to which the restoration • If restoration especially class II, V restorations, cast resto-
duplicates the original contour of tooth. ration gingival margins extends into the biologic width
Common problems with anatomic form are: it can lead to periodontal breakdown and inflammation.
• Over contouring Restorations of this nature also needs to be replaced or
• Under contouring surgical lengthening of crown be done.
• Un even marginal ridges
• Inadequate facial and lingual embrasures. Occlusion and Interproximal Contacts
• Lack of gingival and occlusal embrasures. • Occlusal contacts should be evaluated and checked for
Decision has to be made whether the restoration has to centric and lateral excursions and occlusal interference
be replaced and whether this lack of anatomic form if found should be removed.
has resulted in pathosis or will lead to pathosis (Figure • At same juncture any restorations out of occlusion needs
3-15). to be replaced as it can lead to supraeruption.
 Clinical Decisions in Operative Dentistry 35

Figure 3-16: Interproximal overhangs

• Tightness of interproximal contacts should be evaluated

by dental floss and floss should come out of the contacts Figure 3-17: Secondary caries around restoration
smoothly.
• Too open contact can lead to food impaction. Open
contact restorations needs to be replaced with ideal
contact restorations.

Secondary Caries
• Evaluation of secondary caries in restorations should
be looked in margins of restorations.
• Visual, tactile with explorers, and radiograph use must
be combined.
• Visual examination may reveal discoloration of
margins of restorations indicating caries formation but
this is not definitive indication.
• In non-amalgam restorations esp., in composite
restorations marginal discoloration warrants
replacement. Figure 3-18: Unesthetic discolored composite restoration
• Both in amalgam and anticariogenic restorations (Glass
ionomers) marginal discoloration does not necessitate
Common esthetic problem with restorations are,
replacement of restoration.
1. Display of metal
• Tactilely marginal breakdown or fracture indicates
2. Discoloration or poor shade match
secondary caries around margins of restorations.
3. Poor contour in tooth restoration
• Radiograph may reveal radiolucent area around
4. Poor periodontal tissue response.
radiopaque restoration indicating caries process (Figure
• Most of the time it is not just one factor that influences
3-17). This underlines the importance of radiopacity of
replacement of restoration but rather it will be a
dental restorations.
combination of factors, as all these factors are inter-
related and one factor leads to other factor.
Esthetics • When all these conditions has been evaluated patient’s
• Esthetic evaluation of existing restoration is highly satisfaction with existing restoration must be
subjective. considered.
• When restoration is functionally good but patient may • Besides these factors restoration needs to be replaced if
be not satisfied with esthetics. patient is symptomatic with the restoration like tender-
• When replacing such restorations dentist must consider ness, sensitivity. Then underlying cause has to be
whether further improvement can be done any investigated mostly by radiograph. If restoration
underlying cause for the problem should be evaluated impinges on pulpal horn then restoration needs to be
(Figure 3-18). replaced (Figure 3-19).
 36 Essentials of Operative Dentistry

Percussion
• It involves gentle tapping on the occlusal surfaces of
the tooth with end of mouth mirror handle.
• Tenderness indicates possible pulpal inflammation
spread into periradicular tissues or periodontal
inflammation (Figure 3-21).

Figure 3-19: Restoration impinging on pulp of 36

Examination of Dental Pulp and

Periradicular Tissue
• Evaluation of pulpal health in each and every tooth is
not warranted. Since periradicular tissues are in Figure 3-21: Percussion
continuum with pulp, evaluation of this structure is
also necessary. Palpation
• However, teeth that undergoes extensive restoration,
• It is performed by rubbing the index finger along the
teeth that are critical to treatment plan, teeth with
facial and lingual mucosa overlying apical region of
questionable pulpal health needs to be tested. the tooth.
Routine pulpal and periradicular investigations
• If tenderness or swelling is detected it indicates presence
include:
of periapical pathosis (Figure 3-22).
• Color
• Percussion
• Palpation
• Sinus evaluation

Color
Color of a tooth where the pulp has undergone necrosis
will be darker (Figure 3-20).

Figure 3-22: Palpation with index finger

Sinus Evaluation
• A sinus opening is an epithelium lined tract draining
the infection from interior of body surface to exterior.
• A sinus opening can be active or inactive present in the
facial or lingual mucosa indicates most probably
Figure 3-20: Discolored maxillary incisors presence of an infected necrotic pulp.
 Clinical Decisions in Operative Dentistry 37

Figures 3-23A to C: Sinus evaluation: (A) Presence of sinus, (B) Gutta-percha point inserted into sinus opening,
(C) Radiograph showing gutta-percha tracing sinus tract.

• Sinus can be investigated by inserting gutta-percha • Both static (Centric occlusion) and dynamic (excursive
point into the sinus opening and taking radiograph movements) must be noted, this can be done by using
(Figures 3-23A to C). articulating paper, two colors can be employed for noting
these two relationships.
Special pulpal tests are:
• Study models of both upper and lower jaws can be
• Thermal tests—hot and cold tests.
articulated to study occlusion if deemed necessary or
• Electric pulp test.
in case of multiple restorations of teeth.
• Test cavity.
Radiographs can reveal pulpal problem whether caries Examination of occlusion should include:
has involved pulp or otherwise (Figure 3-24). • Occlusal interference between occlusion of centric
It is advantageous to ascertain pulpal prognosis of a relation and that of maximum intercuspation.
tooth prior to restorative treatment. If pulpal health is • Number and position of occlusal contacts.
uncertain or guarded then it is necessary to perform • Interarch space available for placement of restoration.
endodontic treatment.
Occlusal Interferences
• In most of the patients centric relation and maximum
intercuspation position does not coincide and it does
not cause any pathosis.
• Detailed explanation with this regard can be found on
text dealing with occlusion.

Number and Position of Occlusal

Contacts
• As mentioned earlier an articulating paper can be
employed with this regard.
• Both static and dynamic occlusal relationship has to be
recorded.
Figure 3-24: Caries encroaching pulp

Interarch Space Available

Examination of Occlusion
When there is extensive tooth loss due to attrision or
• It is of paramount importance to know the occlusion erosion sufficient interarch space may not be available for
scheme of teeth preoperatively. intracoronal and extracoronal restorations which may
• Occlusion not only affects type of functional load on necessitate (Figures 3-25A and B):
the restoration but also can alter the design of restoration • Crown lengthening
and type of restorative material to be employed. • Vertical dimension increasing.
 38 Essentials of Operative Dentistry

Figures 3-25A and B: Erosive loss of tooth structure with little

inter-arch spacing necessitating vertical dimension increasing

Assessment of Additional Defects

Figure 3-27: Abrasion
Other defects that may be noted are enamel hypoplasias,
congenital tooth malformations or defects, tooth
discoloration like fluorosis erosion, abrasion, attrition, • Most commonly due to holding pipe cigarette, tobacco
fractures. chewing, nail biting and abnormal tooth brushing.
• Tooth brushing abrasion presents as a wedge shaped
Erosion (Figure 3-26) notch on facial surfaces of tooth in cervical region.
• Is the loss of tooth structure by chemical actions of acids.
• Patients in whom there is a tendency for regurgitation Attrition (Figure 3-28)
of acids have this condition. • Is mechanical wear of incisal or occlusal surfaces of
• Other patients who tend to have it are the persons who tooth due to functional or parafunctional movement of
have habit of ingesting citrus or acidic foods, chronic mandible.
alcoholics, bulimia, and persons working in industries • It is a wear caused by tooth to tooth wear.
exposed to acid vapor like battery industries. • Some amount of attrition is expected in older patients
• Clinically, it presents as a smooth concavity depending due to aging process.
on severity it can be minimal to extensive. Usually • But extensive attrition is pathologic.
present on the lingual surface of tooth. • It usually appears as flat areas with cuspal and incisal
morphology being lost and cupped out areas appear in
the occlusal surfaces of posterior teeth.

Figure 3-26: Erosion

Abrasion (Figure 3-27)

• Is abnormal tooth surface loss resulting from direct
frictional forces between contacting teeth and external
objects or from frictional forces between contacting teeth
in presence of an abrasive medium. Figure 3-28: Attrition
 Clinical Decisions in Operative Dentistry 39
• Sharp edges of occlusal surfaces can result in inadver-
tent biting of tongue or cheek.
In all these pathologic processes the underlying
causative factor has to be analyzed and removed before
restorative treatment.
About other additional defects details can be found on
oral pathology textbooks.

Esthetic Evaluation
• Esthetic evaluation is most commonly necessary for
anterior restorations, in performing posterior
restorations esthetics role is mainly confined to tooth Figure 3-30: Tooth mobility evaluated
colored or nontooth colored restoration. with two instruments
• This area of evaluation is highly subjective one with
patient’s participation is must. • Any calculus and plaque accumulation needs to be
Commonly involved esthetic problems that are noted.
addressed by restorative dentistry are: • A better objective way will be to use any of the various
• Stained or discolored anterior teeth. periodontal, gingival or calculus indices to be employed.
• Unesthetic anterior teeth contour. • Qualitative assessment of gingival tissue can be
• Unesthetic spacing or crowding of teeth. examined by noting the tissue color, texture, contours,
• Carious and unesthetic restorations. edema, and exudates.
• Tooth mobility is evaluated using two instruments
Evaluation of Periodontium preferably mouth mirror its handle is used to hold the
From operative dentistry point of view periodontium is teeth and moved (Figure 3-30). An objective way of
evaluated for two reasons: assessing will be by tooth mobility index.
1. To determine effect of periodontal health on restorations. • Radiographs are used to evaluate the bone architecture
2. To determine effect of restoration on periodontal health. surrounding the teeth.
• Any teeth undergoing extensive restorative treatment
Evaluation of periodontium involves:
with guarded periodontal prognosis should undergo
1. Assessment of attachment levels.
comprehensive periodontal therapy before definitive
2. Alveolar bone topography.
restorative treatment.
3. Tooth mobility.
4. Assessment of gingival tissue health.
5. Radiographic evaluation. Radiographic Examination of
• Periodontal health is assessed by using periodontal probe
and assessing the bony architecture and most impor- Teeth and Restorations
tantly recording any bleeding on probing (Figures • Dental radiographs are essential part of diagnosis.
3-29A and B). • But radiographic exposure is with the associated risk
of radiation hazard, therefore diagnostic yield or
potential benefit must be carefully weighed against
potential risk.
• Radiographs should be of good quality and area of
interest should be well covered (Figures 3-31 and 3-32).
• When taking radiography proper infection protocol
should be followed.
Various radiographic views for caries diagnosis are:
• Intraoral periapical view (IOPA)
Figures 3-29A and B: Periodontal probing of pocket and • Bitewing radiographs.
radiograph revealing the bone loss • Occlusal radiographs.
 40 Essentials of Operative Dentistry

• Most often caries lesion will present in radiograph as

radiolucent lesion of different grades, most often caries
present clinically is much more extensive than what
appears in radiographs (Figures 3-34 to 3-38).

Clinical situations in which radiograph may be necessary

• Previous periodontal or root canal therapy
• History of pain or trauma
• Familial history of dental anomalies
• Clinical evidence of periodontal disease
• Large or deep restorations
Figure 3-31: Poor quality radiographs
• Deep carious lesions
• Malposed or clinically impacted teeth
• Swelling
• Mobility of teeth
• Fistula or sinus tract infection
• Growth abnormalities
• Oral involvement in known or suspected systemic disease
• Evidence of foreign objects
• Abutment teeth for fixed or removable partial prosthesis
• Unexplained bleeding
• Unexplained sensitivity of teeth
Figure 3-32: Radiographic where the area • Unusual tooth morphology, calcification, or color
of interest is not viewed (Cone cut) • Missing teeth with unknown reason.

Radiographic Techniques
Basically two techniques:
1. Bisecting angle technique.
2. Paralleling technique.
Complete mouth radiographic series is also known as
full mouth series or complete series and it consists of
17 periapical views and 4 bitewing views (Figure 3-33).
• For diagnosis of proximal surface caries, restoration
overhangs radiographs are useful.
• When interpreting radiographs it is essential to know
the normal radiographic anatomy and radiographic
presentation of pathology.
Figure 3-34: Early enamel caries

Figure 3-33: Complete series Figure 3-35: Caries that has cavitated
 Clinical Decisions in Operative Dentistry 41

Figure 3-36: Caries that has spread into dentin Figure 3-37: Caries approaching pulp

Figure 3-38: Diagrammatic representation of caries progression in radiographs

 42 Essentials of Operative Dentistry

Limitations with Radiographs

• It is a two dimensional picture of a three dimensional
structure.
• Certain misdiagnosis can occur with use of radiographs.
• Caries is always more extensive clinically compared to
radiographic presentation.
A suggested guide line when to repeat the radiographs
is to take new radiographs in caries active patients Figures 3-39A and B: Tooth sloth bite test
annually and in caries in-active patients radiographs are
taken once in 2-3 years.

Evaluation of Diagnostic Casts

• Diagnostic casts can give valuable information.
• It can be used to study dynamic occlusal relationship.
• It can be used for mock restorative treatment.
• Other areas which are visible clinically can be seen in
casts.
Figures 3-40A and B: Transillumination to detect fracture line

Adjunctive Special Tests History and Examination Process

These tests are done as examination of dentition is done Full history of the problem of patient is to be completed
and as and when necessary. Most of these tests are done to before examination of patient.
know about the condition of pulp or periodontal ligament.
These are: Usual sequence to be followed will be:
• Rubber wheel biting test or tooth sloth test – for detecting • Biographic and demographic information.
cracked tooth (Figures 3-39A and B). • Chief compliant in patients own words followed by
• Transillumination for detecting fracture (Figures 3-40A history of present illness.
and B). • Past dental history about patient’s earlier dental
• Detailed occlusal analysis by mounting study casts in experience or any other dental problem he had treat-
adjustable articulators mostly done in cases where ment.
there’s need for extensive restorations (Figures 3-41A • Medical history and history of hospitalization,
and B). undergoing any medical treatment or allergies.
• Diet analysis if the patient has high susceptibility to • Diet, social, any habits history.
caries (Table 3-10). • A detailed extraoral and intraoral examination.
• Salivary analysis again for patients with high suscep- • Special tests if required.
tibility to caries or any other conditions reducing • Diagnosis and prognosis.
salivary flow. • Treatment planning process.

Figures 3-41A and B: Casts mounted on adjustable articulators when

extensive restorations are planned
 Clinical Decisions in Operative Dentistry 43
Table 3-10: Dietary analysis with sugar exposure being marked

Thursday Friday Saturday Sunday

Time Item Time Item Time Item Time Item
Before
breakfast 7.30 Tea 7.0 Tea 7.30 Tea 7.05 Tea
Breakfast 8.00 2 wheat slices 8.00 2 wheat slices 8.30 2 wheat slices 8.05 2 wheat slices
2 crispbread 2 crispbread 2 crispbread 2 crispbread
1 apple 1 apple 1 apple 1 apple
Coffee Coffee Coffee Coffee
Morning 9.00 Polo 10.00 Murray mint 11.15 Tea 10.00 Lemon Barley
11.30 Tea 12.30 Tea
Biscuit
Mid-day 12.30 Meat roll 2.00 Steamed fish 1.45 Sausage, onion 1.40 Roast lamb,
meal Tea Parsley sauce Boiled potatoes potatoes,
Boiled potatoes Ice cream cabbage,
timed fruit carrots
Afternoon 2.00 2 cream crackers 2.45 Tea 2.30 Tea 2.00 Tea
1 Dairy Lea
Tea
5.30 2 shortbread 6.00 Tea 5.45 Tea 4.00 Tea
biscuits
Tea
Evening 8.00 Chop, leeks,
meal boiled potatoes 8.30 Bacon sandwich 7.30 Fried kipper 8.15 Ham salad,
Choc-ice Tea bread and butter bread and butter
Tea Tea
Evening and 1.00 Horlicks 10.00 Peanuts 9.15 Chocolate 1.15 Horlicks
night Biscuits 1.30 Horlicks 1.45 Horlicks Biscuits
Biscuit Biscuits

Diagnosis and Prognosis today’s operative treatment is aimed at treating patient,

therefore, the activity of caries, patient’s susceptibility
• Diagnosis is arrived by correlating the patient’s history
to caries should all be included in diagnosis so that
of compliant and clinical examination with skill of the
efficient treatment of patient could be done.
dentist.
• Provisional diagnosis is arrived after assessing the
patient history and examination findings, this provisio- Treatment Plan
nal diagnosis is subject to changing once special tests A treatment plan is a carefully sequenced series of services
decision are arrived leading to final diagnosis. designed to eliminate or control etiological factors, repair
• If situation arises a definitive or final diagnosis should existing damage and create a functional, maintainable
be supplemented by differential diagnosis, and final environment.
diagnosis should have sufficient findings to be An accurate prognosis for each tooth and for the patient’s
differentiated from former. overall health is central to a successful treatment plan.
• With regard to operative dentistry diagnosis is straight Development of treatment plan consists of:
forward with examination findings forming the 1. Examination and problem identification: It involves
diagnosis (e.g., Findings - occlusal pit and fissure caries previously discussed examination and history taking.
on left lower molar. Diagnosis will be Class I dental 2. Decision to recommend intervention: Deciding to
caries). But in today’s operative dentistry just Class I intervene is taken when tooth or restoration is going to
dental caries will not suffice as it marks tooth finding, further deteriorate and affect health of patient.
 44 Essentials of Operative Dentistry

3. Identification of treatment alternatives: List of other • When width of intracoronal preparation is below
treatment options available this may include, watch 1/4th intercuspal width a conventional intracoronal
and wait approach, a temporary or interim restoration, restoration will suffice.
repair of the restoration rather than replacement, or • When width of intracoronal preparation exceeds
definitive restoration of tooth. 1/3rd intercuspal width consideration should be given
4. Selection of treatment with patient involvement: to inlays, onlays or crowns.
Patient is informed of treatment options their merits Anterior teeth (Figures 3-44 and 3-45)
and demerits and final decision is taken with this • For conservative preparation in anterior teeth composite
regard. restoration will suffice.
• Treatment plans are influenced by patient’s preferences, • When extensive facial tooth structure is lost veneer could
motivation, systemic health, emotional status and be considered.
financial capabilities. • When both facial and lingual tooth structure is lost
• Treatment plan is not a static list of services. Rather, it crowns are ideal choice.
is a multiphase and dynamic series of events to meet
the patient’s initial and long-term needs. Treatment plan Functional Needs of Each Tooth
should allow for revaluation and be adaptable to meet
• Choice of restorative treatment is greatly influenced by
changing needs.
patient’s functional needs.
• Patients with heavy parafunctional habits like bruxism
Planning the Restoration of Each Individual
or tooth with extensive wear are candidates for cast
Tooth Requires Four Primary Factors to be restorations.
Considered • Patients with high caries susceptibility are restored
Amount and Form of Remaining Tooth Structure with restorative material having glass ionomer and
This factor greatly influences the resistance feature of tooth its modifications esp., for root caries or Class V caries
and restoration. lesion.
Posterior teeth (Figures 3-42 to 3-43)
• For intracoronal restoration of posterior teeth amalgam Esthetic Needs of Each Tooth
and resin composite seems to be ideal with each having • In most instances of restoration dentist will have a choice
its own advantages and disadvantages. of tooth colored or nontooth colored restorations.

Figures 3-42A and B: Caries affected teeth requiring onlay Figures 3-43A and B: Extensively caries affected teeth
requiring crown

Figures 3-44A to C: Composite restorations for minimal caries affected teeth

 Clinical Decisions in Operative Dentistry 45

Figures 3-45A to C: Crowns for extensively caries affected teeth

• Nontooth colored restoration like amalgam and cast Control Phase

metal should be preferred when strength and durability This phase is meant to:
are of paramount importance. • Eliminate pain
• For extensive restorations of posteriors where esthetics • Eliminate active disease progression like caries.
is of concern indirect composites can be suggested. • Eliminate potential cause of disease.
• For conservative anterior restorations composites will • Remove conditions preventing maintenance phase.
suffice. For extensive anterior restorations indirect • Begin preventive aspect.
ceramics are choice of material. Examples of control phase treatment are caries removal,
replacement of defective restorations. This phase also
Final Objective of Overall Restorative Treatment includes measures to prevent dental caries occurrence.
• Final restoration choice and preparation design is
greatly influenced by final objective in treatment Preventive aspects of dental caries
plan. • Chemical: Use of antimicrobial agents to alter the oral flora
• A patient who is going to replace his missing teeth by and administration of topical fluoride to stimulate
remineralization.
implants may require a different type of restoration of
• Surgical: Removal of diseased tooth structure and
teeth compared to patient who is going to replace the
replacement of missing tooth structure with restorative
tooth by fixed partial dentures. material.
• Certain teeth are critical to final treatment objective • Behavioral: Application of appropriate techniques to help
which necessitates it to restore in an extensive manner the patient develop the skills, knowledge, and attitudes to
than if the teeth under consideration is not so critical. alter deleterious dietary intake and improve oral hygiene.
• Mechanical: Mechanical alteration of tooth surfaces at
Treatment Plan Sequence high risk (e.g. sealants), removal of overhanges, re-
establishment of proximal contacts, and restoration of
When the restorative treatment has been decided for the defective contours.
teeth, next step is the treatment plan sequencing. • Dietary: Alteration of the character of the diet.
Sequencing of restorative treatment is dictated by three • Other: Stimulation of salivary flow through increased
factors: chewing, alteration of medications and use of artificial
1. Severity of the disease process (most symptomatic, teeth saliva.
with deepest lesion) are restored first. Patient’s chief
compliant if there is one should be addressed first.
2. Esthetic needs. Holding Phase
3. Effective use of time. This phase is time allowed for resolution of inflammation
or healing.
Phases in Treatment Plan For example, when tooth has been restored with
Control phase, Holding phase, Definitive phase, temporary restoration or interim restoration time gap
Maintenance phase most often in simple restorative treat- between temporary restoration and permanent restoration
ment first three phases are accomplished in single phase. accounts for holding phase.
 46 Essentials of Operative Dentistry

Definitive Phase • Cast restorations can be done after orthodontic treatment

• After the dentist has analyzed initial treatment has been completed.
progress the patient enters the more definitive treatment
phase. Oral Surgery
• This includes operative treatment prior to other inter- Most the times the hopeless and other teeth indicated
disciplinary treatments in endodontics, periodontics, for extractions should be extracted prior to operative
etc. treatment.
But all these interdisciplinary approaches are perfor-
Maintenance Phase med only after patient’s chief compliant has been rectified.
This phase provides for:
• Need for adjustment to prevent future disease Indications for Operative Treatment
progression.
• Opportunity to reinforce home care. Operative Preventive Treatment
Frequency for recall visits of patients who have low
• Primary goal of dentistry is prevention.
risk of caries in 9-12 months.
• Preventive measure in caries management is changing
Patients with high-risk of caries should have recall visits
the oral environment to encourage remineralization of
between 3 and 4 months.
incipient lesions, diet habit is modified to reduce sugar
intake and fluoride is incorporated into the enamel.
Interdisciplinary Considerations
When operative treatment is rendered to a patient most Restoration of Incipient Lesions
the times the patient will also be in need of treatment from
Certain factors play an important role in determining to
other disciplines which also needs to be addressed.
restore the incipient lesion rather than option of
remineralization.
Endodontics These factors are:
• All teeth that need extensive operative treatment like • Poor oral hygiene and low patient compliance with
cast restorations needs pulpal evaluation and if pulpal routine oral hygiene procedures.
health is compromised root canal treatment should be • History of numerous caries and restoration.
done. • Presence or detection of cavitation.
• With regard to ideal amalgam restorations pulpal • Radiographically, the caries has extended into dentin.
evaluation is not mandatory. • Caries susceptibility of patient is high.

Periodontics Treatment of Abrasion, Attrition and Erosion

• Generally periodontal treatment like scaling and These tooth wear pathologies are considered for
root planing should be done prior to restorative restoration only when:
procedure. • Area is cariously involved.
• Periodontally compromised tooth should not undergo • Structural integrity of tooh has been compromised.
restorative procedures. • Sensitivity persists.
• Periodontal surgical procedures should be done prior • Defect is close to pulp.
to extensive restorative treatment. • Affected teeth are needed for other treatment procedures
• Therefore, a thorough periodontal evaluation by clinical like as an abutment tooth.
examination, probing and radiographic evaluation is Extensive tooth loss due to these factors requires
must by a restorative dentist. complete occlusal analysis and complex treatment
planning (Figures 3-46A to C).
Orthodontics
• Since orthodontic treatment is a long-term treatment all
the teeth should be free of caries and ideal intracoronal Treatment of Root Caries
restorations should be done prior to orthodontic This usually occurs in geriatric patients and in post-
treatment. periodontal treatment patients.
 Clinical Decisions in Operative Dentistry 47

Figures 3-46A to C: Erosion of teeth requiring crown restorations

But treatment of root caries and class V lesions presents Indications for Replacing Restoration in
some unique problems: Tooth Colored Restoration
• Location of lesion it is difficult to obtain moisture
• Improper contours and voids
control and most often ginigival tissue overgrowth will • Marginal staining
also be present. • Recurrent caries
• Because dentin and cementum is present thicker • Unacceptable esthetics.
quantity than enamel thickness adhesive bonding is
difficult.
Indications for Amalgam Restorations
• A proper retentive cavity preparation is quite difficult
to achieve. It is generally indicated for:
Because of the factors only active caries lesion is restored • Small cavitated lesions.
and in-active lesion are best not restored. • Lesions where capping cusp is necessary as where
isthmus width approaches half of the distance between
the cusp tips.
Replacement of Existing Restoration
Restoration is replaced in following situations: Indications for Direct Tooth Colored
• Have significant discrepancies. Filling Material
• Tooth is at risk of caries or fracture.
• Can be used in posterior class I and II lesions if satis-
• Restoration is an etiological factor to a pathology or
factory bonding can be achieved and centric occlusal
symptom in a patient. contact is on the tooth surface and not on restorations.
• Mainly indicated for restoring anterior teeth.
Indications for Replacing Restorations
• Marginal void especially in gingival one-third as it Indications for Intracoronal
cannot be repaired at this region. Cast Restorations
• Proximal overhang as it can lead to periodontal • Choice of treatment for patients undergoing occlusal
breakdown. rehabilitation.
• Marginal ridge discrepancy in class II restorations • Teeth with deep subgingival margins are best restored
leading to food impaction interproximally. with cast restorations as they have better control over
• Over-contoured or under-contoured facial and lingual the proximal contour.
surfaces leading to gingival inflammation. • Cavity preparation extending more than 1/4th inter-
• Poor proximal contact, where contact is open in class II cuspal width.
restoration leading to food impaction should be
replaced. Dental Record
• Recurrent caries around the restoration.
• Marginal ditching with caries occurrence in tooth- • Accurate and descriptive record keeping is essential to
restorative interference. quality dental care.
 48 Essentials of Operative Dentistry

Figure 3-47A: In this example, tooth 1 is missing; tooth 4 has been replaced with a metal-ceramic fixed partial denture
that extends from tooth 3 to tooth 5 with ceramic occlusal coverage; tooth 8 has a facial veneer; tooth 9 has a mesial
resin composite restoration; tooth 11 has been endodontically treated and has a post- and metal-ceramic crown; tooth
13 has been replaced by a metal-ceramic fixed partial denture that extends from tooth 12 to tooth 14 with metal
occlusal coverage; tooth 16 is impacted; tooth 17 is missing; tooth 19 has a mesiocclusodistal amalgam restoration;
tooth 20 has been restored with a metal crown; tooth 25 has been endodontically treated, received a retrograde
restoration, and has a resin composite restoration in the lingual access opening; tooth 27 has a facial tooth-colored
restoration; tooth 30 has a metal three-quarter crown; and tooth 32 is missing

• Dental chart should include findings from the history, • Medical history and if needed a physician’s opinion.
examination, problem lists and treatment plan. • Problem list.
This record serves as: • Treatment plan:
• Documentation purposes. • Description of treatment rendered.
• Communication to other professional personnel. • Informed consent document.
• Legal purposes and forensic use. In addition to usual handwritten or typed dental record
Organization and documenting examination findings pictorial charting is an efficient means.
onto a dental chart enables dentist to evaluate the needs
even patient is no longer available.
A dental record should contain:
• Charting of examination findings, including existing
Dental Chart
restorations, dental relationships, existing periodontal There are very many designs of dental chart available each
and endodontic status, carious lesions and existing one has a specific symbol to record the findings (Figures
restorations—this is called as Dental Chart. 3-47A to C).
Clinical Decisions in Operative Dentistry 49

Figure 3-47B

Figure 3-47C
 50 Essentials of Operative Dentistry

Tooth Notations Permanent Dentition

See Figure 3-48A.
• There are various systems for tooth denotation.
• But a clinician should mainly be aware of three system
of tooth notation, they are palmer system, federation Deciduous Dentition
dentaire international system, and universal numbering See Figure 3-48B.
system.
• Most systems divide dentition into four quadrants as Federation Dentaire International System
shown below: (Figures 3-49A and B)
• This is a two digit number system where the first digit
represents quadrant and second number indicates tooth
number.
• Most commonly employed in Europe.

Universal Numbering System

Palmer System (Figures 3-50A and B)
• Entire dentition is divided into four quadrants and in • Most commonly employed in America.
each quadrant tooth is numbered from 1 to 8. • Here tooth numbered from 1 to 32 starting from upper
• Each individual tooth is identified as 6 right quadrant third molar going clockwise to lower
right third molar.

Figure 3-48B: Deciduous dentition

Figure 3-48A: Permanent dentition
 Clinical Decisions in Operative Dentistry 51

Figure 3-49A: Permanent dentition Figure 3-49B: Deciduous dentition

Figure 3-50A: Permanent dentition Figure 3-50B: Deciduous dentition

 52 Essentials of Operative Dentistry

A typical operative dentistry case sheet should be in sequence as shown below.

Name, Age, Sex

Address
Occupation
Chief Compliant and History of Present Illness
Medical History
Past Dental History
Family History
Patient Examination
Vital Signs Evaluation
General Examination:
Gait, Skin tone, Appearance.
Extraoral examination
Face, Head, Neck and Temporomandibular joint (visual, palpation examination)
Soft Tissues
Lymph node, Salivary glands, Muscles of mastication (visual, palpation examination)
Hard tissues:
Temporomandibular joint. Mandible jaw and maxilla jaw (visual, palpation examination)
Intraoral examination:
Soft tissue:
Lips, Oral mucosa, Floor of mouth, Tongue, Palate, Oropharynx (visual, palpation examination)
Hard tissue:
Dentition, Periodontal health, Existing restorations, etc. (which includes visual, palpation,
percussion examination) Occlusal evaluation
Radiographic examination and interpretation.
Additional diagnostic tests:
Pulpal tests, test cavity, etc.
Diagnosis.
Treatment Planning.

Summary Address: 259, East Coast Road, Sholinganallur, Chennai

Occupation: Laborer of daily wages.
• Proper diagnosis and treatment planning is very
essential for a successful operative procedure. This
procedure cannot be accomplished without the Chief Complaint
knowledge of what to look for and how to look for. Complaints of decayed tooth with a hole in the left lower
• A thorough and systematic clinical examination of the back tooth.
patient is essential to avoid any finding being missed.
• Sequence the treatment to be given in a logical manner History of Present Illness
with patient’s chief compliant is attended first or teeth
Left lower back tooth on taking hot, cold or sweet substances
in most acute condition getting the treatment first.
is sensitive which subsides after a second or two. Also
food particles gets stuck in the hole and causes sensitivity,
which makes him to remove the food stuff by finger.
An Example of Long Case There is no complaint of pain or tenderness.

Presentation Medical History

A typical patient named Mr Gowtham enters the operative • No history of hospitalization.
dentistry outpatient clinic with complaints of decayed • Is not under any medication or any drug allergy.
teeth.
Past Dental History
Long Case Sheet Format • Has been to public dental hospital about two times in
Name: Mr Gowtham, Age: 28 Sex: Male last five years, but never had any dental pain.
 Clinical Decisions in Operative Dentistry 53
• Had restorations of upper right back tooth about two Intraoral Examination
years back, but one of the restoration has fractured and
complaints of food particle impaction.
Lips, Oral Mucosa, Floor of the Mouth,
• Dental treatment was uneventful. Tongue, Oropharynx
On visual and palpatory examination no abnormalities or
Oral Habits tenderness were present.
• Brushes with tree twigs or uses ash for cleaning of teeth
since childhood. Evaluation of Dentition
• Has habit of pan chewing and smoking for past It has generalized calculus of grade – 3 and tobacco stains.
15 years.
Caries Risk Assessment
Dietary Habits Patient has high caries risk this is because of oral hygiene
• Has habit of taking in between meals snacks. habits and because of his existing number of restorations
• His staple diet is rice. and carious lesion, also poor oral hygiene and food
habits.
Attitude Towards Dental Treatment
• It is very casual about dental treatment and is not very Caries Lesion
eager to spend much money for dental treatment.
• Class I caries – 16, 14, 46
• However, he wants to fill his teeth and does not wants
• Class II caries – 27, 37
his teeth to be removed in future.
Caries lesion in 27 has leathery soft dentin on floor of
cavity, color of dentin is brown with food debris lodged.
Family and Social Background Tooth 27 has pain on probing and slight tenderness to
• No history of any familial disorders. percussion. But patient is asymptomatic for the tooth.
• Has wife and one child aged 2 years.
• He earns a monthly wages of about Rs 3000. Existing Restorations
• Class I amalgam restoration – 17.
Clinical Examination • Fractured class II amalgam restoration – 15.
General Examination • Fracture has occurred near the marginal ridge and has
Patient has a healthy gait and has a dark complexion. an opening of 2 mm with food impaction between
14 and 15.

Vital Signs
Occlusal Evaluation
• Blood pressure – 120/80 mm Hg
• Respiratory rate – 14/min • Angles class I molar relation.
• Pulse rate – 74/min • No abnormalities noted.
• Temperature – 97.4° F (intraoral)
Evaluation of Periodontium
Extraoral Examination Appearance: Marginal gingival tissues in inflamed and
Facial symmetry is present. reddish in color.
Probing
Lymph Node Examination • On probing there is generalized bleeding on probing.
• Right submandibular lymph node is enlarged and • Periodontal pocket is present in relation to 14, 15.
slightly tender.
• Other lymph nodes or not palpable. Radiographic Evaluation
• IOPA radiograph is required for the tooth 27 to evaluate
Temporomandibular Jaw the pulpal status.
On visual and palpatory examination joint movement is • IOPA radiograph is necessary for periodontal
within normal limits with adequate mouth opening. evaluation of 14, 15.
 54 Essentials of Operative Dentistry

IOPA 27: Reveals carious lesion with pulpal exposure Preventive Management
and periapical inflammation. • Patient has been instructed on usage of fluoridated tooth
IOPA 14,15: Reveals vertical bone loss between 14 and 15. paste.
• Patient has been told to reduce in-between meals snacks
Additional Tests and reduce sugar intake.
• Needs pulpal testing of 27. • Recall visits has been planned within next 4 months.
• Thermal and electrical pulpal testing elicits no response A typical case examination sheet for a operative
in tooth 27. dentistry undergraduate will be only concerned with teeth
that have not endangered pulpal health and requiring a
Diagnosis conventional intracoronal restoration.
• Generalized gingivitis. A short case history for operative dentistry undergraduate
• Class I caries 16, 14, 46. student concerned only with caries will be:
• Class II caries 37. A typical patient named Mr Gowtham enters the operative
• Fractured class II amalgam restoration in 15 with dentistry out-patient clinic with complaints of decayed
periodontal pocket and vertical bone loss between 14 teeth.
and 15.
• Nonvital 27 with chronic periapical periodontitis. Short Case Sheet Format
Name – Mr Gowtham Age – 28 Sex – Male
Treatment Planning
Address – 259, East Coast Road, Sholinganallur, Chennai
Problem List Occupation – Laborer of daily wages.
Operative dentistry
• Class I caries 16, 14, 46. Chief Complaint
• Class II caries 37. Complaints of decayed tooth with a hole in the left lower
• Replacement of class II amalgam restoration in 15.
back tooth.
Periodontal
• Generalized calculus and gingivitis. History of Present Illness
• Vertical bone loss and pocket between 14 and 15. Left lower back tooth on taking hot, cold or sweet substances
Endodontic is sensitive which subsides after a second or two. Also
Nonvital 27. food particles gets stuck in the hole and causes sensitivity,
which makes him to remove the food stuff by finger.
Problem List Worksheet and Treatment Sequencing There is no complaint of pain or tenderness.

Operative dentistry Medical History

• Class I amalgam restoration 16, 14, 46.
• No history of hospitalization.
• Class II amalgam restoration 37.
• Replacement of class II amalgam restoration with • Is not under any medication or any drug allergy.
temporary restoration in 15. Which after periodontal
treatment replaced by amalgam restoration. Past Dental History
Amalgam restoration has been selected because of his • Has been to public dental hospital about two times in
affordability and high caries risk. last five years, but never had any dental pain.
• Had restorations of upper right back tooth about two
Periodontal years back, but one of the restoration has fractured and
• Adviced scaling and oral prophylaxis. complaints of food particle impaction.
• Deep scaling and curettage in relation to 14,15. • Dental treatment was uneventful.
Endodontic
Root canal treatment of 27 followed by crown. Oral Habits
(Patient compliant has been addressed first followed • Brushes with tree twigs or uses ash for cleaning of teeth
by periodontal treatment before endodontic treatment) since childhood.
 Clinical Decisions in Operative Dentistry 55
• Has habit of pan chewing and smoking for past Caries Risk Assessment
15 years. Patient has high caries risk this is because of oral hygiene
habits and because of his existing number of restorations
Dietary Habits and carious lesion, also poor oral hygiene and food habits.
• Has habit of taking in between meals snacks.
• His staple diet is rice. Caries Lesion
• Class I caries – 16, 14, 46
Attitude Towards Dental Treatment • Class II caries – 27, 37
• Is very casual about dental treatment and is not very Caries lesion in 27 has leathery soft dentin on floor of
eager to spend much money for dental treatment. cavity, color of dentin is brown with food debris lodged.
• However, but wants to fill his teeth and does not wants Tooth 27 has pain on probing and slight tenderness to
his teeth to be removed in future. percussion. But patient is asymptomatic for the tooth.

Existing Restorations
Family and Social Background
• Class I amalgam restoration – 17
• No history of any familial disorders.
• Fractured Class II amalgam restoration – 15.
• Has wife and one child aged 2 years.
• He earns a monthly wages of about rs 3000. Occlusal Evaluation
• Angles class I molar relation.
Clinical Examination • No abnormalities noted.
General examination:
Patient has a healthy gait and has a dark complexion. Evaluation of Periodontium
Vital signs: Appearance: Marginal gingival tissues in inflamed and
• Blood pressure – 120/80 mm Hg reddish in color.
• Respiratory rate – 14/min Probing
• Pulse rate – 74/min • On probing there is generalized bleeding on probing.
• Temperature – 97.4°1F (intraoral) • Periodontal pocket is present in relation to 14, 15.

Extraoral Examination Diagnosis

Facial symmetry is present. Operative dentistry
• Class I caries 16, 14, 46
Lymph node examination • Class II caries 37.
• Right submandibular lymph node is enlarged and
slightly tender. Periodontal: Generalized calculus and gingivitis.
• Other lymph nodes or not palpable.
Treatment Planning
Temporomandibular jaw
On visual and palpatory examination joint movement is Problem list
within normal limits with adequate mouth opening. • Operative dentistry – Class I caries 16, 14, 46.
• Class II caries 37.

Intraoral Examination Problem list worksheet and treatment sequencing:

Operative dentistry
Lips, Oral mucosa, Floor of the mouth, Tongue, Oro-
• Class I amalgam restoration 16, 14, 46.
pharynx: On visual and palpatory examination no
• Class II amalgam restoration 37.
abnormalities or tenderness were present.
Periodontal—Adviced scaling and oral prophylaxis.
Evaluation of dentition: Has generalized calculus of grade (Patient compliant has been addressed first followed
– 3 and tobacco stains. by periodontal treatment before endodontic treatment)
 56 Essentials of Operative Dentistry

Preventive Management • Dental chart

• Patient has been instructed on usage of fluoridated tooth • Tooth notations
paste.
• Patient has been told to reduce in-between meals snacks Questions to Think About
and reduce sugar intake.
1. Explain in detail about caries diagnosis methods and
• Recall visits has been planned within next 4 months.
mention about newer caries diagnosis methods.
2. Elaborate about assessment of existing restoration.
Key Terms 3. Discuss about various factors influencing the treatment
plan of restoration of a tooth.
• Diagnosis 4. What are the indications for replacement of restorations?
• Differential diagnosis 5. Discuss about the role of radiographs in caries
• Prognosis diagnosis.
• Chief compliant 6. Explain about the methodologies for caries diagnosis.
• Treatment plan 7. Mention about various tooth notation systems.
• Diet analysis 8. What are the preventive management in caries?
 Isolation of Operating Field 57

4 Isolation of
Operating Field

For best results in operative procedures require adequate • Discolor tooth-colored resin restorations, e.g. with blood
isolation of the operating field. contamination.
• Prevent the creation of a marginal seal where a cement
lute is employed, e.g. for an indirect restoration.
Advantages of Isolation • Contaminate a site that should preferably have as low
• Dry, clean operating field. a bacterial load as possible, e.g. pulp exposures and
• Access and visibility. root canal therapy.
• Improved properties of dental materials. Methods available are rubber dam, absorbents and
• Protection of the patient and operator. suction devices.
• Operating efficiency.
Retraction and Access
This provides maximum exposure of the operating field. It
Isolation of the Operating Field usually:
Isolation of the operating field involves following • Involves maintaining mouth opening.
conceptual elements: • Depressing, retracting gingival, tongue, lips and
• Moisture control cheek.
• Retraction Methods available are rubber dam, high volume evacuator,
• Harm prevention. absorbents, retraction cord, mouth prop, mouth mirror,
retractors.
Moisture Control
Harm Prevention
Refers to excluding sulcular fluid, saliva, gingival
• Do no harm is an axiom taught to all health care
bleeding, handpiece spray, restorative debris from
professional.
obscuring the operating field and also prevent patient from
• As with moisture control and retraction it usually done
aspirating them.
by rubber dam, suction devices, absorbents, mouth
These if not excluded can: prop, mouth mirrors, retractors.
• Dilute or displace etchant or bonding materials.
• Impair the creation of a bond between tooth and
restoration.
Local Anesthetics
• Interfere with cohesion of successive increments of • Play an important role in eliminating discomfort of
restorative material. dental treatment and controlling moisture.
• React with restorative material and thus impair its • Local anesthetics reduces bleeding and hemorrhage
strength or dimensional stability, e.g. with zinc con- because of presence of vasoconstrictor on anesthetic
taining amalgams leading to porosity and expansion. solution.
 58 Essentials of Operative Dentistry

Rubber Dam Materials and Instruments

Introduced in 1864 by SC Barnum, a New York dentist. (Figures 4-1 to 4-4)
Rubber Dam Material
Purpose
• As with all rubber materials it will deteriorate over a
Isolating one or more teeth from the oral environment. period of time.
• Dam is available in 5 × 5 inch or 6 × 6 inch sheets.
Advantages Thickness available are:
Dry, Clean Operating Field • Thin (0.006 inch)
• Medium (0.008 inch)
• Preferred method for obtaining dry field of operation.
• Heavy (0.010 inch)
• At the same time provides a clean field.
• Extra heavy (0.012 inch)
• Special heavy (0.014 inch)
Access and Visibility • Light and dark color dams are available, but its dark
• Provides maximum visibility and accessibility. color dams are preferred because of contrast. Green
• It controls moisture and retracts gingival tissues, lips, color is usually preferred.
tongue and cheek.

Improved Properties of Dental Materials

Because moisture contamination is prevented dental
materials can achieve optimal properties.

Protection of the Patient and Operator

• Rubber dam prevents aspiration of instruments used
or debris from restoration by the patient.
• In addition operator is prevented from contamination
from patient’s mouth.

Operating Efficiency
Operator efficiency is greatly improved. Figure 4-1: Rubber dam template

Disadvantages
• Time consumption procedure, but once technique of
application of rubber dam has been mastered it can be
done in minimum amount of time expenditure.
• Certain patients may object, also asthmatic patient may
find it difficult to breathe through the nose.

Certain Conditions Preclude use of

Rubber Dam
• Teeth not erupted sufficiently to receive retainer.
• Some third molars. Figure 4-2: Rubber stamp for marking on
• Extremely malpositioned teeth. rubber dam tooth position
 Isolation of Operating Field 59
Rubber Dam Retainer (Clamps)
(Figures 4-5 and 4-6)
• Consists of four prongs and two jaws connected by a
bow.
• Retainer is used to anchor the dam to the most posterior
tooth to be isolated.
• Retainers also used to retract the gingival.
• Wide variety of clamps are available, smaller clamps
are for smaller premolars and anterior and larger ones
for molars.
There are two types of clamps:
Figure 4-3: Rubber dam application 1. Winged clamp
2. Wingless clamps.
• Winged clamp have extra wing projection, so that
could be applied to dam before dam is carried into
patient’s mouth. They have disadvantage of
sometimes interfering with matrix band and wedge
placement.
• Wingless clamp should either applied before dam is
applied or after dam applied onto tooth.
• Retainers when applied onto tooth must be tied to a
dental floss so that it could be retrieved in event it is
being swallowed (Figure 4-7).

Figure 4-4: Rubber dam kit

Figure 4-5A: Ferrier or butterfly
• Rubber dam has a shiny shide and dull side, it is clamp for anterior teeth
usually dull side that is less reflective and faces
occlusal aspect.
• Thicker dam is more effective in retracting tissue,
more resistant to tearing.

Gauge Thickness (range)

Thin 0.006 (0.005–0.007) inch
Medium 0.008 (0.007–0.009) inch Figure 4-5B: Winged clamp
Heavy 0.010 (0.009–0.015) inch
Extra heavy 0.012 (0.0115–0.0135) inch
Special heavy 0.014 (0.0135–0.0155) inch

Rubber Dam Holder

• It positions the dam and holds it in place.
• The young holder is a U-shaped metal frame with small
projections to secure the dam. Figure 4-5C: Wingless clamp
 60 Essentials of Operative Dentistry

Lubricant
A water soluble lubricant application onto the punch holes
aids in easy passage of dam material through the contact.

Modeling Compound
Sometimes used to secure the retainer onto the tooth to
prevent its movement.

Rubber Dam Application (Figures 4-8 and 4-9)

• Punching of holes is done by placing a template onto
Figure 4-6: Parts of a clamp
the sheet and position of tooth to work upon is selected.
Hole size is selected from the punch forceps and a punch
hole is made.
• Before rubber dam application local anesthetic
administration is necessary.
• Only the tooth to be treated needs to be isolated, although
access is improved if more teeth are included.
• A clamp of suitable size is selected and tried on the
tooth, placing it just coronal to the gingival margin. The
clamp should be expanded using the forceps so that it
just passes over the bulbosity of the tooth: It is unwise
to open the clamp too widely as it is more likely to
Figure 4-7: Dental floss tied to clamp fracture and there is also a greater risk of the gingival
tissues being ‘nipped’ by the jaws of the clamp.
Retainer’s jaws should not engage beyond the mesial • Floss should be attached to the holes of the clamp so
and distal angles of the tooth because: that it can be retrieved should the clamp fracture across
• They may interfere with wedge placement. the bow.
• Complete seal around the tooth may be difficult. • For a procedure where clamp placement is done prior
• Gingival trauma is likely to occur. to rubber dam application a wingless clamp is selected.
• Having placed the clamp on the tooth, the floss is
Rubber Dam Punch threaded through the punched and lubricated hole in
• Punch is a precision instrument having a rotating metal the rubber dam.
table with six holes of varying sizes and a tapered sharp Another method of applying the clamp and rubber
pointed plunger. simultaneously is to use a winged clamp with the wings
• These are used for punching holes on the rubber dam. engaged in the lubricated hole.
Disadvantage: A disadvantage of this method is that the
Rubber Dam Retainer Forceps gingival margin cannot be seen while the clamp is being
It is used for placement and removal of retainer. placed.

Recent Advancements in Rubber Dam

Rubber Dam Napkin Nowadays simpler design rubber dam and dam without
It is placed between rubber dam and patient’s skin it has retainers are marketed (Figures 4-10A and B).
following advantages:
• Prevents skin contact of dam material and reduces Rubber dam disposal
allergic risk. • Rubber dam sheet is single use disposable (Figure
• Absorbs saliva at corner of mouth. 4-11).
• Acts as a cushion. • While other items are classified under semicritical
• Provides convenient method for wiping patients lips instrument and needs to sanitized and sterilized, before
after dam removal. usage on next patient (Figure 4-12).
 Isolation of Operating Field 61

Figure 4-8: Rubber dam technique for winged retainer. Step 1—Hole is punched on rubber dam sheet hole position
is marked from template. Step 2—Rubber dam retainer forceps is selected. Step 3—Retainer close up view showing
the jaws with grooves to hold retainers. Step 4—Selected retainer is passed through the hole in dam and positioned
with retainer forceps. Step 5—Retainer forceps with retainer and dam sheet is taken into oral cavity to be engaged
on tooth required. Step 6—Retainer with dam sheet is engaged on the axial angles of tooth being careful that jaws
of retainer don’t engage the gingival tissues. Step 7—After engagement of retainer onto tooth the rubber dam sheet
retracted away from the wings of retainer. Step 8—After the sheet is retraced from wings of retainer. Step 9—Rubber
dam sheet in patient mouth with napkin beneath rubber dam sheet

Figure 4-9: Rubber dam technique for wingless retainer. Step 1—Retainer is engaged onto the tooth and tied with
floss. Step 2—Rubber dam with punched hole is stretched over the retainer to engage the rubber dam. Step 3—
Engaged rubber dam in patient

Figure 4-11: Rubber dam

sheet is single use dispo-
sable

Figure 4-12: Rubber dam

Figures 4-10A and B: Opti dam (Kerr Co.) instruments are sterilized
 62 Essentials of Operative Dentistry

Figures 4-13A to C: High volume suction placement during high speed handpiece usage

Saliva Ejectors
High Volume Evacuators
• In use of high speed handpiece it emits water and air
which acts as coolant.
• High volume evacuators are used for suctioning water
and debris from the mouth.
• It is the assistant’s responsibility to place the evacuator
tip as near as to the tooth being prepared as possible.
• High volume evacuator tips are made of plastic and are
single use disposable, but stainless steel reusable are
also available (Figures 4-13A to C).
• Tips are available as straight or slightly angled ones
(Figure 4-14).

Ejectors (Figures 4-15 to 4-17)

• It removes the saliva that collects in the floor of the
mouth. It is used in conjunction with sponges, cotton
rolls and rubber dam.
• It is mostly available as single use disposables.
• It is placed in area least likely to interfere with operator’s
work. Figure 4-14: Tips are placed just lingual and
• Saliva ejectors are made of plastic disposable and could distal to the tooth being worked upon
be molded.
• A Svedopter is saliva ejector with tongue retractor.
• Several commercial devices for holding cotton rolls in
position (cotton roll holder).
Absorbents and Throat Shields • Maxillary teeth is isolated by placing a medium sized
(Figures 4-18 to 4-21) cotton roll in adjacent buccal vestibule, and mandibular
• Such as cotton rolls and cellulose wafers are helpful for teeth are isolated by placing one medium sized cotton
short period of isolation. roll in vestibule and a larger one between the teeth and
• In conjunction with profound anesthesia absorbents tongue.
provide acceptable dryness. • Cellulose wafers may be used to retract cheek and
• Using saliva ejector in conjunction with absorbents will provide absorbency.
further reduce salivary flow. • These wafers are placed on cheek covering the Stenson’s
• Suction tip is placed next to the cotton roll to absorb the duct to absorb saliva and also protect the tissue over
excess moisture. this area.
 Isolation of Operating Field 63

Figure 4-18: Maxillary teeth isolation with

cotton roll

Figure 4-15: Svedopter evacuator

Figure 4-19: Mandibular posterior teeth

isolation with cotton roll

Figure 4-16: Disposable saliva evacuator

Figure 4-20: Mandibular anterior teeth

isolation with cotton roll

Advantages
• Can be placed quickly and securely.
• Are simple to use.
Figures 4-17A and B: Hygoformic saliva evacuator • No additional equipment is needed for placement.
 64 Essentials of Operative Dentistry

Retraction Cord
• Retraction cord properly applied often can be used for
isolation and retraction of gingival tissues (Figure
4-23).
• This is especially useful in cervical lesion restoration,
facial veneering.
• Most brands of gingival retraction cord have some sort
of hemostatic agent mixed with them.

Figure 4-21: Application of cellulose

wafer on cheek

Disadvantages
• Do not prevent contamination of the area by the patient
tongue.
• Do not prevent debris from dropping into the mouth or Figure 4-23: Gingival retraction cord
throat.
• If removed, dry cotton rolls may adhere to the oral
mucosa, which can injury the tissue. Mirror Tip and Evacuator Tip for Retraction
• Must be replaced if they get wet before the procedure is Inaddition to their primary use they also aid in retracting
completed. lip, cheeks and tongue (Figure 4-24).
• Cotton rolls should not be placed when handpiece is
being used oral cavity as it can lead to cotton getting
caught in the running bur.

Throat Shields
• Are indicated when small instruments are being used
without rubber dam, or when indirect restorations are
being inserted.
• A gauze sponge (2 × 2 inch) is folded and spread over
the tongue and posterior part of the mouth (Figure
4-22). Figure 4-24: Mouth mirror used for retraction

Mouth Prop
• A mouth prop is used to establish and maintain suitable
mouth opening, thereby relieving the muscles of fatigue
and pain.
• They can be either as block type or ratchet type (Figures
4-25A to C).

Drugs
• Antisialagogues drugs greatly reduce salivary
secretion, e.g. atropine.
• Adrenaline in local anesthetics also greatly reduces
Figure 4-22: Throat shield application salivary secretions.
 Isolation of Operating Field 65

Figure 4-25C: Ratchet type mouth prop

Figure 4-25A: Floss attached to mouth prop

• Rubber dam retainer

• Rubber dam holder
• Retainer forceps
• Gingival retraction cord
• Absorbents
• Throat shields
• High volume evacuator
• Saliva ejector
• Svedopter ejector
• Mouth prop
• Moisture control
Figure 4-25B: Mouth prop in place

Key Terms Question to Think About

1. Discuss about various moisture control methods and
• Rubber dam
advantages an need of moisture control. Elaborate in
• Rubber dam stamp
detail about rubber dam.
• Rubber dam sheet
 66 Essentials of Operative Dentistry

5
Dental Anatomy,
Physiology, Histology
and Occlusion

Knowledge of dental anatomy, histology, physiology and

occlusion is essential for excellence in performance of
operative dental procedures.
The individual form of a tooth and the contour relation-
ships with adjacent and opposing teeth are major determi-
nants of function in mastication, aesthetics, speech and
protection.

Teeth and Investing Tissues

Structures of the Teeth
The teeth are composed of enamel, pulpdentin complex,
cementum (Figures 5-1 and 5-2).

Enamel
• Enamel is formed by cells called ameloblasts.
• Enamel covers the anatomical crown of the tooth and
varies in thickness in different areas. The enamel is
thicker at occlusal and incisal areas and progressively
becomes thinner and terminates at cementoenamel
junction. Figure 5-1: Components of tooth
• Much of the art of operative dentistry comes from trying
to duplicate the natural beauty of enamel artificially. • The remaining constituents of tooth enamel are an
• Enamel is gray and is semitranslucent, the color of the organic content of about 1 to 2% and a water content of
tooth depends upon the underlying dentin, the about 4% by weight.
thickness of enamel and amount of stain in enamel. • Structurally enamel is composed of millions of enamel
• Chemically enamel is highly mineralized crystalline rods or prisms.
structure containing from 95 to 98% inorganic matter • Rods vary in number from approximately 5 million in
by weight. mandibular incisor to 12 million in maxillary molar.
• Hydroxyapatite, in the form of crystalline lattice, is the • Rods are densely packed and follow a wavy course from
largest mineral constituent. dentinoenamel junction to external surface of the tooth.
• Other minerals and trace elements are contained in • Rods are oriented perpendicular in direction to dentino-
smaller amount. enamel junction in both primary and permanent
 Dental Anatomy, Physiology, Histology and Occlusion 67

Figure 5-4: Enamel rods orientation

Figure 5-2: Observations of clinical

importance on tooth surface

dentition except in cervical region of permanent

dentition where enamel rod direction is oriented slightly
in apical direction.
• Enamel rods measure in diameter of 4 µm near dentinal
borders and about 8 µm near surface.
• Hardest substance in the body is enamel.
• Enamel is brittle substance with high elastic modulus
and low tensile strength. Figure 5-5: Enamel crystals
• Enamel requires a base of dentin to withstand masti-
catory forces. This reason necessitates the need for
proper cavity preparation with enamel being supported • Structural components of rods or prisms are small
by dentin and unsupported enamel fractures off (Figure elongated apatite crystals (Figures 5-4 and 5-5).
5-3). • Each apatite crystals is composed of thousands of unit
• Enamel rods are composed of head portion and tail cells.
portion. • An organic sheath called prism sheath surrounds
individual crystals.
• When a group of enamel rods interwine with adjacent
rods its termed gnarled enamel it occurs near cervical
and incisal and occlusal areas. Gnarled enamel does
not yield to pressure of bladed hand cutting instruments
in cavity preparations.
• Enamel lamellae are thin leaf-like faults between enamel
rods that extend from enamel surface toward dentino-
enamel junction, they mostly contain organic material,
which is a weak area and predisposes the tooth to entry
of bacteria and caries.
• The interface of enamel and dentin is called as dentino-
enamel junction and is scalloped in outline.
• Dentinoenamel junction is a hypermineralized zone of
about 30 µm thick.
• Enamel is incapable of repairing itself once it is
destroyed, because the ameloblast cell degenerates
Figure 5-3: Improper cavity preparation and fracture of
unsupported enamel following formation of enamel.
 68 Essentials of Operative Dentistry

• Although enamel is a very hard and dense structure, its

permeable to certain ions and molecules, permitting
partial and complete penetration.
• Water appears to play an important role as a trans-
porting medium through small intercrystalline spaces.
• This property of semi-permeability makes it act as a
molecular sieve.
• Enamel permeability decreases with age because of
changes in enamel matrix. This is called as enamel
maturation.
• Enamel is soluble in acid medium but its dissolution is
not uniform.
• When fluorides are present enamel solubility greatly
decreases.
Figure 5-6: Dentinal tubules number near the dentinoenamel
Pulp Dentin Complex junction (DEJ) and near the pulp as well as concentration of
• Dentin and pulp tissues are specialized connective tubule number
tissues of mesodermal origin and are formed from the
dental papilla of tooth bud.
• These two tissues are considered as single tissue with
mineralized dentin comprising mature end product of
cell differentiation and maturation.
• Dentin is formed by cells called odontoblasts.
• Odontoblasts are considered part of both dentin and
pulp tissues since their cell bodies are in the pulp cavity
but their long, slender, cytoplasmic cell processes
(Tomes fibers) extend well into the tubules in the
mineralized dentin.
• It is because of these odontoblastic cell processes that
dentin is considered a living tissue, with capability to
react to physiological and pathological stimuli.
Dentin (Figures 5-6 to 5-8)
• Forms the largest portion of tooth structure.
• Externally dentin is covered by enamel in anatomic
crown and by cementum in anatomic root.
• Coronal dentin provides color and an elastic
foundation for enamel and protective encasement for Figure 5-7: Continual deposition of peritubular dentin
occludes the dentinal tubule diameter at the DEJ
the pulp.
• Dentin is composed of small apatite crystals embedded
in a crosslinked organic matrix of collagen fibrils. • Dentin is normally yellow-white and slightly darker
• Dentin is composed of by volume, 45-50% inorganic than enamel, its more opaque and dull, is softer
apatite crystals, about 30% organic matrix and about which tends to catch and hold explorer as its run across
25% water. dentin.
• Dentin is hard, mineralized tissue it is somewhat • Dentinogenesis begins with the odontoblasts laying
flexible with modulus of elasticity of 1.67 × 106 PSI. down collagen matrix, moving from dentinoenamel
Flexibility of dentin helps it support brittle nonresilient junction inward towards pulp.
enamel. • Unmineralized dentin immediately next to cell bodies
• During cavity preparation dentin is usually distin- of odontoblasts is called predentin.
guished by its: (i) Color, (ii) Reflectance, (iii) Hardness, • Unlike enamel, dentin secretion proceeds throughout
(iv) Sound. life.
 Dental Anatomy, Physiology, Histology and Occlusion 69
• Dentin is sensitive to thermal, tactile, chemical and
osmotic stimuli even though dentin is neither innervated
nor vascularized except for about 20% of tubules in
inner dentin.
• Sensitivity of dentin is explained by capillary fluid
dynamics.
• Whenever dentin is cut a thin altered surface is created
called the smear layer, its composed of denatured
collagen, hydroxyapatite and other cutting debris.
• Secondary dentin is formed uniformly throughout life,
but tertiary dentin is a dentin that is formed localized to
the affected area due to external stimuli.
• With age, tubule lumens are gradually constricts by
continuing physiologic mineralization of the peritubular
dentin. Sometimes external stimuli can accelerate the
formation of peritubular dentin leading to dentinal
sclerosis.
Figure 5-8: Some of the noxious stimuli reaching pulp • Sometimes due to virulent bacteria in young individuals
during and after restoration of tooth there’s insufficient time for sclerosis, tubules become
empty and form dead tracts.
• Intense traumatic insult to tooth may be severe enough
• Dentinal tubules are small canals that extend across to cause destruction of both tubules and odontoblasts.
the entire width of dentin, from dentinoenamel junction The adjacent mesenchymal cells are recruited to be
to pulp. converted to odontoblasts and secrete dentin this dentin
• Each tubule contains cytoplasmic process (Tomes fiber) is known as reparative dentin.
of an odontoblast. Each dentinal tubule is lined by layer • Rate of reparative dentin formation is 1.5 µm/day but
of peritubular dentin, which is more mineralized than can be as high as 3.5 µm/day.
the surrounding intertubular dentin.
Pulp
• Number of tubules increase from 15,000-20,000/mm2
• Dental pulp occupies the pulp cavity in the tooth.
at the dentinoenamel junction to 45,000-65,000/mm2
• Dental pulp has 75% water and 25% organic is a viscous
at the pulp. connective tissue of collagen fibers and ground
• Lumen of tubule also varies from the dentinoenamel substance supporting the vital cellular, vascular and
junction to pulp surface. nerve structures of teeth.
• In coronal dentin the average tubule diameter at the • Each pulp organ is circumscribed by dentin and is lined
dentinoenamel junction is 0.5-0.9 µm but increases to peripherally by a cellular layer of odontoblasts.
2-3 µm at the pulp. • Anatomically pulp organ is divided:
• Course of dentinal tubule is slight S-curve. • Coronal pulp located in pulp chamber in crown
• Primary dentin is initially formed dentin that is formed portion of the tooth.
3 years after tooth completion. • Radicular pulp located in the pulp canals in root
• Secondary dentin is dentin that is formed after primary portion of tooth.
dentin throughout life. • Dental pulp is composed of myelinated and
• Intertubular dentin, the primary structural unit is unmyelinated nerves, arteries, veins, lymph channels,
present between the tubules. intercellular substances, odontoblasts, fibroblasts,
• Peritubular dentin is the hypermineralized tubular wall. macrophages and fibers (Figure 5-9).
• Permeability of dentin is directly related to its protective • Pulp is circumscribed peripherally by a specialized
function. Whenever dentinal tubules are exposed due odontogenic area made up of: (1) Odontoblasts, (2) Cell-
to caries, cavity preparation, etc. through capillary free zone, (3) Cell-rich zone.
action, differential thermal expansion and diffusion of • Pulp is unique specialized organ of the human body
various fluids noxious stimuli could reach the pulp serving four functions: (1) Formative or developmental,
tissue. And no restorative material can provide hermetic (2) Nutritive, (3) Sensory or Protective, (4) Defensive or
seal of the cavity wall. Reparative.
 70 Essentials of Operative Dentistry

• Cementum is light yellow color. It has highest fluoride

content of all the mineralized tissue.
• Cementum is permeable and cementum is deposited
throughout the life. Cementum is avascular.
• Two types of cementum are acellular cementum and
cellular cementum. Acellular cemntum occupies
coronal half of the root and cellular cementum in apical
third of root.
• Cemento dentinal junction is smooth. Cementoenamel
junction is referred as cervical line. In about 10% cases
cementum and enamel do not meet and lead to
sensitivity.
• Cementum is resorbed in some pathological conditions.

Gingiva (Figures 5-10A to C)

• Is that part of oral mucosa that covers the alveolar bone,
defines the cervical contours of the clinical crown and
seals the periodontal structures from external
environment.
• A normal healthy gingiva presents a scalloped marginal
outline, firm texture, coral pink.
Figure 5-9: Pulpal histology • Gingival inflammation can lead to periodontal disease.
• Two primary components of gingival tissues are
keratinized tissue and alveolar mucosa. Keratinized
• Formative function is production of primary and
gingival includes both attached gingiva and marginal
secondary dentin.
gingiva.
• Nutritive function provides nutrients and moisture to
odontoblasts and its process through vascular supply. Dentogingival junction
• Sensory function provides sensory innervations to pulp • Complex of epithelial cell types and connective tissues
and dentin (odontoblasts). forming the gingival attachment to the tooth and alveolar
• Defensive function is related primarily to its response bone is called the dento-gingival junction.
to irritation by mechanical, thermal, chemical or • Average pathogenesis free gingival sulcus depth is
bacterial stimuli. 1-2 mm.
• Pain from pulpal inflammation can be due to: (1) Pulpal • From the base of cells a layer of junctional epithelial
Hyperemia, (2) Reversible pulpitis, (3) Irreversible cells forms an adhesive basement membrane to seal
pulpitis, (4) Pulpal necrosis. against the cementum called as junctional epithelium.
• Primary objective during operative procedures should • Connective tissue of the gingiva are made up of dense
be preservation of the health of pulp. interlace bundles of collagen fibers supporting the
gingiva and affixing it to the periosteum and cementum
Cementum of hard tissues. The fibers are classified into following
groups:
• Cementum is the hard dental tissue covering the
• Dentogingival
anatomical roots of teeth and developed by cells
• Alveologingival
cementoblasts.
• Transeptal
• Cementum is slightly softer than dentin and consists of
• Dentoperiosteal
about 45-50% inorganic material by weight and 50-55%
• Circular
organic matter and water by weight.
• Sharpey’s fibers are the portions of the collageneous Restorative dentistry and gingival health
principal fibers of the periodontal ligament embedded • Dental restorations with supragingival margins and
in both the cementum and alveolar bone to attach tooth physiologic contours would be the best to preserve
to alveolus. gingival health.
 Dental Anatomy, Physiology, Histology and Occlusion 71

Figures 5-10A to C: Biologic width or junctional epithelium

• Certain conditions like apical extensions of caries, tooth • Prism

fracture, esthetic considerations may necessitate • Key-hole appearance
subgingival placement of restoration. • Dentinal tubules
• Iatrogenic factors and restoration defects such as • Odontoblasts
gingival overhangs, excessive axial contours, marginal • Zones of pulp
defects, and surface roughness can exacerbate the • Biologic width
gingival inflammation. • Intertubular dentin
• If the dental restorations and technique followed has • Peritubular dentin
been near perfect the most important critical factor in • Reparative dentin
maintaining dental health will be the ‘biologic width’. • Dead tracts
• Molecular sieve
Biologic width
• It is the combined width of gingival connective tissue
and junctional epithelium of approximately 2 mm. Dentitions
• This minimum dimension is of critical importance to
Human teeth are diphyodont which is they have two sets
preserve the attachment and health of periodontium.
of teeth namely deciduous teeth and permanent teeth.
Usually deciduous dentition numbers 20 teeth and
permanent teeth numbers 32 teeth.
Key Terms Also they are heterodont that is they have different
classes of teeth namely, incisors, canines, premolars and
• Enamel
molars to perform functions.
• Dentin
• Pulp
Classes of Human Teeth and Form
• Cementum
• Gingiva Incisors
• Periodontal ligament Incisors are located near the entrance of the oral cavity
• Hydroxyapatite and functions as cutting or shearing instruments for food.
 72 Essentials of Operative Dentistry

Canines root of the teeth meet, its called as cementoenamel

Canines posses longest root and are located at the corner junction (CEJ).
of dental arch. They function in seizing, piercing and • Dentinoenamel junction—its internal meeting of the
tearing of food as well as cutting. enamel and dentin in the crown of the teeth. It is scalloped
in nature.
• Pulp—is the soft tissue which occupies the center of the
Premolars
teeth and contains the blood supply and nerve supply
Premolars serve dual role that it functions like canine in to teeth.
tearing food and similar to molars in grinding food. • Pulp cavity—entire internal cavity in teeth containing
the pulp. It is divided into:
Molars • Pulp canal or root canal—portion of pulp cavity
Molars are large, multicusped strongly anchored teeth, located in root.
they serve in function of crushing, grinding and chewing • Pulp chamber—enlarged portion of pulp cavity
of food. located in crown of the teeth.
• Pulp horns—usually elongated portions on the pulp
Description of Terms chamber corresponding to cusps and lobes of teeth.
Dental Structures
• Anatomical crown—portion of tooth covered by enamel. Supporting Structures (Figures 5-11A and B)
• Clinical crown—portion of teeth visible in oral cavity • Alveolar process—the bony unit which houses the root
due to various factors clinical crown is not stable in of the teeth in jaw.
size. • Periodontal ligament—fibrous attachment of the root
• Anatomic root—portion of teeth covered by cementum. to the alveolar process.
• Clinical root—portion of tooth which is not visible in • Gingiva—soft tissue which covers the alveolar process
oral cavity similar to clinical crown may or may not and the neck of the teeth.
correspond to anatomic root.
• Enamel—hardest tissue covering the dentin of the tooth
crown. Its brittle in nature when not supported by dentin. Teeth Surfaces (Figure 5-12)
• Dentin—hard tissue that forms main body of the tooth.
It covers the pulpal cavity both in crown and root.
Anterior Teeth
Sourrounded by enamel in crown portion and cementum • Teeth present toward front of the mouth. These are
in root portion. incisors and canines.
• Cementum—hard bone like tissue that covers the dentin • Surfaces in these teeth are as:
in root portion of teeth. • Mesial—towards midline
• Cervical line—it is an identifiable line around the neck • Distal—away from midline
of the tooth where the anatomic crown and anatomic • Labial—facing towards lips

Figures 5-11A and B: Tooth supporting structures

 Dental Anatomy, Physiology, Histology and Occlusion 73

Figure 5-12: Teeth surfaces

• Lingual—facing towards tongue also called as

palatal in maxillary teeth.
• Incisal—biting edge.

Posterior Teeth
• Teeth present at back of the mouth.
• Surfaces in these teeth are as:
• Mesial, distal, lingual—same as anterior teeth.
• Buccal—side towards cheek.
• Occlusal—chewing surface.

Root
Root surfaces are named exactly like crown a surface, the
tip of root is called as root apex.

Proximal (Figure 5-13) Figure 5-13: Proximal surfaces

Surfaces in-between any two adjacent teeth, usually the
mesial and distal surfaces.

Line Angle (Figure 5-14)

• Junction of any two surfaces of teeth in naming line
angle the names of two surfaces are included.
• When naming line angles and point angles, the
names of the surfaces are combined by dropping the
‘al’ from the end of the first surface and substituting an
‘0’. Where two o’s, are adjacent. They are separated by
a hyphen.
1. Line angles of anterior teeth
Mesiolabial Labioincisal
Mesiolingual Linguoincisal
Distolabial Mesioincisal
Distolingual Distoincisal Figure 5-14: Line angle
2. Line angles of posterior teeth
Mesiobuccal Buccocclusal
Mesiolingual Linguocclusal Point Angle (Figure 5-15)
Distobuccal Distocclusal Point angle is the junction of three surfaces of teeth and
Distolingual Mesiocclusal takes name from all three surfaces.
 74 Essentials of Operative Dentistry

Figure 5-15: Point angle

1. Point angles of anterior teeth

Mesiolabioincisal
Mesiolinguoincisal
Fistolabioincisal
Distolinguoincisal
2. Point angles of posterior teeth: Figure 5-16: Thirds of tooth
Mesiobuccocclusal
Mesiolinguocclusal
Distobuccocclusal
Distolinguocclusal

Thirds of Teeth (Figure 5-16)

Crowns
Crowns of teeth are divided both horizontally and
vertically into three artificial thirds.

Roots Figure 5-17: Occlusal aspect of maxillary premolar

Roots of teeth are divided only into horizontal thirds.

Other Anatomical Structures

(Figures 5-17 to 5-20)
Crown Elevations
Cusps: Elevated and pointed projections on occlusal
surfaces of posterior teeth. They are usually named
according to position they occupy, but anthropological
terminology is widely used in other fields (based on
evolution).

Tubercles: Rounded or pointed projection they are not

normal finding and rare. They are smaller than cusp, e.g.
cusp of carabelli is a tubercle. Figure 5-18: Incisal aspect of maxillary incisor
 Dental Anatomy, Physiology, Histology and Occlusion 75
Crown Depressions
Fossa
It is an irregular concavity or depression found on the
occlusal surfaces of posterior teeth and lingual surfaces of
anterior teeth. They are named according to anatomical
position they occupy in the tooth.

Figure 5-19: Occlusal aspect of maxillary molar Central Fossa

It is found on the occlusal surfaces of molar teeth,
positioned centrally where all the development grooves
terminate.

Triangular Fossa
These are found on the premolars and molars in occlusal
surfaces mesial and distal to marginal ridges. It is also
found on lingual surfaces of maxillary incisors.
Figure 5-20: Mesial aspect of maxillary premolar
Groove
Cingulum: A large rounded elevated portion found on the
lingual surfaces of anterior teeth and occupies cervical Developmental (Primary) Groove
3rd of lingual surface. A groove or line which denotes union of primary parts
Ridges: Linear and convex elevations on the crown of the or lobes of teeth. Here it denotes coalesced union of
teeth. Several specific types of ridges are: lobes.
Marginal ridge: These are linear and convex elevations
found on the mesial and distal terminations of the occlusal Supplemental (Secondary) Groove
surfaces of posterior teeth and lingual surfaces of anterior It is an outbranching from the primary groove.
teeth.
Triangular ridge: These are linear ridge which descend Pit
from tips of cusps towards central portion of teeth. Small depressed area where the developmental grooves
Transverse ridge: It is combination of two triangular ridges terminate and usually it noncoalesced enamel.
of buccal and lingual cusps which transversely cross and
combine to form transverse ridge on the occlusal surfaces
Fissures
of posterior teeth.
Noncoalesced lobes of enamel results in fissures. Both pit
Oblique ridge: It is a special type of transverse ridges that and fissure are susceptible to caries.
crosses obliquely and present in maxillary molars and
runs from mesiopalatal cusp to the distobuccal cusp.
Other Terminologies
Cusp ridge: Each cusp has four ridges namely, buccal,
lingual, mesial and distal. Usually the ridge that runs Contact Area
towards the center of tooth forms the triangular ridge. The area on the proximal surface of the teeth that contacts
Inclined plane: Sloping plane found between the cuspal the adjacent teeth and its named by its location either
ridges. mesial or distal.

Mammelons Lobe
Mammelons are small rounded projections on incisal One of the primary divisions on crown of the teeth separated
surfaces of anterior teeth which usually worn away. by developmental groove.
 76 Essentials of Operative Dentistry

Crown Surface Form

Geometric form of all crown form of teeth can be categorized
into three categories, viz. triangular, trapezoidal,
rhomboidal (except incisal and occlusal) (Figure 5-21).

Figure 5-23: Proximal view of

maxillary incisor

Figure 5-21: Crown surface forms

Facial and Lingual Surfaces

From the facial and lingual aspects the crowns of all teeth
are trapezoidal (Figure 5-22).

Figure 5-24: Proximal view of

maxillary premolar

Figure 5-22: Facial or lingual surfaces of teeth

Mesial and Distal Surfaces

Anterior Teeth
From proximal view the crowns of these teeth are triangular
(Figure 5-23).

Maxillary Posterior Teeth Figure 5-25: Proximal view of

From proximal view they are roughly trapezoidal in shape mandibular molar
(Figure 5-24).
Permanent Incisors
Mandibular Posterior Teeth • These are first and second teeth from midline. A first
From proximal view they are roughly rhomboidal in shape tooth is called as central incisor and second tooth is
and crowns are tilted lingually (Figure 5-25). called as lateral incisor.
 Dental Anatomy, Physiology, Histology and Occlusion 77
• Maxillary incisors are larger than mandibular incisors. Lingual aspect
• In maxillary incisors the central incisor is larger than • Lingual aspect is also trapezoidal with mesiodistal
lateral incisor and reverse is true in mandibular arch. width being slightly smaller than labial aspect because
of lingual convergence of crown which is present in all
Permanent Maxillary Incisor the incisors.
• 2/3rd of lingual surface is formed by lingual fossa and
Maxillary central incisor is larger than lateral incisor and
cervical third is formed by the cingulum.
lateral incisor is same as central incisor except in smaller
Other aspects are same as labial aspect.
dimension.
a. Lingual fossa
Maxillary Central Incisor It is a large concave depression that is bounded on mesial
and distal margins by mesial and distal marginal ridges
It is first tooth from midline and shares contact with lateral
and incisally by incisal edge and cervically by cingulum.
incisor on distal aspect and other side central incisor on
mesial aspect (Figure 5-26). b. Cingulum
It is a large bulky convexity found on the cervical third
of lingual aspect usually its smooth. Sometimes a groove
called as linguogingival groove and pit may be present,
these features if found are more common maxillary
lateral incisors (Figure 5-27).

Figure 5-26: Labial view of

maxillary central incisor

Labial aspect
• Longer in incisocervical dimension than wider mesio-
distal dimension but when compared to other incisors Figure 5-27: Lingual view of
this dimension is more equal. maxillary central incisor
• Labial aspect is convex in all directions except in the
incisal third.
Mesial aspect: From this aspect they are generally
a. Mesial aspect
triangular in outline (Figure 5-28).
• It is only slightly convex with almost being straighter
in outline. a. Labial outline
• Contact area being near the mesioincisal angle. It is convex with greatest convexity located in the
• Mesioincisal angle is sharper than distoincisal angle gingival third.
which is rounded.
b. Lingual outline
b. Distal aspect • It has both convex and concave outline, concave outline
• It is much more convex than mesial outline. is due to presence of lingual fossa and convex outline is
• Contact area is much more cervical position than mesial due to presence of cingulum.
aspect. • Height of contour for both outline is present at the
gingival third.
c. Incisal aspect
• It may have mamellons. c. Incisal outline
• Incisal outline is straighter It is usually rounded or pointed.
 78 Essentials of Operative Dentistry

Figure 5-28: Proximal view of Figure 5-30: Labial view of

maxillary central incisor maxillary lateral incisor

Lingual aspect (Figure 5-31)

Distal aspect Lingual outline and aspect is same as that of centrals except
• It is same as mesial aspect except is much smaller. Other that lingual fossa and cingulum are not as large. More often
exceptions being, much shorter incisocervically due to lingual developmental groove or lingual pit may be present.
rounded distoincisal angle.
• Much more convex. Mesial aspect (Figure 5-32)
Same as that of central incisor, but smaller dimension.
Incisal aspect (Figure 5-29)
• It is roughly triangular in outline. Distal aspect
• It is centered over the root. Same as that of central incisor, but smaller dimension.
• Lingual aspect converges from the labial aspect. Incisal aspect (Figure 5-33)
• Mesiodistally, it is the widest incisor. • Same as central incisor except cingulum is not as
prominent.
• Labial and lingual surfaces are more convex.

Maxillary central incisor Maxillary lateral incisor

Crown: Not as rounded as lateral Crown: Characterized by its
roundness; slightly more round
on mesioincisal and distinctly so
on the distoincisal angles.
Figure 5-29: Incisal view of Distinct lingual anatomy More distinct lingual anatomy
maxillary incisor
Round root on cross-section Ovoid root on cross-section
More distinct mammelons on Mammelons may be present
Permanent Maxillary Lateral Incisor the incisal edge. only on newly erupted tooth.
• Is second tooth from midline and shares contact with cen-
tral incisor on mesial aspect and canine on distal aspect. Permanent Mandibular Incisor
• It has same morphological features as centrals except • Mandibular incisors are the smallest permanent teeth.
its smaller and more rounded. • Both central and lateral incisor resembles each other
• It is relatively longer incisocervically than wider mesio- more closely when compared to maxillary incisors.
distally (Figure 5-30). • Compared to maxillary incisor they exhibit crowns
Labial aspect which are longer incisocervically than mesiodistally.
• Mesial, distal, incisal outline are same as that of central
incisor except that its more rounded. Mandibular Central Incisor
• Distoincisal line angle is much more rounded making • It is the smallest crown in mesiodistal dimension of all
the incisal outline not so straighter. permanent teeth.
• Labial surface is much more convex than central incisor. • One of the more symmetrical tooth.
 Dental Anatomy, Physiology, Histology and Occlusion 79

Figure 5-34: Labial view of

Figure 5-31: Lingual view of maxillary lateral incisor mandibular central incisor

Figure 5-35: Lingual view of

Figure 5-32: Proximal view of mandibular central incisor
maxillary lateral incisor
Lingual aspect (Figure 5-35)
• Mesial, distal and incisal outline are same as that of
labial aspect.
• Lingual surface is relatively smooth.
• Lingual fossa is present very faintly and bounded by
marginal ridges which are weakly outlined.
• Cingulum is present but not as prominent as maxillary
incisors.
Figure 5-33: Incisal view of Mesial aspect (Figure 5-36)
maxillary lateral incisor
Labial outline
It is slightly convex can also be straighter.
Labial aspect Lingual outline
Mesial outline • Incisal 2/3rd is concave and occupied by lingual
• Is straighter in outline. fossa.
• Mesioincisal angle is sharper. • Cervical 1/3rd is convex and occupied by cingulum.
• Mesial contact area is near the incisal third. Contact area is located half way between labial and
Distal outline: Same as that of mesial outline. lingual outline and located in the incisal 1/3rd.
Labial aspect of crown is convex but not as much as Distal aspect
maxillary incisors (Figure 5-34). It is same as that of mesial aspect.
 80 Essentials of Operative Dentistry

Figure 5-38: Labial view of

Figure 5-36: Proximal view of mandibular lateral incisor
mandibular central incisor

Incisal aspect
• One feature noted from this aspect is the symmetrical
nature.
• Because the crown of mandibular central incisor is
inclined lingually more of labial surface is visible
(Figure 5-37).

Figure 5-39: Lingual view of

mandibular lateral incisor

Incisal aspect (Figure 5-40)

• Incisal edge is rotated towards distal side.
• Cingulum is offset towards the distal aspect.

Figure 5-37: Incisal view of

mandibular central incisor

Permanent Mandibular Lateral Incisor

• It is second tooth on mandibular arch from midline and
shares its contact mesially with centrals and distally
with canines.
• It is slightly larger than central incisor otherwise it Figure 5-40: Incisal view of
closely resembles the central incisors. mandibular lateral incisor
• Since it closely resembles centrals only the distin-
guishing features are explained. Mandibular central incisor Mandibular lateral incisor
Smallest tooth Not as small as central
Labial aspect
Bilaterally symmetric Not symmetric
Distoincisal angle is much rounded (Figure 5-38).
Mirror mesial and distal axial Distoincisal angle more round
Lingual aspect surfaces than sharp mesioincisal angle
The cingulum is offset towards distal aspect (Figure Incisal edge is perpendicular to a Incisal edge not perpendicular
5-39). labiolingual bisecting line to a labiolingual bisecting line
 Dental Anatomy, Physiology, Histology and Occlusion 81
Permanent Canines the prominent development of middle lobe compared to
• Are the most important tooth in the arch. mesial and distal lobe.
• They are often called as corner stones of the arch. Lingual aspect
• Canine teeth exhibit longest root of all teeth. • Its mesial, distal outline are same as labial aspect.
• Lingual surface of this tooth is slightly smaller
compared to the labial aspect.
Permanent Maxillary Canine • Cingulum is bulky than incisors and bounded by
• It is the third tooth from midline and shares contact marginal ridges mesial and distal.
mesially with lateral incisors and distally with first • Lingual fossa is present on the incisal 2/3rd of lingual
premolar. surface and it may present a faint lingual ridge (Figure
• When viewed from labial or lingual aspect the crown 5-42).
form exhibits a pentagonal shape and triangular when
viewed from the proximal aspect.
• Crown is bulky especially in labioligual dimension.
Labial aspect
It is convex in all directions (Figure 5-41).
a. Mesial outline
• It is convex in outline.
• Mesioincisal angle is rounded.
• Height of contact area is located at the junction of incisal
and middle third.
b. Distal outline
• It is slightly concave cervically.
• Distal incisal angle is more rounded. Figure 5-42: Lingual view
of maxillary canine
• Contact area is in the middle third.
c. Incisal margin
• Is divided into two components by the tip of the cusp. Mesial aspect (Figure 5-43)
• Two components are mesioincisal slope and disto- Mesial aspect crown is convex in all directions more so
incisal slope with mesioincisal slope being much than incisors.
shorter than distoincisal slope.
Labial outline
A labial ridge transcends from the cervical 3rd to the
It is convex.
incisal 3rd on labial surface especially becoming
prominent near the incisal 1/3rd. This ridge represents

Figure 5-41: Labial view of Figure 5-43: Mesial view of

maxillary canine maxillary canine
 82 Essentials of Operative Dentistry

Lingual outline
Its cervical third is convex and incisal third is concave
because of presence of cingulum and lingual fossa
respectively.
Contact area and height of contour is located in the
junction of incisal and middle third.
Distal aspect
• The distal surface is similar to the mesial surface, with Figure 5-45: Incisal view of
maxillary canine
the following exceptions (Figure 5-44).
• The distal surface is generally smaller. Permanent Mandibular Canine
• The contact area is more circular than on the mesial,
and is located at a more cervical level which is in the Comparisons with maxillary canine
middle third. • The crown is as long, or longer incisocervically, when
compared to the maxillary canine.
• A concavity is usually present in the cervical half of the
• The mesiodistal and labiolingual dimensions of both
distal surface.
crown and root are normally less in the mandibular
• The height of contour is located at a more cervical level,
canine.
and is associated with the contact area in the middle
• The root is usually shorter than the maxillary canines,
third.
but in some cases, may be as long. The total crown plus
root length is approximately the same for the two
canines.
• The lingual surface and its structures are less well
developed than in the maxillary canine. In fact, the form
of the lingual surface is more closely allied to that of the
mandibular incisors.
• The cusp of the mandibular canine is not so well
developed, nor is its tip as sharp mesiodistally as in the
maxillary canine.
• The labial surface is generally not so convex as in the
maxillary canine.
Labial aspect
Its outline is pentagonal in shape like maxillary canines
Figure 5-44: Distal view of (Figure 5-46).
maxillary canine
a. Mesial outline
It is pretty much straight from the cervical 3rd and
Incisal aspect
contact area is located near the mesioincisal angle.
• From the incisal, the maxillary canine is generally
convex in both its labial and lingual outlines. The b. Distal outline
tooth’s strength is exhibited by the thicker labiolingual • It is much more convex with distoincisal angle being
dimension, when compared to the maxillary incisors. more rounded.
• From this aspect, the canine crown has an asymmetrical • Distal margin is much shorter than mesial margin.
diamond shaped outline. The mesial half is thicker • Contact area is located more cervically at junction of
labiolingually and more convex, while the distal portion incisal and middle third.
is thinner and exhibits a slight concavity in its labial c. Incisal outline
and or lingual outline. The cingulum is offset to the • The cusp is not as long or the tip as sharp as the
distal from this view. maxillary canine cusp. The distoincisal slope is
• The greater development of the middle labial lobe is normally longer, and its angulation cervically is much
also evident from the incisal aspect, and contributes to steeper than the mesioincisal slope exhibits.
the increased convexity of the labial outline, when Labial ridge is not as prominent as in maxillary
compared to the maxillary incisors (Figure 5-45). canine.
 Dental Anatomy, Physiology, Histology and Occlusion 83

Figure 5-46: Labial view of Figure 5-48: Proximal view of

mandibular canine mandibular canine

Lingual aspect (Figure 5-47) • Contact area and height of contour is located more
• Mesial and distal outline mimic those features in labial cervically at junction of incisal and middle third.
aspect.
Incisal aspect (Figure 5-49)
• Lingual aspect of mandibular canine usually lack any
• Although the relative dimensions differ, this tooth is
distinct features, both cingulum, fossa and marginal
similar to the maxillary canine, when viewed from the
ridges are feebly represented.
incisal. The crown is thicker labiolingually toward the
mesial, and the cingulum is offset to the distal.
• The labial outline is more convex mesiodistally than in
the mandibular incisors.

Figure 5.49: Incisal view of

mandibular canine
Figure 5-47: Lingual view of
mandibular canine
Maxillary vs Mandibular Canine
Mesial aspect (Figure 5-48) • Maxillary canine is wider mesiodistally.
• Labial margin. • Maxillary canine is longer (total length).
• The entire labial outline is convex. • Mandibular canine has a longer crown.
Lingual margin • Maxillary canine has more distinct lingual anatomy.
The lingual outline is similar to that of the maxillary canine, • Maxillary canine may have a lingual pit.
except the cingulum convexity is less prominent and • Maxillary canine crown is generally in line with the
located farther cervically. root while the mandubular canine’s crown appears
Mesial aspect is triangular but less wide labioligually distally bent.
compared to maxillary canines. Contact area and height • The contact areas and the mesial and distal heights of
of contour is located in the incisal 3rd. contours are higher or more incisal on the mandibular
canine than on the maxillary canine.
Distal aspect • Maxillary canine crown is shorter and fatter than the
• Same as that mesial aspect except smaller in dimension. long and slim mandibular canine crown.
 84 Essentials of Operative Dentistry

• Maxillary canine incisal edge is in the labiolingual

midpoint. The mandibular canine incisal edge is lingual
to the labiolingual midpoint.

Premolar (Figures 5-50 and 5-51)

• Eight premolars are found in dentition and two per
quadrant.
• Along with molars it comprises of posterior teeth.
• It is also referred to as bicuspids.
• They are succedaneums to deciduous molars.

1. Two roots
Maxillary 2. Prominent mesial concavity
Figure 5.50: Maxillary premolar*
first 3. Mesial intra-radicular groove
premolar 4. Distally displaced buccal cusp and
mesially displaced lingual cusp
5. Mesial marginal developmental
groove

6. Mesiolingual developmental groove

7. Most resembles canine
Mandibular 8. Lingual cusp-like cingulum
first
premolar
9. Transitional tooth
10. Greatest discrepancy of size of buccal
and lingual cusps
11. Lingually slanted occlusal table
12. Transverse ridge.

Mandibular 13. Central pit

second 14. Three cusps Figure 5.51: Mandibular premolar*
premolar 15. Roundest root on cross-section
*
BR—Buccal root
LR—Lingual root
Maxillary Premolar CL—Cervical line
• Maxillary premolars are much more closely resemble BTR—Buccal transverse ridge
MDD—Mesial developmental depression
each other than mandibular premolars.
BCR—Buccal cusp ridge
• Maxillary first premolar is little larger than second MCA—Mesial contact area
premolar reverse is true in mandibular arch. MMDG—Mesial marginal developmental groove
• Maxillary premolars have buccolingual dimensions MLDG—Mesiolingual developmental groove
greater than mesiodistal while in mandibular premolars BC—Buccal cusp
LC—Lingual cusp
its equal.
MBCR—Mesiobuccal cusp ridge
• Maxillary premolars have two cusps of equal size while DBCR—Distobuccal cusp ridge
mandibular premolars may have three cusps and MLCR—Mesiolingual cusp ridge
lingual cusps are always smaller. DLCR—Distolingual cusp ridge
• Mandibular premolars when viewed proximally have a MTF—Mesial triangular fossa
DTF—Distal triangular fossa
lingual tilt, which is not present in maxillary premolars. MMR—Mesial marginal ridge
• Maxillary premolars is the only premolars with two DMR—Distal marginal ridge
roots. CDG—Central developmental groove
 Dental Anatomy, Physiology, Histology and Occlusion 85
Permanent Maxillary First Premolars d. Cervical outline
It is the fourth tooth from midline. It has mesial contact • Cementoenamel junction is evenly curved towards
with maxillary canine and distal contact with maxillary apex.
second premolar. It replaces deciduous maxillary first The most notable feature on the buccal surface is the
molar. Hence it’s a succedaneum tooth. buccal ridge. It extends about halfway along the surface
from the tip of the buccal cusp toward the cervical line,
Buccal aspect and is the result of the greater development of the middle
From the facial aspect, the trapezoidal shaped crown bears buccal lobe. It is comparable to the labial ridge of the
a close resemblance to those of both the maxillary canine canines.
and second premolar. However, the canine crown is Height of contour is located on the cervical third of
somewhat larger in size, with a more prominent cusp tip, crown.
and the crown of the second premolar is smaller, with a less
prominent cusp tip. The occlusocervical dimension of the a. Lingual view (Figure 5-53)
crown is less than for any anterior tooth, but greater than • Lingual aspect of crown is smoothly convex with no
that of the second premolar or any molar (Figure 5-52). prominent lingual ridge.
• Lingual aspect of crown is narrower in mesiodistal
dimension than buccal aspect.
• Lingual cusp is shorter than buccal cusp. And lingual
cusp is slightly offset mesially.

Figure 5-52: Buccal view of

maxillary first premolar

a. Mesial margin
Figure 5-53: Lingual view of
• Mesial margin joins the mesioocclusal slope in an maxillary first premolar
obtuse angle.
• Mesial margin outline from contact area to cervical line i. Mesial and distal margin
is concave. It is shorter and more convex compared to buccal aspect.
• Crest of curvature (height of contour) contact area is
ii. Occlusal outline
located at junction of middle and occlusal third.
• Lingual cusp tip is not as sharp as buccal cusp.
b. Distal margin • Lingual cusp is shorter in height than buccal cusp and
• Same as mesial margin mesiocclusal cusp slope is shorter than distocclusal
• But shorter in length than mesial margin slope.
• Contact area is located little more cervically. Lingual height of contour is located on the middle third
of crown.
c. Occlusal outline
• Occlusal margin is very similar to maxillary canine but b. Mesial view (Figure 5-54)
cusp tip is not as prominent as in canine. From mesial aspect the crown shape is trapezoidal.
• Mesiocclusal slope is longer and straighter compared i. Buccal margin
to distocclusal slope which is shorter and slightly It is convex with height of contour located in the cervical
concave. third of crown.
 86 Essentials of Operative Dentistry

Figure 5-54: Mesial view of Figure 5-55: Distal view of

maxillary first premolar maxillary first premolar

ii. Lingual margin • The distal surface is generally convex in all directions,
It makes even arc with height of contour located in and does not exhibit the concavity which is present on
middle third of crown. the mesial surface.
iii. Occlusal margin
• It is irregular and is made up of mainly by mesial Occlusal Aspect (Figures 5-56 and 5-57)
marginal ridge. It can be described as being hexagonal with buccolingual
• A prominent mesial marginal groove crosses the dimensions being greater than mesiodistal dimensions.
marginal ridge.
iv. Cervical margin
• Cervical line is convex towards the occlusal aspect.
• Buccal cusp height is more than the lingual cusp
height.
v. Mesial concavity: A unique feature of the mesial surface
of the maxillary first premolar is the mesial concavity.
This depressed area is variable in its extent. Most often,
it is limited to the middle portion of the cervical third,
but some specimens exhibit an extension which may
reach as far as the middle portion of the mesiobuccal
line angle area. This landmark is a relatively consistent
way to distinguish the maxillary first premolar from
the second premolar, which usually lacks it.
The mesial height of contour is associated with the Figure 5-56: Occlusal view of maxillary first premolar
contact area, near the junction of the middle and occlusal
thirds. The contact area is roughly circular in shape.
c. Distal view (Figure 5-55)
• Similar to mesial view except it is shorter occluso-
cervically.
• Buccal margin, distal margin, occlusal margin, cervical
margin are very similar to mesial aspect.
• Except here there is no mesial marginal groove.
• The distal contact area is larger than the mesial, and is
located at a slightly more cervical level, but still at the
junction of the occlusal and middle thirds. Its outline is
ovoid, and is wider buccolingually than occlusogin-
Figure 5-57: Occlusal view of maxillary first premolar
givally.
 Dental Anatomy, Physiology, Histology and Occlusion 87

Figures 5-58A to C: Inclined planes and cusp ridges of a buccal cusp (premolar)

a. Buccal outline i. Buccal cusp ridge

Prominent buccal ridge of the buccal cusp forms major It extends cervically from the cusp tip onto the buccal
part of this region. surface.
b. Lingual outline
ii. Lingual cusp ridge
It is convex almost in semicircle shape.
• It extends from the tip of the cusp towards the central
c. Mesial and distal outline
groove.
They are striaght and converge lingually making lingual
• This forms one of the two triangular ridges on this
portion of crown smaller than buccal half.
tooth so also called as buccal triangular ridge.
d. Boundaries
Mesial and distal boundaries are mesial and distal Mesial cusp ridge
marginal ridges and on buccal and lingual by the mesial It expends from the cusp tip towards mesial point angle.
and distal cusp ridges of the cusps.
Distal cusp ridge
It extends from the cusp tip towards distally to a point
Components of Occlusal Table angle.
(Figures 5-58 and 5-59) The buccal cusp has four inclined planes which are
There are two cusps buccal and lingual cusp. Buccal cusp located between the cuspal ridges.
is larger, bulkier, sharper. • Mesiobuccal inclined plane
• Distobuccal inclined plane
Buccal cusp
• Mesiolingual inclined plane
• Buccal cusp is centered more near center of the root
• Distolingual inclined plane
trunk.
In active occlusion only the lingual portion of maxillary
• It has four cusp ridges.
buccal cusps are functional.
Lingual cusp
• It is generally smaller and rounder.
• It also has four ridges and four inclined planes.
• Lingual cusp is functional on all planes.
Transverse ridge
The buccal and lingual triangular ridges meet on central
groove forming transverse ridge.
Marginal ridges
• Form the boundaries of the mesial and distal borders of
the occlusal table.
• They are linear ridges running from bucco-occlusal
Figure 5-59: Pits and grooves of maxillary right first premolar point angle to the linguocclusal point angle.
 88 Essentials of Operative Dentistry

• Two marginal ridges are present mesial marginal ridge

and distal marginal ridge.
• Mesial marginal ridge is interrupted by mesial marginal
groove.

Fossae
i. Mesial triangular fossa
It presents just distal to the mesial marginal ridge
ii. Distal triangular fossa
It presents just mesial to distal marginal ridge.

Pits and Grooves

Exhibits two pits one on each triangular fossa namely
mesial pit and distal pit. Figure 5-60: Buccal view of
maxillary second premolar
i. Mesiolingual triangular groove
This groove extends a short distance from the mesial • The cusp tip is offset to the mesial, thus the mesio-
pit in a mesiolingual direction, where it fades out. occlusal slope is slightly shorter than the disto-occlusal
ii. Mesiobuccal triangular groove slope. The reverse is true of the first premolar.
It is similar to the mesiolingual triangular groove, • The mesiocclusal and distocclusal line angles are not
except that it runs in a mesiobuccal direction. as prominent, and the mesial outline is not quite so
iii. Central groove concave.
The central groove has a mesiodistal direction and
connects the mesial pit and the distal pit. Lingual aspect: The lingual aspect is similar to that of the
iv. Mesial marginal groove maxillary first premolar, with the following exceptions
The mesial marginal groove extends from the mesial (Figure 5-61):
pit in a mesial direction, crossing over the marginal • The lingual cusp is relatively longer, making the crown
ridge a short distance onto the mesial surface, where longer on the lingual side, and so less of the occlusal
it fades out. surface is visible from this aspect.
The grooves just described are primary or develop- • The lingual cusp tip is not quite so far offset to the
mental grooves others if present are secondary or mesial.
supplemental grooves.

Maxillary Second Premolar

• It is the fifth tooth form midline.
• It has mesial contact with first premolar and distal
contact with first molar.
• Its succedaneums to deciduous second molar.

Some Exceptions from Maxillary First Premolar

• Crown of second premolar is slightly smaller than first
premolar.
• Exhibit more rounded crown form.
• Buccal and lingual cusps are of equal height. Figure 5-61: Lingual view of
• There is no mesial concavity present. maxillary second premolar
Buccal aspect: The buccal aspect is similar to that of the
maxillary first premolar, with the following exceptions Mesial aspect: The mesial aspect is similar to the mesial of
(Figure 5-60): the maxillary first premolar, with the following exceptions
• The buccal cusp of the second premolar is not as long (Figure 5-62):
or pointed. • The two cusps are nearly the same length.
 Dental Anatomy, Physiology, Histology and Occlusion 89

Figure 5-64: Occlusal view of

maxillary second premolar

• The line angles of the crown are more rounded, and

Figure 5-62: Mesial view of
maxillary second premolar consequently the crown appears less angular. This
makes the hexagonal outline more difficult to visualize.
• There is no mesial concavity, and instead this portion • The central groove is often shorter, and may be more
of the crown is slightly flattened or convex. irregular, sometimes displaying multiple supplemental
• A mesial marginal groove is usually absent. grooves. Because of the shorter central groove, the
• Both the contact area and marginal ridge are located at mesial and distal pits are located closer to each other
a slightly more cervical level than on the mesial of the and more to the middle of the occlusal table.
first premolar. • The mesial marginal groove is normally absent, but even
if present, it is quite indistinct.
Distal aspect: The distal aspect is similar to that of the • On the lingual cusp, there are four functional inclined
maxillary first premolar, with the following exceptions planes, whereas the first premolar exhibited only three.
(Figure 5-63):
• The two cusps are approximately the same length. Maxillary first premolar Maxillary second premolar
(Figure 5-65) (Figure 5-66)
• The contact area is slightly larger in size, when
compared to the first premolar, since the second 1. Broad shouldered 1. Narrow shouldered
2. Prominent buccal lobes 2. Less prominent buccal
premolar’s distal contact is with the first molar. lobes
• Both the distal contact area and marginal ridge are 3. Buccal cusp-distal and lingual 3. Buccal and lingual cusps
found at a slightly more cervical level than on the distal cusp-mesial centered

of the first premolar. 4. Slightly larger buccal than 4. Buccal and lingual cusp
lingual cusp equal
5. Prominent mesial axial 5. Less prominent mesial
concavity axial concavity
6. Lingual convergence 6. Little lingual convergence
7. Hexagonal occlusal profile 7. Ovoid to diamond occlusal
profile
8. Trapezoidal occlusal table 8. Rectangular occlusal table
9. Two roots 9. One root
[Link] marginal
developmental groove
[Link] intraradicular
groove

Mandibular Premolars
• Mandibular second premolar is larger than first
Figure 5-63: Distal view of premolar.
maxillary second premolar • Mandibular premolars buccolingual and mesiodistal
dimensions are approximately equal.
Occlusal aspect: The occlusal aspect differs from the • Mandibular premolars may have more than 2 cusps
maxillary first premolar in the following ways (Figure and buccal cusps are always more prominent.
5-64): • Mandibular premolars are generally single rooted.
 90 Essentials of Operative Dentistry

Figure 5-65: Maxillary right first premolar

Mandibular First Premolar

• It is the fourth tooth from midline.
• It has mesial contact with mandibular canine and distal
Figure 5-66: Maxillary right second premolar
contact with mandibular second premolar.
• It is succedaneous tooth to deciduous mandibular first
molar. c. Cervical line
• Buccal cusps are more prominent and functional. It is smooth and convex towards apex of root.
• From occlusal aspect, it is of a diamond shape resembling d. Occlusal outline
canine. Mesiocclusal slope is much shorter than distocclusal
• In function its more closely related to canine than any slope.
other tooth. The buccal ridge, representing the middle buccal lobe,
is the most prominent portion of the buccal surface (Figure
Buccal aspect: The pentagonal outline from the buccal 5-67).
aspect is similar to the facial form of both the canine and From this aspect, it is apparent that the contact areas
second premolar. The buccal surface itself is convex both are located at approximately the same level. The marginal
occlusogingivally and mesiodistally. The occlusocervical ridges display a similar arrangement. This feature is unique
dimension is shorter than that of any anterior tooth, but to the mandibular first premolar, since on other permanent
longer than the teeth posterior to it. posterior teeth the distal marginal ridge and contact area
a. Mesial margin are found at a more cervical level.
• It is slightly concave from contact area to cervical Height of contour is found on the cervical third of crown.
line.
• Height of contour is located on the middle third of Lingual aspect
crown. • Lingual surface is smoothly convex.
b. Distal margin • Lingual aspect of crown is smaller in dimensions in all
It is similar to mesial margin but shorter. aspects.
 Dental Anatomy, Physiology, Histology and Occlusion 91

Figure 5-67: Buccal view of Figure 5-68: Lingual view of

mandibular first premolar mandibular first premolar

• Most of the buccal half of the occlusal surface is visible Mesial marginal developmental groove is visible
because of the lingual inclination of the crown and from this aspect.
smaller dimensions of the lingual cusp. Contact area is located in the buccal half of crown
Mesial, Distal margins are similar to buccal aspect and in the middle third of crown (Figure 5-69).
except for much shorter. Cervical line is similar to buccal Contact area is round and somewhat ovoid.
aspect.
Occlusal outline
• Its majority formed by the buccal cusp but for descriptive
purposes lingual cusp outline is described.
• Lingual cusp tip is sharp and mesiocclusal slope in
longer than distocclusal slope as in buccal cusp.
One of the landmark features of this tooth, and its mesial
and lingual aspects in particular, is the mesiolingual
developmental groove. This groove originates in the mesial
pit of the occlusal surface and crosses onto the mesial
surface near the mesiolingual line angle. It normally fades
out at about the junction of the cervical and middle thirds.
It is visible from this aspect because of the convergence of
the mesial surface toward the lingual. Figure 5-69: Mesial view of
mandibular first premolar
Lingual height of contour is located in the middle third
of the crown (Figure 5-68). Distal aspect: The basic outline and anatomy of the distal
surface is similar to the mesial surface, with a few
Mesial aspect
From this aspect crown shape is rhomboidal because of exceptions:
lingual inclination of crown. • There is no distolingual developmental groove, but there
• Buccal margin: Buccal margin is convex and height of is a distal marginal groove.
contour located on the gingival third of crown. • The distal surface is a little shorter occlusocervically,
As in all other mandibular posterior teeth the buccal and it is wider buccolingually than the mesial surface.
outline slants towards the lingual side. • The cervical line curvature is slightly less.
• Lingual margin: It is much shorter and straighter. • The contact area is similarly shaped, but occupies a
• Cervical outline: It is smooth and convex towards the slightly broader area, since it approximates the second
root apex. premolar, which is a larger tooth than the canine. Its
• Occlusal outline: Occlusal surface slants 45° towards location in both dimensions is similar to that of the
the lingual aspect. mesial surface.
Because of this lingual inclination the buccal cusp • The distal marginal ridge does not show quite as steep
tip is centered over the center of tooth. a slope toward the lingual (Figure 5-70).
 92 Essentials of Operative Dentistry

Figure 5-72: Occlusal view of

mandibular first premolar

Buccal cusp
Figure 5-70: Distal view of
mandibular first premolar • It has four cuspal ridges and four inclined planes.
• All four inclined planes are functional.
Lingual cusp
• It is small and no more than half the height of the buccal
cusp.
• This also has four ridges and four inclined planes
• All inclined planes are non-functional.
Transverse ridges
Two triangular ridges becomes continuous with each other
to form the transverse ridge it may be interrupted by central
developmental groove.
Figure 5-71: Occlusal view of
mandibular first premolar
Marginal ridges
• Mesial marginal ridge slopes at 45° angle from buccal
to lingual.
Occlusal aspect (Figure 5-71) • Other tooth marginal ridges are parallel.
• It is of diamond shaped with a notch on mesial aspect • Distal marginal ridge is longer more prominent does
exhibiting mesiolingual developmental groove. not exhibit quite same steep.
• Because of lingual inclination much of lingual aspect Fossae
may not be visible. • Two fossaes mesial and distal fossa are present and
a. Buccal outline they are called so because of the irregularity in form
• It is of convex outline and they correspond to triangular fossas in other
• Prominent buccal ridge is visible. posterior tooth.
b. Lingual outline • Mesial fossa is linear while distal fossa is circular.
• It is also of convex outline.
• much shorter than buccal outline. Pits and Grooves
c. Mesial outline Two pits are present mesial and distal pit.
Nearly straight has a notch representing mesiolingual
developmental groove. Central groove: The central groove extends mesiodistally
d. Distal outline between the two pits.
It is more convex and smooth. Mesiobuccal triangular groove: This groove is similar in
location to that of the maxillary premolars.
Components of Occlusal Surface (Figure 5-72) Mesiolingual developmental groove: This unique groove
Two cusps are present buccal and lingual with buccal has been previously described from mesial and lingual
being larger. aspects. On the occlusal surface, it angles mesiolingually
 Dental Anatomy, Physiology, Histology and Occlusion 93
from the mesial pit, where it crosses over the mesial • Lingual surface is smooth and convex.
marginal ridge onto the mesial surface near the • Mesial and distal outlines are same as in mandibular
mesiolingual line angle. first premolar.
On rare occasions, a mesial marginal groove also • Lingual surface is considerably wider and longer.
originates in the mesial pit. • The three cusp, type exhibits a mesiolingual and a
distolingual cusp. Between the two lingual cusps a
Mandibular Second Premolar lingual groove extends a short distance onto the
• It is fifth tooth from midline lingual surface. The mesiolingual cusp is wider and
• It has mesial contact with first premolar and distal longer, while the distolingual cusp is smaller, but
contact with first molar. often is the sharper of the two. This arrangement
• It is succedaneum tooth to deciduous second molar. leaves the lingual groove offset to the distal in the
• Mandibular second premolar is slightly larger than first occlusal outline.
premolar opposite of maxillary arch. • The two cusp, type displays a single lingual cusp.
• There are two forms of mandibular second premolar There is no lingual groove, but a depression is often
one with two lingual cusps and other with one lingual found toward the distal portion of the surface. The
cusp they differ only in occlusal morphology. single cusp is approximately the same height as the
• This tooth more resembles molar tooth and hence helps mesiolingual cusp of the three cusp type.
in grinding. The height of contour of lingual surface is found in the
occlusal third of crown (Figure 5-74).
Buccal aspect: The mandibular second premolar resembles
the mandibular first premolar from the buccal, with the
following exceptions (Figure 5-73):
• The tooth is slightly larger, even though the tip of the
buccal cusp is shorter and the occlusocervical
dimension is a little less. Since the cusp tip is not so
high, it is not as sharp and the mesiocclusal and
distocclusal slopes are not as inclined.
• The cusp tip is also centered mesiodistally, making the
two slopes approximately equal in length.
Despite these slight differences, it is difficult to
distinguish between the two mandibular premolars from
this aspect.
Lingual aspect Figure 5-74: Lingual view of
• Lingual cusps are larger and more developed than mandibular second premolar
mandibular first premolar. Mesial aspect: Same as in mandibular first premolar with
following differences (Figure 5-75):
• The lingual inclination of the crown and of its buccal
surface is not quite as great as on the first premolar.
Consequently, the buccal cusp tip is not centered over
the root, but rather is buccal of center. The buccal cusp
tip is also shorter and less sharp.
• Lingual cusps are more prominent than on the first
premolar. In the three cusp type, the DL cusp is not
visible from the mesial aspect.
• Occlusogingivally, the mesial surface is convex in the
occlusal portion, and concave in the gingival portion.
• The contact area is located toward the buccal, at the
junction of the occlusal and middle thirds. It is larger in
Figure 5-73: Buccal view of size than the mesial contact of the first premolar. It is
mandibular second premolar also roughly circular in outline.
 94 Essentials of Operative Dentistry

• The contact area is similarly located, but because it is

shared with the first molar, it is larger and somewhat
ovoid, wider buccolingually than occlusocervically.
Occlusal aspect: More nearly in shape of square with
minimal lingual convergence (Figure 5-77).
Groove pattern
• Most often in three cuspal type it Y-shaped groove
pattern.
• In two cusp pattern its either U-shaped or H-shaped.
Three cusp pattern (Y-type)
• Y-pattern groove is formed by central and lingual
Figure 5-75: Mesial view of developmental grooves.
mandibular second premolar • Three cusps present are (from largest to smallest) buccal
cusp, mesiolingual cusp, distolingual cusp.
• All the cusps has four ridges and four planes, with
• The marginal ridge is more nearly horizontal, and much
less of the occlusal surface is visible. buccal cuspal planes exhibiting functional planes.
• There is no transverse ridge in Y-pattern premolars.
• The landmark of the first premolar, the mesiolingual
developmental groove, is absent on the second premolar,
but there is normally a mesial marginal groove present.
• The height of contour of the lingual margin is found in
the occlusal third, a location which is unique to the
mandibular second premolar.
• The cervical line shows less depth in its occlusal
curvature.
Distal aspect: Same as in mesial aspect with following
differences (Figure 5-76):
• The distal marginal ridge is more cervically placed than Figure 5-77: Occlusal view of
on the mesial, resulting in more of the occlusal surface mandibular second premolar
being visible from this aspect, as well as a shorter surface
Fossae
occlusocervically.
• In the three cusp type, the tips of both the mesiolingual • Two fossa namely mesial triangular fossa and distal
cusp and the distolingual cusp are visible. triangular fossa both are more linear shape.
• Both are present adjacent to the marginal ridges.

Pits and Grooves

There are three pits:
• Mesial pit—in the mesial triangular fossa.
• Distal pit—in the distal triangular fossa
• Central pit—found on the central groove where the
lingual groove exits between two lingual cusps.
Two cusp type (U-type and H-type) (Figures 5-78A and B)
• Two cusp type second premolars exhibit a rounded
outline lingual to the buccal line angles, and the buccal
line angles are themselves more rounded and less
distinct than in the Y-type.
Figure 5-76: Distal view of • The mesial and distal surfaces may converge somewhat
mandibular second premolar more toward the lingual, making the lingual portion
 Dental Anatomy, Physiology, Histology and Occlusion 95

Figures 5-78A and B: Occlusal view of

mandibular second premolar
narrower than the buccal, but the taper is never to the
degree of the first premolar.
• The one lingual cusp is placed directly opposite the
buccal cusp and their respective triangular ridges create
a transverse ridge. These teeth do not have either a
lingual groove or a central pit.

Cusps
• Buccal cusp is larger than lingual cusp.
• Lingual cusp in H-type is more sharper than in U-type.
• Both the cusps have four cuspal ridges and planes with
buccal cuspal planes being functional.
Figure 5-79: Mandibular right first premolar

Fossae
Two fossae are present namely mesial and distal fossa
and they are circular in shape differing from first premolar.

Grooves
There is a central developmental groove which extends
from mesial to distal pit in both H and U-types.

Mandibular first premolar Mandibular second

(Figure 5-79) Premolar (Figure 5-80)
1. Wider buccal than lingual 1. Equal buccal and lingual
surfaces surfaces
2. Buccal cusp much greater 2. Buccal cusp almost equal
than lingual to lingual
3. Lingual convergence 3 Little lingual convergence
4. Diamond occlusal profile 4. Square occlusal outline
5. Round root on cross-section 5. Rounder root on cross-
section
6. Resembles canine 6. Resembles premolar

Unique Characteristics Unique Characteristics

7. Mesiolingual developmental 7. May have 2 or 3 cusps
groove (if 3, 2 are lingual with ML
bigger than DL, and have
lingual groove)
8. Transverse ridge 8. Central pit
9. Lingually inclined occlusal 9. Y occlusal pattern for
table 3 cusps
[Link] cusp-like cingulum 10.H occlusal pattern for
2 cusps Figure 5-80: Mandibular right second premolar
 96 Essentials of Operative Dentistry

Permanent Maxillary Molar Permanent Maxillary First Molar

• They are the largest and strongest tooth in the arch. This is the sixth tooth from midline.
• They are not succedaneum to any deciduous tooth.
Buccal aspect: From the buccal aspect crown is trapezoidal
• They are 3 per quadrant and 12 in mouth.
in shape. Crown is larger than maxillary premolar except
• They are cornerstone of occlusion in the arch.
for the occlusogingival height. All cusp tips are visible
There are several factors which aid in distinguishing
except for the smaller distolingual cusp (Figure 5-81).
molars from other permanent teeth:
a. Mesial outline
• Their crowns are generally the largest and most complex.
• Their crowns normally exhibit at least 3 cusps, and • Mesial outline is flat from contact area to the cervical
usually more, of which at least two are buccal cusps. line.
• They are normally multirooted. • Contact area is located at the junction of middle and
Their crowns are shorter in occlusogingival height than occlusal thirds.
any other tooth in the arch but is much larger in all other • Occlusally from the contact area to occlusal margin
dimensions. outline is convex.
Normally, first molar is largest size followed by second b. Distal outline
and third. • It is more convex than mesial outline.
Features of maxillary molars which aid in differentiating • The contact area is located in the middle third.
them from other permanent teeth, particularly mandibular • Distocclusal angle is more rounded than mesio-
molars, include: occlusal angle.
• Crowns which are wider buccolingually than mesio- c. Cervical outline
distally. Mandibular molars are wider in the mesiodistal It is convex towards the root apex.
dimension. d. Occlusal outline
• The presence of four cusps in most specimens, of which • The occlusal margin is divided into two parts by the
the size of the two lingual cusps differs greatly. Some concavity of the buccal groove. These two portions
mandibular molars display four cusps, but the two outline the two buccal cusps, the mesiobuccal cusp
lingual cusps are approximately equal in size. and the distobuccal cusp.
• The presence of an oblique ridge and a distolingual • The outline of the rhesiobuccal cusp is wider, but the
groove on the occlusal surface. No comparable struc- distobuccal cusp tip is sharper. The two buccal cusps
tures are found on the mandibular molars. are approximately the same height, and the
• Crowns which are rhomboidal or heart-shaped from mesiolingual cusp tip is visible between them.
the occlusal aspect. Mandibular molars exhibit a In the occlusal portion of the buccal surface, the buccal
rectangular or pentagonal outline from this aspect. groove occupies a shallow occlusogingival concavity,
• Crowns which are trapezoidal in outline from the mesial which extends apically about halfway to the cervical
or distal aspect. Mandibular molars are rhomboidal and margin. There it most often fades out, but it may end in a
inclined to the lingual in a proximal view. buccal pit.
• The presence of three root branches in most cases.
Mandibular molars normally exhibit two roots.
Maxillary molars Mandibular molars
1. 3 roots 1. 2 roots
2. 3 major cusps 2. 4 major cusps
3. Buccal cusps unequal 3. Buccal cusps equal
4. Lingual cusps unequal 4. Lingual cusps equal
5. Occlusal table centered labio- 5. Occlusal table lingually
lingually placed
6. Equal amounts of buccal and 6. More buccal surface than
lingual surfaces may be seen lingual surface may
for occlusal be seen from occlusal
7. Lingual height of contour in 7. Lingual height of contour
middle 1/3 just above junction in middle 1/3 just below the
of middle and cervical 1/3rd junction of the middle and
occlusal 1/3rd
8. Wider faciolingually than 8. Wider mesiodistally than
mesiodistally faciolingually Figure 5-81: Buccal view of
9. Distolingual groove 9. Buccal pit maxillary first molar
 Dental Anatomy, Physiology, Histology and Occlusion 97
The buccal ridges of the two buccal cusps are convex
areas on the buccal surface which extend cervically about
half its length. They lie on either side of the occlusocervical
concavity containing the buccal groove.
The height of contour in buccal surface is located on the
cervical third.

Lingual aspect
• Lingual surface is almost as same dimension as buccal
aspect.
• Mesial, distal and cervical outline are similar to buccal
aspect (Figure 5-82).
a. Occlusal outline
Figure 5-82: Lingual view of
As on the buccal surface, a groove (the distolingual maxillary first molar
groove) separates the occlusal margin into two unequal
portions. The mesiolingual cusp outline is much longer
and larger, but blunter than the outline of the disto-
lingual cusp. In fact, the mesiolingual cusp is normally
the largest and longest cusp on this tooth.
The distolingual groove originates on the occlusal
surface, and crosses onto the lingual surface distal to the
midpoint of the occlusal outline.
Arising from the lingual portion of the mesiolingual
cusp is a tubercle or minicusp that is known as the cusp of
Carabelli. A groove normally separates the cusp of Carabelli
from the mesiolingual cusp, and is appropriately named
the cusp of Carabelli groove. The prominence of the cusp
Figure 5-83: Mesial view of
of Carabelli and its accompanying groove varies greatly maxillary first molar
from tooth to tooth, but most specimens show at least a
The mesial surface is wider at the cervical than at the
trace of the trait.
occlusal, due to the general convergence of both the buccal
Mesial aspect: Mesial aspect of crown form is trapezoidal and lingual surfaces toward the occlusal.
in shape (Figure 5-83). The contact area varies from round to somewhat ovoid,
a. Buccal margin and is situated slightly to the buccal, at the junction of the
• Beginning at the cervical line, the buccal outline is occlusal and middle thirds.
convex in the cervical third. Then it is flat to slightly The occlusal half of the surface is convex, but there is
concave for a short distance in the middle third. From usually a buccolingual flattening, or even a slight
this point to the cusp tip, the outline is straight, or concavity, located cervical to the contact area.
slightly convex. Distal aspect
• The height of contour is in the gingival third. • Same as in mesial aspect but in lesser dimensions than
b. Lingual margin mesial aspect.
The lingual outline is convex throughout its length, but • Buccal, lingual and cervical outline are same as mesial
may be irregular if the cusp of Carabelli is prominent. aspect.
The height of contour is located in the middle third. Occlusal outline
c. Cervical outline The mesial cusp tips are visible projecting beyond the
It is convex towards root apex. outline of the distal cusps. The distal marginal ridge is
d. Occlusal outline less prominent and dips farther cervically than on the
The only cusps which are visible are the two mesial mesial, thus allowing more of the occlusal surface to be
cusps. seen.
 98 Essentials of Operative Dentistry

The distal contact area is larger than the mesial contact

area (Figure 5-84).

Figure 5-86: Occlusal view of maxillary first molar: MBCR—

Mesiobuccal cusp ridge, DBCR—Distobuccal cusp ridge,
MLCR—Mesiolingual cusp ridge, DLCR—Distolingual cusp
ridge, OR—Oblique ridge, MTF—Mesial triangular fossa, DTF—
Distal triangular fossa, CF—Central fossa, DF—Distal fossa,
MMR—Mesial marginal ridge, DMR—Distal marginal ridge
Figure 5-84: Distal view of
maxillary first molar

Occlusal aspect: From the occlusal aspect, this tooth has a

novel rhomboidal form. This shape creates mesiobuccal
and distolingual line angles which are acute, and
mesiolingual and distobuccal line angles that are obtuse.
The outline is wider buccolingually than mesiodistally,
although these dimensions are more nearly equal than in
any of the other maxillary posterior teeth (Figures 5-85 to Figure 5-87: Cope-Osborne theory of cusp evolution
5-88).

Figure 5-85: Occlusal view of

maxillary first molar

Mesial and distal outlines: The mesial and distal marginal

grooves divide these outlines approximately in half.
• Buccal margin: The facial outline is divided into two
parts by the buccal groove, and the mesial portion is
longer than the distal portion.
• Lingual margin: The lingual margin is also divided Figures 5-88A and B: Occlusal view of maxillary first molar:
CP—Central pit, BG—Buccal groove, BGCF—Buccal groove
into two convex portions by the distolingual groove, of central fossa, CGCF—Central groove of central fossa,
and the mesial portion is longer and less convex than TGOR—Transverse groove of oblique ridge, DOG—Distal
the distal portion. oblique groove, LG—Lingual groove, FCG—Fifth cusp groove
 Dental Anatomy, Physiology, Histology and Occlusion 99
• Boundaries: The occlusal table is bounded mesially • Maxillary molar primary cusp triangle sup-
and distally by the marginal ridges, and on the buccal position follows the Cope-Osborne hypotheses of
and lingual by the mesial and distal cusp ridges of the tooth origin, i.e. there was a tritubercular stage in
four major cusps. human tooth development where the molar forms
only three cusps.
Cusps: There are four major cusps and one minor,
Transverse ridge: The buccal cusp ridge of the
sometimes indistinct cusp, which is the cusp of Carabelli.
mesiolingual cusp and lingual cusp ridge of the
i. Mesiobuccal cusp: It is quite sharp, and the second
mesiobuccal cusp form a transverse ridge.
largest in size. Its four cusp ridges are named
Oblique ridge: An oblique ridge is created by the union
according to the direction. They extend from the cusp
of the distal cusp ridge of the mesiolingual cusp and
tip similar to those of other posterior teeth. They are
the lingual cusp ridge of the distobuccal cusp.
described anatomically as follows:
Marginal ridges: The two marginal ridges are named
Buccal cusp ridge: The buccal cusp ridge extends
mesial and distal marginal ridges like those of other
from the cusp tip about halfway toward the cervical
posterior teeth. They enclose the occlusal surface at
margin on the buccal surface.
these two margins.
Lingual cusp ridge: It extends lingually from the cusp
tip to the mesial portion of the central groove, where Fossae: There are four fossae, and they are named as
it meets the buccal cusp ridge of the ML cusp to form follows:
a transverse ridge. It is also known as the triangular i. Central fossa: The central fossa is roughly triangular
ridge of the MB cusp. in shape, and located mesial to the oblique ridge and
Mesial cusp ridge: The mesial cusp ridge extends distal to the transverse ridge in the central portion of
from the cusp tip mesially to the mesiobucco-occlusal the occlusal table. It is bounded by the mesial cusp
point angle. ridge of the DB cusp, the distal cusp ridge of the MB
Distal cusp ridge: It extends from the cusp tip distally cusp, the oblique ridge, and the transverse ridge. The
to the buccal groove. central fossa is the largest and deepest of the four
Inclined planes: The MB cusp has four inclined fossae.
planes. The two that are functional are associated ii. Distal fossa: The distal fossa is more or less linear in
with the lingual ridge of the cusp, and are named the shape, and located directly distal and parallel to the
mesiolingual and distolingual inclined planes. oblique ridge. It is continuous with the distal
ii. Distobuccal cusp: The DB cusp is the sharpest and triangular fossa in its distobuccal portion, and is
third largest of the four major cusps. The cusp ridges otherwise bounded by the oblique ridge on the mesial,
and inclined planes are named similarly to those of and the mesial and distal cusp ridges of the DL cusp
the MB cusp and only the two lingual inclined planes on the distal.
are functional. Its lingual cusp ridge or triangular iii. Mesial triangular fossa: This fossa is triangular in
ridge forms the buccal portion of the oblique ridge of shape, and is located just distal to the mesial
the tooth. marginal ridge. It is bounded by the mesial marginal
iii. Mesiolingual cusp: The ML cusp is the largest cusp, ridge, the transverse ridge, and the mesial cusp ridges
but its tip is rounded and blunt. The cusp ridges are of the MB and ML cusps.
similar to those of the other cusps, except the distal iv. Distal triangular fossa: This fossa is also triangular
cusp ridge. It extends from the ML cusp tip in a in shape, and is located just mesial to the distal
distobuccal direction, where it meets the lingual cusp marginal ridge. It is continuous with the distal fossa
ridge of the DB cusp to form an oblique ridge. All in its mesial portion, and is bounded on the distal by
four of the ML cusp’s inclined planes are functional. the distal marginal ridge.
iv. Distolingual cusp: The DL cusp is the smallest and
most variable of the four major cusps. Its four cusp Pits and Grooves
ridges and four functional inclined planes. i. Central pit: The central pit is located in the deepest
• The mesiolingual cusp is the largest followed by portion of the central fossa at about the center of the
mesiobuccal, distolingual and distobuccal. occlusal surface.
• Developmentally, there are only three cusps Buccal groove: The buccal groove extends from the
namely primary with mesiolingual cusp central pit in a buccal direction until it passes onto
(primitive), and the two buccal cusps. the buccal surface.
100 Essentials of Operative Dentistry

Central groove: The central groove extends in a • The buccal groove is located farther to the distal,
mesiodistal direction connecting the mesial and resulting in a relatively larger mesiobuccal cusp, and a
distal pits. It is composed of a mesial portion which distobuccal cusp which is relatively sharper, but is
extends mesially from the central pit to the mesial smaller both in size and height.
pit, and distal portion which passes distolingually • Due to the diminished size of the distobuccal cusp,
from the central pit, where it crosses the oblique ridge, portions of the distal marginal ridge and distolingual
to the distal pit. cusp may be visible from the buccal aspect on some
ii. Mesial pit: Present distal to the mesial marginal ridge specimens (Figure 5-89).
in the deepest portion of the mesial triangular fossa.
Mesiobuccal triangular groove: This groove extends
a short distance from the pit toward the mesiobuccal
line angle where it fades out.
Mesiolingual triangular groove: This groove extends
from the pit toward the mesiolingual line angle a
short distance where it fades out.
Mesial marginal groove: It extends mesially over the
marginal ridge onto the mesial surface.
iii. Distal pit: The distal pit is located midway bucco-
lingually, and just mesial to the distal marginal ridge.
Because the distal pit is located in the area where the
distal fossa and distal triangular fossa are confluent,
it is a component of both of them. It is the junction of
five primary developmental grooves:
Distolingual groove: The DL groove extends
obliquely onto the lingual surface, paralleling the
oblique ridge to its distal.
Distobuccal triangular groove: This groove extends Figure 5-89: Buccal view of
a short distance from the distal pit toward the maxillary second molar
distobuccal line angle, where it fades out.
Distolingual triangular groove: It extends a short
distance from the distal pit toward the distolingual Lingual aspect: It differs from maxillary first molar by
line angle, where it fades out. (Figure 5-90):
Distal marginal groove: The distal marginal groove • The distolingual cusp is much smaller in all dimensions
extends distally from the distal marginal ridge onto than in the first molar. This feature allows much of the
distobuccal cusp to be seen from the lingual.
the distal surface.
Occasionally, the distolingual cusp is entirely missing.
• There is no cusp of Carabelli.
Permanent Maxillary Second Molar • The distolingual groove does not extend so far mesially
It is the sixth tooth from midline and has mesial contact or cervically, thus terminating at a point which is
with maxillary first molar and distal contact with maxillary occlusal and distal to the center of the lingual surface.
third molar.
Mesial aspect
The crown is similar in form to the maxillary first molar,
• Occlusogingival crown length is less, but the bucco-
but is generally smaller, especially in the distolingual area. lingual dimension is about the same as in the first molar.
The buccolingual dimension of the second molar is about • The contact area is larger, because it is shared with a
the same, but mesiodistally it is noticeably narrower. It is molar instead of a premolar. It is irregular, although
also shorter occlusogingivally. somewhat ovoid, and wider buccolingually.
Buccal aspect: It differs from maxillary first molar by: • The cervical flattening or concavity seen on the first
• The crown is narrower both occlusogingivally and molar is never as pronounced, and is most often absent
mesiodistally. (Figure 5-91).
 Dental Anatomy, Physiology, Histology and Occlusion 101

Figure 5-92: Distal view of

maxillary second molar
Figure 5-90: Lingual view of • There are two major types of crown form (Figures 5-
maxillary second molar 93A and B).
i. Rhomboidal: The rhomboidal type looks much like
the first molar, except the rhomboidal outline is more
accentuated. This is the most common form.
ii. Heart-shaped: This type is similar to a typical third
molar, with a very small distolingual cusp, and short
distolingual groove. Sometimes the DL cusp is
completely absent, and the distolingual groove is
confined to the occlusal surface.
• Cusps, grooves, pits, etc. With the exceptions previously
noted, they are similar to, and named like those of the
first molar. There are often more secondary grooves on
the occlusal table of this tooth, however.

Figure 5-91: Mesial view of

maxillary second molar

Distal aspect
• Due to the shorter and smaller distobuccal and disto-
lingual cusps, more of the mesiobuccal and mesio-
lingual cusps is visible (Figure 5-92).
Figures 5-93A and B: Occlusal view of maxillary second molar
• The cervical flattening or concavity is not normally
present. Permanent Mandibular Molar
Occlusal aspect Their general size normally decreases from first molar
• The crown is about the same width buccolingually, but through third molar.
is narrower mesiodistally which is at the expense of the A review of the features which serve to differentiate
distal structures. mandibular and maxillary molars includes:
102 Essentials of Operative Dentistry

First (Figure 5-94) Second (Figure 5-95) Third

4 cusps (MB, ML, DB, DL) 4 cusps ± 3 cusps ±
Carabelli cusp No Carabelli cusp No Carabelli cusp
Mesiolingual and ML and mesiobuccal cusps ML and mesiobuccal cusps
mesiobuccal cusps smaller than first are smaller than second
very large
Distobuccal cusp large DB cusp smaller DB cusp smallest
(may be missing)
Distolingual cusp smaller DL cusp smaller (may be missing) DL cusp usually missing
Rhomboidal from occlusal (MB and DL angles Rhomboidal (MB and DL angles more Triangular or heart-shaped
acute, ML and DB angles obtuse) acute, ML and DB more obtuse)
Buccal roots plier-handled, All roots distally inclined Roots very distally inclined; lingual
lingual root straight root may be fused to buccal roots

Figure 5-94: Maxillary right first molar

a. Crowns which are wider mesiodistally than buccolin-

gually.
b. Crowns which are rectangular or pentagonal from the Figure 5-95: Maxillary right second molar
occlusal aspect.
c. Crowns which are rhomboidal and inclined to the • The crown is wider mesiodistally than buccolingually,
lingual, from a proximal aspect. and, in fact, the mesiodistal dimension is greater than
d. The presence of four or five major cusps, of which there that of any tooth in the mouth.
are always two lingual cusps of approximately the same • The crown is relatively short occlusocervically, the only
size. dimension which is normally less than that of the teeth
e. The presence of two roots in most cases. anterior to it.
 Dental Anatomy, Physiology, Histology and Occlusion 103
• It displays a trapezoidal outline from the buccal and i. Mesiobuccal groove
lingual, and exhibits a rhomboidal form from either • This groove is located in a concavity between the
proximal aspect. convex buccal cusp ridges of the mesiobuccal and
• From the occlusal, the general outline is pentagonal. distobuccal cusps.
• From the occlusal outline, it extends straight
cervically to a point about midway between the
Permanent Mandibular First Molar
gingival and occlusal margins, but a little to the
• It is the sixth tooth from midline and has mesial contact mesial of center in the mesiodistal dimension. It
with mandibular second premolar and distal contact most often terminates in a buccal pit.
with mandibular second molar. ii. Distobuccal groove
• It is the strongest and largest tooth in lower arch and • This groove is located in a concavity between the
has two well developed roots. buccal ridge convexities of the distobuccal and
• The crown is mesiodistally wider than any other distal cusps.
teeth but occlusocervically much shorter than anterior • It normally ends in a distobuccal pit.
teeth. The buccal height of contour is in cervical third (Figure
• It displays trapezoidal outline from buccal and lingual 5-96).
outline and rhomboidal in proximal view.
Lingual aspect
Buccal aspect • The lingual surface is also roughly trapezoidal in
• It is the largest aspect of all tooth in lower arch. outline, with the longer parallel side of the trapezoid at
• It is trapezoidal in outline. the occlusal.
• At least part of all five cusps is visible. • Since the crown is widest mesiodistally at the buccal,
a. Mesial outline and its mesial and distal surfaces taper somewhat
• From contact area to cervical it is concave in outline. toward the lingual, portions of both proximal surfaces
• From contact area occlusally it is convex in outline. can be seen from this aspect.
• Contact area is located in junction of middle and • The lingual surface is, in fact, generally smaller than
occlusal thirds. the buccal surface.
b. Distal outline a. Mesial outline
• The distal margin is generally more convex than the • From contact area to occlusally the outline is convex.
mesial outline. • From contact area to cervical the outline is concave.
• In the occlusal portion, it is more rounded, and • Contact area is located at junction of middle and
cervical to the contact area it is straight to slightly occlusal third.
convex, as compared to the concavity of the mesial b. Distal outline
margin. • Entire distal outline is convex.
• The height of contour is found at a slightly more
cervical location than that of the mesial margin.
c. Cervical outline
Cervical is smooth and convex towards the root apex.
d. Occlusal outline
• It is divided into three portions by two grooves, as
they pass onto the buccal surface. They are termed
buccal (mesiobuccal) groove, and distobuccal groove.
• The mesiocclusal and distocclusal slopes of three
cusps are present in the occlusal outline.
• The mesiobuccal and distobuccal cusp tips are
relatively blunt, while the distal cusp is normally
lower, and somewhat sharper than the other two.
The buccal surface itself is divided into three portions
by the two grooves, and these three sections decrease in Figure 5-96: Buccal view of
size posteriorly. mandibular first molar
104 Essentials of Operative Dentistry

• Contact area is located at junction of occlusal and b. Lingual outline

middle third. Is straighter and less convex than lingual aspect.
c. Cervical outline c. Cervical margin
It is smoother and convex apically. Cervical line is straight and may be slightly convex
d. Occlusally margin occlusally.
• The occlusal outline is usually broken by the lingual d. Occlusal outline
groove passing onto the lingual surface. The mesio- Mesial marginal ridge is visible which is confluent with
lingual and distolingual cusps, and a small portion mesial cusp ridges of the two mesial cusps.
of the distal cusp are visible from this aspect. Contact area is round or slightly ovoid and located
• The outline of the mesiolingual cusp is slightly wider slightly buccally and in junction of middle and occlusal
than that of the distolingual cusp. third of crown.
• The two lingual cusp tips are more pointed than the Height of contour is located at the contact area (Figure
buccal cusp tips, and they are approximately equal 5-98).
in height.
The lingual cusp ridges of the two lingual cusps are
convex, with the shallow concavity containing the lingual
groove lying between them in the occlusal third.
Lingual groove
This groove crosses from the occlusal surface onto the
lingual surface slightly to the distal of center, extends
cervically, and terminates in the occlusal third near its
junction with the middle third. It usually fades out.
Lingual height of contour is located in middle third
(Figure 5-97).
Mesial aspect
• From this aspect the crown form is rhomboidal.
• Like in all other posterior teeth the crown is tilted
Figure 5-98: Mesial view of
lingually. mandibular first molar
• Only two cusps are visible from this aspect.
a. Buccal outline Distal aspect
• Is convex from occlusally to cervical third and more • Similar to mesial aspect except smaller in dimensions.
convex in cervical third. • Buccal, distal, cervical outlines are similar to mesial
aspect.
Occlusal outline
• Occlusal outline is concave and shorter than in mesial
aspect.
• Distal marginal ridge is difficult to separate from the
distal cusp.
Distal cusp is more prominent feature of distal aspect.
Because of convergence of distal aspect more of buccal
surface and distobuccal groove is visible.
Distal contact area is same as in mesial aspect but
slightly larger because it contacts the mandibular second
molar (Figure 5-99).
Occlusal aspect
• General considerations: The occlusal form is roughly
Figure 5-97: Lingual view of pentagonal in shape. The distal portion of the buccal
mandibular first molar outline tapers toward the lingual, to create the fifth side
 Dental Anatomy, Physiology, Histology and Occlusion 105
Components of the occlusal table (Figure 5-101)
a. Cusps: There are normally five cusps, all of which are
functional, although the distal cusp is much smaller than
the others. Despite its name, the distal cusp is grouped
with the MB and DB cusps as one of the three “buccal”
cusps. However, from the buccal or occlusal aspects, the
reason for this grouping is evident.
i. Mesiobuccal cusp: The mesiobuccal is the bulkiest
cusp, and the longest of the three buccal cusps,
although rather blunt and rounded.
The MB cusp has four cusp ridges which are
described as follows:
Buccal cusp ridge: The buccal cusp ridge extends
cervically from the cusp tip about halfway down the
Figure 5-99: Distal view of buccal surface.
mandibular first molar
Lingual cusp ridge: The lingual cusp ridge extends
of the outline. The crown is wider mesiodistally than lingually to end at the mesial portion of the central
buccolingually, and it is widest mesiodistally toward groove. It is the longest and most prominent of the
the buccal, and widest buccolingually toward the mesial four ridges.
(Figure 5-100). Mesial cusp ridge: This cusp ridge extends mesially
• Buccal outline: The buccal outline is separated into to the mesiobuccocclusal point angle area.
three sections by the two buccal grooves. The relative Distal cusp ridge: It extends distally to the buccal
length of the three portions decreases distally, so that groove.
the mesiobuccal is longest, distobuccal next, and the ii. Distobuccal cusp: Except for the distal, the disto-
distal is shortest. The buccal line angles are quite buccal cusp is the smallest of the cusps, and it has a
rounded, especially when compared to those of anterior rounded tip. The DB cusp has four cusp ridges which
teeth and premolars. are described as follows:
• Lingual outline: The lingual margin is divided into two Buccal cusp ridge: The buccal cusp ridge extends
slightly convex portions by the lingual groove. The cervically from the cusp tip about halfway the width
mesial portion is slightly the longer of the two. of the buccal surface.
• Mesial outline: The mesial outline is divided into two Lingual cusp ridge: The lingual cusp ridge extends
approximately equal segments by the mesial marginal mesiolingually to the area of the central pit.
groove.
• Distal outline: The distal is the shortest of the four
margins, and consists of two convexities, separated by
the distal marginal groove.
Boundaries: The occlusal table is bounded proximally by
the two marginal ridges, and on the buccal and lingual by
the mesial and distal cusp ridges of the five cusps.

Figure 5-101: Occlusal view of mandibular first molar:

DBCR—Distobuccal cusp ridge, DBDG—Distobuccal
developmental groove, DCR—Distal cusp ridge, DTF—Distal
triangular fossa, DLCR—Distolingual cusp ridge, LDG—
Lingual developmental groove, MLCR—Mesiolingual cusp
ridge, MTF—Mesial triangualr fossa, SG—Supplemental
groove, MBCR—Mesiobuccal cusp ridge, MBDG—Mesio-
buccal developmental groove, CP—Central pit, DMR—Distal
Figure 5-100: Occlusal view of marginal ridge, DP—Distal pit, CDG—Central developmental
mandibular first molar groove, MP—Mesial pit, MMR—Mesial marginal ridge
106 Essentials of Operative Dentistry

Mesial cusp ridge: This cusp ridge extends mesially Distal cusp ridge: It forms the buccal portion of the
to the buccal groove. distal border of the occlusal surface, and extends in
Distal cusp ridge: It extends distally to the a lingual direction rather than distally.
distobuccal groove.
Cusp comparison
The four inclined planes of both the MB and DB
• Relative cusp length (height) from highest to lowest:
cusps are named similarly to those of other posterior The mesiolingual and distolingual cusps are
teeth. The inclined planes of the three buccal cusps approximately the same height, followed by the
are all functional, while only the buccal two are mesiobuccal, distobuccal, and distal cusps.
functional on the lingual cusps. • Relative cusp size (bulk) from largest to smallest: The
iii. Mesiolingual cusp: Along with the DL, the ML cusp mesiobuccal cusp is the largest cusp, followed in
is the longest and sharpest of the cusps, and it is diminishing size by the mesiolingual, distolingual,
second in size to the MB cusp. There are four cusp distobuccal, and distal cusps.
ridges which are described as follows:
Buccal cusp ridge: The buccal cusp ridge extends b. Transverse ridges: There are no transverse ridges on
the occlusal surface of the mandibular first molar.
from the cusp tip distobuccally to end at the mesial
portion of the central groove. c. Marginal ridges: The two marginal ridges are named
Lingual cusp ridge: The lingual cusp ridge extends mesial and distal marginal ridges, and enclose those limits
cervically about halfway down the lingual surface. of the occlusal surface.
Mesial cusp ridge: This cusp ridge extends mesially
d. Fossae: There are three recognizable fossae on the
to the mesiolinguocclusal point angle area.
occlusal table, with the central fossa encompassing by far
Distal cusp ridge: It extends distally to end at the
the largest area.
lingual groove.
i. Central fossa: As the name implies, this fossa is
iv. Distolingual cusp: The DL cusp is quite sharp, but is located in the central portion of the occlusal table. It
slightly smaller in size than the mesiolingual cusp. is somewhat circular in shape, and the largest and
The DL cusp has four cusp ridges, which are deepest of the three fossae. It is bounded by the
described as follows: triangular ridges of the four major cusps, as well as
Buccal cusp ridge: The buccal cusp ridge extends the distal cusp ridges of the MB and the ML cusps
from the cusp tip mesiobuccally to end in the area of and the mesial cusp ridges of the DB and DL cusps.
the junction of the distobuccal groove and the distal ii. Mesial triangular fossa: The mesial triangular fossa
portion of the central groove. has a location and limits similar to the same fossa on
Lingual cusp ridge: It extends in a cervical direction other posterior teeth. It is deeper and more distinct
to the middle third of the lingual surface. than the distal triangular fossa. Its boundaries
Mesial cusp ridge: The mesial cusp ridge extends include the mesial marginal ridge, the triangular
mesially to the lingual groove. ridges of the two mesial cusps, and the mesial cusp
Distal cusp ridge: It extends distally to the ridges of the two mesial cusps.
distolinguocclusal point angle area. iii. Distal triangular fossa: Again, this fossa has a
v. Distal cusp: The distal cusp is much the smallest location similar to its counterparts on other posterior
and shortest of the five cusps, but is relatively sharp. teeth. It is the shallowest and least distinct of the
Its four cusp ridges are described as follows: three occlusal fossae on this tooth. It is bounded by
Buccal cusp ridge: The buccal cusp ridge runs in a portions of the distal cusp and distal marginal ridge,
cervical direction, and occupies much of the area as well as the triangular ridges of the D and DL cusps.
surrounding the distobuccal line angle. Pits and grooves: The occlusal surface of the first molar
Lingual cusp ridge: It extends mesiolingually to end has the most complex groove pattern of any of the
in the distal pit area. Compared to other triangular mandibular molars.
ridges of posterior teeth, it is short and poorly i. Central pit: The central pit is located in the central
defined. fossa, and is the deepest pit on the occlusal surface.
Mesial cusp ridge: The mesial cusp ridge extends It is situated midway mesiodistally, and more than
from the cusp tip mesiobuccally to the distobuccal halfway from buccal to lingual. It is at the junction of
groove. three primary developmental grooves:
 Dental Anatomy, Physiology, Histology and Occlusion 107
Mesiobuccal (Buccal) groove: This groove extends Buccal aspect (Figure 5-102)
from the central pit buccally onto the buccal surface. • It is of trapezoidal in shape but is smaller in dimensions
In its most lingual portion, it is confluent with the than mandibular first molar.
mesial portion of the central groove. • Mesial, distal outlines and cervical line resembles
Distobuccal groove: The distobuccal groove extends mandibular first molar.
in a distobuccal direction from the central pit onto
the buccal surface. In its most lingual area, it is
confluent with the distal portion of the central
groove.
Lingual groove: The lingual groove extends from the
central pit lingually onto the lingual surface.
ii. Mesial pit: The mesial pit is situated halfway
buccolingually in the deepest area of the mesial
triangular fossa. It is not as deep as the central pit.
This pit is the junction of four developmental grooves.
Central groove (Mesial portion): The mesial portion
of the central groove extends mesiobuccally from the
central pit a short distance, via the mesiobuccal
groove, and then after their separation, continues in
a mesial direction to the mesial pit.
Mesiobuccal triangular groove: This groove is similar
Figure 5-102: Buccal view of
to the same groove as it was described for the mandibular second molar
maxillary molars.
Occlusal outline
Mesiolingual triangular groove: It is also similar to
• This margin is separated into two nearly equal halves
the same groove as it was described for the maxillary
molars. by the buccal groove.
Mesial marginal groove: From the mesial pit, this • The two buccal cusps, the mesiobuccal and distobuccal
groove crosses the mesial marginal ridge in a mesial are about equal in length as are their cusp outlines.
direction. The buccal groove breaks the occlusal outline at about
iii. Distal pit: The distal pit is located midway its mesiodistal midpoint. It extends cervically to the middle
buccolingually in the depth of the distal triangular third, where it normally terminates in a buccal pit. There
fossa. It is not so deep as the central or mesial pits. It is no distobuccal groove.
is the union of three developmental grooves: The height of contour is located on the cervical third of
Central groove (Distal portion): From the distal pit, crown.
this groove passes mesiobuccally to become confluent Lingual aspect
with the distobuccal groove. • Lingual surface is trapezoidal and similar to mandi-
Distolingual triangular groove: This groove extends bular first molar except for smaller in dimension.
from the distal pit toward the distolingual line angle, • Mesial, distal and cervical outlines are similar to
where it fades out.
mandibular first molar.
Distal marginal groove: It extends distally from the
distal pit over the distal marginal ridge. Occlusal outline
• The occlusal outline is divided approximately in half
Permanent Mandibular Second Molar by the lingual groove. Only the two lingual cusps are
It is the seventh tooth from midline and has mesial contact visible.
with mandibular first molar and distal contact with The lingual groove crosses the occlusal outline onto the
mandibular third molar. lingual surface, and fades out in the occlusal third near its
The second molar resembles the first molar in many junction with the middle third (Figure 5-103).
respects, although it is more symmetrical, and smaller in There is very little convergence of crown lingually.
all dimensions. It has the least complicated occlusal design Height of contour is located on the middle third of
of any molar. Normally only four cusps are present, and crown.
thus there is no distobuccal groove, and no distal cusp. Rest of the surface are similar to mandibular first molar.
108 Essentials of Operative Dentistry

the distal surface is about the same size as the mesial

surface, and only a little of the cervical third of the buccal
surface is visible.
• The contact area is centered on the surface both
buccolingually and occlusogingivally. It is wider
buccolingually than occlusocervically, but is more
irregular in its configuration (Figure 5-105).

Figure 5-103: Lingual view of

mandibular second molar

Mesial aspect: The mesial aspect is similar to the first molar

except:
• It is smaller in general size and is more convex in all
directions.
• The cervical outline is straighter, but like the first molar
is more cervically positioned on the buccal as compared Figure 5-105: Distal view of
to the lingual. mandibular second molar
• The mesial contact area is definitely ovoid, when
compared to the first molar’s round or slightly ovoid Occlusal aspect
mesial contact (Figure 5-104). General considerations: The occlusal table of most second
molars is rectangular in shape, but the distal outline is
more rounded, when compared to the slightly rounded
mesial half.
Even though the occlusal table itself is rectangular, the
tooth outline from this aspect bulges at the mesiobuccal.
This is due to the greater prominence of the mesial portion
of the cervical height of contour, which is visible because
of the lingual inclination of the crowns of mandibular
posterior teeth.
The design of the occlusal table and its anatomy are the
simplest of any first or second molar.

Components of the Occlusal Table (Figure 5-106)

Cusps: There are normally four cusps on the mandibular
second molar, all of which are functional.
Figure 5-104: Mesial view of
mandibular second molar i. The cusps are termed mesiobuccal. distobuccal.
mesiolingual, and distolingual, and are fairly
Distal aspect: The distal aspect is comparable to the first symmetrical in their position on the occlusal
molar except: surface.
• There is no distal cusp contour, and no distobuccal ii. They are more nearly equal in size than the cusps of
groove. the first molar. Even so, the mesiobuccal cusp is
• Since there is no distal cusp, the buccal surface shows normally the largest, while the distolingual cusp is
much less convergence toward the distal. Consequently, normally the smallest, but its size may vary the most.
 Dental Anatomy, Physiology, Histology and Occlusion 109
molar. The lingual cusp ridges of the buccal cusps
meet the buccal cusp ridges of the lingual cusps to
form two transverse ridges.
Marginal ridges: There are two marginal ridges which are
similar to, and named the same, as those of other posterior
teeth.
Transverse ridges: The two transverse ridges are formed by
the union of the lingual cusp ridges of the buccal cusps and
Figure 5-106: Occlusal view of
mandibular second molar the buccal cusp ridges of the lingual cusps in the central
groove area.
iii. The buccal cusp ridges of the buccal cusps and the Fossae: The three fossae are named and located similar to
lingual cusp ridges of the lingual cusps are similar those of the first molar, although the central fossa is more
to the cusp ridges of the same four cusps on the first regular in shape.

First (Figure 5-107) Second (Figure 5-108) Third

5 cusps 4 cusps 4 cusps
2 buccal grooves (MB and DB) Single buccal groove Single buccal groove
Pentagonal shape (occlusal) Rectangular shape Ovoid shape
Biplanar buccal surface Single plane buccal surface Single plane buccal surface to buccal roots
Buccal surface wider than lingual surface Buccal and lingual surfaces equal Variable
Mesial surface wider than distal Mesial and distal surfaces equal Variable
Medial and distal marginal grooves No marginal grooves No marginal grooves
Mesial and distal root concavities No root concavities No root concavities
Distally inclined roots More distinctly distally inclined roots Extremely distally inclined roots
Rounded apex of root Pointed apex Short roots and fused

Figure 5-107: Mandibular right first molar Figure 5-108: Mandibular right second molar
110 Essentials of Operative Dentistry

Pits and grooves: Unlike the first molar, the major groove of maxillary anteriors and the amount of horizontal
pattern is almost symmetrical, with the central groove and overlap (overjet) and vertical overlap (overbite) can
the buccal and lingual grooves combining to form a cross significantly influence the mandibular movement and
pattern, the intersection of which is in the central pit. There thus influence cusp design of restorations posterior
are often more supplemental grooves on the second molar, teeth.
however. • Centric relation is bone-to-bone relation, whereby the
i. Central pit: The central pit is aptly named, because it condyle is in its most relaxed posterosuperior most in
is located centrally on the occlusal surface. It is the relation to glenoid fossa. The definition is “the centric
deepest of the three pits, and is formed by the junction relation is the maxillomandibular relationship in which
of three developmental grooves. the condyles articulate with the thinnest avascular
ii. Buccal groove: The buccal groove extends buccally portion of their respective disks with the complex in the
from the central pit onto the buccal surface. anterosuperior position against the shapes of the
iii. Lingual groove: The lingual groove extends lingually articular eminencies”.
from the central pit onto the lingual surface. • Significance of centric relation is that it is the most
iv. Central groove: It extends between the mesial and repeatable position that could be recorded.
distal pits in a straight line which passes through
the central pit. The central groove has mesial and Mandibular movement: In 1952, Ulf Posselt described the
distal portions separated by the central pit. capacity of motion of the mandible using Posselt’s diagram
• Mesial pit: The mesial pit is not as deep as the (Posselt’s envelope of motion) which describes the
central pit, and is located midway buccolingually mandibular movement in all axis (Figure 5-109).
in the depth of the mesial triangular fossa.
• Distal pit: The distal pit resembles the mesial pit
in depth and relative location.
Occlusion
• Literally means closing.
• In dentistry occlusion means contact of teeth in opposing
arch when the jaws are closed and during movements.
• Static occlusal relationship—is occlusal contacts
during closed and terminal positions (terminal hinge
closure, retruded, right and left lateral extremes).
• Dynamic occlusal relationship—is occlusal contacts
during various movements of mandible.
• Occclusal relationship has to be understood as any
gross deviation from prescribed occlusal scheme can
result in great discomfort to patient.
General description of occlusion
• Usually maxillary arch is larger than mandibular arch
and when they close maxillary arch teeth cusps overlap
the mandibular teeth. Figure 5-109: Posselt’s movement
• Centric occlusion is the maximum intercuspation of the
tooth. Mandibular movement can occur in three axes (Figures
• During centric occlusion cusps that contact the 5-110 to 5-112):
opposing teeth along the central fossa of opposing teeth 1. Horizontal axis: Occurs when mandible rotates in a
is termed supporting cusp (holding cusp)—maxillary hinge axis point during closing and opening this point
facial cusps and cusps that overlap opposing teeth are is called terminal hinge movement.
termed nonsupporting cusp (noncentric cusp)— 2. Vertical axis: Occurs when mandible moves into lateral
mandibular lingual cusp. excursions.
• In the anterior teeth during centric occlusion mandi- 3. Sagittal axis: When mandible moves to one lateral side,
bular incisors and canines contact the lingual surfaces the condyle on opposite moves downward.
 Dental Anatomy, Physiology, Histology and Occlusion 111

Figure 5-110: Horizontal axis rotation—opening and closing Figure 5-112: Sagittal axis rotation

side of mandible contacts and disoccludes the posterior

teeth.
• Curve of spee: It has been suggested that the composite
arrangement of the occlusal surfaces of all of the teeth
in each dental arch approximate a segment of a sphere,
this curve is called as curve of Spee (Figure 5-113).
• Curve of Wilson: This curvature is reflected by lingual
inclination of mandibular molars—concave and buccal
inclination of maxillary molars—convex (Figure 5-114).

Figure 5-111: Vertical axis rotation—lateral excursions

• Purely rotational movement of condyle occurs only in

terminal hinge position (Centric relation).
• When mandible moves forward it is protrusive move-
ment and when it is retracted back, it is retrusive
movement. Figure 5-113: Curve of Spee
• When mandible moves laterally it is called as
laterotrusive movement. When mandible is moving
laterally the side to which mandible moves, is called as Tooth-to-Tooth Contacts
working side, and opposing half of mandible following
it will be nonworking side. Cusp-Ridge Pattern of Occlusion
• Canine guided occlusion: Where during lateral movement The relation between the upper and lower teeth is such
of mandible, canines of opposing arch on working that one stamp cusp fits in a fossa and another stamp
112 Essentials of Operative Dentistry

Centric Interference
It is a premature contact that occurs when mandible closes
in centric closure. It causes the mandible to deflect in a
posterior, anterior or lateral direction (Figure 5-115).

Figure 5-114: Curve of Wilson

cusp of the same tooth fits into the embrasure area of two
of the opposing teeth. This cusp-ridge arrangement is called
a “tooth-to-two-teeth” occlusion, or a “cusp-embrasure”
occlusal pattern.
Figure 5-115: Centric interference

Cusp-Fossa Pattern of Occlusion

In this pattern, most or all of the stamp cusps fit into fossae.
Working Interference
The “cusp-fossa” relationship normally produces an It may occur when there is premature contact between
interdigitive relation of the cusps and fossae of one tooth maxillary and mandibular posterior teeth on same side of
with the cusps and fossae of only one opposing tooth. the arches in which direction it is moving (Figure 5-116).
This pattern may also be called “tooth-to-one-tooth”
occlusion.
The most stable type of occlusion is tooth-to-two-tooth
contact.

Factors Influencing Occlusion

• Condylar guidance
• Incisal guidance
• Plane of occlusion
• Compensating curve
• Cusp height.

Occlusal Interferences
Interferences are undesirable occlusal contacts that may
produce mandibular deviation during closure to Figure 5-116: Working side interference
maximum intercuspation or may hinder smooth passage
to and from the intercuspal position.
Four types of interferences are: Nonworking Interference
• Centric It is occlusal contact between maxillary and mandibular
• Working teeth on the side of the arches opposite the direction in
• Nonworking which mandible has moved in a lateral excursion (Figure
• Protrusive. 5-117).
 Dental Anatomy, Physiology, Histology and Occlusion 113
• Articulating paper may be used to evaluate the contacts.
Two colors are available one is for centric contact
marking and another for lateral contacts.
• Cellophane paper or shimstock may be used to locate
the contacts, by asking patient to bite on cellophane
paper and then trying to pull out to evaluate the
tightness in bite.
• Occlusal indicator wax may be used, by warming wax
and asking the patient to bite over the wax and areas
where wax has been penetrated by tooth represents
areas of contacts.
• Fremitus test where by asking patient to close the teeth
and feeling the vibration over the tooth can identify
tooth contacts.
Figure 5-117: Nonworking side interference
• Shiny wear facets on enamel or on the restoration can
Protrusive Interference also indicate tooth contacts.

It is a premature contact occurring between the mesial

aspects of mandibular posterior teeth and the distal aspects Key Terms
of maxillary posterior teeth (Figure 5-118).
• Incisors • Canines
• Premolars • Molars
• Anatomic crown • Clinical crown
• Cervical line • Pulp
• Alveolar process • Periodontal ligament
• Gingiva • Line angle
• Point angle • Cusps
• Tuberculum • Cingulum
• Marginal ridge • Triangular ridge
• Transverse ridge • Oblique ridge
• Cusp ridge • Mammelons
• Central fossa • Triangular fossa
• Primary groove • Secondary groove
• Pit • Contact area
Figure 5-118: Protrusive interference • Crown form • Centric occlusion
• Centric relation • Holding cusp
Clinical Identification of Tooth Contacts • Supporting cusp • Lateral excursions
• Posselt’s movement of graph • Articulating paper
Preoperatively centric tooth contacts should be marked
and noted.
Various methods are available to mark occlusal contacts
they can also be used to evaluate the premature contacts.
Question to Think About
Methods are: 1. Describe about tooth morphology of each individual
• Patient may be able to feel the area of contact. tooth.
114 Essentials of Operative Dentistry

6 Cariology

Definition Mutans streptococci is collective term for all the

serotypes.
• Dental caries is an infectious microbiological disease Mutans streptococci and Lactobacillus can produce great
of the tooth that results in localized dissolution and amounts of acids (acidogenic) are tolerant to acidic
destruction of the calcified tissues. environment (aciduric) are primary organisms associated
• A gelatinous mass of bacteria adhering to the tooth with caries causal in man.
surface is termed dental plaque. Organisms which cause caries are cariogenic.
• The plaque bacteria metabolize refined carbohydrates The degree to which a tooth is likely to become carious
for energy and produce organic acids as a byproduct. is described as its cariogenicity potential.
These acids then cause a carious lesion by dissolution Mutans streptococci are pandemic infection in
of tooth’s crystalline structures. humans. Normally, they are present in small component
• Remineralization of the damaged tooth structure occurs in plaque.
as the local pH rises above 5.5.
• Saliva contains high concentration of calcium and
phosphate ions in solution which serve as a supply of Epidemiology of Caries
raw materials for the remineralization process.
• The most common epidemiological measure of caries is
Evidence for the role of bacteria in the genesis of caries
DMF index (Decayed, Missing, Filled) may be reported
is overwhelming:
as DMFT ( number of teeth) or DMFS (surfaces affected).
• Teeth free from infection with bacteria, either in germ
• In developing countries there is alarming increase in
free animals (gnotobiotic animals) do not develop caries.
caries incidence but population’s access to dental care
• Antibiotics are effective in reducing caries in animals
is limited.
and humans.
• Oral bacteria can demineralize enamel in vitro and
produce lesions similar to naturally occurring caries. Hypotheses Concerning
• Specific bacteria can be isolated and identified from
plaque over various carious lesions.
Etiology of Caries
One group of bacteria which consists of eight Two hypotheses are there:
Streptococcus mutans serotypes has been associated with 1. Non-specific plaque hypotheses.
caries. The serotypes have been labelled through a–h. 2. Specific plaque hypotheses (Walter Loesche).
• S. rattans (Serotype b) Differences between both hypotheses are given in Table
• S. cricetus (Serotype a) 6-1.
• S. ferus (Serotype c) Table 6-2 describes new caries treatment model-based
• S. sobrinus (Serotype d, g, h) on medical model.
 Cariology 115
Table 6.1: Differentiating features of nonspecific and specific hypotheses

Nonspecific hypotheses Specific hypotheses

Diagnosis Not required plaque is universal Diagnosis essential only some plaque are pathogenesis
Target population Entire population must be treated Treatment is necessary only in infected or high-risk
individuals
Treatment goal Removal of all plaque Elimination of infection
Purpose of recall Determine need for restoration Determine if infection has been eliminated
Responsibility for outcome Treatment failure primarily is the Treatment failure is primarily dentist’s fault
patients fault

Table 6.2: New caries treatment model based on Proteolytic Theory

medical model • This theory was put forward, because it was believed
that organic portions of tooth played an important role
Etiology Mutants streptococci infection
in carious process.
Symptoms Demineralization lesions in
• Organic structures in enamel are enamel lamellae and
tooth
enamel rod sheaths. These serve as an pathway for
Treatment symptomatic Restoration of cavitated lesion
carious progression.
Treatment therapeutic Eliminate mutans • This theory was forwarded by Gottlieb (1944), he
streptococci infection described caries as essentially an proteolytic process
Post-treatment assessment Examine teeth for new lesions that invade the organic pathways and destroy them in
symptomatic advance.
Post-treatment assessment Bacteriological testing for • The two theories need not be separate and distinct.
therapeutic mutans streptococci Bacteria produce acid from carbohydrate substrate,
while some other bacteria degrade proteins in absence
of carbohydrate.
Theories of Etiology of Dental • By this way two types of caries process may be explained:
Caries 1. Here the microorganisms invade the enamel lamellae,
attack the enamel and involve dentin before clinical
Acidogenic Theory (Miller’s Chemico- evidence of caries appears.
parasitic Theory) 2. In another type, chalky enamel may be produced by
• Proposed by WD Miller in 1882. decalcification of enamel by acids produced.
• Dental decay is a chemicoparasitic process consisting
of two stages, the decalcification of enamel which results Proteolysis—Chelation Theory
in its total destruction and the decalcification of dentin • This was put forward by Schatz.
as a preliminary stage followed by dissolution of the • Chelation is a process involving complexing of a
softened residue. metallic ion to a complex substance through a
• The acid which produces this primary decalcification coordinate covalent bond which results in highly stable,
is derived from fermentation of starches and sugars. poorly dissociated compound.
• Cariogenic carbohydrates which leads to production • Chelation is independent of pH. Therefore, removal of
of acids are of dietary in origin. calcium form hydroxyapatitic in tooth surface may
• Sticky, solid carbohydrates are more cariogenic than occur even at neutral (as) alkaline pH.
liquid carbohydrates. • This theory proposes that bacterial attack on enamel
• Microorganisms implicated for production of acids are initiated by keratinolytic microorganisms consists in a
Streptococcus mutans, Lactobacillus acidophilus, breakdown of the protein and other organic components
Actinomyces species. of enamel chiefly keratin. This results in the formation
• It was shown by Stephan that local pH drops below of substances which may form soluble chelates with
5 decalcification of enamel starts. This he described in the mineralized components of tooth and thereby
Stephan’s curve as “critical pH”. decalcify enamel even at neutral (or) alkaline pH.
116 Essentials of Operative Dentistry

• Thus, this theory states that both organic and inorganic Mutans streptococci are responsible for caries initiation
structures of tooth are affected. and Actinomyces viscosus is responsible for root caries
Increased incidence of caries concomitant with increased initiation.
carbohydrate consumptions is explained in this theory by: Lactobacillus species is responsible for progression of
• Increased carbohydrate increases proteolysis. dentinal caries.
• Producing conditions under which keratinous proteins
are less stable. Clinical Sites for Caries Initiation
• Complexing easily with calcium possible.
• Most susceptible site is developmental pits and fissures.
Increasing caries incidence concomitant with increased
• Smooth enamel surfaces like proximal contacting
lactobacillus count is explained by:
surfaces, gingival to facial and lingual contour of tooth.
• Proteolysis provides ammonia which helps in growth
• Root surface.
of lactobacilli.
• Release of calcium from hydroxyapatite crystals of
enamel through chelation encourage growth of lacto- Pit and Fissure
bacilli. • These are usually colonized by bacteria forms bacterial
• Calcium exerts vitamin– sparing actions or lactobacilli. plug.
Reduced caries incidence with increased fluoride • Type and nature of organisms usually prevailing in
application is by occurrence of formation of fluorapatite oral cavity dominate the pits and fissures.
crystals which strengthen the linkage between organic and • Shape of the pits and fissures also determine caries
inorganic components of enamel, thereby preventing the progression and susceptibility.
occurrence of chelations. • Pits and fissures expand as it penetrates into the enamel.
• Both pits and fissures are characterized by non-
Pathophysiology of Caries coalesced enamel at the base.
In cross-section the gross appearance of a pit and fissure
• Primary damaging effect of caries is demineralization is of an inverted V with a narrow entrance and a
and dissolution of tooth structure. progressively wider area of involvement closer to the DEJ
• This results from: – Highly localized drop in the pH (Figures 6-1A and B).
at the plaque tooth interface.
– Tooth demineralization. Smooth Surface Caries
• Local drop in pH is due to metabolic activity of plaque
• Presents less favorable site for plaque adhesion.
bacteria but only plaque with sufficient number of
• Plaque usually adheres to areas that are near the gingiva
S. mutans and Lactobacillus can lead to drop in pH to
or under the proximal contacts.
cause tooth demineralization.
• Lesions starting in smooth surface have a broader area
• The organic acids primarily lactic acid is responsible
of origin and a pointed or conical end near DEJ.
for drop in pH.
• Path of progression is roughly paralleling the direction
• Frequent sucrose exposure is the single most important
of enamel rods.
factor for sustained drop in pH.
• Cross-section shows V shape with a wider area of
• Output of acid production from caries active plaque is
origin and the apex of V directed towards DEJ. After
twice that of caries inactive plaque.
penetrating DEJ caries spreads laterally and pulpally
• Once the pH drops below 5.5 (critical pH) tooth
in dentin (Figures 6-2A to D).
dissolution starts.
• The initial carious lesion is limited to the enamel and is
characterized by a virtually intact surface but a porous Root Surface Caries
subsurface – incipient caries. • Root surface is rougher than enamel allows plaque
• This incipient caries is reversible by remineralization adhesion in absence of oral hygiene measures.
process. • Cementum covering the root offers little resistance to
• Cavitation of enamel occurs when the subsurface acid attack.
demineralization is extensive that the tooth structure • Root caries has a U shape progression with well-defined
collapses. margins and progress more rapidly because of absence
• Cavitation of enamel is an irreversible process. of enamel protection.
 Cariology 117

Figures 6-1A and B: Pit and fissure caries: (A) Spread of caries from enamel into dentin. Near dentinoenamel
junction (DEJ) it spreads laterally, (B) Various shapes of pit and fissures

Figures 6-2A to D: Smooth surface caries. Prognosis of caries from enamel into dentin. Progression of
caries in V-shape fashion with broad surface of ‘V’ present in external surface of enamel

Histopathology of Caries • Pores or voids form along the enamel prism boundaries
because of hydrogen ion penetration during caries
Zones of Incipient Lesion (Figure 6.3) process.
• Translucent zone • Total pore volume is 1% 10 times greater than normal
• Dark zone enamel.
• Body of the lesion Zone 2: The dark zone
• Surface zone. • Here small air or vapor filled pores makes the region
opaque.
Zone 1: Translucent zone • Total pore volume is 2-4%.
• This is the deepest zone represents the advancing • Size of dark zone is suggestive of amount of
front. remineralization.
118 Essentials of Operative Dentistry

Figure 6-4: Zones of dentinal caries: 1—Normal dentin,

2—Zone 2 and Zone 3, 3—Zone 4 and Zone 5

3. Loss of structural integrity followed by invasion of

bacteria leading to cavitation.

Zones of Dentinal Caries (Figure 6-4)

• Normal dentin
• Subtransparent dentin
• Transparent dentin
• Turbid dentin
Figure 6-3: Zones of enamel caries: a—surface zone, • Infected dentin
b—dark zone, c—body of lesion, d—translucent zone
Zone 1: Normal dentin
Zone 3: Body of the lesion
• Tubules with smooth odontoblastic processes and no
• Largest portion of incipient lesion while in deminera-
crystals in lumen.
lizing zone.
• Intertubular dentin has normal cross-banded collagen
• Largest pore volume varying from 5% at periphery to
and normal dense apatite crystals.
25% at center.
• Bacteria may be present. Zone 2: Subtransparent dentin
• Is a layer of zone of demineralization of intertubular
Zone 4: Surface zone
dentin and initial formation of very fine crystals in
• Relatively unattacked by caries.
tubule lumen.
• Lower pore volume than body of lesion. • No bacteria is found.
• Surface of enamel is hypermineralized because of contact • This layer capable of regeneration.
with saliva and fluoride content.
Zone 3: Transparent dentin
Dentinal Caries • Layer of carious dentin softer than normal dentin many
• Because of intimate relationship between odontoblasts large crystals are present in the lumen.
and dentin, dentin and pulp should be regarded as a • No bacteria is present in this region.
single functional unit. • Collagen crosslinking remains intact in this region.
• Dentinoenamel junction has the least resistance to caries • This intact collagen can serve as a template for
attack and allows lateral spreading once caries has remineralization of intertubular dentin.
penetrated the enamel. Zone 4: Turbid dentin
• Because of these characteristics dentinal caries is • Zone of bacterial invasion is marked by widening and
V-shaped in cross-section with a wide base at the DEJ distortion of the dentinal tubules which are filled with
and apex directed pulpally. bacteria.
• No recognizable structure to dentin.
Changes Brought by Dentinal Caries • This zone cannot be remineralized and should be
Caries advance in dentin produces three changes: removed during restoration.
1. Weak organic acids demineralize dentin. Zone 5: Infected dentin
2. Organic material of dentin particularly collagen is • Outermost dentin consists of decomposed dentin
degenerated and dissolved. teeming with bacteria.
 Cariology 119
• Removal of this layer is necessary for successful Tooth surface can be examined visually and tactilely.
restoration and prevention of spreading of infection. • Visual evidence includes cavitation, surface roughness,
Affected dentin – zones 2 and 3 opacification, and discoloration.
Infected dentin – zones 4 and 5 • Tactile evidence includes roughness and softening of
Affected dentin can be left behind under certain tooth surface determined by sharp explorer.
circumstances, but infected dentin has to be removed.
Pit and Fissure Caries
Caries Diagnosis and Preventive • Cavitation at the base of pit can be determined tactilely
as softness by binding of explorer tip.
Treatment (Tables 6-3 to 6-8) • Additional criteria developed by US department of
• Process of caries diagnosis involves both risk health for pit and fissure caries assessment is:
assessment and the application of diagnostic criteria • Softening at the base of pit
in order to determine the disease state of the tooth. • Opacity surrounding the pit and fissure indicating
• Caries treatment includes preventive measures, undermining or demineralization of enamel.
temporary caries control restorations (Caries Control • Softened enamel that may be flaked away by explorer
Restorations) and permanent restorations. tip.
Preventive measures include:
• Limiting pathogen growth and metabolism. Smooth Surface Caries
• Increasing resistance to the tooth surface to • Bitewing radiographs are most effective method for
demineralization. evaluation of demineralization in proximal smooth
surface.
Caries Diagnosis • It is important to detect the smooth facial surface and
lingual surface caries early as these occur in individuals
Historically, it has been confined to ‘drill and fill’ approach
with high caries risk.
which fails to deal with the underlying etiological
factors.
Variety of diagnostic measures are available they are:
Root Surface Caries
• Identification of subsurface demineralization (inspec- Root surface exposed to oral environment due to gingival
tion, radiographic, and dye uptake methods.) recession are at risk for caries.
• Bacterial testing.
• Assessment of environmental conditions such as pH, Diagnosis of Dental Caries
salivary flow, salivary buffering. • Explorers
Since no single test is 100% predictive a caries risk has • Radiographs
been promoted. • Discoloration

Table 6-3: Caries activity test

Test Principle and result

Buffering capacity Titrates a saliva sample to estimate buffering capacity
Dewar Similar to Fosdick
Fosdick Measures capacity of saliva sample to dissolve powdered enamel
Lactobacillus count Estimates the number of bacteria in saliva by counting colonies on a selective media plate
Reductase Measures activity of reductase enzyme from a saliva sample
Rickles Measures the rapidity of acid formation from a saliva sample in a culture medium
Snyder Measures the rapidity of acid formation from a saliva sample in culture medium
Mutans streptococci Estimates the number of colony forming bacteria in saliva by use of selective culture media
screening (several variations of this test is available)
120 Essentials of Operative Dentistry

Table 6-4: Methods of caries treatment by medical model

Method and indications Rationale Technqiues or material

A. Limit Substrate
Indications Reduce number, duration and Eliminate sucrose from between
Frequent sucrose exposure intensity of acid attacks meal and snacks
Poor quality diet Reduce selection pressure for MS Substantially reduce or eliminate
sucrose from meals
B. Modify Microflora
Indications Intensive antimicrobial treatment Bactericidal mouthrinse
High MS counts to eliminate MS from mouth (chlorhexidine)
High Lactobacillus counts Select against reinfection by MS Topical fluoride treatments
Antibiotic treatment (vancomycin,
tetracycline)
C. Plaque Disruption
Indications Prevents plaque succession Brushing
High plaque scores Decreases plaque mass Flossing
Puffy red gingival Promotes buffering Other oral hygiene aids as
High bleeding point score necessary
D. Modify Tooth Surface
Indications Increase resistance to Systemic fluorides
Incipient lesions demineralization Topical fluorides
Surface roughening Decrease plaque retention Smooth surface
E. Stimulate Saliva Flow
Indications Increases clearance of substrate Eat noncariogenic foods that
Dry mouth with little saliva and acids require lots of chewing
Red mucosa Promotes buffering Sugarless chewing gum
Medication that reduces salivary flow Medications to stimulate salivary flow
F. Restore Tooth Surfaces
Indications Eliminate nidus of MS and Restore all cavitated lesions
Cavitated lesions lactobacillus infection Seal pits and fissures at caries risk
Pits and fissures at caries risk Deny habitat for MS for Correct all defects (e.g. marginal
Defective restorations reinfection crevices, proximal overhangs).

• Patient’s complaints Chronic caries lesion—Caries which has progressed

• Dental floss or tape very little.
• Separation of teeth • Pit and fissure caries
• Transillumination are various methods employed for Smooth surface caries.
dagnosis for caries. • Forward—Caries progressing from enamel to dentin
Backward caries—Caries progressing from dentin
to enamel.
Classification of Caries • Senile carious lesion occurring in older age group on
Classification of caries is based upon the clinical, root surface of tooth.
radiographic, histological appearance of carious process • Residual caries—Caries left after tooth preparation.
involvement of particular tooth, group of teeth or tooth • Simple carious lesion—only one tooth surface.
surface (Figures 6-5 and 6-6). Compound carious lesion—two surface of tooth.
• Incipient caries, initial caries, primary caries lesion— Complex carious lesion—three or more surfaces of
Caries occurring for first time. tooth.
Recurrent caries or secondary lesion—Caries • GV Black classification
occurring on already restored teeth. Class I—Class VI
• Acute or rampant caries—Caries which has progressed • Classification employing surface of tooth involved (e.g.
great deal in short duration. Buccal, Lingual, etc.)
 Cariology 121

Table 6.5: Treatment strategies

Examination findings Nonrestorative treatment Restorative treatment Follow-up

Normal (no lesions) None None One year
Clinical examination
Hypocalcified enamel None for nonhereditary Treatment is elective One year
(developmental white spot) lesions Esthetics (restore defects) Clinical examination
Hereditary lesions
(dentinogenesis imperfecta:
may require special
management)
Incipient enamel lesions only Technqiues A to E in Seal defective pits and Three months
Bitewing radiographs Table 6-4 as indicated fissures as indicated Evaluate
Indicated (demineralized Oral flora, MS counts
white spots) Progression of white spots
Presence of cavitations
Possible cavitated lesions Techniques A to E in Technique F (restora- Three months
(active caries) and other Table 6-4 as indicated tions, sealants ) in Evaluate
incipient lesions present Table 6-4 as indicated Oral flora
Bitewing radiographs MS counts
indicated Progression of
white spots
Presence of new
cavitations
Pulpal response
Arrested caries None Treatment is elective One year
No active (new cavitations) esthetics (restore defects) Clinical examination
or incipient lesions

MS—Mutans streptococci

Table 6-6: Clinical assignment risk for caries Table 6-7: Clinical findings associated with increased
caries risk
A patient is at high-risk for the development of new cavitated
lesions if: Clinical examination Risk-increasing findings
1. High MS counts are found. Bacteriologic testing MS General appearance Appears sick, obese, or
should be done if: malnourished
• The patient has one or more medical health history
risk factors Mental or physical Patients who are unable or
• The patient has undergone antimicrobial therapy disability unwilling to comply with dietary
• The patient presents with new incipient lesions and oral hygiene instruction
• The patient is undergoing orthodontic care Mucosal membranes Dry, red, glossy mucosa suggests
• The patient’s treatment plan calls for extensive decreased salivary flow
restorative dental work
Active carious lesions Cavitation and softening of enamel
2. Any two of the following factors are present:
and dentin, circumferential chalky
• Two or more active carious lesions
opacity at gingival margins
• Large number of restorations
• Poor dietary habits Plaque High plaque scores
• Low salivary flow
Gingiva Puffy, swollen, and inflamed;
bleeds easily
Caries Preventive Treatment Existing restorations Large numbers indicate past high
caries rate; poor quality indicates
Variety of factors having an influence on caries prevention:
increased habitat for cariogenic
• Host resistance organisms
• General health
122 Essentials of Operative Dentistry

Figure 6-5: Classification of pit and fissure caries (Contd...)

 Cariology 123

Figure 6-5: Classification of pit and fissure caries (Contd...)

124 Essentials of Operative Dentistry

Figure 6-5: Classification of pit and fissure caries

 Cariology 125

Figure 6-6: Black’s classification of caries

126 Essentials of Operative Dentistry

Table 6-8: Medical history associated with increased • Term caries control refers to an operative procedure in
caries risk which multiple teeth with acute threatening caries are
treated quickly by:
History factor Risk-increasing observations
• Removing the infected tooth structure
Age Childhood, adolescence, senescence • Medicating the tooth
Gender Women at slightly greater risk • Restoring the defect with a temporary material.
Fluoride exposure No fluoride in public water supply • Caries control procedure must be accompanied by other
preventive measures and subsequently restored with
Smoking Risk increases with amount smoked
permanent restorations.
Alcohol Risk increases with amount consumed
• Intent of the caries control procedure is to prevent and
General health Chronic illness and debilitation assess pulpal disease and avoid possible sequel such
decreases ability to give self-care
as toothache, rootcanal therapy, or more complex
Medication Medications that reduce salivary flow ultimate restorations.
• The treatment objective for caries control is to remove
the decay from all of the advanced carious lesions, place
• Fluoride treatment (Table 6-9) appropriate pulpal medication, and restore the lesions
• Immunization in the most expedient manner.
• Diet
• Oral hygiene Steps
• Pit and fissure sealants • Primary objective here is to provide adequate visual
• Restorations and mechanical access to the tooth to facilitate the
removal of infected portion of the carious dentin.
Caries Control Restorative Treatment— • Initial entry is by largest carbide bur such as No. 4 or
Temporary Restoration (Tables 6-10 and 6-11) No. 6 round bur or No. 271 fissure bur.
• Recognized control of cavitated carious lesion is • High speed handpiece with air-water spray is a
removal of infected area from the tooth and subsequent must.
restoration to the tooth to optimal form, function and • Some steps in fundamental steps in cavity preparation
esthetics. is modified for this technique.
• Once the caries lesion has progressed to cavitation • Retaining unsupported enamel is permissible as it aids
preventive measures are inadequate therefore surgical in retaining temporary restorative material.
removal of the lesion and restoration of the tooth is • Dentin that leathery, peels off in small flakes or can be
required to eliminate the progression of the caries. penetrated by sharp explorer should be removed.

Table 6.9: Fluoride treatment modalities

Route Method of delivery Concentration Caries reduction

(PPM) (%)
Systemic Public water supply 1 50-60
topical Self-application
Low-dose/high-frequency rinses
(0.05% sodium fluoride daily) 225 30-40
High-potency/low-frequency 900 30-40
rinses (0.2% sodium fluoride weekly) after 2 years
Fluoridated dentrifices (daily) 1000 20
Professional application
Acidulated phosphate fluoride gel 12,300 40-50
(1.23% annually or semiannually)
Sodium fluoride solution (2%) 20,000 40-50
Stannous fluoride solution (8%) 80,000 40-50
 Cariology 127
Table 6-10: Equipment necessary Table 6-11: Caries control restoration as a part of the
medical model

No. Stage Equipment/material Initial treatment Thorough evaluation and

documentation of lesions.
1. Access TC high speed bur 010/012
Temporization of all large cavitated
2. Caries removal Slow speed round bur (size 014-023) lesions by caries control restorations.
Specific antimicrobial treatment.
3. Lining Calcium hydroxide (Dycal)
Plaque control
Glass ionomer cement (Vitrebound)
Dietary control
4. Temporary Zinc oxide eugenol (Kalzinol)
Preliminary Gingival response as a marker of
restoration Glass ionomer cement (Fuji VII)
assessment plaque control effectiveness
(Cement)
Pulpal response of teeth with caries
5. Cement mixing Glass slab control restorations
Spatula Assessment of patient compliance
with medications, oral hygiene, and
6. Placement of Plastic instrument
dietary control measures
restorative
material Follow-up care Careful clinical evaluation of teeth
Replacement of caries control
7. Others Gauze
restorations with permanent
restorations
Monitoring of plaque and MS levels
Further antimicrobial treatment and
Effective caries removal is accomplished by:
dietary reassessment as indicated by
• Spoon excavator. new cavitations, incipient lesions, or
• Slow handpiece with large round bur. high MS levels
• High speed handpiece using a large round bur just
above stalling speed. • This procedure is mainly indicated in traumatic or
operative pulpal exposure with no bacterial contami-
Extreme care should be taken while removing caries to
nation with pulpal exposure less than 0.5 mm. The tooth
avoid pulpal exposure.
should have been asymptomatic preoperatively.
Usually, all soft caries is removed but in cases where
• This procedure is contraindicated in caries pulpal
there is deep carious lesion soft caries is left behind to
exposure.
avoid pulpal exposure this is called as ‘Indirect pulp
• Calcium hydroxide is the material of choice for this
capping’. This cavity is then lined with calcium hydroxide procedure but other materials are also used nowadays.
to promote reparative dentin bridge formation which • A direct pulp capping material should be able to:
usually takes place in 6-8 weeks. • Have a superficial effect on the pulp tissue, thereby
Direct pulp capping procedure is done when there is inducing a biological encapsulation process that
accidental pulpal exposure, here the pulpal exposure is results in hard-tissue formation.
lined with calcium hydroxide cement to stimulate dentin • Cause no adverse effects, whether systemically or
bridge formation. locally, such that the pulp is kept alive.
• Protect the pulp from the coronal ingress of bacteria.
Restoration
Procedure
After the cavity has been prepared and all soft caries has
• When pulpal exposure occurs during routine cavity
been removed a lining material is placed usually calcium
preparation no special procedures are required, calcium
hydroxide is applied in ‘non-pressure flow technique’
hydroxide is placed over the exposure in an non-
(described later) followed by temporary restoration with
pressure flow technique.
IRM (mixing of zinc oxide eugenol is explained later)
• Exposed area is dried using a cotton pellet, calcium
(Figures 6-7 and 6-8).
hydroxide paste is carried in a periodontal probe or a
calcium hydroxide applicator and teased over the
Direct Pulp Capping exposure without any pressure. If pressure is applied it
• This is a procedure by which exposed pulp is dressing can lead to debris getting pushed in or pulp being
(covered) directly by dental material. strangulated for blood supply (Figures 6-9A to D).
128 Essentials of Operative Dentistry

Figures 6-7A to C: Caries control method

Figures 6-8A to E: Zinc oxide eugenol temporary restoration compacted by using a cotton pellet

Figures 6-9A to D: Calcium hydroxide application in nonpressure technique

 Cariology 129
• Then the tooth is now restored with zinc oxide eugenol • Critical pH
cement not applying too much pressure. Permanent • Stefan’s curve
restoration can be done on the tooth after 6-8 weeks. • DMF index
• Specific plaque hypotheses
Armamentarium • Acidogenic theory
• Proteolytic chelation theory
• Mouth mirror
• Proteolytic theory
• Explorers
• Pit and fissure caries
• Tweezer
• Smooth surface caries
• Cotton
• Zones of caries
• Calcium hydroxide cement (Base and catalyst)
• Caries activity test
• Paper pad and spatula
• Incipient caries
• Calcium hydroxide applicator or periodontal probe
• Residual caries
• Zinc oxide eugenol cement
• Secondary caries
• Plastic instrument.
• Simple caries
• Compound caries
Indirect Pulp Capping
• Complex caries
It is a procedure done in an asymptomatic tooth which • Forward caries
has a deep caries, some amount of carious (affected dentin) • Backward caries
is left behind to prevent pulpal exposure followed by • GV Black’s classification of caries
calcium hydroxide lining and temporary restoration. • Caries control procedure
Tooth could be given permanent restoration after
6-8 weeks provided tooth is asymptomatic.
Questions to Think About
Procedure and Armamentarium
1. Definition of caries. Explain about different zones in
Same as caries control procedure. enamel and dentin caries.
2. Explain about etiology and pathophysiology of
Key Terms caries.
3. Different classification of caries.
• Dental plaque 4. Explain about pit and fissure caries, smooth surface
• Demineralization caries.
• Remineralization 5. What are diagnosis methods of caries?
130 Essentials of Operative Dentistry

7 Fundamentals in Tooth
Preparation

Tooth preparation is defined as the mechanical alteration precise preparations are still required for amalgam and
of a defective, injured, or diseased tooth in order to best cast metal restorations.
receive s restorative material which will re-establish a However, because of the use of adhesive restorations,
healthy state for the tooth including esthetic corrections primarily composites, the degree of precision of tooth
where indicated along with normal form and function. preparations has decreased. Many composite restorations
may require only the removal of the defect (caries or
defective restorative material) and friable tooth structure
Need for Restoration for tooth preparation, without specific uniform depths,
• Carious lesion wall designs, or marginal forms.
• Replacement or repair of restoration This simplification of the tooth preparation process is
• Fractured teeth due to the physical properties of the composite material
• Restore form and function as a result of congenital and the strong bond obtained between the composite and
malformation tooth structure.
• Esthetic requirement
• Fulfillment of other restorative needs Factors Affecting Cavity
• Preventive aspect.
Preparation
Objectives of Cavity Preparation • Diagnosis
• Occlusal relationship
• Remove all defects and give the necessary protection to • Esthetics
pulp. • Relationship with other treatment planned
• Locate the margins as conservatively as possible. • Caries risk potential
• Form the cavity so that both the restoration and tooth • Knowledge of dental anatomy
can withstand the load of mastication. • Patient factors
• Allow for the esthetic and functional placement of a • Conservation of tooth structure
restorative material. • Minimal extension
Teeth needs restoration for variety of reasons as follows: • Supragingival margins
• To restore the integrity of the tooth surface. • Rounded internal line angles.
• To restore the function of the tooth.
• To restore the appearance of the tooth.
• To remove the diseased tissue from the tooth.
Conservation of Tooth Structure
In the past, most tooth preparations were very precise While one of the primary objective of tooth preparation is
procedures, usually resulting in uniform depths, particular to repair the damage caused by caries, its important to
wall forms, and specific marginal configurations. Such preserve the vitality of pulp.
Fundamentals in Tooth Preparation 131
132 Essentials of Operative Dentistry

While restoring the tooth, the tooth must be prepared as Noncarious Terminologies
minimally as possible, which has advantage of:
• Better retention of restorative material Abrasion
• Better esthetics Is abnormal loss of tooth structure due to contact with
• Stronger unprepared tooth surface. tooth and external objects can also be due to contact with
Features inclusive of this concept are: an abrasive medium. Abrasion occurs due to (Figure 7-1):
• Minimal extension of cavity walls • Habits like holding pipe
• Supragingival margins • Tobacco chewing
• Rounded internal line angles. • Vigorous brushing

Restorative Material Factors

Choice of restorative material affects the design of tooth
preparation.
For amalgam restoration, tooth preparation includes:
• Retention form to retain amalgam
• Strength of amalgam in terms of material thickness and
marginal strength.
An indirect restoration requires:
• Form to include draw or draft of seating the resto-
ration Figure 7-1: Abrasion
• Beveled preparation for better fit.
• Retention by virtue of parallelism in walls and angles. Attrition
• Is abnormal loss of occlusal and incisal tooth structure
due to movements of mandible in parafunctional habits
Extension for Prevention (like bruxism).
• GV Black noted that cavity margins for smooth caries • Proximal tooth loss can also occur due to physiological
be extended to self cleansing areas to prevent recurrence tooth movement (Figure 7-2).
of caries.
• This procedure has been virtually eliminated with view
of preventive measures such as fluorides, improved oral
hygiene, proper diet. This has led to conservative
philosophy in cavity preparation.

Enameloplasty
• Is grinding away a shallow, enamel developmental
fissure/pit to create a smooth, saucer shaped surface
which is self cleansing as well as an area that enhances
proper finishing of a restoration whose margins
Figure 7-2: Attrition
crosses it.
• Prophylactic odontotomy. Erosion
• Is minimally cutting open and filling with amalgam • Wear or loss of tooth structure due to chemico-
in developmental, structural imperfections of enamel mechanical factors.
to prevent caries originating. It is no longer recom- • For example, in bulimia, habitual ingestion of citrus
mended. foods (Figure 7-3).
 Fundamentals in Tooth Preparation 133

Figure 7-3: Erosion Figure 7-5: Dentinogenesis imperfecta

Abfraction knowledge of all terms of tooth description as presented

A wedge shaped defect on cervical aspect of tooth due to in dental anatomy, including the names and positions of
eccentric occlusal contacts results in microfracture or tooth surfaces.
abfraction.
Simple, Compound and Complex Tooth
Amelogenesis Imperfecta Preparations
In amelogenesis imperfecta, the enamel is defective either A tooth preparation is termed simple if only one tooth
in form or calcification as a result of heredity and has an surface is involved compound if two surfaces are involved
appearance ranging from essentially normal to extremely and complex for a preparation involving three (or more)
unsightly (Figure 7-4). surfaces.

Tooth Preparation Walls

Internal wall: An internal wall is a prepared (cut) surface
that does not extend to the external tooth surface.
Axial wall: An axial wall is an internal wall parallel with
the long axis of the tooth.
Pulpal wall: A pulpal wall is an internal wall that is both
perpendicular to the long axis of the tooth and occlusal of
the pulp.
External wall: An external wall is a prepared (cut) surface
Figure 7-4: Amelogenesis imperfecta that extends to the external tooth surface, and such a wall
takes the name of the tooth surface.
Dentinogenesis Imperfecta
Floor (or Seat): A floor (or seat) is a prepared (cut) wall that
Dentinogenesis imperfecta is a hereditary condition in
is reasonably flat and perpendicular to those occlusal
which only the dentin is defective. Normal enamel is
weakly attached and lost early (Figure 7-5). forces that are directed occlusogingivally. Examples are
the pulpal and gingival wall.
Enamel wall: The enamel wall is that portion of a prepared
Tooth Preparation Terminology external wall consisting of enamel.
(Figure 7-6) Dentinal wall: The dentinal wall is that portion of a
A pre-requisite to the comprehension of terms in either prepared external wall consisting of dentin, in which
tooth preparation or classification (following section) is a mechanical retention features may be located.
134 Essentials of Operative Dentistry

Figure 7-6: Description of tooth preparation

Tooth Preparation Angles

The junction of two or more prepared (cut) surfaces is
referred to as an angle, in fact, the junction is almost always
“softened“ so as to present a slightly rounded confi-
guration (the exception being a tooth preparation for gold
foil).
Line angle
• A line angle is the junction of two planal surfaces of
different orientation along a line.
• An internal line angle is a line angle whose apex points
into the tooth (Figure 7-7).
• An external line angle is a line angle whose apex points
Figure 7-7: Line angles
away from the tooth.
 Fundamentals in Tooth Preparation 135
Dentinoenamel Junction
The dentinoenamel junction (DEJ) is the junction of the
enamel and dentin.

Cementoenamel Junction
The cementoenamel junction (CEJ) is the junction of the
enamel and cementum. It also is referred to as the cervical
line.

Enamel Margin Strength

One of the more important principles in tooth preparation
Figure 7-8: Point angles
is the concept of the strongest enamel margin. This margin
has two significant features:
• It is formed by full-length enamel rods whose inner ends
are on sound dentin.
• These enamel rods are buttressed on the preparation
side by progressively shorter rods.
Because enamel rods usually are perpendicular to the
enamel surface, the strongest enamel margin results in a
cavosurface angle greater than 90°.

Intracoronal and Extracoronal Tooth

Preparations (Figures 7-10 and 7-11)
An intracoronal tooth preparation is usually “box-like,“
having both internal and external preparation walls. With
a conservative tooth preparation for treatment of a small
lesion, much of the tooth crown, as well as crown surface,
is not involved. Nevertheless, the remaining tooth usually
is weakened, and the restoration may or may not restore
Figure 7-9: Line angles, point angles and cavosurface the tooth strength.
margins in cavity preparations The extracoronal preparation is usually “stumplike,”
having walls or surfaces that result from removal of most
Point angle to all of the enamel. The extracoronal restoration, termed a
A point angle is the junction of three planal surfaces of
different orientation (Figure 7-8).
Cavosurface Angle and Cavosurface Margin
• The cavosurface angle is the angle of tooth structure
formed by the junction of a prepared (cut) wall and the
external surface of the tooth. The actual junction is
referred to as the cavosurface margin. The cavosurface
angle may differ with the location on the tooth, the
direction of the enamel rods on the prepared wall, or
the type of restorative material to be used (Figure 7-9).
• When discussing or writing a term denoting a
combination of two or more surfaces, the al ending of
the prefix word is changed to an o. Thus the angle
formed by the lingual and incisal surfaces of an anterior
tooth would be termed the linguoincisal line angle. Figure 7-10: Extracoronal restoration—Crown
136 Essentials of Operative Dentistry

Modified preparation designs may not have uniform

axial or pulpal depths or occlusally converging vertical
walls.
Amalgam tooth preparations only use conventional
designs, whereas composite preparations may be any of
the three designs.

Class I to VI Restoration (Figures 7-12 to 7-18)

Figure 7-11: Intracoronal
restoration—Class I Class I Restorations
• All pit and fissure caries are class I restorations.
crown, envelops the remaining tooth crown and thereby • Restoration on occlusal surfaces of molars and
usually restores some of its strength. premolars.
Most extracoronal preparations are known by cast • Restoration on occlusal two-thirds of facial and lingual
restorations. walls of molars.
Cast restorations also include intracoronal restorations • Restoration on lingual surface of maxillary incisors.
inlays and onlays. Cast restorations are restorations that
are processed by lost wax technique of casting metal. Class II Restorations
Restorations on proximal surfaces of posterior teeth.
Classification of Tooth
Preparations
• Classification of tooth preparations according to the
anatomic areas involved as well as by the associated
type of treatment was presented by Black and is desig-
nated as class I, class II, class III, class IV and class V.
• Since Black’s original classification, an additional class
has been added, class VI.
• Class I refers to pit-and-fissure lesions, whereas the
remaining classes are smooth-surface lesions.
• Classification was originally based on the observed
frequency of carious lesions on certain aspects of the tooth. Figure 7-12: Class I caries
• Historical preparation design advocated by GV Black
is denoted by conventional preparation, this preparation
design still holds good for amalgam restoration.
Altered preparation designs are known by:
• Beveled preparation.
• Modified beveled preparation.
The conventional design preparation is typical for an
amalgam restoration and includes the following charac-
teristics:
• Uniform pulpal and/or axial wall depths.
• Cavosurface margin design that results in a 90°
restoration margin.
• Primary retention form derived from occlusally
converging vertical walls.
Beveled conventional designs are characterized as
conventional preparations with beveling of some accessible
enamel margins. Figure 7-13: Class II caries
 Fundamentals in Tooth Preparation 137

Figure 7-16: Class V caries

Figure 7-14: Class III caries

Figure 7-17: Class VI caries

Figure 7-15: Class IV caries

Class III Restorations

Restorations involving proximal surfaces of anterior teeth
without involving the incisal edges.

Class IV Restorations
Restorations on proximal surfaces of anterior teeth that do
involve the incisal edges.

Class V Restorations
Restorations on gingival third of facial and lingual surfaces
of all the teeth.

Class VI Restorations
Restorations on the incisal edges and occlusal cuspal
heights of posterior teeth. Figure 7-18: Class I to V restoration
138 Essentials of Operative Dentistry

Table 7-1: Stages and steps in cavity preparation

Proper Tooth Preparation is accomplished through systematic procedures based on definite

physical and mechanical principles
Initial tooth preparation Final tooth preparation
Step 1: Outline form and intial depth Step 5: Removal of any remaining infected dentin
Step 2 Primary resistance form Step 6: Pulp protection if indicated
Step 3: Primary retention form Step 7: Secondary resistance and retention form
Step 4: Convenience form Step 8: Finishing external walls
Step 9: Cleaning, inspecting, sealing
Initial Tooth Preparation Stage: Is the extension and initial design of the walls of the preparation at a specified depth so as to
provide access to caries or defect reach sound tooth structure.
Step 1: Outline Form and Initial Depth: Establishing the outline form means
• Placing the preparation margins in the positions they will occupy in the final preparation.
• Preparing the initial depth of an 0.2-0.8 mm pulpally of the DEJ position.
Step 2: Primary Resistance Form: As the shape and placmeen tof the preparation walls that best enable the restoration and
the tooth to withstand, without fracture, masticatory forces delivered principally along the long axis of the tooth.
Step 3: Primary Retention Form: Is the shape and form of the conventional preparation that resists displacement of removal of
the restoration by tipping or lifting forces.
Step 4: Convenience Form: Is the shape or form of the preparation that provides adequate observation, accessibility, ease of
operation in preparing and restoring the tooth.
Step 5: Removal of any remaining infected Dentin: Is the elimination of any infected carious tooth structure or faulty restorative
material left in the tooth after initial tooth preparation.
Step 6: Pulp Protection: When remaining dentin thickness is minimal this step is deemed necessary.
Step 7: Secondary Retention and Resistance Forms: Are of two types: (1) Mechanical features, (2) Cavity wall conditioning
features.
Step 8: Finishing External walls: Is the further development when indicated, of a specific cavosurface design and degree of
smoothness that produces the maximum effectiveness of the restorative material being used.

Proper cavity preparation is accomplished through This sequence may be changed in extensive caries
systematic procedures based on definite physical and threatening to involve the pulpal tissue, then it is advisable
mechanical principles. to remove infected dentin in earlier procedure.

Stages and Steps in Cavity Preparation Operating Site

(Table 7-1) • Must be moisture free application of rubber dam is
mandatory.
Initial Cavity Preparation Stage • Protection adjacent soft tissues.
• Outline form and initial depth
• Primary resistance form
• Primary retention form Initial Cavity Preparation
• Convenience form
Stage
Final Cavity Preparation Stage It is the extension and initial design of the external
• Removal of any remaining infected dentin walls of the preparation at a specified limited depth so
• Pulp protection as to provide access to the cavity or defect, reach sound
• Secondary resistance and retention form tooth structure, resist fracture of the tooth or restorative
• Procedure for finishing external walls material for masticatory forces directed along the long
• Final procedure—cleaning, inspecting, varnishing, axis of the tooth and retain the restorative material in the
conditioning. tooth.
 Fundamentals in Tooth Preparation 139
Step 1: Outline Form and Initial Depth
Definition
Establishing outline form means (Figures 7-19 and 7-20)
• Placing the cavity margins in the positions they are
going to occupy in the final preparation.
• Preparing an initial depth of 0.2–0.8 mm pulpally of
the DEJ (Never deeper unless the enamel is thicker
and greater dimension is required for restorative
material strength). This outline form should be
visualized before any mechanical alteration of tooth
structure is done.

Principle
• All friable and weakened enamel should be removed.
• All faults should be included.
• All margins should be placed in a position to afford
good finishing of the margins of restorations.

Factors
Figure 7-20: Bur entry is 2/3rd bur height (2 mm) with relation
• Extent of the carious lesion, defect or faulty old
to facial and lingual walls and half the bur height in central
restorations fissure aspect (1.5 mm)
• Esthetic considerations
• Occlusal relationship Features
• Adjacent tooth contour
Features of establishing proper outline form and initial
• Cavosurface marginal configuration
depth.
• Preserving cuspal strength.
• Preserving marginal ridge strength.
• Minimizing faciolingual extensions.
• Using enameloplasty.
• Connecting two close less than 0.5 mm apart faults or
cavity preparations.
• Restricting the depth of the preparation into dentin to a
maximum of 0.2 mm for pit and fissure caries and
0.2-0.8 mm for the axial wall of smooth surface caries.

Outline Form and Initial Depth for Pit and

Fissure Cavities
Controlled by three factors:
• Extent to which enamel has been involved by caries.
• Extensions that should be made to achieve sound and
smooth margins
• Limited bur depth while extending the preparation
Rules to follow in establishing outline form for pit and
fissure cavities:
• Extend the cavity margin until sound tooth structure is
Figure 7-19: Initial entry into lesion is of 0.2 mm into dentin reached and no unsupported enamel margin remains.
in occlusal aspect and 0.75-0.8 mm in the cervical aspect Avoid terminating on cuspal eminence. Capping of cusp
140 Essentials of Operative Dentistry

should be done extension from primary groove is two

thirds towards cuspal incline (Figure 7-21).
• Extend the cavity margin to include all fissure that
cannot be eliminated by enameloplasty.
• Restrict the depth of preparation to maximum of
0.2 mm into dentin for amalgam and 0.5 mm into dentin
for gold restorations. The depth of a conservative
preparation should be 1.5 mm from the central fissure
and 2 mm from facial and lingual walls (Figures 7-22
to 7-24).
If the amount of pit and fissure at this depth is less
Figure 7-24: Beyond ideal depth and
than 50% on pulpal floor its removed during final stage near pulpal exposure
of cavity preparation. If its greater than 50% the entire
pulpal floor is deepened.
Typically outline form varies from tooth-to-tooth.
• When two pit and fissure has less than 0.5 mm sound
When connecting pits and fissures on occlusal surfaces
enamel between them its removed.
of the tooth margins do not assume a straight line but in
• Extend the outline form for convenience form.
smooth curves to preserve as much of cuspal incline as
possible for strength of tooth structure (Figure 7-25).

Outline Form and Initial Depth for

Smooth Surface Cavities
It can occur in:
• Proximal surfaces.
• Gingival portion of facial and lingual surfaces.
Figure 7-21: Cusp capping should be done when cavity Proximal surfaces (Cl-II, III and IV): Proximal surface
extension is two-third from central fissure to cuspal eminence
presents another controlling factor namely contact area in
relation to the adjacent tooth.
Rules for establishing outline from in smooth surface
caries:
• Extend the cavity margin until sound tooth structure is
reached and no unsupported enamel margin remains.
Avoid terminating on cuspal eminence. Capping of cusp
should be done extension from primary groove is two-
thirds towards cuspal incline.
• Extend the cavity margin for sufficient access for proper
manipulative procedures.
Figure 7-22: Ideal depth • Restrict the depth of preparation to maximum of
0.2-0.8 mm into dentin.
• Extend the gingival margin of cavities apically of the
contact to provide a clearance of 0.5 mm between the
gingival margin and adjacent tooth structure.
• Extend the facial and lingual margins in proximal cavity
preparations into the respective embrasures to provide
specific clearance between the margins and adjacent
tooth. This is done so that the margins can be better
visualized, instrumented and cleaned.
In class II preparations the occlusal outline is governed
Figure 7-23: Pulpal exposure by factors determining the pit and fissure caries.
 Fundamentals in Tooth Preparation 141

Figure 7-25: Various Cl-I restorations

Outline form of Cl-V preparation is mainly governed by Enameloplasty does not extend the outline form as no
extent of caries except pulpally. Pulpally the depth should restorative material is placed in this preparation.
be no more than 0.8-1.25 mm from original tooth surface, This procedure is advocated if 1/3rd or less of enamel
i.e. it will be 0.5 mm into dentin (Figures 7-26A to Q). is involved in faulty process.
Restricted extensions in smooth surface caries are
prepared when: Step 2: Primary Resistance Form
• Proximal contours and root proximity It may be defined as that shape and placement of the cavity
• Esthetic requirements. walls that best enable both the restoration and the tooth to
• Use of modified cavity preparation for composite withstand without fracture, masticatory forces delivered
restorations principally in the long axis of the tooth.

Increased extension
Principles
• Mental and physical handicaps
• Advanced age of the patient • Utilize box shaped preparation with a relatively flat
• Restoration of tooth as partial denture abutment floor (Figure 7-27).
• Need for additional measures for retention and • Restrict the extension of the external walls to allow
resistance form strong cusps and ridges to remain.
• Need to adjust tooth contours. • Slight roundening of internal line angles to reduce the
stress on tooth structure, roundening external line
Enameloplasty angles reduces stress on the restoration.
A fissured enamel is rounded or saucered the area becomes • Cap weak cusps and envelope or include enough of a
clensable and allows conservative placement of cavity weakened tooth within the restoration. To prevent or
margins. resist fracture of the tooth by forces both in long axis
142 Essentials of Operative Dentistry

Figures 7-26A to Q: Various Cl-II and Cl-V restorations

 Fundamentals in Tooth Preparation 143

Figure 7-27: Flat pulpal floor

and oblique forces attained in later cavity preparation

stage.
• Enough thickness of restorative material to prevent its
fracture under load.
Amalgam—1.5 mm, cast metal—1-2 mm, porcelain—
2 mm.
In pulpless teeth special consideration is given
to the brittle nature of the remaining tooth.

Factors
• Occlusal contact and amount force the restoration and Figure 7-28: Minimal exposure of
tooth will be subjected to. restoration to occlusal stresses
• Amount of tooth structure remaining.
• Type of restorative material to be utilized. Stresses on Tooth Structure
Anterior tooth
Features Compressive stresses: Incisal edges of lower anterior
Design features enhancing the resistance form are: lingual surface of anterior.
• Relatively flat floor. Shear stresses: Jjunction between root and crown axial
• Box shape, with definite walls, floors and surfaces to angles.
prevent micromovement of restorations.
Combined stresses: Slopes of cuspid.
• Inclusion of weakened tooth structure.
• Preservation of cusps and marginal ridges. Posterior teeth
• Designing the outline form so that minimal of resto-
Functional side
ration is exposed to occlusal stresses (Figure 7-28).
Compressive stresses: Cusp tip marginal ridges and
• Comparison of the restorative material strength and
crossing ridges axial angles, junction between root and
tooth be evaluated to see whether restorative material
crown
can support the tooth structure.
• Rounded internal line angles. Tensile stresses: Marginal and crossing ridges.
• Adequate thickness of restorative materials.
Shear stresses: Axial angles, junction between root and
• Seats on sound dentin.
crown.
• Reduction of cusps when indicated. Must be done as
early as possible to aid in visualization and accessibility. Nonfunctional side
For composite restorations the walls should be left Tensile stresses: Junction between root and crown axial
roughened to enhance bonding resulting in increased angles.
resistance and retention form. Shear stresses: Axial angles.
144 Essentials of Operative Dentistry

Weak Areas of Tooth • Often features that enhance the retention form also will
• Bifurcation and trifurcation. enhance resistance form.
• Cementum. • Sometimes additional features that enhance retention
• Thin dentin bridges. form are given during later stages of cavity preparation.
• Rootcanal treated tooth floors.
Principles
Stress mentioned here is only on unrestored tooth, restored tooth
has different stress patterns. • Retention form varies with different restorative material.
• For amalgam restorations the retention form is mostly
Vale Experiment given by external walls converging occlusally (Figures
7-29A and B).
Experiment involved preparation of occlusoproximal
• The convergence should not be done to extent of
cavities with different crossing dimensions at the marginal
undermining enamel.
and crossing ridges with a standard depth. The teeth were
• Convergence of proximal portion of Cl-II preparation
then subjected to differing loads.
aids in preserving the marginal ridge of tooth and helps
in resistance form.
Marginal Ridge • For Cl-III and IV preparation the external walls diverge
• By crossing one marginal ridge at 1/4th intercuspal outwards therefore retention coves are given to retain
distance, there is 10% loss of tooth’s resistance to amalgam.
splitting. • Adhesive system aids in micromechanical bonding of
• By crossing two marginal ridge at 1/4th intercuspal amalgam.
distance, there is 15% loss of tooth’s resistance to • Composite restorations are retained by adhesive
splitting. systems but still some composite preparations require
• By crossing one marginal ridge at 1/3rd intercuspal additional retention features.
distance, there is 30% loss of tooth’s resistance to • Enamel beveling is required in composite restorations
splitting. to aid in enamel etching to be done readily.
• By crossing two marginal ridge at 1/3rd intercuspal
distance, there is 35% loss of tooth’s resistance to
splitting.
• By crossing one marginal ridge at 1/2th intercuspal
distance, there is 40% loss of tooth’s resistance to
splitting.
• By crossing two marginal ridge at 1/2th intercuspal
distance, there is 45% loss of tooth’s resistance to
splitting.
Figures 7-29A and B: (A) Converging walls for retention in
amalgam restoration, (B) Occlusally divergent walls for inlay
Crossing Ridge restoration
• By crossing a crossing ridge at 1/4th intercuspal
distance, there is 20% loss of tooth’s resistance to splitting. For cast gold intracoronal restorations, the retention
• By crossing a crossing ridge at 1/3rd intercuspal form is given by almost parallel vertical walls.
distance, there is 35% loss of tooth’s resistance to splitting. For cast restorations, a slight degree of divergence of
• By crossing a crossing ridge at 1/2nd intercuspal 2-5° is given for draw or draft of the pattern. Longer the
distance, there is 45% loss of tooth’s resistance to splitting. wall greater the degree of divergence can be.
Close parallelism and luting agents retaining in micro-
Step 3: Primary Retention Form irregularities are two ways of retention form in cast
restorations.
Definition In Cl-II preparation involving only one proximal surface
• Primary retention form is that shape or form of the a dove tail form is given in occlusal region opposite side
conventional preparation that resists displacement or to proximal box, to prevent tipping of restoration (Figure
removal of the restoration from tipping or lifting forces. 7-30).
 Fundamentals in Tooth Preparation 145
Step 5: Removal of any Remaining
Infected Dentin
Removal of any remaining enamel pit/fissure and infected
dentin and old restorative material is indicated when:
• This step is usually not done in preclinical exercises as
tooth preparation is being done on virgin teeth.
• In teeth with minimal carious lesion the carious material
is removed in initial cavity preparation itself.
• If however carious infected dentin remains after initial
cavity preparation its removed at this stage.

Definition
Removal of any remaining enamel pit/fissure and infected
dentin and old restorative material is the elimination of
any infected carious tooth structure or faulty restorative
material left in the tooth after initial cavity preparation.
Figure 7-30: Dove tail preparation
Exception is during indirect pulp capping procedure
in caries control procedure.
In gold foil restorations the elastic compression It is accepted practice to allow affected dentin to remain
developed as a result of condensation of gold aids in in prepared tooth.
retention. It is not acceptable to leave caries at dentinoenamel
Additional secondary retention form are given in later junction (Figure 7-31).
stages of cavity preparations although with advent of Any old remaining restorative material be removed, if:
bonding agents these procedures have been simplified a • Old material negatively affect the esthetics of new
great deal. restorations.
• Old material may affect the retention of new restoration.
Step 4: Convenience Form • Evidence of caries under old restorations.
• Is that shape or form of the cavity that provides for • Tooth is symptomatic preoperatively.
adequate observation, accessibility, and ease of • Periphery of old restorative material is not intact.
operation in preparing and restoring the cavity. If after initial cavity preparation caries remains only
• Ideally tooth preparation fulfilling all the requirements that small amount of caries be removed leaving adjacent
of outline form, retention and resistance forms will have areas intact.
adequate convenience form.
• Most effective way of obtaining convenience form is by
controlling field of operation.
• In gold foil restoration in addition to above mentioned
factors it includes starting of foil condensation. These
are prepared by deepening or making more acute, one
or more point angles of preparation.
• Occlusal divergence of vertical walls of cavity pre-
parations for class II cast restorations is also considered
as convenience form.
• Extending the proximal portion of cavity form beyond
contacts is also another form of convenience form.
• Instrument modifications like contrangling allows for
better accessibility.
• Separation of teeth also aids in accessibility for
interproximal preparations. Figure 7-31: Nonacceptable residual caries in DEJ
146 Essentials of Operative Dentistry

In large cavities with extensive caries lesion removal of • Ideally, there should be at least three seats tripodally
infected dentin may be accomplished early in the initial disturbuted for the amalgam on sound dentin at the
cavity preparation. prescribed level of the pulpal wall in initial cavity
Another indication is when patient has extensive preparation. This will allow restoration and tooth
numerous caries lesion initial removal of caries is done structure rather than bases or liner to bear occlusal load
followed by temporarization. (Figures 7-32A to D).
Large areas of soft caries is best removed with spoon
excavator. Pulp Protection or Lining Materials
For harder discolored caries its best achieved by small
Can be divided into:
round carbide bur with adequate coolant and slow speed
• Therapeutic lining
to prevent pulpal damage.
• Structural lining.
Removal of older restorations is also done with round
Therapeutic lining is used for its medicinal properties.
carbide burs at slow speed and high volume suction.
While structural lining in addition to its medicinal
To be sure of removal of decay disclosing solutions such
properties is also used for its physical properties.
as 0.2-0.5% basic fuchsin which will stain irreparable
decayed dentin indicating the necessity for removal.
Ideal Requirements of a Base Material
Step 6: Pulp Protection • Material should create an impervious layer of cut
dentin.
• It is a step in adapting the preparation for receiving the
• Material should be biocompatible.
final restorative material.
• Material should be chemically compatible with
• Reason for using liners and bases is to either protect the
restorative material to be used.
pulp or to aid pulpal recovery or both.
• Material should not discolor the tooth.
Pulpal irritants are:
• Material should set quickly so that restorative material
• Operative procedures.
could be placed subsequently.
• Ingredients of various restorative materials.
• Set material should be able to withstand forces of
• Thermal changes through restorative materials.
condensation.
• Forces transmitted through materials to dentin.
• Material should reduce dentin permeability.
• Galvanic shock.
• Material should be able to easily manipulated.
• Ingress of noxious products through microleakage.
• Dentin bonding agents are recognized for beneficial effect
of dentinal sealing under any type of restorative material. Cavity Varnish
• Sometimes undercuts may be given to positively retain • Is a solution liner which seals most of the dentinal
the bases. tubule and is placed on all cavity preparation walls
• Level to which the base given should never compromise for amalgam restorations and dentinal walls of direct
the desired cavity preparation depth resulting in filling gold restoration. Contraindicated in composite
inadequate restorative material thickness. restoration.

Figures 7-32A to D: Tripod effect

 Fundamentals in Tooth Preparation 147
• If caries excavation extends very close to the pulp less
than 1 mm of dentin thickness remain—calcium
hydroxide is preferred choice.
• If caries excavation is not so deep and 1-2 mm of
dentin thickness remain—zinc oxide eugenol liner is
preferred.
• If more than 2 mm of dentin thickness remain no liner is
necessary.
Both calcium hydroxide and zinc oxide eugenol cement
provide adequate strength to support forces of amalgam
condensation in thickness of 0.5 mm usual thickness of
liner is 0.2-1 mm.
Figure 7-33: Cavity varnish In cases of deep excavation a liner or sub-base is
overlayed by stronger base like zinc phosphate cement.
Application
Zinc oxide eugenol:
• Dry the cavity.
• Dispense a drop of eugenol and two scoops of zinc
oxide powder on glass slab.
• Incorporate half of the powder to liquid and mix it until
a homogeneous mix is attained.
• Add small increments of powder into the mix until
desired consistency is obtained (Figure 7-35).
Figure 7-34: Structural lining • Carry a small piece of mix to the cavity with a plastic
filling instrument.
• Compact the mix in cavity with cotton soaked in zinc
• Varnish will be the only material required for a shallow
oxide powder.
cavity preparation (Figures 7-33 and 7-34).
• Allow it to dry for 5 minutes.
Application • Remove the excess from walls of cavity using spoon
• Dry the cavity with short blasts of air and with dry excavator or explorer soaked in alcohol or water.
cotton pellets. • To accelerate setting water can be placed on mix in
• Hold small cotton piece in tweezer and soak it in varnish cotton.
solution.
• Carry it to the cavity, place it one corner and squeeze
the varnish out without moving the cotton.
• Soak the cotton again and place it on another end of
cavity and squeeze it.
• Usually three applications of this nature will be
required to form a continous film over the cavity floor.
• Let it dry for 2-3 min before inserting amalgam.
• To remove varnish film from the cavity walls use sharp
chisels or resin solvents.

Liner
• Term liner is reserved for those agents which can be
applied in thin film especially calcium hydroxide and
zinc oxide eugenol cements.
• Recently glass ionomer cements also included in this Figure 7-35: Mixing zinc oxide eugenol cement consistency
category. should be putty like for base application
148 Essentials of Operative Dentistry

Calcium Hydroxide • When placed in cavity preparation with effective dentin

• In instances of deep excavations with danger of pulp depth of less than 2 mm a sub-base or liner should
exposure or frank pulpal exposure this cement is applied before placing this cement.
utilized. Application
• Calcium hydroxide in these instances is applied in ‘non- • Dry the cavity.
pressure flow technique’. Here it is to be remembered • Dispense a large measure of powder followed by small
that cement must not be forced into the exposures. measure, then dispense one drop of liquid.
• It is recommended a 1 mm thickness of calcium hydro- • Divide the powder into 6-8 parts.
xide be present over which a base material be applied. • Incorporate the first part in liquid, mix it in over large
Application area of glass spatula until it is completely dissolved in
• Dry the cavity. liquid (Figure 7-37).
• Squeeze equal parts of base paste and catalyst paste • Repeat with second part and so on until there is a thick
onto a paper pad. Incorporate each paste into each other enough consistency to be handled with fingers.
mixing with a spatula for a homogeneous mix. • Soak fingers in alcohol and take a piece of mix, roll into
• Take a bead from the mix using a calcium hydroxide a small ball. Carry the cement ball into this cavity with
applicator or periodontal probe and flow into cavity or a plastic instrument wet in alcohol or cement powder,
area of eminent exposure. Allow it to dry for 1-3 minutes. adapt it over the floor of cavity, allow it to set for 5
• If calcium hydroxide is in powder form and mixed with minutes.
distilled water to create paste of thick consistency in • Remove the excess using a sharp explorer or excavator.
paper pad, it is carried with applicator or probe and
placed in cavity (Figure 7-36).

Figure 7-37: Mixing of zinc phosphate cement, here whole

of glass slab is utilized for mixing to dissipate heat

Zinc Polycarboxylate Cement

Figure 7-36: Calcium hydroxide cement mixing • It can be used a base material with or without sub-
bases.
Base • No varnish application is necessary beneath this
• In cavity preparations of castings with deep excavations cement as it can hinder the adhesive property of this
a base material of stronger cement like zinc phosphate, cement.
zinc polycarboxylate or glass ionomer cement can be Application
utilized. • Dry the cavity.
• Such base material should be positively retained by • Dispense one measure of powder and one drop of liquid
undercuts in cavity preparations. on a pad surface.
• Usual thickness of base is 1-2 mm thickness of base • Incorporate half of the powder into the liquid mix it in a
should never compromise on desired thickness of folded motion then followed by addition of small
restoration. increments powder until desired thickness is obtained
(Figure 7-38).
Zinc Phosphate Cement • Take the mix using a plastic filling instrument which is
• Application of this cement is always preceded by dusted with powder, apply onto cavity excavation area
application varnish to cut dentin because of acidic and shape the cement.
nature of this cement. • Remove excess using sharp explorer or excavator.
 Fundamentals in Tooth Preparation 149
• With newer generation bonding agents being
introduced and newer information are gathered these
traditional bases and liners are becoming obsolete, as
these bonding agents are being widely used in areas
where traditional cements have been used.

Step 7: Secondary Resistance and

Figure 7-38: Mixing of polycarboxylate cement, cement should Retention Forms
be applied onto tooth before the mix loses its glossiness • Most compound and complex cavity preparation
require these features. Unless it is a conservative cavity
Glass Ionomer Cement form.
• It has same indications as polycarboxylate cement, in • When tooth preparation involves both proximal and
addition it could be placed under composite restorations occlusal portion both should have independent
(Class II) as ‘sandwich restorations’ retention and resistance features.
• Since there are several modifications of glass ionomer • Since many features that improve retention improves
cement a conventional glass ionomer application is resistance features and vice versa both are presented
explained here. together.
Two categories:
Application • Mechanical features
• Dry the cavity. • Cavity wall conditioning.
• Condition the cavity with 10% polyacrylic acid before
application of the cement to tooth preparation.
Mechanical Features
• Mixing procedure is same as polycarboxylate cement
done on a paper pad as it doesn’t absorb the liquid and These features require removal of additional tooth structure.
mixed with plastic spatula as glass particles in powder Retention locks, grooves and coves (Figures 7-39 to 7-44)
can abrade the stainless steel spatula leading to • Locks and grooves are longitudinally orientated
discoloration of cement. features. Locks are for amalgam restorations and
• The cement mix should be applied before the glossiness grooves are for cast restorations.
in cement is lost, as it indicate free carboxylic groups • Transversely oriented retention grooves are prepared
which aid in bonding to tooth surface. in Cl-III and V cavities.
• Here the plastic filling instrument is wet with liquid to • Retention coves are appropriately placed undercuts for
prevent adhering of cement mix onto the instrument. the incisal retention of class III amalgams, class V
• All the cement liners and bases are not to be applied on amalgams and start of insertion of gold foil restorations.
margins or walls exposed to oral environment because
Groove extensions
of solubility factor, except for glass ionomer cement in
Extending cavity preparation for molars onto the facial
Cl-II sandwich restoration.
and lingual surface to include the grooves especially in
• Cement bases or liners are to be applied prior to matrix
cast metal restorations for retention this feature also
band adaptation in Cl-II restoration.
enhances resistance.

Figures 7-39A and B: (A) Retentive locks and (B) Retentive grooves, FPG—Facial proximal groove,
LPG—Lingual proximal groove
150 Essentials of Operative Dentistry

Figure 7-40: Transverse oriented retention locks

Figure 7-41: Groove extensions

Figure 7-44: Amalgam pins

Figures 7-42A to D: Skirts

• Primarily used for better junctional relationship

between metal and tooth.
• In composite restorations its done to increase the
surface area for etching and bonding.
Pins, slots, steps and amalgapins
These are used when there is large need for additional
retention for amalgam.

Cavity Wall Conditioning

This includes the acid etching followed by dentin bonding
agent application.

Figure 7-43: Amalgam slots

Step 8: Procedures for Finishing External
Skirts Walls of the Cavity Preparation
Used in cast gold restorations to extend the preparation • It entails both degree of smoothness and cavosurface
around some if not all transitional longitudinal angles of design.
the tooth. • Most conservative composite restorations and amalgam
Beveled enamel margins restorations do not require any special external wall
• Both cast gold, metal and composite restorations make design features.
use of this feature. • Most external walls will be in the enamel.
 Fundamentals in Tooth Preparation 151
Definition
Finishing of the cavity walls is the further development,
when indicated, of a specific cavosurface design and
degree of smoothness that produces the maximum
effectiveness of the restorative material being used.

Objectives
• Create best marginal seal possible.
• Afford smooth marginal junction.
• Provide maximum strength both to tooth and restorative
material.

Factors to be Cosidered
Figure 7-46: All external walls should have
• Direction of enamel rods. full length enamel rods with dentin support
• Support of enamel rods.
• Type of restorative material to be employed.
• Location of margin.
• Degree of smoothness desired.
An acute abrupt change in an enamel wall outline form
results in fracture potential, even though enamel may have
dentin support. This necessitates cavity outline be smooth
curves (Figure 7-45).

Figure 7-47: Chipping of unsupported

enamel wall

Figure 7-45: Junctions of walls whether it is acute or • Beveling of enamel margins is employed for intra-
obtuse should be smooth coronal gold metal cast restorations and composite
restorations.
Noy’s Structural Requirements
• Enamel wall must rest upon sound dentin. Beveling serves four purposes (Figures 7-48 to 7-51)
• Enamel rods which form the cavosurface angle must • Produces stronger enamel margins.
have their inner ends resting on sound dentin (Figures • Permits marginal seal.
7-46 and 7-47). • Provides marginal metal that is more easily burni-
• Rods which form the cavosurface angle must be shable.
supported or be resting on sound dentin and their outer • Adaptation of gingival margins of castings that fail to
ends be covered with restorative material. seat.
• Cavosurface angle must be so trimmed or beveled that • Beveling of enamel margins should result in
the margins will not be exposed to injury in condensing marginal gold alloy of 30-40°.
the restorative material. • Beveling is contraindicated in amalgams except in
gingival floor of a class II preparation. A minimal
Features bevel of 15-20° is given this is done to remove
unsupported enamel rods.
1. Design of cavosurface angle
• Tooth-colored materials like silicate cements and
• Is dependent on restorative material being used.
porcelain also contraindicate the use of bevels.
• Because of low edge strength of amalgam a cavosurface
angle of 90° produces maximum strength both for Bevels are indicated for composite restorations because of:
amalgam and tooth. • Advantages of acid etching.
152 Essentials of Operative Dentistry

Figure 7-49: Inlay bevel

Figure 7-48: Bevel preparation

Figures 7-50A to D: Inlay bevel

• With direct filling gold, amalgam, composite a smoother

finish is not a requisite.

Step 9: Final Procedures: Cleaning, Inspecting,

Varnishing and Conditioning
• Removing all the chips and loose debris, drying of cavity
without desiccating, to make complete inspection for
any remaining infected dentin, unsupported enamel
Figure 7-51: Amalgam bevel margins or any other unfavorable conditions existing.
• Usual procedure is cleaning of cavity walls with warm
• Minor defects are included in preparation and better water, followed slow air drying if necessary cotton
esthetic results obtained. pellets or explorers can be utilized.
2. Degree of smoothness
• With advent of high speed instruments, tactile sensa- Sterilization of Cavity Walls
tions are lost and rapid loss of tooth structure results. • Basic as early as 1943 contended that caries in dentin
• Plain cut fissure burs produces smoothest surface. stops or gradually ceases as soon as the carious lesion
• Proximal margins with minimal extensions for esthetic is closed to the oral environment.
purposes can be finished with hand cutting instru- • In many instances presence of reparative dentin acts as
ments. a deterrent bacterial progress.
• For cast restorations like inlay and onlay a smooth wall • Routine use of a sterilizing medicaments is no longer a
is desired. consideration.
 Fundamentals in Tooth Preparation 153
Summary • Pulp injury due to inherent irritation potential of
restorative material can also occur, in this regard the
Increasing bond strengths of bonding agents has most critical factor is the remaining dentin thickness.
significantly altered the cavity preparation procedure. The For most materials 2 mm of remaining dentin thickness
factors to be considered here will be (Table 7-2): affords adequate protection.
• Complete removal of infected dentin and friable enamel. • Protective bases can be inserted in all deep cavity lesions.
• Appropriate conditioning of enamel and dentin.
• Proper manipulation of restorative material. Irritating Agents of Tooth Preparation
• Contour restoration to proper form and function. • Actual cutting of dentin in every square mm contains
Emphasis will shift away from cavity preparation to 30,000-45,000 tubules can irritate millions of odonto-
knowledge of restorative material and dental anatomy. blasts.
• Pressure of instrumentation can destroy the odonto-
Table 7-2: Factors to be considered before cavity blasts. Also this pressure may drive microorganisms
preparation into the cavity.
• Sharp hand cutting instruments are biologically most
Extent of caries Extent of defect
Occlusion Pulpal protection acceptable cutting instruments.
Pulpal involvement Contours • Depth of cavity is the most detrimental irritating factor
Esthetics Economics to the pulp. Most important is the thickness of the dentin
Patinet’s age Patient’s risk status bridge between the floor of the cavity and roof of the
Patient’s homecare Bur design
pulp chamber called the effective depth. Less the
Gingival status Radiographic
Anesthesia assessment effective depth more destructive reaction in pulp.
Bone support Other treatment factors • Heat production is the second most detrimental factor.
Patient’s desires Patient cooperation If pulp temperature is raised by 11 F destructive
Material limitations Fracture lines reactions occurs in pulp-dentin organ. Heat production
Operator skill Tooth anatomy depends upon:
Enamel rod direction Ability to isolate area
Extent of old restorative material
• RPM
• Pressure
• Surface area of contact
Biological Form • Desiccation
This includes added modification of tooth preparation • Coolants
instrumentation to ensure minimal irritation to pulp-dentin • Vibrations
organ and the investing periodontium. • Extensiveness of preparation and duration of prepara-
tion is directly proportional to the extensiveness of
reaction of the pulp-dentin organ.
Pulpal Consideration
Pulp-dentin organ irritation is not due to single factor,
Clinical Considerations it is a cumulative effect, which starts from decay process,
• Do no harm is basic principle. then cavity preparation, instrumentation, restorative
• Iatrogenic pulp injury can occur during preparation materials. So during tooth preparation these factors must
and restoration of tooth due to: be kept in mind to do as little harm as possible.
• Inherent irritational potential of restorative material
Determination of the Effective Depth
used.
• Residual bacteria left behind. Following procedures can be employed:
• Bacteria gained through microleakage. • Radiograph
• Microscopic pulpal exposure. Effective depth in radiograph Actual effective depth
• Heat generation and dentin desiccation during tooth ⇔
Enamel thickness in radiograph Actual enamel thickness
preparation.
• Heat generation and desiccation can be avoided by Disadvantage: It is a two dimensional picture only.
water coolant in high speed handpieces. • Correlating the actual depth of the lesion with tooth
• Pressure exerted during condensation of amalgam, gold structure. This requires comprehension of tooth anatomy
can also cause pulp injury. and extensive clinical experience.
154 Essentials of Operative Dentistry

• Sonic probes are available to detect the dentin depth.

• By correlating dentinal items recognizable on the
radiographs like dead tracts, sclerotic dentin and
estimate thickness of dentin.

Biologic Basis of the Periodontium as

Related to Operative Procedures
Clinical Considerations
• Whenever possible margins of the restorations be placed
Figure 7-53: Intruding into biologic width leads to
coronal to the gingival margins.
inflammation and bone resorption
• Placement of subgingival margins especially, in silicate
and resins be avoided.
• Glazed porcelain and well-polished cast alloys are well-
A restoration will be of little use if pulpal and perio-
tolerated by gingiva comparatively.
dontal integrity is lost and not maintained (Figure 7-53).
• Avoid overhangs in proximal restorations.
• Avoid overcontouring and undercontouring of
restorations. Key Terms
• Proper occlusion is necessary without any interferences.
• Tooth preparation • Enameloplasty
Irritating Factors to Periodontium • Prophylactic odontotomy • Walls of tooth preparation
• Line angles • Point angles
• Mechanical trauma be it cutting, contusion, crushing
• Outline form • Capping of cusp
of periodontium can result from any type on instru-
• Retention form • Resistance form
mentation.
• Vale experiment • Convenience form
• Excessive pressure applied during instrumentation
• Residual caries • Affected dentin
especially if not applied parallel to long axis of the tooth.
• Tripod effect • Infected dentin
• Vibrations to tooth can tear periodontium.
• Secondary retention • Noy’s structural
• Thermal injury from rotary instrumentation can cause
features requirement
burns, ulceration in adjacent periodontium. • Bevels • Remaining dentin
• Effective depth thickness
Biologic Width (Figure 7-52) • Biologic width
It is the combined width of epithelial attachment and
connective tissue attachment. It is of 2 mm in width.
Restorations should not impinge on this width especially Questions to Think About
in proximal restorations and cast restorations, if this is
1. Classify cavity preparation according to GV Black
violated, it can lead to periodontal inflammation. classification and mention about fundamental steps in
cavity preparation.
2. Define tooth preparation, its need, objective and factors
affecting tooth preparation.
3. Define outline form and rules to be followed for
amalgam restoration of pit and fissure caries and
smooth surface caries.
4. Define resistance form. Explain features in resistance
form for amalgam restoration.
5. Define retention form. Explain about retention form in
amalgam restoration.
6. Explain about step in finishing of enamel wall. Give a
Figure 7-52: Biologic width—combined width of epithelial
attachment and connective tissue attachment—2 mm description about bevels in cavity preparation.
 Instruments and Equipment

8 Used for Diagnosis,

Tooth Preparation and
Restoration

Hand Cutting Instruments Hardening and Tempering Heat

Treatments
• These were mainly employed in early days of dentistry
• Hardening heat treatment is done to improve the
(Figure 8-1).
hardness of the material
• Nowadays powered cutting instruments has obligated
• Tempering heat treatment is done to improve the
the need for hand cutting instruments except in certain
toughness of material.
situations.
• Any improper heating of heat sterilization during
• GV Black has been credited with nomenclature and
dental use can alter the properties of the instruments.
classification of hand cutting instruments.

Effects of Sterilization
• Carbon steel can corrode if sterilized by moist heat,
therefore electroplating of instruments or use of rust
inhibitors like alkaline solutions.
• High heat can reduce the sharpness of the instruments.
• Stainless steel does not corrode.

Hand Instruments
• Used for exploration—examination instruments.
• Used for removal of tooth structure—hand cutting
instruments.
• Used for restoration of tooth structure—restorative
Figure 8-1: Olden days
instruments.
hand instruments
• Accessory instruments.

Materials Can also be classified as:

• Carbon steel and stainless steel are mainly employed. • Cutting instruments, e.g. excavators, chisels, others.
Carbon steel is much harder than stainless steel, but • Noncutting instruments, e.g. mirrors, explorers,
corrode easily. condensers etc.
• Carbide inserts are employed for cutting edges for more
durable cutting edges. Instrument Design
• Other alloys of nickel, cobalt, chromium are employed • Most hand instruments are composed of handle, shank,
but are restricted mainly to noncutting instruments. blade, cutting edge (Figures 8-2A to C).
156 Essentials of Operative Dentistry

Figures 8-2A to C: Parts of hand instrument

• For noncutting instruments blade is termed as nib.

• End of the nib or working surface is termed as face of
instruments.
• Some instruments are double bladed instruments.
• Handle of early instruments were large.
• Today’s instruments handles are knurled, eight sided,
tapered. Small diameter to facilitate control.
• Shank connects the handle to the blade of the instru- Figures 8-3A to C: Hand instruments must be balanced
ment, usually shank has one or more bend to prevent
twisting of instrument in hand. • Balance is accomplished by angling the shank so that
• Cutting edge is usually in the form of a bevel with the cutting edge of the blade lies within the projected
different shapes. diameter of the handle and coinciding with the diameter
• Hand instrument must be balanced to allow concen- of the handle.
tration of force onto the blade without causing rotation • For optimal antirotation blade edge must not be off axis
of the instrument in grasp (Figures 8-3A to C). by more than 1-2 mm.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 157

Figure 8-4: Mouth mirrors: A—No. 5 (5/8 inch diameter), B—No. 4 (7/8 inch diameter),
C—No. 5 (15/16 inch diameter)

Figure 8-5: Types of explorers

• This is called as contrangling. Explorers

• In addition to balancing contrangling also aids in These are pointed instruments used to feel for the surface
visualization and better access. irregularities, roughness, hardness of exposed dentin.

Types (Figure 8-5)

• Shepherds hook or No. 23
Exploring Instruments • Cow horn or pigtail or 3CH
• No. 17 interproximal explorer
Mirrors (Figure 8-4) • Straight explorer
• To visualize the area • Right angled explorer.
• To illuminate the area
• To retract soft tissues Periodontal Probes
• Types—front surface mirror (to prevent reflection of • Are designed to detect and measure the depth of
light), various sizes are available (No. 2, 4, 5). periodontal pockets.
158 Essentials of Operative Dentistry

Forceps (Figure 8-7)

• Cotton forceps or cotton tweezers are used to pick-up
cotton rolls, pellets, etc. Types College (No. 17), Meriam
(No. 18).
• Hemostats—Halstead mosquito straight, Halstead
mosquito curved.
• Articulating forceps are used to carry articulating papers.

Instruments Name or Nomenclature

GV Black called all tooth cutting instruments as excavators
today the naming has slightly changed.
• Function (e.g. scaler, excavator)—Order.
• Manner of use, e.g. hand condenser—Suborder.
• Design of working end, e.g. sickle scaler, spoon
Figures 8-6A to C: Periodontal probe with different markings: excavator—Class.
(A) Michigan O probe, (B) PCP12 probe, (C) PSR probe
• Shape of the shank, e.g. mon-angle, bin-angle—Angle.
These names are combined to form complete description
• In operative dentistry its used to measure dimensions of instrument, e.g. bin-angle spoon excavator (Figures
of instruments and various features of preparations and 8-8A to E).
restorations.
Operative Cutting Instrument
Types (Figures 8-6A to C) Formula
• Michigan O probe • Cutting instruments have formulas which are inscribed
• PCP 12 (Marquis markings) on the handle of the instruments. This number utilizes
• PSR (periodontal screening probe) metric scale (Figure 8-9).
• Williams probe. • They are usually three numbered or four numbered.

Figure 8-7: Types of forceps

 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 159
• 3rd number (second number of three coded instru-
ments)—blade length in millimeters.
• 4th number (third number of three coded instrument)—
blade angle relative to the long axis of handle in
centigrade.
Three number formula is used in instruments where
cutting edge if right angles to the blade (Figure 8-10).
Four number formula is used where cutting edge is not
right angles to the blade (Figure 8-11).
Two types of measuring gauges are used in standar-
dizing instrument designs or in ascertaining formulas,
they are:
1. Dental instrument gauge
2. Boley gauge

Figures 8-8A to E: Various angles in shank of similar

instrument (enamel chisel)

Figure 8-10: Three numbered formula (Enamel Hatchet)

Figure 8-11: Four numbered formula

(Gingival Marginal Trimmer)

Dental instrument gauge helps in measuring the angle

Figure 8-9: Cutting instrument formula of blade and cutting edge angle (Figures 8-12 and 8-13).

This was given by Dr GV Black.

• 1st number—width of the blade or primary cutting edge Armamentarium and Instruments
in tenths of millimeter. for Tooth Structure Removal
• 2nd number—primary cutting edge angle measured
from a line parallel to the long axis of the handle in • Hand cutting instruments
centigrade. If the instrument is circumferentially beveled • Rotary cutting instruments and abrasives
then this number is omitted. • Ultrasonic instruments
160 Essentials of Operative Dentistry

Figures 8-12A and B: Boley gauge

Figures 8-14A and B: (A) Lateral cutting and

(B) Direct cutting

Figures 8-13A and B: Dental instrument gauge Single Beveled Instrument

Right and Left Instruments
• Air abrasive instruments • Direct cutting instruments are made left and right by
• Lasers placement of bevel on one side instrument. Here non-
beveled side of instrument should be in contact with
Hand Cutting Instruments the well-being shaved (Figure 8-15).

Direct Cutting and Lateral Cutting

Instruments (Figures 8-14A and B)
• Direct cutting instruments are one in which the force is
applied in same plane as that of the blade and handle—
single planed instruments, e.g. enamel hatchets.
• Lateral cutting instruments are those in which the force
is applied at right angles to the plane of blade and
handle—double plane instruments, e.g. spoon
excavators, gingival marginal trimmer. Figure 8-15: Direct cutting
• Double plane instruments have curves or angles in instrument
shank which are right angle to the plane of blade and
handle. • Lateral cutting instrument cutting motion is of scraping
• Single planed instruments can be used in both cutting motion, movement is from beveled side to non-beveled
motions, while double planed instruments can only be side. Right and left is determined by the direction of
used in lateral cutting. curve in the shank (Figure 8-16).
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 161

Figure 8-16: Lateral

cutting instrument

Mesial and Distal Bevel (Figures 8-17A and B)

• These are instruments where the cutting edges are right
angles to the long axis of the shank of the instruments.
(like carpenters chisel), e.g. bin angle chisel, Wedelstaedt
chisel, hoes.
• If they are beveled on side towards shank they are
mesially beveled instrument (reverse bevel), if they are
beveled on side away from the shank they are distally
beveled instrument. Figures 8-17A and B: Mesial and distal bevel

Bibeveled Instrument
• Only ordinary hatchets and straight chisels are bi-
beveled instrument and are used by pushing motion in
long axis of the blade (Figure 8-18).
• They are not used today but if used they are employed
to create mechanical retention points in areas where
bur cannot reach.

Triple Beveled Instruments (Figure 8-19)

• Beveling the blade laterally (secondary cutting edge)
together with the edge of blade (primary cutting edge)
forms three distinct cutting edges.
• Most modern instruments are of this design. Figure 8-18: Bibeveled instrument

Figure 8-19: Triple beveled instruments

162 Essentials of Operative Dentistry

Circumferentially Beveled Instruments Terminology and Classification

These are usually done in double planed instruments Cutting Instruments
where the blade is beveled at all peripheries, e.g. spoon
Excavators, chisels and others.
excavator (Figure 8-20).
Excavators: Ordinary hatchet, hoes, angle formers, spoons
excavator.
Chisels: Straight chisel, curved chisel, bin angle chisel,
enamel hatchet, gingival marginal trimmers.
Other cutting instruments: Knives, files, scalers, carvers.

Excavators
These are used for removal of caries and refinement of
internal parts of the cavity.
• Ordinary hatchet
• Hoe excavator
• Angle formers
• Spoon excavators
Ordinary hatchet excavator:
• Has cutting edge of the blade same plane as that of the
long axis of the handle and is bibeveled.
• Used primarily in anterior tooth for preparing retentive
areas, sharpening internal line angles in DFG (Figure
Figure 8-20: Circumferentially beveled
instrument (Spoon Excavator) 8-22).

Single Ended and Double Ended

Instruments (Figures 8-21A and B)
• Most modern instruments are double ended instruments
incorporating either right and left or mesial and distal.
• Single ended instrument are confined to instrument
with one specific function.

Figure 8-21A: Double ended instrument

Figure 8-21B: Single ended instrument

Hand Cutting Instruments Types

• Excavators
• Chisels
• Special forms of chisels
• Other cutting instruments Figure 8-22: Hatchet excavator
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 163
Hoe excavator Spoon Excavator (Figures 8-25A and B)
• Primary cutting edge perpendicular to axis of the handle. • Used to remove caries, carving amalgam or direct wax
• Used for planning cavity preparation walls, forming pattern.
line angles, especially in Cl III, V DFG. • Blade is curved and cutting edges are circular or claw
• Come in pairs of mesial and distal (Figures 8-23A to C). like.
• Circular edge—discoid and claw like blade—cleiod.
Angle Former • Shanks may be mon-angled or bin-angled.
• This is a special type of excavator. It is a single plane
instrument. Chisels (Figures 8-26A to D)
• Used primarily for sharpening line angles, creating These are intended to primarily cut enamel.
retentive features in dentin for DFG, also used to bevel • Straight chisel
enamel margins. • Mon-angle chisel
• Primary cutting edge not at 90° to the blade.
• It is a combination of gingival marginal trimmer and
chisel.
• Available as pairs of right and left (Figure 8-24).

Figures 8-25A and B: (A) Cleiod and discoid excavator and

(B) spoon excavator

Figures 8-23A to C: Hoe excavator

Figure 8-24: Angle former Figures 8-26A to D: Types of chisels

164 Essentials of Operative Dentistry

Figure 8-27: Straight Figure 8-28: Bin- Figure 8-29: Wedelstaedt chisel
chiesel angle chiesel

• Bin-angle chisel
• Wedelstaedt chisel
• Enamel hatchet
• Gingival marginal trimmer. Figure 8-30: Enamel hatchet

Straight chisel (Figure 8-27) Gingival marginal trimmer (Figure 8-31)

• Has a straight shank and blade with bevel on only one • Is designed to produce a proper bevel on gingival
side. margins of proximoocclusal preparations also used to
• Primary cutting edge is perpendicular to axis of the rounden the axiopulpal line angle.
handle.
• Designed like a carpenter’s chisel.
• Force used with all chisel is essentially thrust motion.
Mon-angled and bin-angle chisel (Figure 8-28)
• Its available in mesial and distal bevel.
• Shanks have one or two angles.
Wedelstaedt chisel (Figure 8-29)
• Similar to straight chisel except that shank makes slight
curve with handle.
• Primary cutting edge perpendicular to axis of handle.
• Available in mesial and distal bevel.
• Used for cleaving undermined enamel and shaping of
walls.
Enamel hatchet (Figure 8-30)
• Is a chisel similar to ordinary hatchet except that blade
is larger, heavier, beveled on only one side. The shank
has one or more angle.
• Cutting edge in a plane parallel with axis of the handle.
• Used for cutting enamel.
• Available as right and left. Figure 8-31: Gingival marginal trimmer
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 165
• Similar in design to enamel hatchet except the blade is
curved and primary cutting edge not perpendicular to
the blade axis.
• Available as right and left.
• Right and left pair is also further made into distal and
mesial.
• When second number in formula is 90-100 its distal,
when is 85-75 its mesial. 100 and 75 pairs are used in Figure 8-33: Files
inlay preparations for steep bevels.
• 90 and 85 pairs are used in amalgam preparations
where gingival bevel is only slight.
• Cutting edge of an instrument that makes an acute angle
furthest from handle is distal and one making nearer to
the handle is mesial.
• When bevel on the instrument is on right side its right
Figure 8-34: Cleiod carver
instrument and on the left side its left instrument.
• They are primarily used in lateral cutting action.
Other Instruments According to Marzouk
Other Cutting Instruments Offset Hatchet
• Knife Similar to regular hatchet except that the whole blade is
• File rotated a quarter turn forward or backward (Figure 8-35).
• Discoid—cleiod instrument.
Used mainly for trimming restorative material rather Triangular Chisel
than cutting enamel.
Blade of a chisel in triangular in shape (Figure 8-35).
Knives (Figure 8-32)
• Known as finishing knives, amalgam knives, gold Hoe Chisel
knives.
Similar to hoe excavator but has sturdier blade.
• Made in thin knife like blade comes in various shapes
and sizes.
• Used for trimming excess material and contouring of
the material.

Figure 8-32: Knives

Files (Figure 8-33)

• Used for trimming excess material.
• Particularly useful in gingival margins. Figure 8-35: Triangular chisel and
• Available in various shapes and angles. offset hatchet
Discoid-Cleiod (Figure 8-34)
• Used primarily for carving unset amalgam Chisel vs Hoe (Figures 8-36A and B)
• May be used to trim and burnish onlay – inlays. • Bin-angle chisel is an instrument that has blade angled
• Working ends are slightly larger than excavators. to handle up to 12.5 centigrade.
166 Essentials of Operative Dentistry

Figure 8-37A: Amalgam carrier

Figure 8-37B: Amalgam carrier—plastic

Amalgam Well (Figure 8-38)

• Used to carry amalgam and dispensing.
• Available in metal and plastic.

Figures 8-36A and B: (A) Hoe,

(B) Bin-angle chisel
Figure 8-38: Amalgam well
• If blade of instrument is angled more than 12.5
centigrade its hoe.
Condensers (Figures 8-39 and 8-40)
Recommended Instrument Kit • Compress amalgam into the cavity.
• Black recommended a ling set of 96 cutting instruments, • Working ends are available in various shapes usually
but a university set up of 44 cutting instruments or short round or flat ends preferred.
set of 25 cutting instruments.
• Summit recommends a set of 12 hand cutting instru-
ments because advancement in dental materials,
bonding technology and rotary instruments.

Noncutting Instruments
(Restorative Instruments)
• Are similar to cutting instruments except that the blade
of the instrument is replaced with nib or point.
• Flat end of a condenser is face.
Amalgam carvers has carving blades.

Amalgam Carriers (Figures 8-37A and B)

• Consists of a hollow cylinder that is filled with
amalgam.
Figures 8-39A to D: Amalgam condensers
• A plunger with finger lever used to push amalgam into
the cavity.
• Plastic cylinder is employed for more viscous resin Carvers
materials. Used to shape amalgam and resin materials.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 167

Figure 8-40: Compressing amalgam

into the cavity

Types (Figures 8-41A to F) Figures 8-42A to C: Types of burnishers: (A) PKT burnisher,
• Cleiod-discoid (B) beaver tail burnisher, (C) Ovoid burnisher, (D) Ball burnisher
• Walls No. 3 carver
• Hollen back carver No. ½ • Beaver tail No. 2
• Interproximal carver • Football or ovoid burnishers.
• No. 14L carver. Used primarily to burnish amalgam and bend the cast
gold alloys to narrow the marginal gap.

Plastic Instruments
• Originally used with plastic restorative materials such
as silicates and acrylic resins.
• Commonly used instrument is No. 1-2.
• Also used in addition to carrying and contouring
restorative materials like packing of gingival cord,
rubber dam placement (Figures 8-43A and B).

Figure 8-43A: Plastic filling instrument

Figures 8-41A to F: Types of carvers

Burnishers
Types (Figures 8-42A to D)
Figure 8-43B: Usage of plastic filling
• PKT 3 instrument for composite restoration
168 Essentials of Operative Dentistry

• Available in plastic and metal. Plastic ones are used to

prevent abrasion from glass filler particles of restorative
materials to prevent graying of restorations.

Cement Spatulas (Figures 8-44A to D)

• Available in various sizes and shapes. Figure 8-45: Calcium hydroxide applicator
• Larger spatulas are for luting and smaller spatulas fro
liners and bases.
Accessory Instruments
Types
• No. 24 – luting cements. Dappen Dish (Figure 8-46)
• No. 313 – cavity liners. • Available in glass and plastic
• Used to hold various materials.

Figures 8-44A to D: Cement spatula

Figures 8-46A and B: Dappen dish
Agate Spatula or Plastic Spatula
• Mainly used in manipulation of glass ionomer cement. Cotton Holder
• Because glass particles in glass ionomer cement can Aids in holding cotton.
abrade steel spatula.
Macintosh Sheet
Glass Slab • It was invented by Charles Macintosh of Great Britain.
• They are available in amber colored or clear. • Mostly supplied in two color with one color at top and
• They are mainly uaed for mixing dental cements. another color at bottom. Two colors are provided so
• Zinc phosphate cement should be mixed only on glass that one color is always kept side up.
slab as it will only dissapiate the heat produced during • Mainly employed to keep the area clean in laboratories.
mixing.
• Other cements like zinc oxide eugenol, polycarboxylate, Chip Syringe (Figure 8-47)
glass ionomer can be mixed both on glass slab and paper
• Also called as Chip Blower or Student’s air syringe.
pad.
• Used mainly to clear off debris from cavity preparation.

Paper Pad
Mainly used for glass inomers as liquid is not absorbed by
paper pad and also it is easy to clean.

Calcium Hydroxide Applicator (Figure 8-45)

• Similar to periodontal probe with a blunt end.
• Used to flow calcium hydroxide cement by ‘non-pressure
flow technique’. Figure 8-47: Chip syringe
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 169
Kidney Tray
• Is a kidney shaped tray mainly available in stainless
steel and platic.
• In medical and surgical ward used to receive solid
dressings and medical waste.
• Shape of the dish allows the tray to be held close to
patient’s body to collect falling debris or other discharge
(Figure 8-48).
• It is available in various sizes.

Figure 8-50: Articulating paper

Figure 8-48: Kidney tray

Surgical Tray
Mainly used to carry instruments and prevent contami-
nation of instruments (Figure 8-49).

Figure 8-49: Surgical tray

Articulating Paper
• These are similar to carbon paper. Figure 8-51: Basic instrument set-up
• These are used for evaluation of occlusal high points.
• These are available in two colors one is for evaluating
the maximum intercuspation and the other for lateral Hand Instrument Techniques
excursion contacts (Figure 8-50). Four grasps used are:
1. Modified pen
Instrument Tray Set-up 2. Inverted pen
• From left to right will be (Figure 8-51) 3. Palm and thumb
• Examination instrument 4. Modified palm and thumb
• Additional examination instruments Pen grasp is not acceptable instrument grasp.
• Restorative instruments Modified pen grasp and inverted pen grasp are
• Accessory items. universal for most of the application (Figures 8-52A to E).
170 Essentials of Operative Dentistry

Figure 8-53: Indirect rests

Guards
These are hand instruments or other items to prevent injury
to soft tissues.

Sharpening of Hand Instruments

Instruments with dull cutting edges cause more pain,
prolong operating time, less controllable, reduce quality,
and precision in cavity preparation.
Sharpening equipments are:
• Stationary sharpening stones (Figures 8-54A and B)
• Mechanical sharpeners
• Stones used in handpieces

Figures 8-52A to E: Application of various hand instruments:

(A) Modified pen, (B) Inverted pen, (C) Palm thumb, (D) Modified
palm and thumb, and (E) Modified pen grasp most commonly Figures 8-54A and B: Manual sharpening
used
Stationary Sharpening Stones
Rests • Commonly called as oil stones.
• A proper rest is required to steady the instrument during • Available in various shapes, sizes and grits.
operative procedures (Figure 8-53). • Fine grit stone is suitable for final sharpening
• When modified pen grasp and inverted pen grasp is • Coarse and medium grit stones are used for reshaping
used ring finger or ring and little finger is used as close badly damaged instruments and for bench knives.
as possible to operating site as possible.
• Closer the rest is to operating site more steady the Material used for Sharpening Stones
instrument is. Material used for sharpening stones are:
• Indirect rest is where operating hand rests on the • Arkansas stones.
opposite hand which rests on a stable oral structure. • Silicon carbide
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 171
• Aluminum oxide Principles of Sharpening
• Diamonds. Sharpening of instrument should be done at the first sign
of dullness.
Mechanical Sharpeners (Figures 8-55A and B) • Sharpen instrument only after they are cleaned and
For example, Rx honing machine. sterilized.
Here a stone is moved in a reciprocal direction. • Establish proper bevel angle.
• Use light pressure against stone to minimize the
pressure.
• Use a rest wherever possible.
• Remove as little as metal from instrument.
• Lightly hone on the unbeveled side to remove fine spur
of metal.
• After sharpening re-sterilize the instrument.
• Keep the sharpening stone clean free of metal cuttings.

Sharpness Test
Instrument with cutting edge is placed on a plastic surface
and moved forward if it digs in its sharp if not the instru-
ment is dull (Figure 8-57).

Figures 8-55A and B: Mechanical sharpener

Handpiece sharpening stones

• Mounted silicon carbide and aluminum oxide stones
Figure 8-57: Plastic test stick
are available for use.
• Because of their round shape they difficult to produce
Sterilization and Storage of Hand Cutting
flat edges in cutting instruments (Figure 8-56).
Instruments
• Can be accomplished by autoclaving, dry-heat
procedures, ethylene oxide equipment, chemical vapor
sterilizers.
• Storage be done in a sterile wrapping or tray.

Key Terms
• Contrangling
• Instrument formula
• Instrument nomenclature
• Direct cutting
• Lateral cutting
• Excavators
Figure 8-56: Handpiece sharpening • Chisels
172 Essentials of Operative Dentistry

• Hatchet • Ability to discriminate diseased tissue and remove

• Gingival marginal trimmer disease tissue alone.
• Angle former • Being painless, silent and requiring minimal amount
• Wedelstaedt chisel of force.
• Sharpening • Should not generate heat or vibration during the usage.
• Instrument grasp • Being affordable and easy to maintain.

Questions to Think About Development of Rotary Cutting

1. Classify hand instruments and identify parts of
instruments. Explain in detail about chisels, hatchets, Instrument
excavators. Mechanical nonrotary instruments (Excavators):
2. Explain about instrument formula and measuring • In 16th century Giovanni Di Viggo advocated removal
devices used to establish instrument formula. of caries with drills, scrapers and files.
3. Explain about different bevel designs in hand cutting • Pierre Fauchard advocated removal of caries with strong
instruments. probes and plugged the cavities with lead or tin foils.
• In 1815, Derrabare and in 1826 Koecker advocated the
Powered Cutting Instruments complete removal of caries they advocated usage of
enamel cutters.
Various methods in modern day dentistry for removal of • In 1908, GV Black introduces several fundamantal
caries lesion or for tooth preparation are (Table 8-1): principles for cavity preparation and several hand
cutting instruments were designed by him.
Table 8-1: Classification of various tooth-cutting • Early hand instruments were bulky and cumbersome
techniques they were made of steel (Figures 8-58A to C).
Category Technique • Newer instruments were made of stainless steel or
Mechanical, rotary Handpieces + burs tungsten carbide.
Mechanical, non-rotary Hand excavators, Air-abrasion,
Air-polishing, Ultrasonics, Instrumentation for Mechanical Rotary
Sonoabrasion Instruments (Figure 8-59)
Chemomechanical Caridex™, Carisolv™, enzymes • Dental drills were evidently used in Mayan and Indian
Photoablation Lasers civilizations 1000 years ago.
• In 1846, first dental drill designed by Westcott consisted
Ideal caries removal method should satisfy: of dental drill held in finger rotated between thumb
• Comfort and ease of use in clinical environment. and forefinger.

Figures 8-58A to C: Early hand instruments

 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 173

Figure 8-59: Mechanical rotary instruments

• In 1858, Merry drill was introduced which consisted of • Early dental cavity preparation were performed by a
two parts one to hold the instrument other to drive the technique called as ‘Hydro Flo’ technique which is
instrument. alternate flushing of area with irrigant while evacuating
• In 1871, James B Morrison manufactured first foot the washings by vacuum air stream—given by Dr EO
treadle dental engine rotating speed of 200-300 rpm. Thompson.
By 1900, electricity invention triggered introduction of • In 1948, Ivan Norlen a Swedish dentist first introduced
electric engines to dentistry (Figure 8-60). air turbine handpieces to dentistry—Dentalair by Atlas
• Same year George Green patented first electric dental Corp, in 1957.
engine. • In 1949, Sir John Walsh a New Zealander invented
• By 1911, Belgian Emile Huet increased the speed of contrangled handpiece with turbine in its head—first
electric dental motors to 10000 rpm. of its type where turbine was located within handpiece
• Subsequently, airdriven dental turbines were produced itself speed of 60000 rpm.
by the manufacturer. • In 1952, Robert J Nielsen of National Bureau of
• Norlen in 1955, termed Dentalair, and in 1957 as the Standards, Washington DC produced water powered
Borden Airotor by Dr John Victor Borden. (hydraulic) contrangled handpieces achieving speeds
• This electric driven motors were not popular until of 61000 rpm.
1950s. The decade of 1950s was time of unparalled • In 1955, Richard Page introduced a belt driven
developments in the field of dental cutting. handpiece which achieved speed of 100000 rpm
• In 1954, Kerr Dental Corp introduced belt driven dental marketed as Page-Chayes handpieces.
motors with chucking mechanisms and achieved speeds • In 1957, an American dentist Dr John Victor Borden
of 30000-35000 rpm without eccentricity. introduced airotor handpieces with speeds of up to
174 Essentials of Operative Dentistry

Figure 8-60: Electrically rotary instruments

150000-350000 rpm its key in development of high

speed handpieces.
• In 1955, dental handpieces with water jet spray were
used.
Significant improvement after 1980s were introduction
of miniature heads, 360° swivel heads, push type hand-
pieces and fiber optic handpieces (Figure 8-61).

Figure 8-62: Future development

Handpieces
• Is a device for holding rotating instruments, transmitting
power to them, and for positioning them intraorally.
• Basically it is of two types straight and contrangle.
Straight handpieces are mainly employed for surgical
and laboratory purposes, while contrangle handpieces
are multipurpose in usage.
Figure 8-61: Modern day handpieces
• Early handpieces were belt driven electric motor units.
• Early high speed handpieces were having internal
Future Developments turbines but were water driven.
Handpiece combining both the air turbine and electric • Torque of newer airturbine handpieces are low and they
motor design concepts are being introduced (Figure 8-62). stall when lateral loads are applied.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 175
• It was only after 1950’s with introduction of speeds of Newer electric motors depending on application can
above 10,000 rpm that they have been used successfully achieve speeds from 250 to 160000 rpm depending on
for cutting enamel. application.
• High speed handpieces are generally preferred for Electric motor handpieces are generally employed for
cutting enamel and dentin, also for extending cavity refining cavity preparation, finishing and polishing
preparations. restorations.
Specialized electric motor handpieces:
Electric Dental Motors (Figures 8-63 and 8-64) • Endodontic usage
• Soon after introduction of air turbine handpieces in • Surgical bone cutting
1950s dental electric motors without belts were • Implant fixation (Physiodispenser)
introduced borrowed from aircraft technologies speeds • Lab purposes
of up to 25000 rpm achieved—marketed as Electro- • Drilling amalgam pin holes.
torque by Kerr Dental Co.
• By 1970s and 1980s, 1:3 step up motors capable of Rotary Speed Ranges
achieving speeds of 120000 rpm. Three speed ranges are generally recognized given by rpm:
• In 1990s, 1:5 step up motors capable of achieving speeds 1. Low or slow speed range—below 12000 rpm
of up to 250000 rpm. 2. Medium or intermediate speed—12000-200000 rpm
• In Western Europe and Scandinavian countries electric 3. High or ultra high speed—above 200000 rpm.
motors have gained greater popularity. A low speed option is mainly employed for cleaning
teeth, occasional caries excavation, finishing and polishing
Advantages Over Air Turbine procedures.
• Speed and torque can be controlled Use of low speed is associated with following
• Constant speed under load advantages:
• Constant torque • Better tactile sensation
• Better bur concentricity • Less chance of overheating.
• Quieter operation. At high speed advantages of tooth preparation and
removing older restorations are:
Disadvantages • Diamond and carbide instrument remove tooth
• Bulkier and heavier units structure faster, with less pressure, better control, ease
• Costlier. of operation, less vibration.
• Number of rotary cutting instrument needed is reduced.
• Instruments last longer.
• Several teeth in one arch can be prepared.

Air Turbine Handpieces (Airotor)

(Figures 8-65A and B)
• Dental handpiece is a slender tube shaped device which
connects the drill bit with driving motor. Handpiece
can be belt drive, pneumatic or electric driven.
• Dental handpiece consists of a head portion which has
the turbine or motor driven by compressed air.
• Also continuing with head portion will be the grip
portion containing the interconnecting hoses which
connects the handpiece to the compressed air supply.
• Dental bur is engaged onto the turbine or cartridge via
a chuck which is present in the turbine which tightly
holds the bur. In friction grip (Jacob chuck) mechanism
Figure 8-63: Early day Figure 8-64: Modern day the chuck is tightly engaged onto the bur by tightening
electric handpieces electric handpieces using a key or wrench.
176 Essentials of Operative Dentistry

Figures 8-65A and B: Air turbine handpieces

 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 177
• At the back of the handpiece connector is present with
opening for internal hose which is connected to the
coupling, it has openings for compressed air, coolant
and if necessary for fiber optic cable.

Cleaning and Lubricating Handpieces

(Figures 8-66A and B)
• Approved handpiece lubricants are available and they
are to be used prior to sterilization cycle and handpiece
allowed to run for 30-40 secs to expel any lubricants off. Figure 8-67A: Rotary vane compressor
Here manufactures instructions has to be followed.
• Most lubricants are ester based lubricants containing
various gases like propane, butane and solvent like
ethanol.
• Nowadays mechanical lubricating devices are available
for lubricating the handpieces.
• Handpieces are semicritical devices coming in contact
with mucous membrane they are to be cleaned with
any germicidal solutions.
• Sterilization is to be done by autoclave.

Figure 8-67B: Rotary vane dental compressor

Figure 8.66A: Lubricating oil and method of lubricating But newer age compressor with better air dryers and
handpieces
filters circumvent these problems.

Electric Motor Handpieces

(Figures 8-68 to 8-73)
• These equipments include the electric motor based
electromagnetic brushless motors (micromotors) or the
airmotors which is driven by compressed air.
• Electric motors or low speed handpieces mechanism is
much more complex consisting of bearings, magnets,
Figure 8.66B: Mechanical lubricating devices
coils, brushes and armatures.
Compressor (Figures 8-67A and B) • Bur holding mechanism in most of the handpieces is by
• Power for air turbine handpieces is derived from latch type, but newer generation handpieces are
compressed air generated by compressors. available with friction grip chuck mechanism.
• Most common dental compressors are of rotary vane
type, which has the advantage of silent running and
better efficiency.
Compressed air has disadvantages of:
• Oil for compressor coolant getting mixed with air.
• Compressed air has moisture contamination. Figure 8-68: Airmotors driven by compressed air
178 Essentials of Operative Dentistry

Figure 8-69: Types of low speed electric

motor handpieces

Figure 8-71: Close-up view of low speed handpiece

Figure 8-72: Working mechanism in low speed electric

Figure 8-70: Low speed handpiece assembly set-up motor handpieces

Cleaning and Lubrications

Same protocol as that of air turbine handpieces.

Characteristics of Rotary Instruments

Speed
• Speed not only refers to rotation per minute (rpm) but
also surface speed of instrument, the velocity at which
the cutting instrument pass across the surface being
cut. Figure 8-73: Electric micromotor
• Surface speed is influenced by rpm and diameter of
cutting instrument, with slower speed rotation a larger • Low speed handpiece requires force of 2-5 pounds.
diameter cutting instrument be required to achieve ideal • High speed handpiece requires force of 1-4 ounces.
surface speed. Heat production
Pressure • Is directly proportional to pressure, RPM, area of tooth
• Two factors control it: being cut. If any of these factors increase heat production
• Force: Applied onto the tooth with handpiece. increases.
• Area: Surface area of cutting tool contacting tooth • A temperature raise of 130° F can cause irreversible
surface. damage to pulp of tooth.
P = F/A • For high speed handpieces efficient cooling system by
• Smaller tools apply greater pressure than larger tool. water or air or combination of both is required.
While using smaller bur its necessary to reduce the force Vibration
applied and increase the speed (rpm) so that surface • Causes fatigue of operator, excessive wear of instrument,
contact speed is maintained. destructive reaction in tooth and supporting structure.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 179
• High speed handpieces have greatly reduced vibrations Photo Activated-Disinfection
compared to low speed handpieces.
• Employs a low powered disinfectant solution to be
Torque
applied on dentin followed by application of laser
• Is the ability of the handpiece to withstand lateral
(635 nm).
pressure on the revolving tool without decreasing its
• Disinfectant solution is Toulidine blue which binds to
speed or cutting efficiency.
bacteria in carious dentin.
• Generally electric motors have higher torque settings
compared to air turbine handpieces.
Sonic and Ultrasonic Caries Removal
Other Powered Equipments for
Caries Removal Ultrasonic
• This was mainly introduced for tooth removal by
• With the advent of newer adhesive restorations minimal
Nielson in 1950s.
cavity preparations or minimal intervention dentistry
• He designed a magnetostrictive unit with oscillating
seems the order of hour.
frequency of 25 kHz.
• Some of the newer techniques are adaptation of the older
• This is used in conjunction with aluminum oxide
techniques.
abrasive and water slurry.
• Newer techniques available are:
• Air abrasion. • This technique eliminates noise, vibration, heat and
• Photodisinfection. pressure.
• Sonic and ultrasonic caries removal. Disadvantages
• Chemomechanical caries removal. • Limited availability of instrument tips.
• Laser caries removal. • Slowness of action.
• Enzymes. • Poor visibility due to the abrasive slurry.
• Maintenance problems.
Air Abrasives (Figures 8-74A to C)
Introduced by Dr Robert B Black in 1945s. Sono abrasion (Figures 8-75 and 8-76)
• This is based on powered aluminum oxide particles • Modified original ultrasonic units being sonic units with
which travel at high speed and remove tooth structure modified abrasive tips are sonic air scalers.
without perceivable vibration, noise or heat. • The Sonicsys micro unit, designed by Drs Hugo,
• In 1951, first manufactured unit by SS White Dental Unterbrink and Mösele in a venture between Ivoclar-
Co.—Airdent. Vivadent and KaVo that oscillate in frequency less than
• This was later discarded due to absence of tactile 6 kHz.
sensation and difficulty in carving and defining angles • Tips vibrate in an elliptical motion.
in cavity preparation. • The tips are diamond coated on one side and cooled by
• First manufactured units was Airdent units. water irrigant.
• This technique is now reintroduced as Kinetic Cavity • Conventional diamond tips cannot withstand sonic
Preparation System (KCPS) where high velocity vibrations.
alumina particles (alpha) are used with much more • Therefore, CVD (chemical vapor deposition) diamond
precision (used in Minimal Invasive Dentistry). burs are employed.

Figures 8-74A to C: Air abrasion unit

180 Essentials of Operative Dentistry

• Carious dentine, softened further by NMAB (GK-101E),

should be readily removed by lightly abrading its
surface with the applicator tip.
• Recently Carisolv gel has been introduced, to be used
with specially designed noncutting hand instruments
to abrade the carious dentine surface.
• Carisolv was introduced by Mediteam in Sweden in
1998.
• Carisolv consists of two carboxymethyl cellulose based.
• Gels: A red gel containing 0.1 M amino acids (glutamic
acid, leucine and lysine).
• NaCl, NaOH, erythrosine (added in order to make the
gel visible during use); and a second containing sodium
hypochlorite (NaOCl — 0.5% w/v).
• The solution has a pH of around 11 and it is postulated
Figure 8-75: Chemical vapor deposition burs
that the positively and negatively charged groups on
the amino acids become chlorinated and further disrupt
the collagen crosslinkage in the matrix of the carious
dentine (Table 8-2).

Figure 8-76: Sonic handpieces Disadvantage

• More time consuming
Chemomechanical Caries Removal • Rotary instruments are still required for initial entry
(Figures 8-77 and 8-78) to lesion.

• In 1976, Goldman and Kronman advocated the usage

of N-monochlorglycine for caries removal.
Lasers (Figure 8-79, Tables 8-3 and 8-4)
• Subsequently, after modification, the Caridex system, • Lasers introduced in dentistry some 20 years ago.
containing N-monochloro-D, L-2-aminobutyrate • Hard lasers that are able to coagulate, cut and vaporize
(NMAB, GK-101E), was introduced. tissues is being mainly employed in dentistry.

Figure 8-77: Carisolv application

 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 181
Table 8-2: Comparison of Caridex and Carisolv

Caridex Carisolv
Solution 1 1% NaOCl 0.5% NaOCl
Solution 2 0.1M aminobutyric acid glycine 0.1M glutamic acid/leucine/lysine
0.1M NaCl NaCl*
0.1M NaOH NaOH*
Dye - Erythrocin (pink)
pH 11 11
Physical properties Liquid Gel
Volume Needed 100-500 ml 0.2-1.0 ml
Time required 5-15 mins 5-15 mins
Equipment required Applicator unit None
Instruments Applicator tips Specially designed
Time the preparation remains
active after mixing 1 hour 20 mins
* Concentration not stated.

Figure 8-78: Excavation of caries after Carisolv application

• Currently used laser systems are CO2, Argon, Er:YAG,

Nd:YAG, excimer systems.
• Lasers in addition to cutting tooth structure are also
able to kill cariogenic bacteria like S. mutans.
• Surgical employment of lasers was done during Figure 8-79: Modern day laser unit
1967-1970 Dr Thomas Polanyi and Geza Jeka with CO2
lasers. • These factors coupled with the expense and size of the
• In 1989, Dr Terry Myers an American dentists equipment have meant their use in general practice as a
introduced dental laser Nd:YAG. hard tissue cutting tool has been effectively limited to date.
Disadvantages
• At present, there is significant interest in these Enzymes
instruments but problems still persist regarding thermal • In 1989, Goldberg and Keil successfully removed soft
irritation to the pulp, the control of the procedure and carious dentine using bacterial Achromobacter
the possible alteration/destruction of the adjacent collagenase, which did not affect the sound layers of
sound tissue. dentine beneath the lesion.
182 Essentials of Operative Dentistry

Table 8-3: Various dental lasers

Type Source Wavelength Mode Output

CO2 10.60 μm Continuous 1000 W
Infrared CO2 10.60 μm Pulsed 1000 mJ/p
Ho: YAG 2.06 μm Pulsed 800 mJ/p
Nd:YAG 1.06 μm Pulsed 1000 mJ/p
Nd: YAG 1.06 μm Continuous 100 W
Visible HeNe 633 nm Continuous 25 W
Argon 514 nm, 488 nm Continuous 20 W
XeF 351 nm Pulsed 50 mJ/p
Ultraviolet XeCl 308 nm Pulsed 300 mJ/p
(Excimer) KrF 248 nm Pulsed 1000 mJ/p
ArF 193 nm Pulsed 800 mJ/p

Table 8-4: Dental laser application

CO2 Ho:YAG Nd:YAG HeNe Argon Excimers

Cutting and coagulation X X X X
Stimulation of healing X
Analgesia (low power) X X
Fissure sealing X X X X
Caries treatment X X X X
Composite curing X
Surface modification X X X X
Root canal X X X X
Apicoectomy X X X
Root sealing X X X
Gingivectomy X X

Table 8-5: The relative ability of the various excavation techniques to remove tooth tissue

Method Sound Sound Carious Carious Notes

enamel dentine enamel dentine
Hand excavators – – + ++
Rotary burs +++ +++ +++ +++ Air-turbine and
slow-speed handpieces
Air-abrasion +++ +++ ++ + Depends upon
abrasive agent used
Air-polishing + + + – Requires hard
surface substrate
for abrasion
Ultrasonics + + + – Retrograde root
filling cavity preparation
Sonoabrasion – + + ++ Further work required
Caridex/Carisolv – – – +++ Still requires conventional
access to dentine
Lasers + + + + Depends on wavelength,
intensity, pulse duration, etc.
Enzymes – – – + Further work required
+ : Indicates removal; – : indicates does not remove
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 183
• More recent study has used the enzyme pronase, a non- Shank (Figures 8-81 to 8-84)
specific proteolytic enzyme originating from • This part fits into the dental handpiece, accepts rotary
Streptomyces griseus, to help remove carious dentine. motion from the handpiece.
• Further research in his aspect is necessary (Table 8-5). • Three designs are: Straight handpiece shank, latch type
shank, friction grip angle handpiece shank.
Key Terms
Straight handpiece shank
• Merry drill • It is simple cylinder form.
• Foot treadle engine • Held in handpiece by metal chuck accepts wide range
• Borden’s handpiece of diameters.
• Straight handpiece • Precise control of shank diameter is not required.
• Contrangle handpiece • Used mainly for finishing and polishing finished
• Air turbine handpieces restoration in straight handpiece.
• Cartridge
• Chuck Latch type shank
• Torque • Shorter shank permits working in posterior tooth.
• Surface speed • Handpieces have metal bur tube within which the bur
• Electric micromotors fits as closely as possible.
• Rotary vane compressor • Posterior portion of bur fits into D shaped socket of
• Air abrasion handpiece.
• Chemomechanical caries removal • Bur is retained by a retaining latch that slide into the
• Speed groove found at the end of the bur.
• Torque • Used predominantly in low to medium speed for
finishing procedures.
• At higher speed this design produce greater wobbling.
Questions to Think About
1. Explain various caries removal techniques. Give a
detailed description of air turbine handpieces.
2. Explain about chemomechanical caries removal and
give a brief description about Carisolv.

Rotary Cutting Instruments

• ADA No. 23 dental excavating bur.
• These are instruments intended for use with dental Figure 8-81: Shank design
handpieces and manufactured in hundreds of different
shapes, sizes, designs.

Common Design Characteristics (Figure 8-80)

Consists of three parts: Figure 8-82: Straight handpiece shank
1. Shank
2. Neck
3. Head

Figure 8-83: Latch type shank

Figure 8-80: Parts of bur Figure 8-84: Friction grip shank

184 Essentials of Operative Dentistry

Friction grip shank • Early tungsten carbide burs were of only 4 basic shapes
• Was developed for high speed handpieces. namely—round, inverted cone, tapering and straight
• Smaller in length than latch type. fissure.
• Shank is simple cylinder close to dimensional tolerances. • Carbide burs perform better than steel burs at all speed
• Held in handpiece by close positive contact between especially high speed.
instrument and handpiece. • All carbide burs have heads of cemented carbide in
which microscopic carbide particles usually tungsten
Neck carbide are held together in a matrix of cobalt or nickel.
• Carbide is much stronger than steel.
• Intermediate portion connecting head to shank.
• Carbide head is attached to steel shank or neck for
• Main function of neck is to transmit rotational or
economy reasons by welding or brazing.
translational forces to head.
• Carbide is much brittle than steel.
• Neck usually tapers to smaller diameter from shank.
• In 1897, William and Schroeder of University of Berlin
• Neck represents a compromise between large cross-
were credited with development of diamond burs. These
section to provide strength and small cross-section to
early burs were made by hammering diamond powder
provide visibility and access.
into the surface of soft copper or iron blanks.
• Modern diamond burs were created in 1939 by WH
Head Design
Drendel of Germany, who developed the process of
• Head is working part of instrument. bonding diamond particles to steel and carbon blanks.
• Head of instrument greater variation than any other • After 40 years with introduction of air-turbine units the
portion of instrument, this usually forms the basis for tungsten carbide burs of smaller, varied shapes and
classification of instrument. stronger ones were introduced.
• Most important classification is: • Early diamond burs through 1940s were not popular
• Bladed instrument because of cost and manufacturing constraints.
• Abrasive instrument • However during World War II diamond burs became
popular because of shortage of steel and silicon carbide.
Dental Burs • Recent advancement in diamond burs include
• Bur is applied to all rotary cutting instruments that have introduction of single use disposable diamond burs.
bladed cutting heads. • In 2000, Boston introduced polymer burs which was
• Include instruments for finishing metal restorations, advocated as it removes only carious dentin.
surgical removal of bone, instruments for tooth removal. • Micropreparation burs (Fissurotomy burs) which
removed only 1/4th–1/5th of intercuspal tooth
Historical Development structure (Figure 8-85).
• Earliest burs were handmade. • Chemomechanical assisted cutting using diamond burs
• Early burs were made of steel. have been introduced here diluted alcohol or glycerol-
• Steel burs dull quickly, leads to heat production and based mouthwashes (surface active agents) has been
vibration. added to the coolant spray.
• First dental burs were hand made burs of steel.
• Its unknown who exactly invented the burs.
• Early burs were inefficient in cutting enamel.
• Before 1890’s silicon carbide disks and stones were
used to cut enamel. In 1891, Acheson discovered a
method for making an industrial abrasive composed of
silicon carbide, which he patented in 1893 and named
Carborundum.
• In 1891, first machine made burs were manufactured
by SS White Dental Corp named as ‘Revelation burs’.
• In 1917, Furke patented a process of hardening steel by
carbide, with that introduction of tungsten carbide burs
emerged. Figure 8-85: Fissurotomy burs
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 185
• Even though burs are universal in usage there still some Bur Classification
concerns they are: International Dental Federation (FDI) and International
• Sensitivity of vital dentin. Standard Organization (ISO) tend to use separate
• Pressure exerted on tooth. designations for shape (shape name) and size (head
• Bone conducted noise and vibration. diameter in tenths of a millimeter), EG round 010, straight
• Development of high temperature rise. fissure plain 010, inverted cone 008.
Composition and Manufacture
Shapes (Figure 8-88)
• Steel burs is usually cut from blank stock by a rotating
cutter that cuts parallel to axis of bur. • Refers to contour of the head.
• Bur is then hardened and tempered. • Basic shape are round, inverted cone, pear, straight
• Tungsten carbide bur is a product of powder metallurgy. fissure, tapered fissure.
• Powder metallurgy refers to a process of alloying in
which complete fusion constituents do not occur.
• Composition of tungsten carbide burs are 5-10% cobalt,
remainder being tungsten carbide, iron 0.2%, nickel
0.15%, titanium 0.1%.
• A blank is formed and tungsten carbide bur is cut with
diamond tool and fastened to steel blank or in some
cases entire tool is made of tungsten carbide (Figures
8-86 and 8-87).

Figure 8-88: Basic bur head shapes

Round bur: Used for initial entry, extension of preparation,
preparation of retention features, caries removal.
Inverted cone: For providing undercuts.
Pear shaped: Advocated for class I gold foil preparations,
Figure 8-86: Diamond instrument construction amalgam preparations.
Straight fissure bur: For amalgam preparations.
Tapered fissure: Tooth preparations for indirect restora-
tions. Aamong these basic shapes other variations are
available.

Sizes
• Numbering system originally developed by SS White
Dental Co. in 1891.
• Original numbering system grouped burs by 9 shapes
and 11 sizes.
• ½, ¼ were added later as smaller sizes were introduced.
• Cross-cut burs were given designation by adding
Figure 8-87: Tungsten carbide and steel burs No. 500 (Table 8-6).
186 Essentials of Operative Dentistry

Table 8-6: Head diameters in inches (mm)

0.020 0.025 0.032 0.040 0.048 0.056 0.064 0.073 0.082 0.091 0.100 0.110 0.120 0.130
Head Shapes (0.5) (0.6) (0.8) (1.0) (1.2) (1.4) (1.6) (1.9) (2.1) (2.3) (2.5) (2.8) (3.0) (3.3)
Round ¼ ½ 1 2 3 4 5 6 7 8 9 10 11
Wheel 11½ 12 14 16
Inverted cone 33½ 34 35 36 37 38 39 40
Plain fissure 55½ 56 57 58 59 60 61 62
Round cross-cut 502 503 504 505 506
Straight fissure cross-cut 556 557 558 559 560 561 562 563
Tapered fissure cross-cut 700 701 702 703
End cutting fissure 957 958 959
Round finishing A B C D 200 201 202 203
Oval finishing 218 219 220 221
Pear finishing 230 231 232
Flame finishing 242 243 244 245 246

Modification of Bur Design

Three major trends in designs are discernible:
1. Cross-cuts are needed on fissure burs to obtain adequate
cutting efficiency at low speeds (Figures 8-89A and B).
But at high speeds produce highly rough surface, so
they have now been replaced.

Figure 8-90: Rounded corners

These modifications simplify techniques and reduce

efforts needed for optimal results.
Figures 8-89A and B: Cross-cut feature
Design of Dental Burs
2. Carbide fissure burs with extended head lengths 2–3
times those of normal burs are introduced. Features (Figure 8-91)
Such a design would not be practical if using a brittle • Tooth face, back or flank.
material at low speed. • Tooth face is surface of bur tooth towards direction of
3. Rounding of the sharp corners (Figure 8-90). rotation also called as rake face.
Sharp angles produced by conventional burs can result • Tooth back or flank is surface away from direction of
in high stress concentrated for tendency for tooth to fracture. rotation also called as clearance face.
Burs last longer because sharp corners are not present • Rake angle—angle between face of bur to the radial
to chip and wear. line.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 187

Figure 8-91: Direction of rotation

• Face of bur leads the radial line it is negative rake

angle.
• Face of bur corresponds to radial line it is zero or
radial rake angle.
• Face of bur behind radial line is positive rake angle. Figure 8-93: Rake angle representation
• Clearance angle—angle between back of tooth and
work.
• Primary clearance angle—angle between land and
work.
• Secondary clearance angle—angle between back of
tooth and work.
• Tooth angle—angle between face and back of tooth.
• Flute or chip space—space between successive teeth.
• Number tooth in a dental bur is usually 6-8 for cutting.
• More than 10 tooth is used for finishing and polishing.

Rake Angle (Figures 8-92 to 8-95)

• Positive angle is more commonly used in industrial
cutting.
• It improves flow of metal along face of the tooth.

Figure 8-92: Schematic representation of bur blade design Figure 8-94: Positive rake angle cutting
188 Essentials of Operative Dentistry

Number of Teeth
• If too many bur teeth are present then there will be less
flute space.
• Fewer the teeth present greater will be the vibration of
instrument.

Concentricity and Runout

(Figures 8-98 and 8-99)
• Concentricity is static measurement how precisely a
single circle can be scribed through the cutting edge of
all the blades of bur.

Figure 8-95: Negative rake angle cutting

Figure 8-98: Runout

Figure 8-96: Bur with land Figure 8-97: Bur with radial
clearance

• In negative rake angle the chip moves directly away

from edge and is fractured into small bits.
• In dentistry if positive rake angle is employed then the
tooth of bur will be small and can wear off easily.
• Therefore, negative rake angle with radial clearance and
short tooth height provide maximal strength and longer
bur life (Figures 8-96 and 8-97).

Clearance Angle
• To provide clearance between work and cutting edge to
prevent tool back from rubbing the work.
• Clearance angle should be small to provide additional
bulk to cutting edge.
• Any dulling or flattening of tooth edge may provide a
plane surface to rub against work. Figure 8-99: Concentricity
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 189
• Runout is a dynamic measurement of the accuracy with
which cutting edge pass through a single point as the
bur turns.
• Increased runout results in lack of cutting efficiency.
• Runout can cause vibration and lack of proper
preparation.

Bur Life
Life of bur depends on many factors many of which are
not under control of dentist.

Influence of Load
• Force or load exerted by dentist on a bur during cutting
is related to rotational speed of a bur. Figures 8-100A and B: Spiral angle
• Maximum of 60 gm is required force to be exerted.
• Forces large enough to stall the bur rotation is abusive • Head length should be adequate to reach full depth of
and ineffective. preparation.
• Rate of cutting increased with speed of rotation up until • Reduced spiral angle is necessary for high speed
150000 rpm. handpiece (Figures 8-100A and B).
• Minimal rotational speed for cutting depends upon • In high speed cutting cross-cut burs produce more
material being cut, design and composition of bur, other rougher surface.
factors.
Diamond Abrasive Instruments
Coolant • Abrasive instruments are based on small, angular
• Coolant reduces heat generation and increases efficacy particles of a hard substances held in matrix of soft
of cutting. substance.
• Chief purpose of coolant is to reduce temp, removal of • Cutting occurs along the numerous points protruding
debris, lubricate rotary tool. from the matrix rather than along the cutting blades.
• Three types of coolants are: • Abrasive instruments are grouped as, diamonds and
• Air other instruments.
• Water • Diamonds have long life and greater cutting efficiency.
• Water spray.
• Water seems to be the best coolant. Terminology
• Diamond instruments consists of three parts, a metal
Heat Generation blank, powdered diamond abrasives, metallic bonding
• During cutting heat is generated because of friction. that holds diamond powder onto blank.
• This heat is dissipated by conduction through tool, • Blank resembles bur without blades.
conduction by work, by chip as its removed, coolant. • Diamonds employed may be industrial diamonds,
• Use of coolant greatly reduces heat generation water natural or synthetic diamonds.
flow rate of 35-50 ml/min should be maintained. • Shape and particle size of diamonds play an important
• Intermittent cutting reduce heat generation consi- role.
derably. • Diamonds are attached to blank by electroplating a layer
of metal on the blank while holding diamonds onto it
Additional Features in Head Design (Figures 8-101A and B).
• Head length and taper angle are varied with intended
use of bur. Classification
• Taper angle is intended to produce desired occlusal These are produced in myriad of shapes and sizes, besides
divergence in a preparation. standard shapes.
190 Essentials of Operative Dentistry

Figures 8-101A and B: Diamond abrasives

Figure 8-102: Various shapes of diamonds

Head shape and size (Figure 8-102) Other Abrasives

• Available in all shapes and sizes but cannot be made to
They are primarily used for finishing and polishing of
smallest size of a bur.
instruments.
• There is no uniform nomenclature for diamond
abrasives.
Classification
Diamond particle factor
Two types (Figures 8-104 to 8-108):
• Clinical performance of diamond abrasives depend on,
1. Molded abrasives
size, spacing, uniformity, exposure, bonding of
2. Coated abrasives.
diamond particles, diamond particle size, coarse (125-
150 µm), medium (88-125 µm), fine (60-74 µm), very Molded abrasives
fine (38-44 µm) (Figure 8-103). • Have heads manufactured by molding or pressing a
• Most common failure with this instrument is loss of uniform mixture of abrasives and matrix around roug-
particles from critical areas. hened shank or cementing premolded head to shank.
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 191

Figures 8-106A and B: Flexible molded abrasives

Figure 8-103: Different grades of abrasives

(left to right) coarser, medium, finer

Figures 8-107A and B: Rigid molded abrasives

Figure 8-104: Molded or bonded abrasives

Figures 8-108A and B: Coated abrasive disks and strips

• Mounted heads are termed points or stones.

• Hard and rigid molded instrument use polymer or
ceramic material for their matrix—used for grinding
and shaping.
• Flexible matrix materials such as rubber also used—
used for finishing and polishing.
Figure 8-105: Coated abrasives • Unmounted disks or stones also available.
Coated abrasives: These are mostly disks with flexible
• Have softer matrix which wear to expose new diamond backing to which thin layer of abrasives are cemented.
particles unlike diamond abrasives. • Used for finishing and polishing.
• Available in full range of sizes and shapes. • Here abrasives are softer and less wear resistant.
192 Essentials of Operative Dentistry

Materials
• Matrix materials are usually phenolic resins or rubbers.
• Rubber matrix for flexible head and harder matrix for
molded SiC disks.
• Synthetic or natural abrasives including SiC, aluminum
oxide, garnet, quartz, pumice, cuttle bone are commonly
employed.

Cutting Mechanisms Figure 8-110: Abrasive instruments cutting

on ductile material
Evaluation of Cutting
Ductile material
Cutting effectiveness: It is the rate of tooth structure removal
• When diamond contacts a ductile material most
(mm/min or mg/s).
material flows laterally with repeated deformation
Cutting efficiency material work hardens and break off (Figure 8-110).
• Percentage of energy expended during cutting • This type of cutting is less efficient so burs are preferred
procedure. for cutting ductile material like dentin.
• Is reduced when energy is wasted as heat or noise.
Brittle material
General agreement is that increased rotational speed
• Results in tensile fractures leading to subsurface
results in increased effectiveness and efficiency.
cracks.
• Most efficient to cut brittle materials.
Bladed Cutting • Diamonds produce rougher surface to increase bonding,
• Low speed cutting produces plastic deformation before used in CAD CAM restorations (Figure 8-111).
tooth structure fractures (Figure 8-109).
• High speed cutting proceeds by brittle fracture.
• For the blade to initiate cutting it must be sharp have
high hardness, modulus of elasticity must be pressed
against material with sufficient force.
• First when the bur contacts tooth structure stress
produced is of elastic, it soon exceeds proportional limit
and a permanent deformation followed by fracture.

Figure 8-111: Abrasive instruments cutting

on brittle material

Cutting Recommendations
• Air-water spray high operating speed (> 200000 rpm)
light pressure.
• Carbide burs are better for end cutting, punch cuts,
intracoronal preparations, amalgam removal,
Figure 8-109: Bladed instrument secondary retention features, small preparations.
cutting a ductile material • Diamonds are more effective for intra-, extracoronal
preparations, beveling enamel margins, enameloplasty.
Abrasive Cutting
• Very high hardness of diamonds provides superior Hazards of Cutting Instruments
resistance to wear. • Pulpal precautions
• Individual diamond particles are very sharp and • Soft tissue precautions
irregular leading to large negative rake angle. • Eye precautions
 Instruments and Equipment used for Diagnosis, Tooth Preparation and Restoration 193
• Ear precautions: • Rake angle
• Turbine handpiece with ball-bearings at 30 lbs • Clearance angle
produce noise levels of 70–94 db. • Bur tooth
• Noise levels above 85 lbs may require protective • Bur face
measures. • Tooth back
• Inhalation precautions: • Concentricity
• Mercury vapor released when amalgam is cut. • Runout
• Monomers are released when composites, sealants, • Diamond abrasives
acrylic resins are finished or polished. • Bladed cutting
• Abrasive cutting

Key Terms
Questions to Think About
• Latch type shank
• Friction grip shank 1. Explain about design characteristics of dental burs and
• Dental burs elaborate about shank and bur head designs.
• Tungsten carbide burs 2. Describe the modifications in dental bur design.
• Steel burs 3. Discuss in detail about diamond abrasives and mention
• Spiral angle about other types of abrasives.
194 Essentials of Operative Dentistry

9 Infection Control

Introduction • Rationale for infection control procedure is to reduce

the impact of iatrogenic, noscomial infections among
• Sterilization—is defined as the process by which an patients and also to reduce the risk of care takers being
item, surface or medium is freed of all microorganisms exposed to infections.
either in the vegetative state or spore form. • In dentistry, the infection transmission can be patient
• Disinfection—means destruction of all pathogenic to dentists, dentist to patient and patient to patient.
organisms capable of giving rise to infection.
Transmission routes are given in Figures 9-1A to D.
• Antiseptics—used to indicate the prevention of
• Percutaneous
infection usually by inhibiting the growth of bacteria,
• Inhalation of aerosols
chemical disinfectants that can be safely applied to skin
• Direct contact
or mucous membrane are called as antiseptics.
• Indirect contact through fomites.
• To prevent transmission of serious diseases all health
care providers who come in contact with mucosa, blood Immunization against diseases, use of practical barrier
or blood contaminated body fluids are required to techniques, use of personal protective equipment,
adhere to universal barrier methods and other methods engineering and work practice controls, disinfection of
to minimize infection risk. contaminated surfaces/equipment, sterilization of critical
• Universal use of gloves, masks, protective overgarments, and semi-critical instruments, and use of aseptic protocols
scrupulous equipment disinfection and instrument during treatment, broadly encompass the realm of Dental
sterilization are now mandatory. Infection Control and Safety.
• Hepatitis B is one of the major blood-borne disease that
could be transmitted from health care professional, but
introduction of vaccine has dramatically reduced
Decontamination (Figure 9-2)
incidence of transmission of hepatitis-B. • First level of decontamination is sanitization to reduce
• With modern infection control procedures HIV the load of microorganisms, i.e. to reduce the bio-burden,
transmission has also controlled and would be this process involves thorough physical cleaning of the
prevented. instruments.

Figures 9-1A to D: Routes of disease transmission

 Infection Control 195

Figure 9-2: Decontamination

• The next level is disinfection, a process that kills all 3. Noncritical and
vegetative microorganisms, fungi and some viruses but 4. Environment surfaces
not necessarily bacterial endospores using chemical • Universal precaution is that all patients are to be treated
germicides, radiation, ultraviolet rays or heat. as potentially infectious. Rationale for universal
• The third level is sterilization, a process that kills all precaution is that most of the patients do not know
bacteria, fungi, viruses, and bacterial endospores using their disease status.
chemical methods such as liquids and gases, chemical • Personal protective equipment (PPE) is term used for
methods in combination with heat and pressure, barriers such as gloves, gown or mask. PPE must not
physical methods such as dry heat, steam under allow blood or other potentially infectious material to
pressure, or radiation. pass through to contaminate personal clothing, skin or
Earl H Spaulding categorized instruments and mucous membrane.
environment surfaces based on their potentiality to cause • Work practice controls and engineering controls are
disease transmission into: terms that describe and used of devices to reduce
1. Critical contamination risk, e.g. high volume suction, rubber
2. Semicritical dam, protective sharp containers.
196 Essentials of Operative Dentistry

• Housekeeping is a term that regulates to clean-up of directions for use of universal barrier protection. Some
treatment soiled operatory equipments, instruments, of PPE are:
counters, floors as well as to management of gowns • Protective gloves, appropriate protective body
and waste. clothing such as gowns, protective eye wear, face
• Environmental surfaces: Walls, floors and non-high touch shields, goggles, facemasks, surgical caps and shoe
or non-intimate surfaces should be maintained through cover.
housekeeping methods. • As soon as possible after treatments attend to
• Standard operating procedures (SOP) is a term used for housekeeping requirements including floors, coun-
step-by-step description of tasks. tertops, sinks and other environmental equipment that
Following is a summary of current Occupational are subject to contamination (Table 9-1).
Safety and Health Administration (OSHA) regulations: • For contaminated spills prescribe an appropriate
• Provide hepatitis B immunization to employees without method for cleaning and then applying disinfectant.
charge within 10 days of employment. Broken glassware should be removed only by
• Requires that universal precaution be observed to mechanical means never with gloved hands.
prevent contact with blood and other potentially • Contaminated equipment that requires servicing first
infectious materials. must be decontaminated before servicing.
• Implement engineering controls to reduce production • Contaminated sharps are regulated waste, to be
of contaminated spatter, mists and aerosols, e.g. use of discarded in hard walled container. For OSHA regulated
rubber dam, high volume suction. waste in dentistry implies:
• Implement work practice controls precautions to • Liquid or semiliquid or other potentially infectious
minimize splashing, spatter or contact of bare hands materials.
with contaminated surface, e.g. careful handling of • Contaminated items that would release blood or
sharp instruments, not putting hands into sharps other potentially infectious materials.
container. • Items that are soaked in blood.
• Providing facilities and instructions for washing hands These items are to be disposed of in containers
and other skin after exposure to potentially infectious with properly labeled biohazard symbol.
materials. Flush eye or mucosa immediately after contact • Provide laundering of protective garments used for
with potentially infectious materials. universal precautions.
• Prescribe safe handling of needles and other sharp Infected health care personnel (HIV or hepatitis B) are
items. advised not to perform exposure prone procedures unless
• Prescribe disposal of single use needles, wires, carpules they have sought counsel from an expert review panel.
or sharps as close to place of use in a hard walled
leakproof containers that are closable. Containers must
be red or bear a biohazard label. Teeth must not be
Common Infections in Dentistry
discarded into trash but can be given to patient or (Table 9-1)
discarded into sharps containers.
• Contaminated reusable sharp instruments must not be AIDS / HIV Infection
stored or processed in a manner that requires reaching With the proper use of infection control procedures there
hands into container to retrieve them. Use of baskets or should be no risk of contracting HIV both for patient and
instrument cassettes is recommended. health care personnel.
• Prohibit eating, drinking, handling contact lenses and • Unlike hepatitis B, HIV has been found in very low
application of facial cosmetics in contaminated levels in bloods of infected persons.
environments such as operatories and clean-up areas. • In saliva HIV has been detected in still low levels.
• Place blood and contaminated specimens (e.g. • In dried blood HIV becomes inactive within 90 minutes.
impressions that have not been cleaned, teeth, biopsy But caution should be exerted when wet contaminated
specimens, blood specimens, culture specimens) to be instruments are handled.
shipped, transported be stored in a suitable container • HIV is killed by all methods of sterilization.
that prevent leakage. • HIV has been transmitted by blood contaminated fluids
• At no cost to employees provide them with necessary that have been heavily spattered. However, aerosol
personal protective equipment (PPE) and clear transmission of hepatitis B or HIV is not recorded.
 Infection Control 197
Table 9-1: Commonly encountered infections in dental set-up

Conditions Habitat Routes of transmission

Sexually Transmitted Diseases
1. Herpetic infections Oral, pharynx, anogenital, skin, Contact-lesion exudate, saliva,
viscera, eye sexual contact, blood
2. Acute herpetic gingivostomatitis Oral, gingiva, pharynx Contact-lesion exudate, saliva, blood
3. Herpetic Whitlow Fingers, hands Contact-lesion exudate, saliva, blood
4. Goncoccal infections Oral, pharynx, genitals Contact-lesion exudate, saliva, blood,
nasopharyngeal secretions
5. Chlamydial infections Genitals, eyes oropharynx Contact-lesion exudate, genital
secretions, secretions from eye
6. Trichomonal infections Genitals, oropharynx, oral gastrointestinal Contact-lesion exudate, mucosa,
saliva, blood, body fluids
7. Condyloma acuminatum Anogenital skin, oral, mucosal areas Contact-lesion, mucosa, blood
8. Syphilis Genitals, skin, oral mucosa, oropharynx Contact-lesion, mucosa, saliva,
blood, body fluids
9. Infectious mononucleosis Skin, oral mucosa, genitals, parotids, Contact-mucosa, saliva,
saliva lesion exudate
10. Hepatitis B virus infection Liver, blood, body fluids Contact-blood, saliva, body fluids
11. Hepatitis D virus infection Liver, blood Contact-blood, saliva, body fluids
12. Hepatitis C virus infection Liver, blood Contact-blood, saliva, body fluids
13. Human immunodeficiency Blood, oral mucosa, skin Contact-blood, semen, non-intact skin
virus infection
Respiratory Diseases
1. Common cold Upper respiratory tract Aerosol, contact
2. Sinusitis Upper respiratory tract Aerosol, droplet
3. Pharyngitis Upper respiratory tract Aerosol, droplet
4. Pneumonia Respiraotry tract Aerosol, droplet
5. Tuberculosis Respiratory tract Aerosol, droplet
6. SARS Respiratory tract Aerosol, droplet, intimate contact
7. Avian influenza (HSN 1 Fla) Respiratory tract, gastrointestinal tract Aerosol, droplet, intimate contact
Childhood Diseases
1. Chickenpox Oral, skin Droplet, contact
2. Herpangina Oral, oropharynx Droplet, contact
3. Head, foot and mouth disease Oral, hands, feet Droplet, contact, ingestion
4. Rubella and Rubeola Respiratory tract, oral skin Droplet, contact, saliva, blood, exudate
5. Mumps Parotids, pancreas, testis, CNS Droplet, contact saliva
6. Cytomegalovirus infection Salivary glands Droplet, contact, saliva, blood
Other Common Conditions
1. Hepatitis A virus infection Liver, gastrointestinal tract Ingestion, rarely blood
2. Hepatitis E virus infection Liver, gastrointestinal tract Ingestion, rarely blood

• Personnel barriers has been successful in preventing • Hepatitis B virus (HBV) carries 2 times the mortality
HIV infection transmission. risk of a similar HIV exposure.
• Vaccination for hepatitis B reduces mortality rated to
zero.
Viral Hepatitis • All forms sterilization kills HBV.
• Personnel can be infected by parenteral exposure, • Vaccination along with personal protection equipment
mucosal exposure to infected blood, blood contami- (PPE) can dramatically reduce transmission of HBV.
nated saliva, and spatter of blood contamination to eyes, Vaccination requires one dose followed by another one
mouth or broken skin. Plain saliva can also be weakly month later and a third dose 6 months after first dose.
infectious. Protection is 100%.
198 Essentials of Operative Dentistry

Table 9-2: When clinician can return to work after being infected

Condition When should one return to work OR what is to be done

Conjunctivitis After discharge ceases
Staph aureus (active) After lesions have healed
Strep. group A 24 hours after starting effective antimicrobial treatment
Viral respiratory Infection After resolution of acute symptoms
Active tuberculosis After treatment with antimicrobials and deemed noninfectious
Positive skin text for TB After evaluation for infectious status, chest X-ray, and treatment if needed till
deemed noninfectious
Influenza After symptoms resolve
Pediculosis (hair lice) After treatment provided and no lice
Herpetic Whitlow After lesions heal
Orofacial herpes After lesions heal, need to be regularly on anti-herpes medicines for the rest of the life
Chickenpox (Varicella) After lesions dry and crust out
Shingles (Herpes Zoster) After lesions dry and crust out
Hepatitis B (HBe antigen +ve) After deemed HBe antigen –ve, UP/SP and expert panel/infectious diseases
MD to monitor clinician
Hepatitis C Seropositive Need to use UP/SP, proper aseptic techniques to protect patients, antiviral
medication, monitoring
HIV/AIDS After antiretroviral therapy started, UP/SP and expert panel/infectious
Diseases MD to monitor clinician
Measles After 7 days from the appearance of rash
Mumps After 9 days from start of parotitis
Rubella After 5 days from the appearance of rash
Pertussis After 5 days from start of effective antimicrobnial therapy
Diarrhea After symptoms resolve
Amebiasis After starting effective antimicrobial therapy and symptoms resolve
Enteroviral Infections After symptoms resolve
Hepatitis A After 7 days from the onset of jaundice

One to six months later, it is necessary for dental cleaning and sterilization of instruments and all those
personnel to test for formation of antihepatitis B surface who are in the clinical area or the preclinical area of the
antigen. dental teaching institution must to be vaccinated
Proposed protocol for HBV vaccine for Dental against hepatitis B.
Undergraduate and Postgraduate Students and Dental • It is also mandatory for the institution managements
Teaching Faculty in India (Table 9-2): including government owned institutions to provide free
• It is mandatory for every dental student undergraduate hepatitis B vaccine to all its students both undergraduate
and postgraduate and dental teaching faculty to be and postgraduate, teaching and nonteaching faculty.
vaccinated against hepatitis B with a three dose regimen
and a booster. The institute head will confirm that the
Tuberculosis
undergraduate and the postgraduate students have had
a course of HBV vaccination before the admission • If diagnosed with active infection the patient must be
procedures are completed. Other than the teaching treated till pronounced non-infectious and then may
faculty all nonteaching faculty which include dental access dental care. It is pragmatic to defer care for
assistants, dental hygienists, dental mechanics and all patients with active TB till such time the disease is
those who come directly in contact with patient care, controlled.
 Infection Control 199
• All emergency dental treatments may be provided in • Parachlorometaxylenol (PCMX) liquid, iodine liquid or
institutions that are equipped to deal with the control triclosan liquid, gel or foam could also be employed.
of cross contamination or occupational exposure. • Washing of hands is also recommended when changing
Such facilities should include negative air pressure gloves.
treatment rooms with the air vented to the outside of the Sequence followed in routine handwash procedures
building. (Figure 9-3):
• The air conditioning and ventilation system must also • Remove jewellery and wrist watch and examine hands.
be equipped with HEPA filters and the personnel must • Wet hands with warm water.
use masks that have a HEPA filter during the contact • Dispense an adequate amount of soap.
with infected patients. • Thoroughly rub both surfaces of the hands including
• As in India most of population is infected with TB its around the thumb and fingers for about 30–60 seconds.
required that dental personnel required to undergo • Wash hands with warm water to remove the soap.
regular tests for TB infection. • Dry hands with paper towels.
• Examine hands for injuries such as nicks, cuts and
Medical History bruises and treat as needed.
Medical history serves several purposes: • Wear single-use disposable gloves.
• To detect any unrecognized illness that requires medical
diagnosis and care. Hand Sanitizers
• To assist in managing and caring for infected patients.
• Are alcohol based with or without germicides.
• To identify any infection or high-risk that may be
• These items are primarily for use when handwashing
important to a clinical personnel when exposed.
is impractical or cannot be done (non-availability of
• To reinforce infection control protocol.
water and antimicrobial handsoap). Hand sanitizers
But most of the general infectious disease are asympto-
with alcohol have been showed to be effective in
matic and only precaution of employing universal pre-
germicidal control on hands.
cautions precludes the chance of infection transmission.
Washing hands multiple times per day with soaps
tends to make the skin dry. At the end of each session
Infection Control Methods (during lunchbreak, or at the end of the clinic day) a
Personnel Barrier Protection good quality emolient/skin cream should be used for hand
care.
Personal Protective Equipment (PPE) commonly used in
general dental care are single-use-disposable gloves (sterile
Gloves (Figures 9-4 to 9-6)
or nonsterile), protective eyewear, faceshields, masks,
gowns and utility gloves used to protect personnel from • Its mandatory that all clinical personnel must wear
blood and body fluids and chemical hazards. The main treatment gloves during all treatment procedures.
use of barriers is to control gross contamination and not • After each appointment or if there is any leak in gloves,
prevent spread of every single microbe. hands need to washed and new gloves worn.
• Gloves should not be washed and reused.
• Gloves that are washed with soap has been shown to
Handwashing
reduce glove integrity.
• Handwashing is mandatory before examination of • Exam gloves can be made from latex, vinyl, nitrile, and
patient. polyurethane.
• Before handwashing it’s mandatory that jewellery, • While cleaning and sorting instruments (especially
watches are removed and hand is examined for any sharp instruments) wear puncture resistant utility
cuts, bruises and overgrown nails. gloves (nitrile latex gloves). Nitrile gloves can be washed
• Hand should be washed with anti-microbial soap, inside and out, disinfected or steam autoclaved.
recommended agents are chlorhexidine gluconate • Protective nitrile utility gloves are made up of nitrile
(CHG) at 0.75-4%. Four percent is recommended as latex and are most puncture resistant and these can be
surgical scrub, may be dispensed in liquid form or soap washed and wiped with disinfectant or autoclaved as
form. necessary.
200 Essentials of Operative Dentistry

Figure 9-3: Handwashing and hand care

Figure 9-6: Removing gloves

Figure 9-4: Single use latex gloves

Masks (Figure 9-7)

• Face shields are appropriate for heavy spatter, but a
mask is still required to protect against aerosols that
drift behind the shield.
• Change of mask is necessary every hour or sooner it
becomes wet.
• Masks should be grasped only by string on side of mask.
• Rectangular folded type mask have highest filtration.
To best provide protection against aerosols press edges
of rectangular mask around the bridge of nose.

Protective Eyewear (Figure 9-8)

Figure 9-5: Utility nitrile gloves • Consists of goggles or glasses with solid side shields.
 Infection Control 201

Figure 9-7: Handling of mask

Figure 9-9: Distribution of spatter during a

dental procedure

Figure 9-8: Protective eyewear and masks

• In dentistry it can be goggles, polycarbonate glasses

with side-shields, faceshields and prescription glasses
with disposable side-shields.
• Most eyewear should at least be cleaned with soap and
water at the end of each session or when visibly
contaminated.
Figure 9-10: No anticipation of splash or splatter
• While trimming models, dentures, cutting wires and
requires only application of gloves
doing lab work or during reprocessing of instruments,
use of protective eyewear is a must to reduce the
• A fluid resistant gown that is full sleeved is adequate
probability of exposure to hazardous materials and
for use as protective equipment.
hard particulate matter that may damage the eyes.
• Gowns are to be changed between patients to control
Hair should be kept back out of treatment. Hair can cross-contamination between patients.
trap heavy contamination. Personnel must protect hair
• Large cuffs can easily harbor large amounts of microbes,
with a surgical cap when encountering heavy spatter
therefore sleeves with knit cuffs are recommended.
(Figure 9-9).
• A simple light weight garment that covers the arms and
chest up to the neck as well as lap when seated appears
Protective Overgarments (Figures 9-10 and 9-11) to be adequate.
• An overgarment must require minimum handling and • Wearing contaminated garments out of clinical area is
should be easily laundered. not permissible.
202 Essentials of Operative Dentistry

Overview of Aseptic Techniques

Whatever operatory personnel touch and handles is
contaminated and has to be cleaned and sterilized
properly.

During Each Appointment

• Directly touch only what has to be touched.
• Remember whatever touched is contaminated.
• Use one of the following control contamination:
• Clean and sterilize it.
• Use a disposable device and discard it.
• Protect with disposable single covers.
• Scrub and disinfect it as well as possible.
• Consistently practising these concepts of asepsis can
reduce cross-infection links.
• Some of the instruments that are needlessly contami-
Figures 9-11A and B: When splash or spatter is expected nated in dental office set up are telephones, faucet
facemasks, gloves eyewear are mandatory handles, switches, cabinet, drawer handles, radio-
graphy controls, charts, pens.
• Laundering with regular laundering detergent seems • With treatment soiled gloves avoid unnecessary contact
acceptable. with above mentioned instruments. Use wrist, arm,
paper towel as when necessary to contact this
instrument.
Disposal of Clinical Waste
• Use single use plastic bags, foils, or plastic baggies to
• Infected blood and other liquid chemical waste can be cover dental units, controls and radiography unit.
poured down sewer, but not mercury.
• Adding 5% sodium hypochloride in water to each Operatory Asepsis (Figures 9-12 to 9-14)
30 ounces of fluid collected in surgical aspiration bottles
• Operatory surfaces that will be repeatedly touched or
is recommended before disposing fluid down the drain.
soiled are best protected with disposable covers that
• Contaminated materials like used mask, gloves, blood
can be discarded after each appointment.
soaked sponges must be discarded safely and
• Surface barriers are a practical and an easy way to
separately and not into trash.
contain cross-contamination.
• Barriers can be sterile or non-sterile depending on
Needle Disposal whether they are used for a surgical or a non-surgical
Goals of needle disposal are: routine dental care.
• Dispose needles in hard walled container which has • Changing covers eliminates cleaning and disinfecting
biohazard symbol. the surfaces.
• Locate the needle disposal container close to where • Inexpensive large clear bags are used in numerous
needle is used. offices to cover dental units.
• Avoid carrying unsheathed needles that may • Many preformed barriers are available that are relatively
endangered others. inexpensive and specific to certain equipment surfaces.
• Pointed instrument that are not hollow are less Other less expensive alternatives are generic plastic
danger in transmitting infected blood than needles. cling-wrap or food wrap.
• Use great care in passing instruments and syringes
with unsheathed needle to another person. Turn Critical Instruments (Figure 9-15 and Table 9-3)
sharp and curved ends away from the recipient’s • These instruments that contact cut tissues or penetrate
hand. tissues.
• Remove burs from handpieces when finished if left • These instruments require thorough cleaning and
in place point it away from body and hands. sterilization.
 Infection Control 203

Figure 9-12: Some of the commonly touched objects in operatory room is covered by barriers

Figure 9-13: Clinical set-up contact surfaces

204 Essentials of Operative Dentistry

Figure 9-14: Housekeeping surfaces

Figure 9-15: Examples of Spaulding classification instruments

 Infection Control 205
Table 9-3: Preparation of semicritical items and noncritical items

Level Risks Control methods Materials /devices

Critical High Sterilization by: Items that are used in surgery which pierce soft and
• Autoclave hard tissue
• Chemiclave Scalpel blades, burs, extraction forceps, elevators,
• Dry heat needles, files, bone-rongers, periodontal instruments
• Immersion in full strength used in prophylaxis, surgical drains for abscesses, and
• Glutaraldehyde (8 hours) any other insturment used in surgery, dental explorers,
for sterilization and rinsed with periodontal probes, biopsy punch, surgical drains,
sterile water) endodontic files and reamers, and implants
or
• Sterile single-use-disposables
Semicritical High Sterilization by: Items that do not necessarily penetrate soft and hard
• Autoclave tissues but which cross the vermilion border (lip) into
• Chemiclave the oral cavity
• Dry heat Mouth mirrors, handpiece, aesthetic syringes, chip
• Immersion in full strength glutaraldehyde syringes, amalgam condensers, impression trays, air/
(3 hours for sterilization and rinsed water syringe tips, high-volume evacuator tips
using sterile water)
or
• Sterile single-use-disposables
• Clear but nonsterile use disposables
supplies
Noncritical Moderate Surface disinfection with intermediate
to low level hospital disinfectants Items used in dentistry which do not cross the vermilion
• Hydrogen peroxide based border or penetrate the soft tissues—chairlight
• Phenols handles,instrument trays, high touch work surfaces,
• Iodophors bracket tables, chair controls, Air/water syringes, hoses
• Quaternary Ammonia Compounds and dental chairs
or
• Disposable Barriers
Environmental Low Disinfection with Intermediate to low level
disinfectants: Floors, walls and door handles that are not considered
• Phenols high touch surfaces. General housekeeping rule
• Iodophors applies to these surfaces
• Quaterary ammonia compounds
Sanitization:
• Scrub wash with soap and water

This classification of items based on infection potentiality was given by Earle H Spaulding in 1968.

Semicritical Instruments Disinfection

• Are items that touch mucosa and are handled by and It is always two step procedures.
touched by gloved hand coated with blood and saliva. • Initial step involves vigorous scrubbing and wiping
• Must be removed for cleaning and sterilization or they clean of surfaces to be disinfected.
must be disposables or should be protected from • Wetting the surface with disinfectant and leaving it
contamination by plastic covers. wet for prescribed amount of time for particular
disinfectant.
Noncritical Instruments • Wear protective utility gloves to clean equipment that
• These items that are not touched ordinarily during treat- cannot be covered. Nitrile gloves are used for cleaning
ment procedures. These include environmental surfaces. instruments.
• Contaminated noncritical items require cleaning and • Use a water based disinfectant cleaner (e.g. synthetic
disinfection. phenol disinfectant, chlorhexidine antiseptic scrub).
206 Essentials of Operative Dentistry

• Dry the instruments with a paper towel. a short duration of contact is also called a high level dis-
• Then wet the instrument with disinfectant and leave infectant where all vegetative bacteria, fungi and viruses
them wet for prescribed period of time. are killed including M. tuberculosis (Tuberculocidal).
• Intermediate level disinfectants should kill all vegetative
Disinfectants microorganisms, fungi, viruses and M. tuberculosis
(Tuberculocidal).
Common germicides used in dentistry can be categorized
• Low-level disinfectants are those that kill vegetative
into (Figure 9-16).
microorganisms, some viruses and no kill claim for
M. tuberculosis.

Spectrum of Disinfectant
• Mycobacterium tuberculosis kill claim
• At least one hydrophilic virus kill claim (difficult
organism to kill)
• Rotavirus WA
• Rotavirus SA 11
• Poliovirus Type 2
• At least one lipophilic virus kill claim (easier organisms
to kill than hydrophilic viruses)
• Herpes simplex 1
Figure 9-16: Various commercial liquid disinfectant
• Herpes simplex 2
• Influenza A2
Liquid Sterilants / High Level Disinfectants
• Human immunodeficiency virus (HIV)
• Glutaraldehyde
• Chlorine dioxide Use and Misuse of Disinfectants
• Hydrogen peroxide
• An immersion disinfectant like glutraldehyde cannot
be used as a spray disinfectant.
Disinfectants (Intermediate and Low Level)
• A disinfectant cannot be used as an antiseptic and vice
• Hydrogen peroxide versa.
• Sodium hypochlorite • Generic house hold bleach cannot be used for
• Chlorine dioxide disinfectant purposes in dental set up.
• Iodophors
• Synthetic phenols Immersion Disinfectants / Liquid Sterilants /
• Quaternary ammonia compounds High Level Disinfectants
These could be:
Antiseptics (For Oral and Nonoral Use) • 2-3% glutaraldehyde
• Active chlorine dioxide germicides • Chlorine dioxide
• Essential oil compounds • Sodium hypochloride (Bleach)
• Iodinated compounds • Iodophors
• Chlorhexidine compounds • Phenolic compounds
• Cetylpyridium compounds • Quaternary ammonia compounds
• Sanguinarine based compounds Immersion time may vary form 3 to 30 min based on the
• Parachlorometaxylenol compounds ability to kill mycobacterium.
• Other bacteriostatic/bactericidal compounds Only items that cannot be heat sterilized or other mode
Based on duration of exposure a sterilant may act as of sterilization is used by this method (e.g. impression
disinfectant (e.g. glutaraldehyde exposure for 10-12 hours trays, photographic mirrors, casts).
is sterilant same for 30 minutes exposure is disinfectant). Most items require a time of 6 hours or more for
• Sterilants should kill all bacterial endospores, vegetative sterilization.
microorganisms and viruses. A sterilant that is used for They cannot be monitored for sterilization.
 Infection Control 207
Method Alcohol-based Disinfectants
• Rinse out the bioburden (Sanitization) • They are available as foams, sprays.
• Immersion for disinfectant (Disinfection) • They have problem of fixing the microbes and blood on
• Rinse out disinfectant. surfaces and hinder the procedure of sanitization.
• Also they tend to evaporate more quickly.
Surface Disinfectants
• Hydrogen peroxide, chlorine dioxide, bleach (Sodium Water-based Disinfectants
Hypochlorite), iodophors, synthetic dual and • Are more reliable than alcohol-based and they do not
triphenolic compounds and quaternary ammonia com- fix the bioburden.
pounds are also considered as surface disinfectants. • Do not evaporate and tend to settle in area where they
• These germicides also have a disinfection time are applied.
based on M. tuberculosis kill time ranging from 3 to
30 min.
Antiseptic Germicides
• Surfaces that cannot be immersed such as bracket table,
light handles, hoses, counter surfaces, chair controls, • These are germicides that are used on the skin and
X-ray unit head/ handles/controls and other surfaces mucosa of the patient.
that have a tendency to get contaminated during patient • Alcohol swabs are used to clean skin surface prior to
care must be disinfected. injection of medicines/anesthetics. Intraorally, tinctures
and paints are use to clean and decontaminate surgical
sites.
Method
• Mouthwashes having antimicrobial claims (chlor-
1. Spray to wet surface, and wipe to remove bioburden hexidine, listerine, scope) are also beneficial in reducing
(sanitization) (Figures 9-17A to C). the microbial load in the mouth when used as a pre-
2. Spray to wet complete surface and wait for the procedural mouthrinse prior to treating the patient.
prescribed disinfection time (disinfection) and wipe to • Antiseptics must not be used to decontaminate work
remove excess of disinfectant. surfaces, equipment or reprocessing instruments
• Certain surfaces such as electrical controls, the chair as they are not potent enough to kill microbes as
surfaces including the headrest, armrest and seat may disinfectants are.
be sanitized and disinfected by initially spraying the Alcohol by itself is not recommended as disinfectant in
disinfectant on a disposable paper towel and wiping dentistry.
the surfaces thoroughly once to remove the bioburden
and then repeating the same process over and finally Few Facts About Disinfectants (Table 9-4)
wiping dry the surface with a new paper towel.
• Bioburden can reduce efficacy of the disinfectant
Reusable cloth towels are not to be used as they harbor
therefore sanitization and reduction of bioburden prior
large amounts of bioburden.
to disinfection application is necessary.
• Certain disinfectant are capable of altering surface
Dispensing details and dimension stability of certain impression
Some manufacturers dispense the disinfectant in materials therefore manufacturer’s instructions be
concentrate doses to be diluted and used. followed.

Figures 9.17A to C: Use of surface disinfectant

208 Essentials of Operative Dentistry

Table 9-4: Advantages and disadvantages of germicides

Advantages Disadvantages
Iodophors
Broad spectrum Unstable at high temperatures
Short biocidal activity Dilution and contact time critical
Few reactions Solution to be prepared daily
Residual biocidal action Rust inhibitor needed
Inactivated by hard water
Many discolor some surfaces
Hypochlorite (Bleach)
Rapid antimicrobial action Very corrosive to metals
Broad-spectrum kill Damages plastic and rubber, clothes
Effective in dilute solution To be prepared daily
Economical Unpleasant odor
Toxic disinfection by-products
Chlorine Dioxide
3 minutes for disinfection Highly corrosive to metals and certain
6 hours for sterilization plastics on prolonged exposure
No trihalomethanes To be mixed daily
Adequate ventilation needed
Hydrogen peroxide (0.05%)
Rapid antimicrobial action Not many reported disadvantages as
Broad-spectrum kill it is still new in the market
Effective in dilute solution
Economical
Compatible with metals, plastics
and impression materials
Synthetic Phenols
Triphenols are better than dual phenols May affect some polymers
Broad spectrum kill Some have film accumulation
Compatible with most materials May not be used in neonatal and pediatric practices
Residual biocidal action due to possible adverse reaction
Fast acting
Very long shelf life (some 60 days)
Good cleaners
Quaternary Ammonia Compounds
Good cleaners Inactivated by hard water
Some have M. tuberculosis kill claim Some have variable bactericidal activity
Good Vacuum line cleaner Most do not have M. tuberculosis kill claim
Alcohol based quarts may affect low viscosity
impression dimensional stability
Hydrogen Peroxide (7%)
Very potent germicide Can be corrosive on metals
Sporicidal at prolonged short exposure Can be dangerous to skin (burns)
Active in the presence of bioburden Not tested widely (very little data available)
Prolonged shelf and active life
Reusable
Compatible with plastics and impressions
Good for use in dental laboratories
Glutaraldehyde and OPA
Very potent germicide Items must be rinsed with sterile water
Sporicidal at prolonged contact Only for immersion and not for surface use
Active in the presence of bioburden Severe tissue/respiratory irritant
Prolonged shelf and active life Must use closed containers
Reusable Must have good ventilation and evacuation
Compatible with most materials Can sensitize users
Good for use in dental laboratories
 Infection Control 209
• All disinfectants are toxic and handle with care. • Drain and air dry the instruments in cassettes then
Handling should be done by protective eyewear, mask, dispense the instrument onto an absorbent towel.
utility gloves and protective gown. • Still wearing protective gloves, properly package the
• At the end of the day, the suction lines (High-volume- instrument with sterilization indicators.
evacuator, and Saliva Ejector) should be cleaned with • Protective nitrile utility gloves are made up of nitrile
either a quaternary ammonia compound cleaner or an latex and are most puncture resistant and these can be
enzymatic detergent mixed in water. washed and wiped with disinfectant or autoclaved as
• The cleaner should be sucked through the lines either necessary.
aerosolized or as a liquid and let sit for about 10 minutes.
• After the 10 min soak, water should be sucked through Instrument Containers
the lines to wash out the cleaner along with patient These must be:
debris and other materials. The suction traps must be • Immediately or soon after use the reusable instrument
examined and replaced at least weekly. are placed in containers, that must be puncture resistant,
leakproof properly labeled, color coded.
• Reusable sharps must not be placed in a container where
Instrument Reprocessing and it is to be reached into by hands to handle it.
Sterilization Monitoring Instruments must be placed in a disinfectant soaking
or holding solution, to prevent debris from hardening on
• Instrument reprocessing is the most important aspect the instruments. This solution must be aldehyde free to
of Dental Infection Control as it deals with items that prevent fixation of blood onto the instrument.
have the greatest potential for disease transmission
during dental care. Disinfectant holding solution for transporting and soaking used
• Any dental instrument that enters the oral cavity is instruments should:
classified as critical or semi critical surfaces per • Contain detergent
Spaulding’s classification and must be sterilized. • Be economical
• Common methods of in-office sterilization in dentistry • Not corrode
are autoclaving, chemiclaving and dry heat. For items • Not inactivated by organic debris.
that are heat labile, chemical immersion methods using Some concentrated phenolic products can be diluted
and used as holding solution. No currently available
an approved chemical sterilant although rare, must be
product can completely disinfect soiled instrument so
used. Today, all items that are used in dentistry as
utility gloves must be worn.
critical and semicritical. Items are heat sterilizable or
Usually instruments are soaked for about 10 min.
sterile-single-use disposable.
Manual Cleaning of Instrument
Principle and Procedure for Handling and
• A long-handled pan scrubbing brush is to be used.
Cleaning Instrument
• Face shield, protective eyewear and utility gloves are
• Instruments are cleaned to reduce the bioburden load necessary to prevent spatter.
prior to sterilization. • Aerated water from tap is used to clean instruments as
• Instrument cleaning procedures should be effective and they can prevent spatter.
at same time avoiding exposure prone tasks. • Scrapping or appropriate solvent cleaner can be used
• Safest and most efficient way of cleaning instrument to remove coatings such as plaster, wax, cement and
involves ultrasonic cleaning of used instrument kept in impression material.
perforated basket or cassette. • When finished cleaning use paper towels to clean the
• Wearing of protective utility gloves at all times of sink.
cleaning and handling instruments is mandatory.
• Used instruments are commonly placed in an Ultrasonic Cleaners and Solutions
antimicrobial cleaning solution before cleaning as they • Ultrasonic cleaning is the safest and most efficient way
soften and loosens the debris. to clean sharp instruments after they have been rinsed
• Next put the instrument in ultrasonic cleaning device. and soaked.
• Following this dip instruments if necessary in rust • Ultrasonic cleaning (sonication) is very efficient and
inhibition solution. works by a process called cavitation where there is
210 Essentials of Operative Dentistry

implosive activity or cavitation that helps tear away 10 secs. Upon completion the foil is inspected and every
dirt and debris from instrument surfaces square ½ inch of foil should show indentations if unit is
• Burs should be ultrasonically cleaned. working properly.
• Ultrasonic cleaning is 9 times as effective as manual
cleaning. Instrument Inspection
• Even after an ultrasonic process patient material may
still be on the surface of instruments that may need to • After ultrasonic cleaning of instrument, the instruments
be physically removed by using a long handle brush to should be rinsed in running water to remove residual
reduce the risk of sharps injury. dirt or disinfectant solution.
• Sonication of loose instruments should be carried out • Instruments in basket are then placed on paper towel
for 8-10 min and the period doubled (15-20 minutes) and pat dried.
for instruments in cassettes. • Then the instrument is noted for any residual debris
• Ultrasonic solutions that are non-ionic and some and manually cleaned using a long handled brush.
enzymatic ultrasonic solutions are less corrosive on • Instruments are now arranged and set in bags or
instruments than others. One should not use dis- cassettes.
infectant solutions instead of ultrasonic solutions.
Instrument Containment
Operations • Cloth packs, wraps, commercial plastic bags are suitable
• Operate tank on-half to three fourths full of cleaning for instrument containment if they are compatible with
solutions. method of sterilization.
• Use cleaning solutions recommended by manufacturer. • Various kinds of instrument trays and cassettes are
• Operate the cleaner for 5 min or longer as recommended available that can rinsed, ultrasonically cleaned and
by manufacturer. packaged for sterilization and maintenance of
• Coating such as plaster, wax, cement can be removed instrument organization.
with appropriate solvent cleaner. • If instruments are to be used as loose or in cassettes it
• Verify ultrasonic performance monthly and can be should be properly packaged with sterilization
assessed by foil test. indicator or process indicator.
Ultrasonic solutions should be prepared daily per • Place the sterilized instrument in a dry dust free place.
manufacturer’s dilutions and the machine run for a • Packaged sterile instruments can be stored for as long
minimum of 15 minutes at the beginning of the day without as the integrity of the pouch/package is not broken,
instruments to remove bubbles, this process is call damaged or affected by moisture after being sterilized
degassing. Degassing is done to remove bubbles that and dried (Figures 9-19 and 9-20).
hinder the process of sonication (Figure 9-18).

Figure 9-18: Ultrasonic cleaner with solution

Foil Test
An aluminium foil can be used to hang like curtain without
touching the tank edges, ultrasonic cleaner is operated for Figure 9-19: Instrument cassettes for packaging
 Infection Control 211
Sterilization
• Infectious patients go undetected more often than they
are recognized.
• Sterilization provides method of instrument recycling
that can be monitored and documented to show that
conditions for disease transmission control were
established (Figure 9-21).

Accepted Methods of Sterilization

• Steam pressure sterilization (Autoclave)
• Chemical vapor pressure sterilization (Chemiclave)
• Dry heat sterilization (Dry clave)
• Ethylene oxide sterilization.
Figure 9-20: Instrument packaging Each method and commercial modification has very
specific requirements that need to be fulfilled.

• Usage non-bagged sterilization of instruments, the

Selection of Sterilization Methods and
instruments have to be used immediately and cannot
be bagged after sterilization, preserved or considered
Equipments
sterile for later use. • It is best to evaluate office needs and examine sterilizer
• If instruments are to be “cold sterilized” in capabilities and then select one or two methods of
glutaraldehyde or any approved immersion sterilant, sterilization.
the instruments should not be packaged but should be • Stainless steel instruments and mirrors used for
rinsed with sterile water to remove residual chemical operative, endodontic procedures can be sterilized by
sterilant from the surfaces of the instrument and used any accepted method.
immediately. • Handpieces can be autoclaved.
• Keep sterile and non-sterile instrument separately.

Figure 9-21: Methods of sterilization (instrument sterilization cycle)

212 Essentials of Operative Dentistry

• Burs can be safely sterilized by dry heat or chemical Disadvantages

vapor in chemiclave, but many rust or corrode if
• Items sensitive to elevated temperature cannot be
autoclaved. sterilized.
• Metal impression trays could be sterilized by any • Tends to rust carbon steel instruments and burs.
methods but dry heat may remove soldered handles.
• Towels can be best autoclaved.
• Sterilizer will be used everyday of practice. Choose Sterilization of Burs
reliable sterilization equipment of proper size and cycle • To avoid corrosion in burs they are sterilized in dry
time compatible with needs of practice. heat oven or ethylene oxide gas sterilizer.
• For autoclaving the bur, burs can be protected by
keeping them submerged in a small amount of 2%
Steam Pressure Sterilization (Autoclaving)
sodium nitrite solution.
(Figure 9-22)
• Place the bur along with solution in the sterilizer and
• This is the most common and reliable method of operate the sterilizer for normal sterilization cycle
sterilization, but can corrode carbon steel instruments. (Figure 9-23).
• For a light load instruments the time required at • Before use nitrite residue can be wiped off or rinsed off
250° F (120°C) is a minimum of 15 mts at 15 lbs pressure with clean and sterile water.
or 273°F (134°C), 7 mts, 30 lbs pressure.
• Autoclave can be manual or automatic.
• Instruments should be dry before placing in autoclave.
• Large tight packs of instruments should not be used as
steam cannot enter through the package.
• Only distilled water be used for autoclave.
• Sterilization should be routinely monitored.

Parameters Standard cycle Fast cycle

Sterilization time 15-20 minutes 3-5 minutes
Temperature 121° C (250°F) 134°C (273°F)
Pressure 15 pounds per 30 pounds per
square inch (psi) square inch

Advantages
Figure 9-23: Bur stand
• Most rapid and efficient way of sterilizing cloth surgical
packs and towel packs.
• They handle trays and paper packed instruments. Chemical Vapor Pressure Sterilization
(Chemiclave) (Figure 9-24)
• Sterilization by chemical under pressure is performed
in a chemiclave.
• Chemical vapor pressure sterilizers operate at 270° F
(131° C) and 20 lbs pressure.
• They can handle aldehyde vapors.
• Loading of instruments be done same as autoclave.

Advantages
Carbon steel and other corrosion sensitive burs,
instruments, pliers can be sterilized.

Disadvantages
Figure 9-22: Autoclave • Items sensitive to elevated temperature will be damaged.
 Infection Control 213

Figure 9-24: Chemiclave

• Instruments must be lightly packed. Figure 9-25: Dry heat sterilizer

• Towels and cloth surgical wrapping cannot be
penetrated by chemical vapor. Parameter Slow cycle Fast cycle Rapid heat2
• Should be monitored regularly. Temperature 160°C (320°F) 170°C (340°F) 190°C (375°F)
Sterilization time 120 minutes 60 minutes 6-12 minutes

Dry Heat Sterilization Advantages

• Carbon steel instruments and burs do not corrode, lose
Conventional Dry Heat Ovens
cutting edges.
• Dry heat sterilization is achieved at temperatures above • Rapid cycles are possible.
320° F (160° C).
• Conventional dry heat ovens are merely heated Disadvantages
chambers that allow air to circulate by gravity flow • Heat sensitive items like plastic goods or rubber may be
(gravity convection). damaged.
• Temperature of 320°F for 30 minutes. • Heavy loads of instruments may defeat sterilization.
• Time required for sterilization depends upon efficiency
of oven, size of load. Ethylene Oxide Sterilization (Figure 9-26)
• Additional 0.5 to 1.5 hrs may be required. • Is the gentlest method for sterilizing complex
• Most sterilization failures are obtained with dry heat instruments and delicate materials.
ovens. • Automatic devices sterilize items well below 100° C in
• Accurate way of calibration is by using an external hours.
thermometer gauge. • Overnight devices achieve sterilization by overnight at
room temperature.
Short Cycle High Temperature Dry Heat Ovens • Porous and plastic materials absorb gases and they
(Figure 9-25) require aeration for 24 hrs before safely employed on
patients.
• A rapid high temperature process that uses a forced-
draft oven (a mechanical convection oven that circulates
air with a fan or blower) requires total sterilization time
Boiling Water
of 6-12 mts. • Does not kill spores and cannot sterilize instruments.
• They operate at temperature of approx 370-375° F. • Boiling is a method of high level disinfectant when
Properly weekly monitoring of these ovens is necessary. actual sterilization cannot be achieved.
214 Essentials of Operative Dentistry

• These markers are important to identify and differentiate

those packs that are sterilized from those not.
• Used alone these indicators are not enough to monitor
sterilization.

Process Indicator Strips

• Provide an inexpensive, qualitative, daily monitor of
sterilizer function and heat penetration into instrument
packs.
• Place one of the color change process indicator strips
into every surgical pack, and in atleast one of the
operative instrument in center of each load.
• As soon as the pack is opened the strip can identify
breakdowns or gross overloads.
Figure 9-26: Ethylene oxide sterilizer • Strip is not an accurate measure of sterilization time
and temperature exposure.
• Well cleaned instruments must be completely sub-
merged and allowed to boil at 98-100° C for 10 mts. Biologic Monitoring Strips
• Pressure similar to autoclaving can also be employed.
• Biologic monitoring spore test strip is the accepted weekly
monitor of adequate time and temperature exposure.
New Methods of Sterilization • Spores dried on absorbent paper strips are calibrated to
• Microwave oven have limitations for sterilizing metal be killed when sterilization conditions are reached and
items, but research are on for better microwave maintained for the necessary time to kill all pathogenic
technology. microoganisms.
• Peroxide vapor sterilization is under development. • Strips can be send to laboratory for verification.
• Ultraviolet light is not highly effective against RNA • In office 24 hour monitoring kits are available which
viruses such as HIV and against bacterial spores. can be tested for sterilizer efficiency inmmediately.
• Ultraviolet radiation can be used for sanitizing rooms.
Documentation Notebook
Monitors of Sterilization In a notebook affix a single dated, initiated, indicator strip
• Effective instrument sterilization is assured by routine to a sheet or calendar for each work day followed by a
monitoring of instrument sterilization. weekly spore strip report.
• Sterilization is defined as killing all forms of life
including most heat resistant form bacterial spore.
• For instruments that penetrate mucosa this provides
Types of Instruments and Sterilization
control of spore forming tetanus and gas gangrene Methods (Table 9-5)
species. Hand Instruments
• For instrument that touches mucosa this prevents
• Sterilizing carbon steel instruments can lead to
hepatitis-B, TB transmission.
discoloration, rust and corrosion.
Sterilization monitoring has four components: • Usually manufacturers electroplate the instrument to
• Sterilization indicator on bag. prevent this.
• Daily process indicator strips. • Plating can get removed off from handles, shank and
• Weekly biological spore test. blade due to usage.
• Documentation note book. • A second method for rust inhibition is employing rust
inhibitors 2% sodium nitrate) which are soluble alkaline
Sterilization Indicator solutions.
• These are marked with heat sensitive dyes that can • Third method is promptly removing the instrument after
change color easily on exposure to heat or sterilization sterilization cycle and dries them thoroughly and place
chemicals. them in instrument trays.
 Infection Control 215
Table 9.5: Types of instruments and sterilization methods

Aluminium Instruments—need special care. Use neutral cleaning agents and disinfectants suitable for aluminium. Check
cleaning agent label for precautions for use with aluminium. Do not clean in an ultrasonic cleaner.
Amalgam Carriers—remove amalgam residue immediately after use.
Aspirators and Aspirator Tips—clean, disinfect and sterilize only in a completely disassembled state.
Crown Remover (CRL and CRU)—do not process in dry heat. Do not disinfect with phenols or iodophors.
Plastic Retractors (CRPC and CRPA)—can only be disinfected by chemical disinfection.
Hinged Instruments—process in an open state and lubricate prior to sterilization.
Mouth Mirrors—to avoid scratches on the mirror surface from other pointed instruments, reprocess in an instrument tray with
instrument rails
Plastic Filling Instruments—process in cassettes or trays with instrument rails to avoid scratches on the surface from other
pointed instruments. Residues of filling materials and etching products must be removed immediately. Plastic filling instruments
are designed with an extra smooth surface, in order to provide a better handling with composite materials. Scratches that are not
visible might cause composite materials to stick to the rougher surface.
Resin Instruments and Resin Components or Resin Cassettes—dry heat is explicitly not compatible with instruments with
resin handles (handle #8), with resin or Silicone components, inserts on any instruments, or with resin cassettes. For resin or
silicone products do not use detergents or disinfectants containing phenols or iodophors.
Root Canal Instruments—reprocess in suitable endodontic stands. Pretreatment should be conducted outside the endodontic
stand.

• Instruments made of aluminium, chrome, chrome plated

nickel, carbon are highly prone to corrosion.
• Stainless steel instrument do not rust but prolonged
immersion in cold disinfectant solution can lead to rust
formation.
• Care should be taken not to expose stainless steel
instruments for more than 4 hours in following
chemicals, these chemicals include: Aluminum chloride,
barium chloride, bichloride of mercury, calcium
chloride, carbolic acid, chlorinated lime, citric acid,
Dakin’s solution, ferrous chloride, Lysol, mercuric Figure 9-27: Processing of hinged
chloride, mercury salts, phenol, potassium perman- instruments in open position
ganate, potassium thiocyante, sodium hypochlorite,
stannous chloride and tartaric acid.
• The following chemicals should never be used with
stainless steel: Aqua regia, ferric chloride, sulfuric acid,
hydrochloric acid and iodine.
• In addition, cleaning, disinfection and sterilization is
also required for the first use of non-sterile instruments
after removal from the protective packaging (Figures
9-27 to 9-29).

Dental Instrument Staining

• Dental practitioners continue to be plagued by staining
and corrosion of instruments.
Figure 9-28: Instrument cassettes utilized for holding
• Stains can either be deposited onto the instrument, as instruments, cleaning of instruments, sterilizing and packaging
in the case of spotting due to contaminated water in and storing of instrument
216 Essentials of Operative Dentistry

the autoclave, or develop from within, as occurs with

rust.
• Identification of the source of the stain is fundamental
to solving instrument-staining problems.
• The origin of the stain may be the instrument itself or
another source. Possible causes of staining include an
inadequately maintained sterilizer, instrument contact
with harsh detergents and chemicals, and processing
dissimilar metals during cleaning and sterilization
cycles. In general, most stains occur during the
sterilization cycle (Table 9-6).
Figure 9-29: Instrument packaging

Table 9-6: Troubleshooting guide for dental instruments

Problem Cause Prevention

Spotting Insufficient rinsing after • Rinse thoroughly under steady stream of water for
ultrasonic cleaning recommend time
Insufficient drying after • Rinse with hot water
ultrasonic cleaning Optional: Dip cassettes in alcohol after rinsing
Contaminated ultrasonic • Solution should be changed at least once daily
Sterilizer has not been cleaned • Sterilizer should be cleaned weekly per manufacturer
recommendation
• Use only distilled water for reservoir
Rust Worn chrome plating of brass instruments • Look for plating wear; remove from service
Corrosion from carbon instruments • Separate stainless and carbon steel instruments during
spreads to stainless steel instruments cleaning and to sterilization cycle
inexpensive instruments not having • Dip carbon steel instrument in “milk bath”
undergone passivation process • Remove instruments from service
Improperly maintained • Clean and flush water lines in sterilizer to manufacturer
autoclave: Rust transfers recommendations
from corroded pipes • Disinfect inner chamber
and drum to instruments
Pitting Chemical attack on instruments • Rinse and dry instrument thoroughly; use approved
cleaning, sterilization solutions only
Brown/orange stain Contaminated sterilizer; high alkaline • Clean sterilizer
detergents, cold disinfectants, Use neutral pH solutions
dried blood, copalite Clean and rinse instruments thoroughly
Black stain Acid reaction from low pH detergents; • Maintain neutral environment in the sterilizer; avoid
tartar and stain remover, residual contact with incompatible solutions
amalgam oxidation Remove excess amalgam from carrier
Bluish-black stain Mixing dissimilar metals • Segregate carbon steel, aluminium, and stainless steel
during cleaning and sterilization instruments
Inferior or worn plating of carbon • Segregate instruments or remove from service
steel instruments
Gray stain Permanent cement remover sulfuric • Avoid contact with these solutions
acid or hydrochloric acid
Rainbow color stain Chromium oxide stains resulting • Can be polished off, but need to have manufacturer
from excessive heat check hardness
Cracked hinge Excessive force by user; • Confirm intended use for instrument
Sterilization in the closed position Replace instrument
Broken Excessive force by the user • Confirm intended use for instrument
elevator tip cracked handle Replace instrument
 Infection Control 217
• When we anticipate exposure of deeper structures such
as bone, it is pragmatic to use sterile single-use
disposable gloves as an additional measure of safety
for the patient.

Some Single-use Disposables

Personal Protective Equipment
• Exam gloves, surgical gloves, overgloves and finger-
cots.
Figure 9-30: If any of these is found then its • Side shields for prescription glasses.
better to replace the instrument • Surgical masks with or without eye protection and
dome-shaped masks.
Instrument Audit for Dental • Gowns, bonnets and shoe-covers, patient bibs.

Instruments (Figure 9-30) Surface Barriers

• A quick instrument audit should be conducted before • Headrest covers, chair covers, bracket table cover,
each use. The health care worker should be looking for X-ray tube, X-ray switch control, and barrier for work
signs of pitting, corrosion, chipped or peeled plating, surface.
discoloration, cracks, dull cutting edges or worn out • Plastic barrier for light handles, light switch, chair
blades, broken tips and damaged beaks. Mouth mirror controls, saliva ejector and high speed evacuation
should be clear and free from scratches. syringe/hose sleeve, air/water syringe/hose sleeve,
• Scissors specifically should be assessed to confirm that high and slow speed handpiece sleeves.
blades are free of nicks and glide smoothly. To prevent • Barrier sleeves for composite curing lights, IO videocam
scissors’ blades from becoming misaligned, screws wands, IO radiology film barriers.
should never be tightened or loosened. • Sterilization pouches and instrument tray covers.

Summary Items Used Intraorally

Care and maintenance of the dental instruments used in • Single-use disposable needles and burs, anesthetic
your practice is directly related to the overall life span of cartridges, air/water syringe tips, saliva ejector and
your instruments. high volume evacuator tips.
Proper handling, cleaning and sterilization will • Matrix bands, mylar strips, wooden wedge, packing
enhance the function of quality instruments. cord, articulating paper, Thompson’s marker and
sandpaper.
Single-use Disposables • Dispensing tips for flowable and condensable compo-
sites, enchants dispensing tips, irrigation syringes,
• In the absence of a decontamination process one can
Monojet syringe, plastic impression trays, fluoride trays,
use single-use disposable devices such as barriers for
plastic composite mixing trays, plastic mixing spatula,
surfaces.
composite brush, unit dose composite carpules and
• Today, single-use disposable devices comprising
bonding agents.
personal protective equipment, surface barriers and
• Rubber dam, tongue blade, cotton swab, cotton roll, floss,
consumables are to be used regularly in the dental
prophy paste cups, floss threader, disposable prophy
practice.
angle, biteblocks for bitewing radiographs.
• The oral cavity is not a clean site, and therefore, use of
nonsterile disposable gloves are permitted as long as
they have been stored hygienically and have not been Concept of Unit Dose
overtly exposed to contaminants. A nonsterile glove is • Unit dose means to have ready consumables,
to protect the clinician against possible contaminants instruments and dental materials dispensed for a given
from the patient’s mouth. standard procedure.
218 Essentials of Operative Dentistry

• The total amount of the consumables and dental contaminated gloves and other aerosols being
materials needed for the procedure must be dispensed generated chair-side.
irrespective of being used up during the procedure. • It is essential for the clinicians to completely get
• The sterile single-use disposables remaining must not rid of the disposable PPE after treating each patient
be recycled or reprocessed but discarded. and decontaminate devices designed for repro-
• An example of unit dosing PPE for a procedure cessing.
anticipating splash or spatter such as doing an amalgam
restoration would be to have a set that includes:
Handpiece Asepsis
• Reusable protective eyewear or disposable side
shields. • Airdriven and electric motor handpieces are one
• Disposable mask. component of a complex system of instrumentation.
• A pair of disposable exam gloves. • Oral fluid contamination problems of rotary equipment
• Disposable plastic overglove. and especially high speed handpiece involve:
• Disposable gown. • Contamination of external surfaces and crevices in
• A bib and protective eyewear for the patient. handpieces.
The dental unit should have the following single-use • Turbine chamber contamination as it enters the oral
disposables: cavity.
• Headrest/back cover. • Water spray retraction and aspiration of oral fluids.
• Barriers for: • Exposure of personnel to spatter and aerosols
• Light handles. generated by intra oral use of handpiece.
• Chair controls.
• HVE and saliva ejector syringe sleeves. Handpiece Surface Contamination Control
• Sleeves for the highspeed handpiece. • Blood and saliva contaminate the surfaces of
• Barrier for the bracket table. handpieces are difficult remove with wiping by regular
• Single-use disposable air/water syringe tips, HVE and disinfectants.
SE tips. • Immersion of handpiece in disinfectants is not
• Barrier for the work surface/bench. recommended.
For the same procedure materials to be unit dosed • Only sterilization can ensure complete infection control
would be: of handpiece.
• Sterile exam kit.
• Sterile assorted burs in a bur block.
• Sterile highspeed handpiece. Turbine Contamination Control
• Restorative instrument kit including matrix band, • Contaminated oral fluids can be sucked back into the
retainer and an interproximal wooden wedge. handpiece turbine chamber because of negative
• Articulating paper. pressure.
• Cotton rolls and 2 × 2 gauze. • This contamination can be controlled by flushing the
• Topical anesthetic and cotton tip applicator, sterile handpiece in between patients.
needle, syringe and a carpule of a local anesthetic.
• Cavity liner, calcium hydroxide cement including
the mixing tip and tray and adequate amalgam
Water Retraction System Correction
capsules. • Dental unit water control systems made before late 1980s
• The single-use PPE should be discarded and reusable usually water gets retracted once the water spray control
PPE such as protective eyewear decontaminated with is stopped, but this also absorbs oral fluids.
at least soap and water. • This can be prevented by usage and application of check
• A common error by clinicians is to continue using valve.
the same eye-protective devices, mask and gown over • A minimum recommendations to operate the handpiece
multiple patients. As observed by the investigator, spray for 20 sec to expel any aspirated infectious
adjusting eyewear and the mask is quite common material.
during the clinical procedure with the contaminated • Nowadays dental unit without retraction valve has
gloves. Gowns normally come in contact with been manufactured.
 Infection Control 219
Table 9-7: Some disinfectants used for cleaning water system

Some periodic cleaners Method of use

Alkaline peroxide—Sterilex ultra Full strength, overnight contact followed by flushing with hot water
Chlorine dioxide tablets—Vista tabs 30-50 ppm in water, 5-10 min followed by flushing with water
Chlorine dioxide 2 part liquid—BioClenz 30-50 ppm in water, 5-10 min followed by flushing with water
Electrochemical oxidants—Sterilox Full Strength 30 minutes—overnight contact, followed by flush with dilute oxidant
Silver citrate powder—Specific to pure tube Dissolved in water with low total dissolved solids (TDS) and left over night,
followed by a water flush
Peracytic acid—TAED+Perborate (Italy/EU) 5-10 min between patients used in the Castellini Autosteril system,
followed by sterile water flush
Some irrigants Method of use
Boiled water/Distilled/Sterile water Directly in the bottle as irrigant
Silver nitrate tablets—ICX Dissolve in 700 ml of municipal water
Silver citrate tablets—BluTabs Dissolve in 700 ml of municipal water
Silver—Pure tube (Sterisil) Silver ions in water with Low TDS
Iodine—Dentapure (DP 40, 90 and 360) Used inside the bottle replacing the intake tube, or placed in line with water flow
(3-4 ppm)
Chlorine dioxide 2 part liquid—BioClenz 2-4 ppm in municipal water
Electrochemical oxidants—Sterilox Concentrate diluted for irrigant purposed
Grapefruit extract botanical—Vistaclean 5 drops per 700 ml of municipal water (emulsifying agent)

Water System Contamination (Table 9-7) Sterilization of Handpieces and Rotary

• Bacterial growth in biofilms on the inner walls of dental Instruments
unit water lines is a universal occurrence unless steps • Prophylactic handpieces, latch angles, rotary stones
are taken to control it. used in mouth must be sterilized for reuse.
• Main inhabitants are opportunistic gram negative, • Handpieces are semicritical instrument requiring
aquaphilic bacteria, flavo bacteria. sterilization.
• Flushing of handpiece and sterilization of handpiece • More handpieces in inventory the less each one is
cannot be expected to control this contamination which used and lesser each should last until maintenance is
is present in the whole waterline. needed.
• Waterlines can be flushed with 0.5% sodium • Motor end of low speed handpiece can be scrubbed
hypochloride without handpiece in the system. and disinfected after each use.
• This along with flushing of handpiece and sterilization
of handpiece can prevent contamination. Steam Sterilization of Handpieces (Figure 9-31)
• Autoclave of handpieces is one of the most accepted
Control of Contamination from Spatter systems.
and Aerosol • Prior to autoclaving handpieces are to be lubricated,
• Operating handpieces inside oral cavity necessarily cleaned and manufacturer’s instructions has to be
spatters oral fluids and microorganisms onto clinical followed in this regard.
personnel and attending persons and aerosol produc- • Automatic lubricant and cleaning systems are available
tion. for handpieces.
• Aerosols can easily spread mycobacterium species.
• Rubber dam and high volume evacuation can effectively Other Methods of Handpiece Sterilization
reduce aerosol production.
• There is no way of preventing 100% aerosol production Chemical Vapor Sterilization
therefore universal use of barrier must be used. Works well with handpieces having ceramic bearings.
220 Essentials of Operative Dentistry

Considerations in Dental Laboratory

• Risks in the dental laboratory are slightly different from
in the clinic. Due to safety reasons, gloves are not used
while handling lathes (risk of glove snagging in the
lathe) and during most laboratory procedures.
• Whatever comes into the dental laboratory must be
decontaminated or shipped decontaminated to the
dental laboratory.
• Items that are sent back to the clinic for patient
care from the laboratory must also be cleaned and
disinfected.
• Items that can withstand sterilization (veneers,
porcelain/porcelain fused to metal crowns and bridges)
Figure 9-31: Automatic handpiece
maintenance system must be sterilized. Items that cannot be sterilized must
be cleaned, disinfected and rinsed in clean water before
being used in the patient’s mouth.
Ethylene Oxide (ETOX) • Surface covers must be used regularly so that there is
minimal contamination or dirtying of the bench tops.
Takes several hours for reprocessing handpieces.
Laboratory work surfaces must be cleaned and
disinfected at the end of each day.
Dry Heat Sterilization • Before disinfection, all stone/plaster, wax, metal or
Generally not recommended for handpieces. other filings must be cleaned or scraped off of the
surface.
• All sharps such as burs, knifes and scalpels must be
cleaned and decontaminated and stored safely to
Infection Control with Regard to avoid any sharps injuries.
Impression Making • While handing acrylic monomer, there should be
adequate ventilation or evacuation of the air to reduce
• Universal precautions and personal barrier protection
inhalation of the monomer.
needs to be employed while making impressions.
Personal protective equpment used in the laboratory as
• Dispensing materials for impression can be done by
follows:
unit dose method.
• Mask to reduce splash/spatter from trimmers, rag-
• Impressions are to be disinfected according to material
wheels, etc.
to be employed.
• Goggles/protective eye—wear to protect eyes from
• Impressions are to be sent to lab in sealed, labeled plastic
particulate matter and flying debris.
bags.
• Fluid resistant gown as needed.
Infection control procedure if impression is to be poured
• Heavy-duty heat resistant gloves while handling hot
in dental clinic:
devices/investment flasks, hot water baths for removal
of invested wax or for curing acrylic dentures.
Aqueous Impression Material (Alginate) • Colonization of microbes and spread of infection from
• Thoroughly rinse under tap water for 15 sec to remove pumice can be reduced by suspending pumice in
any saliva or blood. disinfectant solution along with surfactant and
• Disinfect the impression by submerging it for 10 m in changing pumice regularly.
0.5% sodium hypochloride. • Polishing and trimming stones, rag wheel has to
• Rinse the impression after this procedure to remove any disinfect daily along with other laboratory tools. Lathe
residual disinfectant. machine should also be disinfected daily.
• Cast could be poured and cast made from this • Work areas should be cleaned and disinfected daily as
impression need not be disinfected. done in dental clinic set-up.
 Infection Control 221
Table 9-8: Infection protocol during radiographic procedure

Materials during film exposure Materials during transportation

1. One dose of pre-procedural anti-bacterial mouthrinse Without barrier envelopes:
2. Paper towels 1. Empty paper cup
3. Disinfectant 2. Cup with exposed films
4. Barriers (preformed or a roll of plastic wrap) 3. Paper napkin/barrier
5. Powder-free gloves (latex or vinyl) 4. Overgloved hands
6. Radiographic films
7. Sterile film holders
8. Two paper cups
9. Overgloves (food handlers gloves) with wrist With barrier envelopes:
area of gloves everted Noncontaminated exposed film packets
10. Leaded thyroid collar and apron
11. Masks, eyewear and protective gowns are needed
when a patient has a known gag-reflex

Considerations in Dental Radiography for shear bond strength tests), they must be immersed
(Table 9-8) in 0.05% thymol solution in water or formalin for at
least a couple of weeks with solution changed daily.
• Most of oral and maxillofacial radiology normally
Bleach should not be used in this instance as it can
consists of noninvasive procedures. Although exposure
dissolve the organic matter in the teeth and alter
to blood is not common, contact with saliva does
outcomes. Teeth can be autoclaved and then discarded
occur. in regular waste.
• Unit dosing of materials and specific step-by-step • Teeth with amalgam fillings should also be disposed
infection control protocols are required. as medical waste that is not incinerated. Teeth with
• Dental radiology objects fall under the category of semi- amalgam fillings can be stored in formalin for
critical objects. disinfection and should not be autoclaved.
• Whenever a potential for contamination by saliva exists • If patients request extracted teeth, the teeth must be
during any OMR procedure, universal precautions must washed, soft tissue tags trimmed, placed in 5000-6000
be observed including the use of adequate personal ppm (1:10 dilution in commercial liquid bleach) bleach
protective equipment (PPE) such as gloves, the proper for at least 10 minutes, rinsed again and dried using a
handling of contaminated materials, and the deconta- paper towel and then provided to the patient in a plastic
mination of surfaces exposed to saliva or contaminated bag/ziplock bag. The patient should also be informed
materials. that it is potentially infectious and not to allow others to
handle the tooth/teeth. It is always better not to give it
back to the patient, but dispose of the extracted teeth as
Considerations for Extracted Teeth medical waste.
• Extracted teeth are infectious and must be treated as • If extracted teeth are to be stored, the teeth should be
medical waste if being discarded. Medical waste that washed, soft tissue trimmed, teeth soaked in a
includes teeth and tissues is potentially infectious and disinfectant for a minimum of 2 weeks (10% formalin)
can be a risk for personnel handling waste. with the disinfectant being changed every 24 hours.
• Extracted teeth that are to be used in the dental The jars/containers with extracted teeth must be
laboratory for shade-matching, in research and in handled with gloves and other required PPE as it is still
materials testing laboratories, or in the preclinical considered potentially infectious.
laboratory for practicing cutting/restorative procedures • Further discussions with this regard are found on
or for preclinical examination must be decontaminated. chapter in preclinical conservative dentistry.
• Methods to decontaminate teeth could be heat
sterilization, immersion in a sterilant such as 5000 ppm Key Terms
bleach, or in glutaraldehyde for the sterilization time.
• If the teeth are to be used in preclinical laboratories or • Sterilization
for research purposes (bonding of composite to teeth • Disinfection
222 Essentials of Operative Dentistry

• Critical • Single-use disposables

• Semicritical • Unit dose
• Noncritical • Instrument reprocessing
• Environmental surfaces
• OSHA
• Personal barrier protection Questions to Think About
• Hand sanitizer 1. What are commonly encountered infections in dental
• Gloves operatory?
• Masks 2. Explain about personal barrier protection.
• Disinfectants 3. Explain about instrument reprocessing and sterilization.
• Surface disinfectants 4. Discuss about handpiece asepsis.
• Instrument containers 5. Elaborate about infection control in dental laboratory.
• Ultrasonic cleaners 6. What are various sterilization techniques available.
• Sterilization indicators Mention their advantages and disadvantages.
 10 Preclinical Conservative
Laboratory Exercises

Certain basic rules are to be followed in laboratory: • Next exercise will be cavity in step form with one of the
• No eating, drinking, or smoking. walls not present. All the dimensions of cavity being
• Keep all cosmetics out of this area. equal.
• Wear personal protective equipment when working in
the laboratory. Exercises in Plaster Tooth Model
• Keep hair back. (Figures 10-1A to E)
• Report all accidents to the attending staff immediately.
• Plaster tooth model is fabricated either from silicone
• Clean the work area before and after every procedure.
tooth model or from alginate mould taken from acrylic
• All exercises are to be done under the guidance of a
tooth form.
supervisor.
• Acrylic tooth model could be processed by using silicone
mould and a handle could be fixed onto the acrylic tooth
Safety in Laboratory model. Usage of acrylic tooth model instead of silicone
mould preserves the silicone mould which is quite costly.
• Physical safety: Know the location of the fire extinguisher • Plaster tooth model is made from alginate mould in a
and fire escape routes. rubber bowl, even 2–3 plaster models could be fabricated.
• Chemical safety: Take care in the handling of corrosive, • Plaster tooth model should be smooth, polished and a
toxic, or carcinogenic substances. base has to be formed.
• Biohazards: Items brought into the laboratory can also
• Plaster models and their excess should be trimmed off
harbor blood and saliva that could be potentially
using plaster knife and smoothened with sandpaper.
infective.
Final gloss is added by soaking the model in soap water
for about 1 hour and then polish with wet cotton.
Plaster Model Exercises • Cavity preparation is done using a sharp enamel chisel
of fairly large size. A chip syringe is a must to clear off
To start the preclinical operative dentistry exercises, it will all the debris.
be better to start the exercises in a plaster square block then • Before commencing cavity preparation the cavity outline
going onto the tooth preparation in plaster tooth models, should be drawn on the model with a pencil.
followed by exercises in natural teeth or typodont tooth. • Cavity preparation form and shape should be same as
on tooth except larger size, all cavity forms should be in
Exercises in Plaster Square Block smooth flowing curves.
• Square block should be of smooth and equal in • Cavity prepared on the plaster tooth model is restored
dimensions in all aspects. with wax (usually modelling wax). Wax should be
• This will preparing cavity in box form with all four added in drops after heating it so that there are no voids.
walls being present and cavity is of equal dimension in • With regard to inlay exercise the cavity prepared is lined
all aspect. by a separating media preferably cold mold seal before
224 Essentials of Operative Dentistry

Figures 10-1A to E: Exercises in plaster tooth model

restoring with wax and a sprue made of stainless steel • Before teeth are to be used they should be cleaned of
wire is attached. patient adherent materials in water and detergent or in
• Wax restoration is carved with lecron wax carver. an ultrasonic unit.
• Methods to decontaminate teeth could be heat
Care of Plaster Models sterilization, immersion in a sterilant such as 5000 ppm
bleach, or in glutaraldehyde for the sterilization time.
• Plaster models needs to handle with utmost care as
• If the teeth are to be used in preclinical laboratories or
they are fragile materials.
for research purposes (Bonding of composite to teeth
• These models have to be kept in a container with cotton
for shear bond strength tests), they must be immersed
wrapped around for protection.
in 0.05% thymol solution in water or formalin for at
least a couple of weeks with solution changed daily.
Restoration with Wax Bleach should not be used in this instance as it can
See Figure 10-2. dissolve the organic matter in the teeth and alter
outcomes. Teeth can be autoclaved and then discarded
in regular waste.
Extracted Teeth for Operative • Teeth with amalgam fillings should also be disposed
as medical waste that is not incinerated. Teeth with
Dental Procedures amalgam fillings can be stored in formalin for
• Extracted teeth are infectious and must be treated as disinfection and should not be autoclaved.
medical waste if being discarded. Medical waste that • If patients request extracted teeth, the teeth must be
includes teeth and tissues is potentially infectious and washed, soft tissue tags trimmed, placed in 5000-
can be a risk for personnel handling waste. 6000 ppm (1:10 dilution in commercial liquid bleach)
• Extracted teeth that are to be used in the dental bleach for at least 10 minutes, rinsed again and dried
laboratory for shade-matching, in research and in using a paper towel and then provided to the patient in
materials testing laboratories, or in the preclinical a plastic bag/zip-lock bag. The patient should also be
laboratory for practicing cutting/restorative procedures informed that it is potentially infectious and not to allow
or for preclinical examination must be decontaminated. others to handle the tooth/teeth. It is always better not
 Preclinical Conservative Laboratory Exercises 225

Figure 10-2: Restoration with wax

to give it back to the patient, but dispose of the extracted 2. Secondary receptacle—leakproof plastic bag (Figure
teeth as medical waste. 10-3).
• If extracted teeth are to be stored, the teeth should be 3. Outer carton—a cardboard box.
washed, soft tissue trimmed, teeth soaked in a Specimen in primary receptacle is stored in 10%
disinfectant for a minimum of 2 weeks (10% formalin) formaldehyde.
with the disinfectant being changed every 24 hours. Primary receptacle should be wrapped in cotton in case
• The jars/containers with extracted teeth must be of leakage and then put in plastic bag.
handled with gloves and other required PPE as it is still Infection protection is not just confined to sterilization
considered potentially infectious. of extracted teeth, but adherence to personal protection
barrier technique is a must.

Transport of Extracted Teeth Natural Tooth Exercises

Extracted teeth are considered infectious material so when
packing and transporting utmost care should be taken.
Advantages
Transporting system consists of three layered • Students can feel the tactile sensation feel of enamel
packaging: and dentin.
1. Primary receptacle—specimen containing container. • Dentinoenamel junction could be visualized.

Figure 10-3: Extracted tooth is transported in a leakproof plastic bag

226 Essentials of Operative Dentistry

• Resin materials could be bonded to tooth surfaces.

• Polishing of restorations against natural tooth surface
interfaces.

Disadvantages
• Infection control management.
• Limited availability.
• Contacts with adjacent tooth cannot be perfect.
• Difficulty in mounting in arch exact arch form.

Criteria for Natural Teeth to be used in

Operative Procedures
• Teeth should be clean and sterile. Figure 10-4: Cleaned, sterile teeth with
• Teeth should have relatively good cuspal morphology good cuspal morphology
free of wear or caries on teeth (Figure 10-4).
• They could be either mounted on acrylic or in dental
• Teeth should not contain any type of restorations.
plaster or stone.
• They could be mounted as individual teeth or as set of
teeth in an arch form.
Mounting • They could also be mounted in typodont arch model
also.
Mounting of Extracted Teeth
• There can be many number of ways by which the natural Mounting in an Acrylic Model
teeth could be mounted to arch form which could be Shown here is a natural tooth mounting in an acrylic form
either hand held or can be mounted on to a dental that could be fixed in a dental simulator and also a slot for
simulators. radiograph positioning (Figures 10-5A to D).

Figures 10-5A to D: Mounting in an acrylic model

 Preclinical Conservative Laboratory Exercises 227
Mounting in a Plaster Model
(Figures 10-6A to 10-8)
• This is a simple inexpensive mounting of natural teeth
in arch form using plaster.
• But it cannot be mounted in a dental simulator. It could
be mounted if a provision of screw placement is provided
in plaster model.

Figures 10-6A and B: After natural teeth has been collected they
are mounted on a wax rim with its occlusal edges upside down Figure 10-8: After the plaster has been removed
from rubber bowl

Figure 10-7: Then root portion exposed they are placed in

plaster poured in a rubber bowl Figure 10-9: Natural teeth mounted in arch form

Mounting in an Arch Form portion of crown and above should be exposed outside for
Here natural teeth are arranged in an arch form utilizing tooth preparation.
a edentulous model and modelling wax. This procedure Besides above mentioned methodology a preformed
is little bit complicated and time consuming (Figure metal phantom jaws are available with slots for natural teeth
10-9). to be affixed by modelling wax (Figures 10-11A and B).
Also any ingenuity can bring novel method of mounting
Mounting of Natural Teeth in natural teeth in an arch form.
Typodont Arch Form
Natural teeth is tried in a typodont arch form and any size
Mounting of Single Natural Tooth
discrepancy is modified and fitted on to the arch form and (Figures 10-12A and B)
secured in place using a polyvinylsiloxane impression • Natural tooth could be mounted as single in either
material (Figures 10-10A to E). plaster or acrylic.
Criteria for mounting natural teeth should be that there • For this procedure empty gutta-percha boxes or a box
should be tight contacts between the teeth and cervical carton could be used.
228 Essentials of Operative Dentistry

Figures 10-10A to E: Teeth secured in place using polyvinylsiloxane impression material

Figures 10-12A and B: Mounting of single tooth in dental stone

• Typodont teeth are made of ivorine a kind of plastic

Figures 10-11A and B: Endodontic typodont where natural with radiopaque quality and feel like natural teeth
teeth could be fixed with wax in the slots provided material. First typodont teeth for educational purposes
were designed by Ben Spitzer in 1920’s (Figures
10-16A and B).
For endodontic purposes single tooth mounting done
by following steps or otherwise endodontic typodont could
be used (Figure 10-13). Working in Typodont
Working is similar to working in dental chair except
Dental Simulators instead of patient a manikin is present; apart from it has
dental delivery tray, operating light. This manikin could
• Modern preclinical operative dentistry labs consists of be adjusted in all directions to keep operator working in
state of the art dental stimulators with virtual reality comfortable way (Figures 10-17 and 10-18).
based stimulation with video projection of the work Typodont teeth set could be mounted and dismounted
being done and its computer evaluation (Figures 10-14 quite easily from the dental simulator. Each individual
and 10-15). teeth could be replaced in teeth set also gingival form also
• Dental simulators are called by various names like could be removed. Each typodont is given with a screw-
typodont, phantom head, dentoform. driver for these purposes (Figures 10-19 to 10-21).
• Typodont is artificial teeth with gums of upper and Besides operative procedures dental simulators are
lower arch for educational purposes. available for various purposes from oral surgery,
 Preclinical Conservative Laboratory Exercises 229

Figure 10-13: Steps in single tooth mounting

Figure 10-14: Modern preclinical laboratories Figure 10-15: Students using video projection to evaluate
their work
periodontal procedures to orthodontic tooth movement
(Figures 10-22 and 10-23).
• Handpieces should be placed securely in the delivery
unit slot before leaving the unit.
Certain Precautions while Working of • Under no circumstances should tooth preparation be
Dental Simulator done by removing typodont and holding them in hand.
• Working on simulator should as same as working on a • Know the working of your typodont unit thoroughly
patient. and where the controls are before engaging in tooth
• Infection control protocol such as personal protection preparation.
barrier is must. • Keep your working unit organized and clean.
230 Essentials of Operative Dentistry

Figure 10-16A: Human teeth typodont Figure 10-18: Dental simulator. A—Operating light, B—Operator,
C—Delivery tray, D—Manikin or dental simulator, E—Handpiece
and three way syringe, F—Dental operator stool, G—Foot control
unit

Figure 10-19: Attaching and detaching typodont teeth set on

to manikin

Figure 10-16B: Canine typodont

Figure 10-20: Replacement of individual teeth

Figure 10-17: Dental chair: A—Suction unit, B—Operating light,

C—Spittoon/Sink, D—Dental delivery unit, E—Handpiece and
three way syringe, F—Foot control unit Figure 10-21: Removal of gingival form
 Preclinical Conservative Laboratory Exercises 231
• Operators position, and chair position for the patient
• Basic aspects of sterilization of instruments and
equipment
• Basic aspects of management of various restorative
materials
(Amalgam, Cement, Glass ionomer, Composites)

Practical Exercises
Exercise I: Excavation of deep caries and indirect pulp-
capping: One molar tooth—1.
Exercise II: Excavation of deep caries and direct pulp-
capping: One molar tooth—1.
Figure 10-22: Preclinical lab set-up in India
Exercise III: Pulpotomy on one molar tooth—1.
Exercise IV: Class I preparations to receive silver amalgam:
One lower molar—1. One lower molar with buccal exten-
sion—1. One lower premolar—1. One upper molar—1.
Exercise V: Class II preparations for silver amalgam: One
lower molar with (mesiocclusal)—1. One lower premolar
(distocclusal)—1. One upper molar (distocclusal)—1.
Exercise VI: Class III preparations for tooth colored material:
One upper central incisor (palatal approach)—l. One lower
central incisor (labial approach)—1. One lower molar—1.
Exercise VII: Class V preparations: One upper canine (tooth
colored material)—1.
One lower molar (amalgam)
Figure 10-23: Dental simulator parts: A—Delivery tray,
B—Typodont teeth set, C—Handpiece and three way syringe, Exercise VIII: Inlay preparations. One lower molar
D—Dental simulator or manikin, E—Suction unit (optional), (mesiocclusodistal)—1.
F—Foot control unit One upper molar (occlusal)—l
Exercise IX: Access cavity preparation. One upper lateral
Syllabus for Preclinical incisor—1
Conservative Dentistry Exercise X: Demonstration on fractured teeth. One natural
central incisor: Restoration by light cure material—1.
• Introduction to operative dentistry
These exercises are done either on natural teeth or on
• Glossary and its significance
typodont teeth.
• Tooth designation and system followed
• Classification of caries
• Basic principles in cavity preparation
• Instruments and equipment for tooth preparation Key Terms
• Cavity preparation for amalgam
• Cavity preparation for inlay • Sterilization of extracted teeth.
• Tooth preparation for tooth colored materials • Transport of extracted teeth.
• Matrices and retainers • Dental stimulators.
• Deep caries management • Typodont.
• Introduction to root canal treatment and pulpotomy • Mounting and dismounting of typodont.
232 Essentials of Operative Dentistry

11 Amalgam Restorative
Material

• Amalgam is an alloy that contains mercury as one of its mixed to produce amalgam. Factors governing quality
component. of dental amalgam can be divided into two groups:
• Dental amalgam is produced by mixing liquid mercury 1. By dentist
with solid particles of an alloy of silver, tin, copper, and 2. By manufacturer.
sometimes gold, indium, palladium, platinum, zinc, • By dentist: A. Selection of alloy, B. Mercury/alloy
selenium. ratio, C. Trituration procedure, D. Condensation
• General description of reaction is as follows: technique, E. Marginal integrity, F. Anatomical
characteristics, G. Final finish.
Alloy particles for amalgam + mercury → dental amalgam +
non-reacted alloy particles • By manufacturer: A. Composition alloy, B. Heat
treatment of alloy, C. Size, shape and method of
production of alloy particles, D. Surface treatment
Alloy Composition of particles, E. Form in which alloy is supplied.
• To produce dental amalgam mercury is mixed with
• ANSI/ADA specification no. 1 requires that amalgam powder of amalgam alloy. The powder may be produced
alloys contain predominantly silver and tin. by milling or lath cutting a cast ingot of amalgam alloy.
Unspecified amount of other elements, for example, This mixing procedure is known as trituration. The
copper, zinc, gold and mercury are allowed in concs. product of trituration is a plastic mass, this plastic mass
less than the silver or tin content. is forced into prepared cavity by a process of
• It is now less common to use silver-tin alloys of GV condensation.
Black, none the less silver-tin alloy is still the major
constituent of alloy system.
• Before these alloys are mixed with mercury they are
History and Controversies
called dental amalgam alloys. Historically, amalgam • Word amalgam is derived from Greek name 'Emolient'
alloys contained atleast 65 wt.% silver, 29 wt.% tin, and which means paste. Earliest records was in 1695 AD by
less than 6 wt.% copper a composition close to GV Black Chieng Sung in China.
in 1896. During 1960s many amalgam alloys containing • Amalgam are alloy of various metals with mercury, in
6 wt.% and 30 wt.% copper were developed. early 1800's in France. D Arcet's Mineral Cement.
• Copper is added up to 4 wt.% to decrease the plasticity • Room temperature amalgam as a restorative material
and to increase hardness and strength of alloy. are attributed to Bell in England and was known as
• Zinc is added to act as deoxidizer of alloy and to 'Bell's Putty'.
decrease brittleness. • Combination of silver and mercury to form 'silver paste'
• Clinical success of amalgam restorations is based on was announced by O Tarcau of Paris in 1826.
meticulous attention to detail. This is one of the • Amalgam had an inauspicious introduction on US in
technically least sensitive material in dentistry. The two 1833 by the name of 'Royal Mineral Succedanem' by
components alloy and mercury are purchased and Crawcour Brothers.
 Amalgam Restorative Material 233
First Amalgam War
• In 1845, 'Amalgam Pledge' was adopted to pledge never
use amalgam.
• First amalgam war gradually abate during the latter
half of 1800's as improved Amalgams of Elisha
Townsend, J Fost Flagg, GV Black came into wide-
spread.
• It was the classical work of GV Black in 1895 that a
systemic study was done on properties and appropriate
manipulation of amalgam.

Second Amalgam War

• Erupted in Europe in 1926 as a result of writings of
German chemist Dr Alfred Stock.
• He became poisoned with mercury through 25 years of
exposure to metal in his lab.

Third Amalgam War

• Began primarily through seminars, writings and
videotapes of Dr HA Higgins, a Dentist from Colorado
Springs in 1981.
• This problem flared in 1990's by the telecast of television
program '60 minutes' in CBC television.

Classification of Amalgam
According to Alloyed Metals
• Binary alloys, e.g. silver-tin.
Figures 11-1A to C: Types of amalgam alloy
• Ternary alloys, e.g. silver-tin-copper.
• Quaternary alloys, e.g. silver-tin, copper, indium.
According to Copper Content
According to Whether the Powder Consists • Copper content of 4% less is called ‘low copper
of Unmixed or Admixed Alloys amalgam’.
• Certain amalgam alloy powders are made only of one • More than 6% is called as ‘high copper amalgam’.
alloy.
• Others have one or more alloys or metals physically
added, e.g. adding copper to basic binary silver-tin alloy.
According to Zinc Content
• Alloys that contain zinc in excess of 0.01% is zinc
According to Shape of Powdered Particle containing alloy.
• Alloys that contain zinc less than 0.01% is non-zinc
Alloy particles have spherical shape or irregular shape containing alloy.
from spindles to shavings (lathe cut) or in between shapes,
e.g. spherical with irregular surfaces (Figures 11-1A to C).
According to Addition of Noble Metals
According to Powder Particle Size When metals such as palladium, gold, platinum are
Particles can be used to classify microcut, finecut, alloyed to powder the resulting amalgams may be classified
coarsecut, etc. as 'noble metal alloys'.
234 Essentials of Operative Dentistry

First Generation After conclusion of heat cycle, the ingot is brought to

Recommended by GV Black, it consists of silver-tin reaction room temperature.
with mercury.
Particle Treatments
Second Generation • Many manufacturers perform some type of surface
To this composition zinc and copper were added. treatment of particles. The alloy particles are usually
surface treated with acid, its probably related to
Third Generation preferential dissolution of specific components from the
alloy. Amalgams made from acid treated powders tend
Admixing of spherical alloy Ag3-Cu eutectic alloyed to
to more reactive than those made from unwashed
original particles.
powders.
• Stresses induced into particles during cutting and ball
Fourth Generation milling must be relieved. The stress relief process
Alloying copper to silver and tin in percentages of up to involves an annealing cycle at a moderate temperature
29% forms. A ternary alloy, tin is firmly bonded to copper. usually for several hours at 100°C. The alloy is generally
then stable in its reactivity and properties when its
Fifth Generation stored for an indefinite time.
Alloying silver, copper, tin and indium together, creating
a true quaternary alloy in which almost none of the tin are Atomized Powder/Spherical Particles
available to react with mercury. Made by melting together the desired elements. The liquid
metal is atomized into fine spherical droplets of metals. If
Sixth Generation the droplets solidify before hitting a surface, the spherical
Alloying of palladium 10%, silver 62% and copper 28% to shape is preserved, these atomized powders are called
form a eutectic alloy, which is lathe cut and blended into ‘spherical powders’. Diameter of spheres varies from
1st, 2nd, 3rd generation in ratio of 1:2. 2-43 µm.

Particle Size
Manufacture of Alloy Powder • Average particle sizes of modern powders range from
Lathe Cut Powder 15-35 µm. Most significant influence on amalgam
properties is the distribution of sizes around the mean
Metal ingredients are heated and protected from oxidation
value. A powder containing tiny particles requires
until melted and in-turn poured into mould to form an
greater amount of mercury to form an acceptable
ingot. The ingot is then reduced to filings by being cut as a
amalgam.
lathe or ball milled. The particles are typically 60-120 µm
• The particle size are graded and the graded particles
in length, 10-70 µm in width, 10- 35 µm in thickness. Lathe
are mixed to produce a powder with an optimum size
cut alloys can be purchased in regular-cut, fine-cut and
distribution. Presently, favors the use of small average
microfine-cut version.
particles size, which tend to produce a more rapid
Freshly, cut alloys amalgamate and set more promptly
hardening of amalgam with greater early strength.
than aged particles. Ageing of particles is done to improve
• Bulk of set amalgam restoration consists of unreacted
shelf life. Irregularly shaped high-copper particles are
matrix surrounded by reacted particles. If the unreacted
made by spraying the molten alloy into the water under
matrix particles are larger, during final carving these may
pressure.
be pulled out resulting in rougher surface and corrosion.
Lathe-cut powders compared with atomized spherical
Homogenizing Annealing powder:
It is done to establish equilibrium phase relationship. The • Amalgams made from lathe-cut powders resist
ingot is placed in an oven and heated at a temp. Below the condensation better than any spherical alloys.
solidus, for sufficient time to allow diffusion of atoms to • A contoured and wedged matrix is essential to prevent
occur and phases to reach equilibrium. Usually, 24 hr is formation of flat and open contacts in case of spherical
time allowed for this. alloys.
 Amalgam Restorative Material 235
• Spherical alloys require much less mercury than lathe- is triturated, the silver and tin in the outer portion of the
cut alloys as they pack more effectively and have less particles dissolve into the mercury. At the same time
surface area. Amalgams with less mercury usually have mercury diffuses into the alloy particles. The mercury
better properties. has limited solubility for silver (0.035 wt%) and tin
(0.6 wt%).
Metallurgical Phases • When the solubility in mercury is exceeded two metallic
Silver-tin Alloy compounds γ1 Ag2Hg3 and γ2 Sn7-8Hg precipitate.
• When alloy containing 27% tin is slowly cooled below • γ1 and γ2 crystals grow into the remaining mercury, as
a temperature of 480°C, an intermetallic compound mercury disappears, the amalgam hardens.
known as gamma phase is formed. • Alloy powder is usually mixed with mercury in a ratio
• Ag3Sn formation is critical as it combines with mercury of about 1:1. This is in sufficient mercury to completely
to produce dental amalgam of desired mechanical consume original alloy, consequently unconsumed
properties and handling characteristics. particles are present in set amalgam. Alloy particles are
• Silver-tin compound is formed only over a narrow range. surrounded and bounded together by solid γ1 and γ2
• Silver content for such an alloy would be approximately crystals.
73%. Reaction is:
• Tin content held between 26 and 30% and remainder Alloy particles (β + γ) + Hg → γ1 + γ2 + unconsumed
alloy particles (β + γ)
alloy contains of silver, copper, zinc.
• Physical properties of hardened amalgam depend on
the relative percentages of each microstructural phases.
Components of Alloy Powder The more the unconsumed Ag-Sn particles that are
retained in final structure the stronger the amalgam.
Silver
The weakest phase is γ2 is also the least stable in a
• Increases creep and setting time corrosive environment and suffer corrosion attack.
• Decrease corrosion • The interface between γ and γ1 matrix is important. High
• Increase hardness and edge strength
proportion of unconsumed alloy particles will not
• Increase tarnishing.
strengthen the amalgam unless its bound to matrix.
• γ1 crystals are generally small and equiaxed. Most of
Tin
the matrix is Ag-Hg. γ2 crystals are long and blade like
• Low strength penetrating throughout the matrix, they constitute less
• Larger contraction decreases expansion than 10% in final composition and form penetrating
• Increased corrosion matrix. This phase is prone for corrosion in clinical
• Increased plasticity restoration a process that proceeds from outside of
• Increased setting time.
amalgam along the crystals, connecting to new crystals
at intercrystalline contacts. This is penetrating corro-
Copper
sion. Two key features of this degradation process are:
• Decreases plasticity A. Corrosion prone character of Sn-Hg.
• Increase hardness strength of alloy. B. Connecting path by blade like geometry of crystals.

Zinc
High Copper Alloys
• Nonzinc containing alloys are brittle, less plastic
(decreases brittleness) • Compare with low copper alloys, high copper alloys
• Acts as deoxidizer. have become material of choice, because of their
improved mechanical properties, corrosion resistance,
better marginal integrity and improved performance in
Amalgamation and Resulting clinical trial. Two types are:
Microstructures 1. Admixed, and
2. Single composition both types, contain more than
Low Copper Alloys 6 wt% copper.
• Amalgamation occurs when mercury contacts the • During 1960's major research emphasis was placed on
surface of the silver tin alloy particles. When a powder benefits of increased copper contents.
236 Essentials of Operative Dentistry

• It was confirmed that by effectively increasing the Reaction:

copper content to 12% reduced Sn-Hg phase the Alloy particles (β + γ) + Ag-Cu eutectic+Hg γ1+ η +
corrosion phase. unconsumed alloy of both types of particles.
• Flagg originally explored effect of copper in 1860's but • γ2 phase has been eliminated in this reaction. γ2 phases
copper was not effectively prealloyed with silver or tin form at the same time as γ phase is formed but later
or both. So no effect was shown. replaced by it.
• In 1930's, Gayler investigated effect of copper and found • To virtually eliminate γ2 phase, net copper content
that in the coarse filings alloys of that time, copper should be at least 12% in alloy powder.
contents greater than 6 wt.% produced excessive • Some set admixed amalgam do contain γ2, although
expansion. the percentage is less than in low copper amalgam. The
• In 1930's, early pioneers were admixing copper with effectiveness of copper containing particles in
amalgams to produce corrosion resistant composition. preventing γ2 phase depends upon their percentage in
• It was not until Innes and Youdelis added Ag-Cu mix.
spheres to conventional amalgam alloy, with the intent
of producing dispersion hardening amalgams, that Single Composition Alloys
effect of copper on corrosion resistance was observed.
• Each particle of the same chemical composition. Major
• A solid state dispersion within the amalgam mass of
components of the particles are usually silver, copper,
another phase, preferably one which has a different
tin.
shape and dimension than the original phase can
• It contains 60 wt.% Ag, 27 wt.% Sn, 13 wt.% Cu.
distort the original space lattices, precipitating
• Copper content varies from 13-30 wt.%.
interferences with slip and consequently increasing
• In addition indium or palladium also used.
strength of amalgam. This is being advocated by
• Phases found are β-Ag-Sn, γ-Ag3-Sn, •-Cu3Sn also
addition of eutectic Ag-Cu.
γ-Cu6Sn5.
• When triturated with mercury, silver and tin from
Admixed Alloys Ag-Sn phases dissolve in mercury. Very little Cu dissolve
In 1963, Innes and Youdelis added spherical silver-copper γ1 crystals grow, forming a matrix that binds together
eutectic alloy (71.9 wt% Ag and 28.1 wt% Cu) particles to the partially dissolved alloy particles. η-crystals rod
lathe cut low copper amalgam alloy particles. like structures much larger than found in admixed.
These are called admixed alloys as they contain at least • Meshed γ-crystals on unconsumed alloy particles may
two kinds of particles. Amalgams made from these strengthen bonding between the alloy particles and γ1
powders is stronger than low copper lathe-cut amalgam grains. γ-crystals dispersed between γ1 grains may
powder because of increase in residual alloy particles and interlock γ1 grains and aids in resistance to deformation.
resultant decrease in matrix rather than the dispersion Reaction can be summarized as:
strengthening mechanism as originally advocated. Ag-Sn-Cu alloy particles + Hg → γ1 + η +
Ag-Sn particles probably act as strong fillers in amalgam. unconsumed alloy particles
Admixed alloy powders usually contains 30 to 55 wt% Undesirable γ2 crystals does form but is of little. This is
spherical high copper powder. Total copper content in particularly true if the atomized powder has not been heat
admixed alloys range from 9-20 wt%. treated or powder heated long.
When triturated with mercury, silver and tin from Ag-Sn
phases dissolve in mercury. Very little copper dissolves in
mercury. Silver dissolves in mercury from Ag-Cu. Microstructure of Amalgam
Alloy particles and both silver and tin dissolves into (Figure 11-2)
the mercury from Ag-Sn alloy particles. The tin in solution
diffuses to the surfaces of the Ag-Cu particles and with In dental application, the amount of liquid mercury used
copper to form η phase Cu6Sn5. to amalgamate with alloy particles is less than that required
• γ1 phase form simultaneously with ? phase, surrounds to complete the reaction. The set amalgam mass consists
both η-covered Ag-Cu spherical alloy and silver-tin lathe of unreacted particles surrounded by a matrix of the
cut alloy particles. reaction products (Figure 11-3). The reaction is principally
 Amalgam Restorative Material 237
Properties of Amalgam
Dimensional Stability
Dimensional Change (Figure 11-4)
• Amalgam can expand or contract depending on
manipulation.
• Severe contraction leads to plaque accumulation and
secondary caries. Expansion leads to postoperative
sensitivity due to pressure on pulp.
• ANSI/ADA specification No. 1 requires that amalgam
Figure 11-2: Microstructure of amalgam neither contract or expand more than 20 µm/cm,
measured at 37°C between 5 min and 24 hr after
beginning of trituration.

Figure 11-3: Set amalgam

a surface reaction and matrix helps bond the unreacted Figure 11-4: Dimensional change
particles.
Theory of dimensional change
Fifth Generation • Most modern amalgam exhibit net contraction.
• Here tin (Sn) is more strongly bound to silver, copper by • Classical picture of dimensional change is one in which
alloying indium to these elements. the specimen undergoes an initial contraction for
• So little tin is available for reacting with mercury. approx 20 min after beginning of trituration and then
begins to expand.
• Indium improves plasticity as well acts as deoxidizer.
Three distinct stages occurs in dimensional change:
Stage 1: Contraction
Sixth Generation Stage 2: Expansion due to growth of crystals
• Here a eutectic alloy consisting of silver 62% copper Stage 3: Delayed contraction of mass resulting from
28% and palladium 10% is dispersed in 1st, 2nd and absorption of unreacted mercury.
3rd generation amalgam in a ratio of 1:2. • When alloy and mercury are mixed, contraction results
• When mixed with mercury the reaction is similar to 1st as particles begin to dissolve and γ1 crystals grow.
three generations. Calculations show that final volume of γ1 is less than
• Two additional solid state reaction occurs, first will be the sum of the initial volumes of dissolved silver and
precipitation of a Cu3Pd phase within γ1 and η phases. mercury used to produce γ1 crystals.
Second increased possibility of eliminating γ2 phase. • As γ1 crystals grow impinge upon on one another and
• Finally, it consists of a dispersed palladium consisting if conditions are appropriate produce an expansion.
phase which is more noble than γ 1 and greatly • If sufficient mercury is present to produce a plastic
diminished presence of γ2 create a final product with matrix, expansion occurs as a result of growth of γ1
improved mechanical and inert properties. crystals. Contraction will occur if there is no mercury,
238 Essentials of Operative Dentistry

as crystals into interstices between them and consume Measurement of Strength

mercury. • Traditionally, the strength of dental amalgam has been
Factors influencing dimensional change measured under compressive stress. When measured
• Constituents: More the basic γ phase greater possibility in this manner it should be at least 310 MPa.
of expansion. Greater traces of tin produces less • High copper amalgam have higher strength than low
expansion. copper amalgam.
• Mercury: More the Hg more is expansion. • Strength of amalgam is more than adequate to withstand
• Particle size: Smaller particle more surface area. So, there potential compressive load.
is accelerated consumption of mercury so both • Amalgam is much weaker in tension than compression.
contraction and expansion will be achieved too early. So the design of cavity should include supporting
So apparent expansion will not be noticed. A delayed structures wherever there is danger that it will be bent
stage 3 reaction of contraction may be noticed. or pulled in tension.
• Trituration: More energy used for trituration, smaller
the particle sizes, also greater will be the distribution of Factors Affecting Strength
matrix crystals all over the mix preventing expansion.
Temperature
• Condensation: More energy used for condensation, closer
Amalgam loses about 15% of its strength when temperature
the original particles of powder are brought together,
is elevated from room temperature to mouth temperature
also squeezes more Hg out of the mix. Both these
loses 50% of its strength when elevated to 60°C.
situation leads to more contraction.
• Particle shape: Smoother particle sizes, faster will be the Trituration
wetting by mercury and faster amalgamation rate. No • More trituration energy is used more continuous are
expansion occurs. the interphases between amalgam matrix crystals and
the original particles, which contributes to greater
Effect of Moisture Contamination strength.
• Zinc containing low copper/high copper amalgam is • If trituration is continued after matrix formation, excess
contaminated by moisture during trituration or energy leads to crack formation.
condensation, a large expansion can take place. This • Both under/over trituration creates weaker amalgam.
expansion usually starts after 3-5 days and may conti-
Mercury content
nue for months reaching values greater than 400 µm.
• Each alloy particle must be wet by the mercury, otherwise
This is delayed expansion or secondary expansion.
dry granular mix results. Such mix can lead to corrosion.
• Delayed expansion is associated with Zn in amalgam.
Any excess mercury left in restoration can produce a
The effect is caused by reaction of Zn with water and is
marked decrease in strength.
absent in nonzinc amalgam. Hydrogen is produced by
• If mercury content increases more than approximately
electrolytic action involving zinc and water. The
hydrogen does not combine with amalgam rather it 54% the strength is markedly reduced.
collects within amalgam, increasing internal pressure • Strength of an amalgam is a function of the volume
of amalgam leading to expansion. fraction of unconsumed alloy particles and mercury
• After the amalgam is condensed in cavity the external containing phase. Low mercury content amalgam have
surface may come in contact with saliva without greater of strong unreacted alloy particles as a result
occurrence of expansion. they are stronger.
Zn + H2O → ZnO + H2↑ • In high copper amalgam, increased mercury leads to
formation of increased weaker γ2 phase.
Strength Effect of condensation
• A primary requisite for any restoration material is When typical condensation technique and lathe cut alloys
sufficient high strength to resist fracture. are employed, the greater the condensation pressure,
• Most common are defects at margins of amalgam. There higher condensation pressure, higher will be compressive
is difference of opinion whether the gaps are produced strength. Good condensation technique expresses excess
at interfacial region is due to fracture of amalgam or mercury and more continuous will be the interphases
tooth. between original particles and matrix.
 Amalgam Restorative Material 239
In spherical amalgam lighter pressure produces • More trituration energy.
adequate strength. • More condensation energy.
• Homogenizing heat treatment of alloy particles.
Effect of porosity
• Constituents of original alloy particles that has good
Although porosity cannot be avoided in an agglomerated
affinity to mercury.
mass such as amalgam, its very important to minimize the
number and size of pores, as well to keep them away from Creep
critical areas of restoration. • Amalgam creep is plastic deformation principally
• Porosity can be expected and increased by under resulting from slow metallurgical phase transformation
trituration, irregularly shaped particles of alloy powder, that involve diffusion controlled reaction and produce
insertion of too large increments into the cavity, delayed volume increases.
insertion after trituration. • Phenomenon of flow is measured during the setting of
• For spherical alloys, that voids due to inadequate an amalgam. Creep on the other hand is usually
condensation is not a problem. Thus, lighter forces can measured after amalgam setting and it reflects the
be used. constant change in dimension under either static or
Particle size dynamic loading. Under continued application of a
Smaller the particle diameter of the original particles, is compressive forces an amalgam showed a continued
greater will be strength of set amalgam. deformation even after mass has completely set.
• Creep rate has been found to correlate with marginal
Gamma 2 phase
breakdown of traditional low copper amalgam.
Reduction/prevention γ2 phase can definitely increase the
• For high copper amalgam, creep is not a good predictor
strength, as γ2 is the weakest phase in set amalgam.
of marginal fracture.
Corrosion • According to ANSI/ADA specification No. 1 creep rate
Decreasing the corrosion actively within an amalgam be below 3%.
restoration will protect the adhesive integrity between • Low copper amalgam has creep range between 0.8 and
multiple phases, thus preventing the strength from 8%, high copper amalgam has less than 0.1%.
deteriorating. • This associated expansion beyond tooth margins in
Effect of amalgam hardening rate occlusal surface may lead to fracture margins and
• This property is of considerable importance to dentist, ditching. In nonoccluding surfaces, the entire restora-
as a patient may be dismissed from a clinic in 20 mins tions may appear extruded.
after amalgam restoration, after which biting on • Extrusions at margins is promoted by electrochemical
amalgam restoration may result in fracture. corrosion, during which mercury may from Sn-Hg
• Amalgam does not gain strength as rapidly as might be rereacts with Ag-Sn particles and produce further
desired. At the end of 20 min, compressive strength may expansion during this reaction. This mechanism is
be only 6% of 1 week strength. ANSI/ADA specification called mercuroscopic expansion proposed by
stipulates that minimum compressive strength of Jorgenson.
80 MPa at 1 hr. High copper single composition 1 hr Influence of microstructure on creep
strength is higher than 24 hr strength of admixed. • γ1 phase influences greatly creep values in traditional
Even if a fast hardening amalgam is used, patient amalgam.
should be cautioned not to subject the restoration to • Creep values increase with higher γ1 volume fraction
high biting stresses for 8 hr. By that time typical amalgam
and decrease with larger γ1 grains.
has reached at least 70% of its strength. Rate of attaining
• γ2 phase increases creep values.
strength is dependent on 2 major factors:
• In high copper amalgam creep values are lower due to
1. Maturity—complete crystallization of matrix phase.
absence of γ2 phase and η rods which acts as barrier to
2. Completion (or attainment of maximum continuity)
deformation.
of the interphases between matrix phases and
original particles. Effect of manipulative variables on creep
This rate can be accelerated by: Those manipulative features like alloy mercury ratio,
• Reduction of particle size. condensation and trituration pressure which increases
• Regularity and smoothness of particle shape. strength also decreases creep value.
240 Essentials of Operative Dentistry

Clinical performance of amalgam restoration • Active corrosion takes place as tooth-restoration

• Exceptionally fine clinical performance of dental interface, sealing the gap making dental amalgam a
amalgam may be linked to its tendency to minimize self sealing restoration.
leakage. • Precise role of corrosion in marginal breakdown has
• Small amount of leakage under amalgam is unique. If not been established.
the restoration is properly inserted, leakage decreases • Electrochemical measurements of pure phases show
as restoration ages in the mouth. This may be caused by that γ1 Ag3Sn has highest corrosion resistant, followed
corrosion products that form along the interface by γ Ag3Sn, Ag3Cu2, Cu3Sn •, Cu6Sn5 η, Sn7-8Hg γ2.
between and restoration, sealing the interface and there However, this is true only if the phases are pure, but in
by preventing leakage. dental amalgam the phases are not pure. Higher the tin
• The ability to seal against microleakage is shared by content lower its corrosion resistance.
both the low copper amalgam and high copper • In low copper amalgam, the most corroding phase
amalgam. Sn7-8Hg γ2 is present in 11-13% corrosion results in
formation of tinoxychloride from tin in γ2 phase and
Factors Affecting Success of Amalgam liberate mercury. This liberated mercury further reacts
Restoration with γ phase and results in production of γ1 and γ2
phases. This results in porosity and lower strength.
• There are very few materials in dentistry that are as
Sn7-8Hg + 3O2 + 6H2O + 2Cl2 → 2Sn4(OH)6Cl2 + Hg
technically as insensitive as amalgam. Survival rate of
High copper admixed and unicompositional alloys
amalgam after 10 years is 90%.
do not have γ2 phase. The Cu6Sn5 or η phase has better
• If a restoration fails its mainly due to fault in dentist,
corrosion resistance. However, here η phase is least
auxiliary or patient rather than on material amalgam.
corrosion resistant phase and a corrosion product of
• Amalgam is weak in tensile stress and cavity design
CuCl2 3Cu(OH)2 is formed.
should be such that amalgam does not undergo tensile
• Every effort should be made to produce a smooth,
stresses. All manipulative characteristics for amalgam
homogeneous surface on restoration to minimize tarnish
play a role in success of amalgam.
and corrosion, regardless of the alloy system used.
• A high copper amalgam is cathodic in respect to low
Properties of Mercury copper amalgam, so when both of these materials are
• ANSI/ADA specification No. 6 (ISO 24234) for dental present it leads to corrosion and failure of latter. In high
mercury requires that mercury have a clean reflecting copper amalgam the most corrosive phase is γ2 which
surface that is free from the surface film when agitated is eliminated, but if mercury to alloy ratio is high it can
in air. It should have no visible evidence of surface lead to formation of γ2 phase, thus promoting corrosion.
contamination and contains less than 0.02% non-
volatile. Mercury should comply with requirements of Manipulation of Amalgam
United States Pharmacopoeia (USP). Selection of Alloy
• Mercury with high purity exhibits slight tarnish after Selection of an alloy involves number of factors, including
sometime because of surface contamination and setting time, particle size and shape and composition,
produces dull surface. Impurities in mercury can reduce particularly as it relates to elimination of the γ2 phase and
the rate at which it combines with silver alloy. presence or absence of zinc. Majority of the alloys selected
are high copper unicompositional spherical alloys.
Tarnish and Corrosion
• Amalgam restoration often tarnish corrode in the oral Mercury/Alloy Ratio
environment. The degree of tarnish and resulting • Historically, the only way to achieve smooth and plastic
discoloration appear to depend greatly on the mixes was to use mercury considerably in excess of
individual's oral environment and to a certain extent that desirable in final restoration.
on particular alloy employed. • For conventional mercury added systems, two
• Electrochemical studies indicate that tarnish offers techniques were employed to remove excess mercury.
passivating effect against corrosion. Tarnish with • Removal of excess mercury was accomplished by
unesthetic black silver sulfide does not imply failure of squeezing or wringling the mixed amalgam in a
restoration. squeeze cloth.
 Amalgam Restorative Material 241
• Also additional excess mercury was worked to top
during condensation of each increment.
• Although excellent restorations can be made with this
technique, the amount of mercury removed greatly
varied.
• The most obvious method for reducing mercury content
is to reduce the original mercury/alloy ratio. Minimal
mercury technique or Eames technique.
• Sufficient mercury must be present in the original mix
to provide a coherent and plastic mass after trituration,
however, the amount of mercury present must also be
low enough so that the mercury content of the restoration
is at an acceptable level without the need to remove an
appreciable amount during condensation.
• Mercury content of finished should be about 50 wt.%
with lesser amount for spherical alloy.

Proportioning
• The amount of alloy and mercury to be used for a mix is
designated as mercury/alloy ratio which signifies parts Figure 11-5: Amalgam capsules
by weight of mercury and of alloy to be used.
• Some manufacturer employ weight by percentage. Disadvantages
• Recommended ratio varies for different alloy composi- • Expensive
tion, particle sizes, shape and heat treatment. • No minor adjustments to mercury/alloy ratio possible.
Recommended mercury/alloy ratio for most modern
lathe-cut alloy is approx 1:1 or 50% mercury and for Mechanical Trituration
spherical alloys its closer to 42% mercury.
• Originally, the alloy and mercury were mixed/
• Proper proportioning of mercury alloys is essential for
triturated byhand with a mortar and pestle. Today
a proper mix.
however mechanical trituration saves time and
• Wide variety of mercury/alloy dispensers are available.
standardizes the procedure.
Most common is based on volumetric proportioning.
• Objectives of trituration is to provide a proper
• Preweighed pellets or tablets are a more convenient
amalgamation of mercury and alloy. The alloy particles
method for correct dispensing of alloy.
are coated with a film of oxide which is difficult for
• As a liquid mercury can be measured by volume without
mercury to penetrate, the oxide layer is removed by
appreciable loss of accuracy. Dispenser should be held
abrasion during trituration.
vertically to ensure consistent spills. Dispenser should
• Capsules serves as mortar, a cylindrical metal or plastic
be half full. Probably most common cause of in accurate
piston of smaller diameter than capsule inserted into
delivery of mercury is use of contaminated mercury.
capsule serves as pestle.
• Disposable capsules containing preproportioned
• Alloy and mercury are dispensed into capsule or
aliquots of mercury are available. To prevent any
disposable capsule system can be used. There is
amalgamation during storage, mercury/alloy are
automatic timer in amalgamator, multiple speed
physically separated from each other (Figure 11-5).
amalgamator are available (Figure 11-6).
• Alloys are now available in self activating capsules
• Newer amalgamators have a hood covering the
which automatically release mercury into the alloy
reciprocated arm to prevent mercury spill.
chamber during first few oscillations of amalgamators.
• Reusable capsules can be friction fit and screw cap lids.
Advantages Disposable capsules should never be used again.
• Convenient. • Wide variety of capsules/pestle combination are
• Elimination of chance of mercury spills. available. One type is one piece construction which
• Reliable mercury/alloy ratio. would be broken after trituration.
242 Essentials of Operative Dentistry

• To dissolve the particles or part of particles in mercury

• To keep the amount of γ1, γ2 matrix crystals to minimum.

Consistency of Mix
• Under triturated mix is grainy mix. This restoration
results in weak and rough surface increases suscep-
tibility to tarnish.
• Properly triturated mass is warm, smooth. This mix will
have maximum strength and a smooth surface retained
for long-time.
• Over triturated mix appears soupy and tends to stick
inside the capsule.

Figure 11-6: Amalgamator Condensation

• It is essentially a continuation of trituration process,
• Pestles can be metal/plastic and come in variety of serves to complete objectives of trituration as well as to
shapes, sizes and weights. If pestles is too large, mix encourage conclusion of amalgamation.
may not be homogeneous. • Goal of condensation is to compact the alloy into the
• Amalgamators should be used at speed recommended prepared cavity so that greatest possibility of density is
by manufacturer. attained and complete continuity of matrix phase and
• A reusable capsule should be clean and free of between the remaining alloy particles.
previously hardened alloy. This can be accomplished
• Also mercury rich layer is brought to the surface of
by removing the pestle from capsule and activating the
restoration, so that successive layers bond to each other.
capsule in an amalgamator for 1-2 secs. This 'mulling'
Also excess mercury is removed from each layer as its
causes mix to cohere and can be removed readily.
brought to top layer.
• Spherical or irregular low copper alloy may be triturated
• After trituration the mix should be condensed within
at low speed and high copper alloy require high speed.
3 mins.
• Low, medium, high speed amalgamators operate at
• Condensing amalgam after its set leads to fracture and
about 3200-3400, 3700-3800, and 4000-4400 cycles/
crack development, also because of loss of plasticity of
min.
material it is difficult to condense without producing
• A general rule of thumb is that for a given alloy and
internal voids and layering.
mercury/alloy ratio increased trituration time and
speed shortens working and setting time. • The field of operation should be dry.
Three basic movements of mechanical trituration are: • Condensation can be accomplished with either hand/
1. Back and forth movement. mechanical.
2. Back and forth in figure of 8 motion.
3. Travels in a centrifugal motion. Hand Condensation
Trituration energy is correlated to: • Amalgam mixture should never be touched with bare
• Speed or number of unit movements per unit time hands.
• Thrust of the movement • Once amalgam is inserted into the cavity preparation,
• Weight of capsule and pestle it should be immediately condensed with sufficient
• Time involved in trituration pressure into the cavity.
• Difference in size between pestle and encasing capsule. • Condensation is usually started at center and moved
towards periphery. For nonspherical alloys the
Objectives of Trituration condensation is applied at 45° to walls and floors.
• Achieve workable mass within a minimum time. • All amalgams except spherical alloys are condensed
• To remove oxides from particle surface. by small condensers to reduce voids and as well as
• To reduce particle size leading to faster and more filling small details. As the surface of preparation is
complete amalgamation. reached a larger condenser can be used.
 Amalgam Restorative Material 243
• Larger amalgam increments may be difficult to adapt • If proper technique is followed, amalgam could be
and precipitate voids. carved immediately after condensation.
• After the carving is complete, the surface of the
Condensation of Spherical Alloys (Figure 11-7) restoration should be smoothed. This is accomplished
by burnishing the surface and margins of restoration
• Necessary to use larger increments to fill entire cavity.
with a ball burnisher and a rigid flat bladed instrument
• Necessary to use the largest condenser to fill the cavity.
for smooth surface.
The differences in condensation pattern are
• Even after carving and burnishing the surface of
necessitated by spherical shape particles which have a
amalgam is rough with scratches and pit and can lead
tendency to roll over each other.
to concentration cell type corrosion.
• So final finishing by polishing is to be done. This should
be done after complete set of amalgam and usually done
after 24 hrs. Use of dry polishing powders and disks
can raise the temperature of pulp above 60°C so wet
abrasive powder be used.

Clinical Significance of Dimensional Change

• Variety of changes occur at both the microstructural
and visual levels as amalgam ages.
• The leading causes for failures are:
• Secondary caries
Figure 11-7: Condensation of lathe cut alloy and • Marginal fracture
spherical alloy • Bulk fracture
• Tooth fracture
Condensation Pressure • Combination of brittleness, low tensile strength and
• Pressure exerted on the condenser is inversely electrochemical corrosion make occlusal amalgam
proportional square root of surface area of nib of susceptible to marginal fracture. Then at some point,
condenser. occlusal stress during opponent tooth contact causes
• Average forces applied is in a range of 13.3-17.8 N fractures that produce a ditch along the margin.
(3-4 lb). Condensation forces should be as great as the Progression of the events to deeper or more extensive
alloy will allow and consistent with patient comfort. ditching has been used as visible clinical evidence of
• Spherical alloy are less sensitive to condensation forces conventional amalgam deterioration and was the basis
and offer only minimal resistance to condensation. of ‘Mahler Scale’ (Figure 11-8).
Disadvantages are tendency for overhangs in proximal • Marginal breakdown are often attributed to contraction
areas and weak proximal contact. of amalgam, but this is not often the case, if unsupported
enamel is left in the marginal areas of cavity preparation,
the tooth structure may fracture leading to ditching
Mechanical Condensation
(Figure 11-9).
• Procedures are same here also. • Improper carving and finishing of restoration and or
• Two types are available: Impact type and vibratory type. failure to remove excess mercury rich layer, they leave
• Here less type of energy is required and similar clinical thin layer of amalgam over the enamel which may
results are obtained. fracture.
• Ultrasonic mechanical condensers tend to increase the
mercury vapor level.

Carving and Finishing

• After amalgam been condensed into prepared cavity,
the restoration is carved to reproduce the proper tooth
anatomy. Figure 11-8: Mahler scale
244 Essentials of Operative Dentistry

Allergy
• Typically allergic responses represents an antigen-
antibody reactions marked by itching, rashes, sneezing,
difficulty in breathing, swelling or other symptoms.
• Contact dermatitis/Coomb's type IV reaction represents
most common physiologic side effect of mercury. But
these are represented in less than 1% of population.
• A small percentage of people are allergic to mercury,
just as certain number of people are allergic to many
other elements.
• In these cases other alternative materials be used.

Toxicity
Figure 11-9: Marginal breakdown
• It is still sometimes conjectured that mercury toxicity
from dental restoration is cause of certain undiagnosed
diseases and a real hazard may exist for dentist and
Repaired Amalgam Restoration dental assistant when mercury vapor is inhaled during
• Flexural strength of repaired amalgam is 50% of mixing and placement of amalgam.
unrepaired amalgam. • Few cases are reported nowadays because of improve-
• Bond is source of weakness and its interfered by ments in encapsulation technology, capsule design,
corrosion and saliva contamination. scrap storage methods and elimination of carpets and
• Repair should be attempted only in no-high stress other mercury retention areas.
regions, and only if two parts adequately supported • Mercury reaches pulp from restoration, released
and retained. during mastication, but toxicity from these release is
• Another option for minor marginal breakdown is very slight.
application of dentin bonding adhesive. • Most significant contribution to mercury assimilation
from dental amalgam is via vapor phase. Exposure via
Advantages of Amalgam this medium is very minimal to patients.
• Patients with amalgam restoration were exposed to
• Less technique sensitive
mercury of about 1.7 µg/day. Patients with 8-10
• More durable
amalgam restoration is in range of 1.1 - 4.4 µg/day. The
• Less costly
threshold values for workers in mercury industry is
• Excellent abrasion and wear resistance
350-500 µg/day. Thus, patient exposure values is far
• Tends to seal itself against leakage
below this limit.
• Bacteria do not adhere to it as strongly as on composite.
• Maximum level of occupational exposure considered
Most reliable material if esthetics is not a concern
safe is 50 µg Hg/mm3 of air/day. Mercury has vapor
and in high stress bearing regions.
pressure of 20 mg/[Link] of air. Mercury vapor has no
odor, color, or taste. Mercury is 14 times denser than
Disadvantages of Amalgam
H2O. An eyedropper of mercury is enough to saturate
• Esthetics, metallic color an average operatory.
• No bonding to tooth surface • Mercury level in blood of patients with amalgam
• Extensive tooth preparation restoration was 0.7 ng/ml. An average sea food meal
• Concern over mercury toxicity. raised mercury level in blood from 2.3 to 5.1 ng/ml. The
normal intake of mercury from food is 15 µg, 1 µg from
Side Effects of Mercury air, 0.4 µg from water.
• Amalgam restoration is possible only because of the Potential hazard of mercury can be reduced by:
unique characteristics of mercury. • Operatory be well ventilated disposable capsules,
• Use of mercury in the oral environment has raised amalgam removed restoration be stored in well sealed
concerns regarding safety for more than 170 years. containers.
 Amalgam Restorative Material 245
• Amalgam scrap and material should not be • Two commercial materials are, Galloy, Gallium alloy
incinerated or heat sterilized. G-F.
• Mercury suppressant powders be used in case of
mercury spill. Disadvantages
• Vacuum cleaner should not be used.
• Low resistance to corrosion.
• If mercury comes in contact with skin it should be
• When gallium alloy is placed along with high Cu
washed with soap.
amalgam the former corrodes.
• Periodic monitoring of actual exposure levels be
• Handling is difficult.
estimated. Film badges are available to estimate
• Left a dark residue on gloves.
actual exposure.
• Moisture contamination leads to dramatic expansion.
• Risk from mercury exposure to dental personnel
• High cost.
cannot be ignored.
• But close adherence to simple hygiene procedures
help ensure a safe working environment. Mercury Free Direct Filling Silver Alloys
• In 1994, David et al developed this system. In which
silver particles suspended in a dilute acid solution
Amalgam Waste Management which aids in cold welding.
• During intraoral condensation of amalgam some • Here a mercury coated Ag-Sn that can be self welded by
mercury vapor is released, therefore a high-volume compaction to create a restoration.
suction and rubber dam application is essential.
• Scrap dental amalgam from condensation procedures Indium Containing Alloy Powder and
should be collected and stored under water, glycerine Binary Mercury-Indium Liquid Alloy
(or) Spent X-ray fixer in a tightly capped jar. X-ray fixer • Powell et al 1989, added pure indium powder into
(main content is ammonium thio-sulfate-hypo reacted disperse phase high Cu alloy and triturated with
with silver ions) has silver and sulfide ions to react mercury. They found significant decrease in mercury
with mercury to minimize the release of mercury. evaporation from amalgam. This was marketed as
• When an amalgam restoration is being removed and ‘Indisperse’ and ‘Indiloy’.
polished. • In 1994, Okale et al added indium to mercury and alloy
o
• Ag2 Hg3 (has low melting point of 127 C) can be powder was triturated with this mercury, here also
liquefied to release mercury. So a high volume suction vapor release decreased significantly.
is needed during this procedure. • Whether indium added to powder or liquid it decreased
• Instruments used for amalgam restoration contain mercury vapor release because of reduction in mercury
traces of mercury, therefore, sterilization room be releasing phases in amalgam and also more efficient
properly vented. formation of surface oxide layer.
• Spent amalgam capsules, mercury contaminated cotton
and gauze should not be thrown is trash. They should
be properly isolated in a tight plastic container for Fluoride Containing Amalgam
separate disposal. Addition of fluoride to conventional amalgam was
proposed by Innes and Youdelis 1966, Serman 1970, Stone
1971. Mechanism of release by:
Recent Advancements in • Dilution of salt crystals that are in contact with cavity
Amalgam wall.
• By corrosion that liberates flouride contained in mass
Gallium-based Alloys of amalgam, e.g. Fluoralloy.
• This direct filling material contains no mercury. Its use
is based on remarkable ability of liquid gallium to wet Low Mercury Amalgams
surfaces of many solid. Gallium is liquid at room If alloy particles are closely packed together, mercury
temperature. content in restoration can be reduced by 15-25%.
246 Essentials of Operative Dentistry

Bonded Amalgam • Creep

• ‘Baldwin technique’ here amalgam was condensed onto • Tarnish or corrosion
unset ZnPO4 cement. Upon setting amalgam was • Minimal mercury technique or Eames technique
retained by ZnPO4 cement. Other cements like Glass • Amalgamator
Ionomer Cements (GIC), Zn polycarboxylate have been • Marginal fracture
used. • Mahler’s scale
• Recently, 4 META has been used for bonding amalgam • Baldwin technique
to cavity walls.
Questions to Think About
Key Terms 1. Define amalgam. What are the different classifications
of amalgam?
• Lathe cut alloy powder 2. What are the advantages and disadvantages of
• Atomized allloy powder amalgam? Elaborate about high copper and low copper
• Spherical alloy powder amalgam.
• Gamma 1, 2 phases 3. Describe about dimensional changes and strength
• Low copper amalgam properties of amalgam.
• High copper amalgam 4. Write about mercury toxicity. Discuss about amalgam
• Dispersion stregthening waste management.
• Delayed expansion or secondary expansion 5. Brief about recent advancements in amalgam.
 Amalgam Class I Preparation and Restoration 247

12
Amalgam Class I
Preparation and
Restoration

The restorative materials available differ as to their and excursive contacts so that these areas can either be
performance characteristics, cost, ease of use, esthetic excluded or properly restored.
appeal, long-term effectiveness and safety.
As a result, their suitability for the different types of Local Anesthesia
clinical situations varies. No single restorative is ideal for
Given both to reduce pain and also reduction of salivation.
all indications (Figure 12-1). Not required in preclinical exercises.

Amalgam Class I Restorations Conservative Cavity Preparation

Indications and Contraindications It is recommended to preserve the integrity of pulp and
also strength of the tooth.
• Extent of pit and fissure caries
• Amalgam is appropriate choice of material when
tooth structure loss is not extensive. Isolation of Operating Site
• If extensive tooth structure has been lost cast gold or Rubber dam application is mandatory for isolation and
bonded restoration will be considered. salivary control.
• Incidence of proximal surface caries
When numerous proximal caries lesion is present Initial Cavity Preparation
amalgam is indicated till the patient’s caries
susceptibility reduces. Outline Form, Resistance Form, Retention Form
• Age of patient • Include all pits and fissures and sharp marginal outline
Amalgam restoration is not much influenced by age. form is avoided.
• Esthetics • Marginal outline form for a maxillary premolar is
When esthetics is of primary concern amalgam is not butterfly shape.
preferred.
General principles
• Economics
• Going around the cusps to conserve the tooth
Amalgam is most effective restoration.
structure.
• Preventive procedures
• Not extending the facial and lingual margins more than
• Prophylactic odontotomy is adviced for minimal
half-way between central groove and cusp tips.
caries lesion.
• Extending the outline to include fissures thereby
• Newer techniques like fissure sealent, minimal in-
placing the margins on relatively smooth sound tooth
vasive procedures or enameloplasty are also options.
structure.
• Minimal extension into the marginal ridges.
Occlusion • Joining two faults when less than 0.5 mm apart.
Use of articulating paper to register centric holding cusps • Establishing ideal conservative depth of cavity.
248 Essentials of Operative Dentistry

Figure 12-1: Various types of restoration materials

 Amalgam Class I Preparation and Restoration 249
Preparation Sequence (Figures 12-2 to 12-5)
• Beginning of cavity preparation is done by performing
a punch cut over the deepest involved pit or the distal
pit. A pilot groove can be scribed on the occlusal surface
resembling final outline form so that outline form could
be preserved. This could be performed with a No. 1/2
round bur. This could be done for all preparations.
• No. 245 bur with a head length of 3 mm and a diameter
of 0.8 mm is used to prepare the class I cavity
preparation.
• No. 330 bur (pear shaped) is used for conservative cavity
preparation.
• The bur should be rotating when it enters and should
not stop until its removed from tooth.
• As the bur enters the tooth the depth should be kept as
1.5-2 mm (1/2–2/3rd the length of cutting portion of
bur).
• Distal extension into the marginal ridge to include a
fissure or caries sometimes indicates a slight tilting of
the bur distally to prevent undermining of the marginal
ridge.
• Premolars – distance from margin of cavity to proximal
surface must not be less than 1.6 mm.
Figures 12-3A to C: Conventional class I preparation with
• Molars—this distance be minimum of 2 mm. burs No. 245 or No. 330
• 169L bur can be used for extension from pits and fissures
facially and lingually.
• In larger teeth with steep cuspal inclines floor of the
cavity can follow the rise of cusps.

Figure 12-4: Marginal ridge width of

1.6 mm in premolars

• Ideally, the isthmus width be width of the bur.

• Minimal faciolingual width of the outline and minimal
occlusal convergence is desired.
• An ideal conservative class I cavity should have a
Figure 12-2: Pilot groove placement faciolingual width of no more than 1-1.5 mm and a
using No. ½ round bur depth of 1.5-2 mm.
250 Essentials of Operative Dentistry

Pulp Protection
• In cavities of ideal depth no liners or bases is required.
• In regions where cavity depth is of moderate zinc oxide
eugenol liner or base is preferred.

Finishing Enamel Walls

It is finished during the earlier steps itself so no special
steps are required.

Cavity Preparation for Extensive Caries

Caries is extensive if the distance between infected dentin
and the pulp is judged to be less than 1 mm.

Initial Cavity Preparation

• Here outline, resistance, retention forms are deferred
Figure 12-5: Prevention of undermining marginal ridge by until the excavation of infected dentin is completed
distal inclination of bur followed by insertion of base.
• Reason is to protect the pulp as early as possible from
Final Cavity Preparation insult of cavity preparation.
Includes removal from pulpal wall of any remaining
defective enamel, pulp protection, procedure for finishing Final Cavity Preparation
external walls, cleaning and inspection of cavities.
• If pulp exposure occurs during removal of caries direct
pulp capping could be tried.
Removal of any Defective Enamel • Here using a non-pressure flow technique to insert a
• No. 245 bur can be used to deepen the floor of cavity to 0.5-0.75 mm of calcium hydroxide cement is used to
remove caries. cover exposures of pulp.
• A small round carbide bur or spoon excavator can be
used to remove small caries lesions (Figure 12-6). Insertion of Amalgam
• At least three seats of sound dentin be there periphery
• Use an amalgam carrier to transfer amalgam to the
to the excavated areas.
cavity preparation.
• Removal caries be stopped once we feel the excavated
• Use a flat faced circular or elliptical condenser to
dentin hardness is same as that of surrounding
condense amalgam over the floor.
dentin.
• Initial condenser be small followed by larger condenser
for overpacking.
• Each condensing stroke should overlap each other.
• Each condensed increment should only fill 1/3rd–
1/2nd cavity depth.
• Condensation of mix be done within 2½–3½ mins.
Otherwise crystallization of amalgam be over. A new
mixture has to be remixed.

Precarve Burnishing
• Is a form of condensation.
• Cavity preparations be overfilled with amalgam.
• Burnisher head be large enough it will contact slopes
not the margins.
• This is done to remove excess mercury and also adapt
Figure 12-6: Caries excavation using spoon excavator amalgam closely to cavity margins.
 Amalgam Class I Preparation and Restoration 251
Carving Procedure
• Carving can be done immediately.
• Sharp discoid – cleiod instruments are selected.
• All carving be done with the edge of the blade
perpendicular to margins and moved parallel to
margins.
• Part of the edge of carving blade should rest on
unprepared tooth surface adjacent to cavity margins.
After carving the outline of amalgam restoration should
reflect the contour and location of the prepared cavosurface
margins revealing a regular outline with gentle curves.

Postcarve Burnishing
• Is the slight rubbing of the carved surface with a
burnisher of suitable size and shape to improve
smoothness and produce a satin appearance.
• With precarve burnishing and now postcarve burni-
shing the polishing of amalgam becomes unnecessary.

Occlusion of Restoration
• After completion of procedure patient is advised not to
Figure 12-7: Polishing of amalgam restoration
bite because of danger of fracturing of restoration which
is weak at this stage.
• To ensure occlusion is correct its checked using • Instead of rubber points, rubber cups with pumice could
articulating paper. be used (Figure 12-7).
• While carving it is advised to establish stable centric
contacts which is perpendicular to direction of occlusal Occlusolingual Cavity Preparation and
load. Restoration (Figures 12-8 and 12-9)
Initial cavity preparation
Finishing and Polishing Procedures • On maxillary molars, it is indicated when the distal
• Not all amalgam restorations require these procedures pit and distal oblique ridge and lingual fissures are
but some do: connected.
• To complete carving procedure • Some special considerations are:
• Refine the restorations • Cavity should be no wider than necessary.
• Enhance surface texture of restorations. • When indicated the cavity preparation should be
• This procedure is not attempted within 24 hrs. done more at the expense of oblique ridge rather than
• Finishing and polishing of restoration should not leave centering over the fissure.
a underfilling. • Especially in smaller teeth the occlusal portion can
• After this procedure an explorer should pass from the have slight distal tilt.
tooth surface to restoration without any catch or jump. These features help in strengthening the restoration and
• A white fused alumina or green carborundum stone is tooth.
used to correct the discrepancy.
• A flame shaped finishing burs may be used to define Preparation Procedures
the grooves and fissures.
• Using a mouth mirror indirect vision and No. 245 bur
• Polishing procedure is initiated by coarse rubber
enter the distal pit. Bur should be parallel to long axis
abrasive point at slow speed.
of tooth.
• A high polish may be imparted using series of medium
• To preserve distal marginal ridge it may be necessary to
and fine abrasive points.
cut more mesial tooth structure.
252 Essentials of Operative Dentistry

Figure 12-8: Occlusolingual preparation and matrix band application

• Slight distal inclination of bur may be necessary to

preserve the distolingual cusp.
• Next is preparation of the lingual surface. Tip of the bur
should be located at the gingival end of the lingual
fissure. Lingual portion should have a uniform depth
of 1.5 mm. Axial wall should follow contour of lingual
tooth structure.
• Mesial and distal walls of lingual portion should
converge slightly and axiopulpal line angle be rounded.

Final Cavity Preparation

Secondary retention and resistance form:
• It can be prepared using No. 1/4 bur to prepare locks
on mesio- and distoaxial line angles.
• Locks should be of depth 0.5 mm into dentin.
Figure 12-9: Axial wall should be • Cutting direction is bisector of the line angle. The depth
parallel to long axis of tooth of lock should decrease in depth as it moved towards
occlusal surface.
 Amalgam Class I Preparation and Restoration 253
Insertion and Carving Procedures
• A rigid matrix is necessary to prevent land sliding of
the restoration during condensation of lingual portion.
• A tofflemire retainer is used to retain a matrix band but
this does not allow intimate adaptation of matrix to
lingual portion of tooth.
• An additional step here is to cut a piece of stainless steel
matrix (0.0002 inch thick, 5/16 inch wide) that will be
Figure 12-11A: Facial pit in mandibular molars
used to fit in space between tooth and matrix band.
• Break off a round tooth pick holding it in No.110 plier.
• Heat a green stick compound cover this with end of a
tooth pick, now insert the tooth pick with heated
compound between tooth and matrix band.
• Now using a burnisher the matrix band is contoured
with firm pressure.
• This was suggested by Barton and is called “Barton
Matrix”.
• Condensation of amalgam is started from the gingival
end of lingual portion.
• As the condensation is finished the matrix band is
removed using No. 110 plier by slightly moving it
lingually and then occlusally.

Additional Class I Preparations

(Figures 12-10 and 12-11) Figure 12-11B: Lingual pit in incisors

Facial Pit of Mandibular Molar Lingual Pit in Maxillary Incisors

• Facial surface of a mandibular molar has often a faulty (Figure 12.11B)
pit and not a fissure.
• Usually, a No. 245 bur is used in direction with orien-
• Cavity preparation is accomplished by a No. 245 bur
tation of the pit which is usually apical in direction.
positioned perpendicular to the tooth surface.
• Since the lingual enamel is thinner its recommended
• When the defect is small a No. 330 or No. 169L burs
depth be only 1-1.2 mm only.
may be used.
• Sometimes anterior maxillary teeth may develop dens
• Cavity depth is usually 1.5 mm.
in dente which may also require intervention and
restoration.

Occlusal Pits of Mandibular First Premolar

(Figures 12.12 to 12.15)
• Mostly because of presence large facial cusp a central
fissure is absent.
• A No. 245 bur is used to prepare a punch cut of
1.5-2 mm depth.
• Orientation of bur should be parallel to long axis of the
tooth.
• This orientation preserves the small lingual cusp.
• Sometimes if a central fissure is present its connected
Figures 12-10A and B: Facial fissure in mandibular molars by a conventional outline.
254 Essentials of Operative Dentistry

Figure 12-12: Lower premolars

Figure 12-15: Axial wall parallel to

external surface of tooth

Occlusal Pits and Fissures in Maxillary

First Molar (Figures 12.16A to C)
Leaving the oblique ridge can preserve the strength of the
tooth but if required the oblique fissure must be involved.

Figure 12-13: Correct angulation of bur

resulting in correct floor angulation

Figure 12-14: Incorrect angulation of

bur and overcutting Figures 12-16A to C: Maxillary molars
 Amalgam Class I Preparation and Restoration 255
Occlusal Pit and Fissures in Mandibular Second Indications
Premolar, Molar (Figures 12.17A and B) • Caries cone into dentin 1 mm or more from DEJ.
• Cavity width is more than 1/4th interproximal width.
• If mandibular second premolar has two lingual cusps
• As a preventive measure in patients with high caries
the lingual development groove may be restored.
index.
• Often in mandibular molars a facial fissure may involve
the occlusal surface and may require restorations.
• Facial extension preparation is same as that occluso-
lingual preparation in maxillary molars.

Figure 12-19: Design 2

Class I: Design 3
Location: Occlusal 1/3rd of facial and lingual surfaces of
Figures 12-17A and B: Mandibular second premolars
molars and lingual surfaces of upper anterior teeth (Figure
12-20).
Designs of Class I Preparation
Indications
(According to Marzouk) • A pit in aforementioned location decayed.
• Used as a prophylactic procedure.
Class I: Design 1 • Involved pit in this location not connected with other
Location: Occlusal surface of molars and premolars (Figure surfaces of tooth.
12-18). • Used in dens invagintus.
Indications
• Caries cone into dentin no more than 1 mm.
• Patient has low caries index.

Figure 12-20: Design 3

Figure 12-18: Design 1

Class I: Design 4
Class I: Design 2 Location: In molars in addition to involving their occlusal
Location: Occlusal surfaces of premolars and molars (Figure surfaces the grooved part of facial and lingual surfaces
12-19). also involved (Figure 12-21).
256 Essentials of Operative Dentistry

Figure 12-21: Design 4

Class I: Design 5
Location: In molar tooth in addition to occlusal surface
involvement most of the facial or lingual surfaces are also
included in the preparation (Figure 12-22). Figure 12-23: Design 6
Indications
• Facial and lingual cusps are undermined by backward
caries.
• Outline is not conducive to retention of restoration.
• Foundation for cast restoration.

Figure 12-22: Design 5

Class I: Design 6
Location: Design included for part of the occlusal surface Figure 12-24: Design 8
of molars or premolars as well as a portion of the facial,
proximal or lingual surface in the form of a table of an
entire cusp (Figure 12-23). Indication: Designed specifically for endodontically treated
tooth.
Indications
• Portion or an entire cusp undermined by caries.
• Marginal ridge adjacent to an occlusal preparation is Features of a Prepared Class I
crossed by a fissure to the facial or lingual embrasures. Cavity
• Foundation for future cast restorations.
• Tooth preparation is in center of the tooth.
Class I: Design 7 • Cavity preparation is in smooth flowing curves with
no abrupt curvatures. Cavity form should go around
Location: Design usually involves occlusal, facial lingual
the cusp and mesial, distal outlines of cavity should be
surfaces of molars and premolars.
parallel to the marginal ridges or external contours of
teeth (Figures 12-25A and B).
Class I: Design 8 • Width of cavity should be no more than 1/4th
Location: Used in molars, premolars and incisors (Figure intercuspal width and depth being 1.5-2 mm of which
12-24). 0.5 mm into dentin.
 Amalgam Class I Preparation and Restoration 257

Figures 12-25A and B: Marginal ridge walls should follow the external surface of tooth

• Marginal ridge width in premolar is 1.5 mm and molar Common Pitfalls

is 2 mm. • Cavity preparation is not centred to tooth.
• All defective pits and grooves are involved in • Cavity depth or width is excessive.
preparation. • Cavity form is not in smooth flowing curves.
• Pulpal floor be flat and smooth unless until residual • Restoration not carved or restoration being underfilled
caries has been excavated. or overfilled.
• Cavity form should be occlusally converging without
danger of undermining the enamel.
• No unsupported enamel should be present.
Armamentarium
Restoration (Common to all Types of From Left to Right
Restorations) • Mouth mirrors
• Restoration should be well-carved, polished and • Explorers
burnished (Figure 12-26). • Tweezers
• No excess amalgam and underfilling should be present • Chip syringe
(Figure 12-27). • Cotton holder with cotton
• Spoon excavator
• Cement spatula
• Plastic filling instrument
• Enamel chisel
• Enamel hatchet
• Amalgam well (Dappen dish)
• Amalgam carrier
• Tofflemire retainer and matrix band No. 8 (for palatal
extension in upper molar)
• Amalgam condensers (parallelogram and round)
Figure 12-26: Carved and well-polished restoration • Amalgam burnisher (football or ovoid)
• Amalgam carvers (cleiod – discoid carvers, hollenback
carver)
• Articulating paper and articulating forceps.

Rotary Cutting Instruments

Figure 12-27: Various walls and angles in
occlusal class I preparation • Airotor handpiece, slow speed handpiece.
258 Essentials of Operative Dentistry

• Burs (tungsten carbide burs No. 330, 245) (diamonds • Palatal extension
round ½, pear shaped 245, straight fissure 271, inverted • Marginal ridge width.
cone 33½ ).
• Amalgam finishing stones.
• Rubber cup. Questions to Think About
• Pumice.
1. What are the indications and contraindications of
Miscellaneous class I amalgam restoration?
2. Elaborate the steps in class I amalgam cavity pre-
• Gauze cotton
paration in maxillary premolar.
• Rubber dam kit.
3. Discuss about steps in cavity preparation and resto-
ration of class I palatal extension of maxillary molar.
Key Terms 4. Write about the features in class I amalgam cavity
• Pilot groove preparation.
 Amalgam Class II Preparation and Restoration 259

13
Amalgam Class II
Preparation and
Restoration

Indications and Contraindications Local Anesthesia

• Should be administered both for the tooth as well as
Incidence and Extent of Proximal Caries adjacent soft tissues.
• When incidence of caries is high amalgam restoration • In addition to anesthetic effect this also effectively
is considered. reduces the salivation.
• When extensive loss of tooth structure is there cast • Not required in preclinical exercises.
restorations are preferred.
Isolation of Operating Site
Age of Patient
• Rubber dam application is primarily important for
Amalgam restoration can be used irrespective of age. providing a dry field of operation.
• A interproximal wedge could also be applied to
Esthetics compress down interproximal tissues and also rubber
Amalgam is not preferred if esthetics is of primary dam.
concern.
General Principles of Cavity
Economics
Amalgam restorations are more economical than cast gold
Preparation for Class II Lesion
or tooth colored restorations.
Outline Form
Galvanism Proportional Size of Caries Cone and their Relative
Amalgam restorations are not placed in teeth juxtaposed
Size to Uncleansable Proximal Areas
to gold restoration because of galvanic shock. • If caries both forward and backward does not involve
fully into cleansable areas of contact areas. Then cavity
outline is extended into the cleansable area of the contact
Abutment Teeth for Partial Dentures area (Figures 13-1A and B).
If caries involved teeth is taken as abutment then its best • If the lesion exceeds the cleansable area of contact area
restored with full crown. the cavity outline is determined by the caries cone extent
(Figure 13-1C).
Occlusion
Centric holding cusps and eccentric contacts should Extension for Convenience or Access
be properly marked with articulating papers preopera- • In most of the class II cases it is necessary to involve the
tively. occlusal portion to gain access to the proximal portion.
260 Essentials of Operative Dentistry

Figure 13-2: Maintaining

intact marginal ridge
Figures 13-1A to C: (A, B) Cavity outline determined by
extension into cleansable area, (C) Cavity outline determined Generalized plaque index
by caries extension Cavity preparation outline is directly proportional to the
plaque index of patient.
Seldom is there any other way to access the proximal Localized cariogenic factors
area. Greater the cariogenic factors that are present greater
• In some teeth the proximal portion can be accessed extent of cavity preparation into self cleansable area is
without occlusal entry. required.
Esthetics
Location and Condition of Gingiva • Facial wall extent is limited especially in upper first
• It is imperative that gingival margin is place supra- premolar to limit the exposure of restoration.
gingivally in most of the situations. • Facial wall could be made to follow the curvature of the
• If necessary certain amount of gingival could be tooth.
surgically removed to place the gingival seat.
Tooth position
Malaligned or rotated teeth may necessities a change in
Condition of Marginal Ridge tooth preparation strategy.
• If proximal portion could be instrumented through the
embrasures then the marginal ridge could be left intact. Resistance Form
• If even possible a separate occlusal and proximal
portions could be prepared leaving an intact marginal • Fundamental concept of resistance form development
ridge (Figure 13-2). is based on reaction of both restoration and tooth to
occlusal loading.
Convexity of the Proximal Surfaces • When internal stresses exceed certain limits both the
tooth and restoration fails which can microscopic or
• Convexity should be reproduced as it was macroscopic.
preoperatively in the tooth involved. • During occlusal tooth and restoration undergo tensile,
• More convex the tooth structure larger will be embrasure compressive and shear stresses which can be static or
and smaller will be the contact area. dynamic both in centric and in eccentric movements.
(Figure 13-3).
Modifying Factors Influencing Outline Form • Restoration if not in occluding contact then tooth can
Masticatory loads supraerupt into a new occluding contact which will be
• Greater the masticatory load smaller should be the dimen- deleterious both mechanically and biologically.
sion of the cavity preparation facially and lingually. • If restoration is in premature contact will exaggerate
• To reduce the occlusal contact of the restoration. the stresses on restoration and lead to failure.
 Amalgam Class II Preparation and Restoration 261

Figure 13-4: Axiopulpal line angle not rounded

and amount of stress on restoration

Figure 13-3: Effect of occlusal loading

Design Features for Protection of Mechanical

Integrity of Restoration
Isthumus
Isthmus, i.e. junction between occlusal part and proximal
part potentially deleterious stress develop there.
Stresses here are:
1. Fulcrum of bending occurs at the axiopulpal line
angle.
2. Stresses increase closer to the surface of restoration Figures 13-5A to C: Logic behind
axiopulpal line angle beveling
than away from it.
• These problems can be solved by increasing the bulk of
restoration.
• Every part of restoration should be retentive.
• If cavity floor is deepened then it can lead to pulpal
• Avoid as much as possible any surface discontinuities
involvement.
during carving of restoration.
• Axiopulpal line angle could be raised to reduce the
• Finally checking for occlusal prematurities.
stresses but this leads to reduction in bulk of restoration
and failure.
• Amalgam bulk could be increased in marginal ridge by Margins
slanting the axiopulpal line angle. Four design features are essential in margin of restoration:
• This slanting also improves the accessibility to the 1. Create butt joint on cavosurface margin.
proximal portion during cavity preparation. 2. Leave no unsupported enamel on cavosurface margin.
• Axiopulpal line angle roundening reduces the stress 3. Remove flashes of amalgam on occlusal surface.
concentration in these areas (Figures 13-4 and 13-5). 4. Amalgam and tooth interface should not be in occlusal
• Pulpal and gingival floor should be flat. contact both in centric and eccentric contact.
262 Essentials of Operative Dentistry

Design Features for Protection the Integrity of

Tooth Structure
Isthmus
• Increasing the width of isthmus of cavity preparation
greatly reduces the fracture resistance of tooth and
weakens it.
• Intercuspal width of isthmus area be only 1/4th-1/5th
of tooth.

Occlusal Surface
• Occlusal part of preparation be same as that of class I
preparation.
• Design features include divergence of walls near
marginal ridges, preserving the crossing ridges and
marginal ridges, rounded line and point angles.
• Cusps and axial angles.
• If cusp length width ratio is less than 1:1 (e.g. 2:1) then
capping of cusp may be necessary. Figures 13-6A to C: When extending preparation
past contact area it is necessary to have a sweeping
Margins curve of margins as reverse curve

• Facial and lingual walls and margins of occlusal part

should approach proximal part at right angles.
• These walls should terminate past the contact areas
into embrasure.
• Normal sweeping curve of tooth must be reversed when
its necessary to broaden the tooth preparation to include
self cleansable areas (Figures 13-6A to C).
• Occlusoproximal cavity preparation should always be
stepped form gingivally to avoid pulpal involvement Figures 13-7A to C: Proximal displacement of restoration
and improve retention and resistance form. due to occlusal loading

Retention Form • Lateral rotation of restoration: This is prevented by

Possible displacement of restorations can be: definite point and line angles (Figures 13-8A to D).
• Proximal displacement of entire restoration. • Occlusal displacement: Prevented by inverted truncated
• Proximal displacement of proximal portion. cone of restoration.
• To prevent such displacement self retaining facial and Although these displacements are microscopic levels
lingual grooves are placed in proximal portion of cavity when repeated thousands of times over, they can lead to
in addition to occlusal dovetail (Figures 13.7A to C). microleakage and initiate failure of restoration and tooth.

Figures 13-8A to D: Lateral rotation of restoration

 Amalgam Class II Preparation and Restoration 263
Convenience Form
• Occlusal involvement in proximal portion preparation
is in itself for convenience form.
• However, if possible proximal portion be accessed
through embrasures keeping occlusal surface intact.

Two Surface Cavity Preparation

For descriptive purposes a mesiocclusal cavity preparation
in mandibular second premolar is taken up.

Initial Cavity Preparation

Occlusal Outline Form (Occlusal Step)
Figure 13-9: 0.8 mm diameter head bur is cutting
• Outline form of occlusal step of class II preparation is 0.5-0.6 mm into dentin and 0.2-0.3 mm into enamel
similar to occlusal outline form of class I preparation.
• No. 245 bur could be used for punch cut nearest to
involved proximal area.
• Bur should always be rotating when applied to tooth
and should not be stopped until removed.
• During whole cutting procedures the bur should be kept
parallel to long axis of the tooth.
• Depth of cavity preparation be 1.5-2 mm.
• The width of isthmus be ideally ¼ the interproximal
distance (width of No. 245 bur).
• During extension of cavity outline into distal pit disto-
lingual and distofacial grooves are involved to provide
dovetail retention form against tipping of mesial end.
• Before entering into proximal marginal ridges
visualization of final facial and lingual proximal walls
in relation to proximal contacts be made. Maintaining Figure 13-10: Deep gingival margin in cementum
bur at same pulpal depth extend the cavity preparation pulpal-depth of proximal box be 0.75-0.8 mm
0.8 mm short of marginal ridge. Faciolingual width at
this area of occlusal step is slightly wider than in
class I preparation (depth of cavity preparation is more
important for strength).

Proximal Outline Form (Proximal Box)

Proximal Ditch Cut (Figures 13-9 to 13-12)
• Initial step in preparing the proximal box is isolation of
proximal enamel by proximal ditch cut.
• Allow the end of the bur cut a ditch gingivally along the
exposed DEJ, 2/3rds at expense of dentin and 1/3rd at
expense of enamel (0.8 mm dia bur—0.5-0.6 mm in
dentin and 0.2-0.3 mm in enamel) (Figure 13-9).
• Bur is moved facially and lingually along the DEJ.
• As a rule extend the ditch gingivally beyond the caries Figure 13-11: Occlusal view as proximal
or contact width whichever is greater. ditch cut has been made
264 Essentials of Operative Dentistry

Figure 13-12: After occlusal step preparation

and proximal ditch cut Figure 13-13: Isolating proximal enamel wall

• Harder intact proximal enamel will act as guide and

creating axial wall that faciolingually follows the
contour of the proximal surface.
• The mesiofacial and mesiolingual margins should clear
the adjacent tooth by atleast 0.2-0.3 mm.
• In gingival extension the gingival wall should clear the
adjacent tooth by only 0.5 mm.
• Clearance of proximal margins greater than 0.5 mm is
unnecessary unless indicated by presence of caries,
undermined enamel, and existing restorations.
• Location of final margins of proximal portion is finished
with handcutting instruments margins should not be
overextended with No. 245 bur.
• Extension of gingival margin into gingival sulcus be
avoided to prevent gingival inflammation. Figure 13-14: Bur emerging through
• Proximal ditch dentin depth be ideally 0.5-0.6 mm. the proximal wall
• Because the enamel becomes thinner as we go from
occlusally to gingivally bur touches the external surface
of the tooth as we progress gingivally.
• When gingival extension is taking the preparation
gingivally into the tooth the depth must be ideally
0.7-0.8 mm.
• Proximal ditch cut is diverged gingivally to create
retention form.
• Occasionally, it is permissible not to extend the facial
and lingual margins beyond the contact regions in
patients with broad proximal contact and clean mouth.

Completion of Proximal Extensions

(Figures 13-13 to 13-23)
• Next two cuts are made at the facial and lingual limit of
the proximal ditch extending toward proximal contact
and nearly through the enamel. Figure 13-15: Facial and lingual proximal walls are not
• This weakens the proximal enamel and prevents from overextended with burs and clearance from adjacent tooth by
damaging the adjacent tooth structure. 0.2-0.3 mm
 Amalgam Class II Preparation and Restoration 265

Figure 13-19: Reverse curve on mesiofacial wall

Figure 13-16: Gingival floor of proximal wall clears the

adjacent tooth by 0.5 mm and it is tested by an explorer
Figure 13-20: Wedge placement to
protect gingiva and rubber dam

Figure 13-17: Removing proximal enamel

wall with spoon excavator
Figure 13-21: Removing off spurs of enamel with hatchet

Figure 13-18: Occlusal view after Figures 13-22A to C: Maintenance of proper 90° proximal
proximal wall removed enamel wall
266 Essentials of Operative Dentistry

Final Cavity Preparation

Removal of any Remaining Caries
(Figures 13-24 and 13-25)
• Infected dentin is removed by small round bur or spoon
excavator.
• Stop excavating once dentin feels hard or firm.
• Removal of remaining caries should not affect resistance
form of cavity.

Figure 13-23: Facial and lingual proximal walls

should follow the external surface of the tooth

• If enamel breaks off a matrix band may be applied to

prevent damage to adjacent tooth.
• Remaining unbroken enamel is fractured off with a
spoon excavator.
• To protect the gingiva and rubber dam during gingival Figures 13-24A to C: Removal of caries from cavity floor
extension a wedge can be placed interproximally. and floor facially and lingually at ideal depth
• Round wooden wedge is usually preferred.
• But a triangular wooden wedge is preferred in deep
gingival extension because of its greatest cross-sectional
diameter of the wedge at its base.
• With enamel hatchet (10-7-14) or bin-angle chisel
(12-7-8) establish proper direction to mesiofacial and
mesiolingual walls they should have 90° angle.
• Also weakened enamel wall in gingival floor is also
remove by scrapping with enamel hatchet.
• Viewed from occlusally mesiofacial enamel wall is Figures 13-25A to C: Removal of caries from axial wall and
lining with ZOE cement
parallel to enamel rod direction creating a reverse curve
in outline, this is not necessary for lingual wall.
• Finishing of proximal wall is done by hand instrument Old Restorative Material
as rotary instrument has the danger of marring adjacent
• Is removed only when the margins show secondary
tooth or crawling out of gingival marring to create a
caries, tooth is symptomatic.
rounder cavosurface margins.
• If caries is present on the axial wall in central only, that
portion alone is excavated rather than whole axial wall
Primary Resistance Form and being deepened.
Retention Form • If caries is remaining on the gingival floor part of the
Primary resistance form is provided by: floor alone be extended. If whole of the floor is extended
• Floors and walls being perpendicular to forces directed then proper application of matrix and wedging becomes
along long axis of the tooth. difficult.
• Restricting the extensions to preserve stronger cusps • These partial extension areas are filled with amalgam
and marginal ridges. first followed by other areas.
• Restricting the outline form to receive as minimal A partial extension of a facial or lingual wall is
occlusal forces as possible. permissible (Figures 13-26 and 13-27):
• Roundening of internal line angles. • Entire wall is not weakened.
• Providing enough thickness of restoration. • Extension remains visible and accessible.
 Amalgam Class II Preparation and Restoration 267

Figures 13-28A and B: Beveling axiopulpal line angle

• Occlusal convergence and dove tail form should be

sufficient for occlusal step retention.
• Occlusal convergence of proximal box should also give
Figure 13-26: Partial extension in gingival floor retention form, to enhance retention proximal locks are
placed.
• Using 169L bur proximal locks are placed.

Four Characteristics of Proximal Lock

(Figure 13-29)
1. Position 2. Translation
3. Depth 4. Occlusogingival orientation.
• Other burs like 33½ or ¼ round bur are also employed.
• Narrow proximal boxes require shallow locks and
wider proximal boxes require deeper locks.
• Slots in gingival floor may be given in preparations
where facial and lingual walls extend beyond the
proximal line angles.
• It is prepared with ¼ or ½ bur is used, 0.5-1 mm deep
Figure 13-27: Partial extension in gingivally, 2-3 mm length faciolingually, 0.2-0.3 mm
facial wall of proximal box inside DEJ.
Pot-holes are also prepared in gingival floor, its prepared
• Sufficient gingival seat remain to support restoration. with ½ or 1 bur. 0.5-1 mm deep gingivally and 0.2-0.3 mm
• A butt joint is possible. inside DEJ.

Pulp Protection Procedure for Finishing Enamel Walls

Calcium hydroxide or zinc oxide eugenol liner or base can • Butt joint of amalgam with cavosurface margin is the
be applied same as in class I preparation. strongest margin.
• Gingival marginal trimmer is used to bevel (20°) at the
Secondary Resistance and Retention Form gingival margin enamel.
• When gingival margin is present gingival to CEJ no
• This form entails protection of both tooth and restoration
beveling is indicated (Figure 13-30).
from oblique forces.
• Gingival marginal trimmer is used to bevel axiopulpal
line to increase the restorative material thickness in this Final Procedures
region (Figures 13-28A and B). • Cleaning of cavity is done.
• Secondary retention form for proximal and occlusal • If cavity varnish is to be applied its done before
portion of the cavity is given separately and should be application of matrix band to prevent pooling of varnish
independent of each other. (Figure 13-31).
268 Essentials of Operative Dentistry

Figure 13-29: Proximal lock placement

Figure 13-30: Beveling gingival cavosurface margin

• Injudicious cutting of central groove can weaken the

lingual cusp.
• Most of time because of absence of a central groove (and
presence of strong transverse ridge) only the proximal
portion alone is prepared without occlusal step (Figures
13-32 and 13-33).
• Usually No. 245 bur is used for preparation.

Maxillary First Molar

• If oblique ridge is unaffected two separate proximal
cavities can be prepared.
• Sometimes facial fissure may be involved preparation
may be extended onto this groove (in mesiocclusal
Figure 13-31: Finished class II preparation preparation) (Figure 13-34).
in lower second molar • In distocclusal preparation, if distolingual groove is
involved special care should be taken to prevent
undermining of distolingual cusp.
Variations of Single Proximal • If necessary capping of distolingual cusp be performed.
Cavity Preparations Maxillary First Premolar
• Class II preparations for mandibular first premolar differs • A mesial class II preparation here is treated with special
from other tooth preparations because of presence of a attention because of esthetic importance of mesiofacial
small lingual cusp and lingual inclination of the tooth. wall.
 Amalgam Class II Preparation and Restoration 269

Figure 13-32: Lingual inclination of floor of

cavity in lower premolars Figures 13-35A and B: Minimal facial extension in
maxillary first premolar

involvement, Almquist, Cowan, Lambert and Markley

advocated this design.
• Here retention is given by occlusal convergence of
proximal walls and proximal retentive locks of 0.5 mm
deep gingivally and disappearing to 0.3 mm occlusally
(Figure 13-36).

Figure 13-33: Transverse ridge (strong) is

left in lower premolar

Figure 13-36: Small box preparation

Slot Preparation
• Older patients because of gingival recession and
cemental exposure caries occurring on tooth surface
well below contact can occur.
• Cavity preparation in form of slot without involving
contact area is advocated.
• A facial or lingual approach can be done.
• A No. 2 bur or No. 4 bur can be used to gain entry depth
Figure 13-34: If oblique ridge is of cavity be 0.75-1 mm pulpally if no enamel, 1-1.25 mm
unaffected it can be left intact occlusal wall if enamel is present.
• External walls have 90° cavosurface angle.
• Minimum of extension into mesiofacial wall is permitted • Facial wall could be extended for convenience.
(Figures 13-35A and B). • Retentive grooves be made of No. 1/4 bur in occlusal
• Gingival divergence of this wall is limited to prevent and gingival walls it should be of 0.3-0.5 mm depth
extension into esthetic zone. (Figure 13-37).
• In some instances this preparation could encircle the
whole tooth if necessary.
Modifications in Cavity Design
Simple Box Preparation Rotated Tooth
• In restoring teeth with small proximal lesion, small • Cavity preparation is same as that of conventional
proximal contact without any occlusal fissure preparation.
270 Essentials of Operative Dentistry

Figure 13-37: Slot preparation

• Sometimes, if tooth is rotated 90° isthmus preparation

may be required in cuspal eminence (Figure 13.38). Figure 13-40: Two restoration joining
• Slot preparation could be done if lesion is small. should be right angles

• Two restorations should have separate resistance and

retention form.

Abutment Teeth for Removable Partial

Denture
• If a rest is planned on teeth involved by occlusoproximal
lesion an additional extension be prepared (Figure
Figure 13-38: Isthmus present on the 13-41).
cuspal eminence • Rest could either be completely on amalgam or both on
amalgam and tooth.
Unusual Outline Form
If there is coalesced enamel this could be treated with
individual amalgam restorations (if fissures are not closer
than 0.5 mm) (Figure 13-39).

Figure 13-41: Tooth borne removable

partial denture (RPD)

Figure 13-39: Unusual groove morphology Cavity Preparation Involving

Adjoining Restorations Both Proximal Surfaces
• This could be done if older restoration has no defects. An uncomplicated two surface preparation is same as
• The adjoinment of two lesion be butt joint (Figure that on surface preparation except its two surface
13-40). involvement.
 Amalgam Class II Preparation and Restoration 271
Mandibular First Premolar Reduction of Cusps for Capping
• Support of lingual cusp should be taken care of (Figures (Figures 13-44 to 13-47)
13-42 and 13-43). • When extension is 2/3rd from a primary fissure toward
• Preparation should involve more of facial tooth cusp tip reduction of cusps for amalgam capping is
structure. mandatory for adequate resistance form.
• If capping of cusp is deemed necessary depth gauge • Reduction for cuspal capping be done early in cavity
cuts are employed. preparation as it greatly aids in access and visibility.
• Nonfunctional cusps require amalgam capping of • Cuspal reduction is done by depth gauge cuts of 1.5 mm
1.5 mm. on nonfunctional cusps and 2 mm on functional cusp.
• Functional cusp requires 2 mm of amalgam. • Cuspal reduction is done as anatomically as possible.
To preserve strength of tooth and restoration.

Figures 13-44A to D: Reduction of distolingual cusp of

Figure 13-42: Lingual cuspal strength upper molar
should be taken care of

Figures 13-45A to D: Cuspal capping of distal cusp of

lower molar
Figure 13-43: Capping of lingual cusp
in lower premolar

Maxillary First Molar

Here support of distolingual cusp be taken care of.
Oblique ridge is involved in preparation only: (a) ridge
is undermined by caries, (b) crossed by deep fissure,
(c) when less than 0.5 mm of tooth structure is left.

Procedure for Distal Cusp of

Mandibular First Molar
Distal cusp may be completely removed during distal
proximal preparation and margins may be placed just
mesial to distofacial groove.
Alternative would be to cap the distal cups this has the
advantage of:
• Proper application of matrix band. Figures 13-46A to C: Depth orientation grooves are put to
• Development of proper embrasure form. have cuspal reduction in an anatomic form
272 Essentials of Operative Dentistry

• Facial, lingual surfaces of teeth form smooth curvatures

as also from mesial and distal aspect.
• These contours play important role in gingival
stimulation and gingival health.
• Buccal and lingual contours helps to push away the
food particles from gingival tissues.
• Generally, these increase in curvatures of tooth is called
as cervical ridges (height of contour).
Figure 13-47: Measurement of bur height • Generally mesial height of contour is occlusal than
using periodontal probe or caliper distal.
• Lingual height of contour of mandibular posterior teeth
• Depth gauge cuts ensure smooth and uniform is occlusal than maxillary teeth.
reduction. • Facial height of contour of maxillary teeth is more
• Cuspal reduction significantly reduces the retention occlusal than mandibular teeth.
form because of loss of vertical height of cusp. • Facial and lingual height of contour is generally
• Length of bur heads should be known before cuspal 0.5 mm except mandibular lingual contour which is 1
reduction (periodontal probes are used). mm (Figure 13-49) (Table 13-1).
• Additional retention is given in form of slots, grooves,
pot-holes or pins. Facial Surfaces
Heights of contour for both anterior and posterior teeth
Contact and Contours are located in the cervical third (Figure 13-50).
• Fundamental curvatures of tooth is very important for
proper maintenance of surrounding gingival and Lingual Surfaces
periodontal tissues health. • Anterior teeth: It is located on the cervical third.
• Generally tooth shapes can be divided into: (a) tapering • Posterior teeth: Present on middle or occlusal third.
form, (b) ovoid dorm, (c) square form (Figure 13-48).
Proximal Contact Areas
A tooth has positive contact on two sides mesially and
distally with adjoining teeth.
Proper contact relation between adjoining teeth is
important for:
• Prevents food packing between teeth.
• Stabilize the dental arch with positive contact.
• Proper occlusal force distribution.
Contact areas are appreciated from labial and occlusal
aspect.

Interproximal Spaces
• Are triangular shaped spaces filled by gingival tissues.
• Base of triangular space is formed by alveolar process,
sides by proximal surfaces of tooth, apex by contact
areas (Figure 13-51).

Figure 13-48: Shapes of teeth Embrasures (Spillways)

• Two teeth in same arch contacting their curvatures
Height of Contour adjacent to contact areas form spillway spaces called
• Height of contour (crest of curvature) is the greatest area embrasures.
of contour incisocervically on the facial and lingual • These embrasures are continuous with interproximal
surfaces of teeth best viewed from proximal aspect. spaces.
 Amalgam Class II Preparation and Restoration 273
Table 13-1: Height of contour of various teeth

Lingual Facial Mesial Distal

Maxillary
Central incisor Cervical 1/3 Cervical 1/3 Incisal 1/3 Junction of middle
and incisal 1/3
Lateral incisor Cervical 1/3 Cervical 1/3 Junction of middle Middle 1/3
and incisal 1/3
Canine Cervical 1/3 Cervical 1/3 Junction of middle Junction of middle
and incisal 1/3 and occlusal 1/3
First premolar Junction of cervical Cervical 1/3 Junction of middle Junction of middle
and middle 1/3 and occlusal 1/3 and occlusal 1/3
Second premolar Junction of cervical Cervical 1/3 Junction of middle Junction of middle
and middle 1/3 and occlusal 1/3 and occlusal 1/3
First molar Junction of cervical Cervical 1/3 Junction of middle Middle 1/3
and middle 1/3 and occlusal 1/3
Second molar Junction of cervical Cervical 1/3 Middle 1/3 Middle 1/3
and middle 1/3
Third molar Junction of cervical Cervical 1/3 Middle 1/3 Middle 1/3
and middle 1/3
Mandibular
Central incisor Cervical 1/3 Cervical 1/3 Incisal 1/3 Incisal 1/3
Lateral incisor Cervical 1/3 Cervical 1/3 Incisal 1/3 Incisal 1/3
Canine Cervical 1/3 Cervical 1/3 Incisal 1/3 Junction of middle
and incisal 1/3
First premolar Junction of cervical Cervical 1/3 Junction of middle Junction of middle
and middle 1/3 and occlusal 1/3 and occlusal 1/3
Second premolar Middle 1/3 Cervical 1/3 Junction of middle Junction of middle
and occlusal 1/3 and occlusal 1/3
First molar Middle 1/3 Cervical 1/3 Junction of middle Middle 1/3
and occlusal 1/3
Second molar Middle 1/3 Cervical 1/3 Middle 1/3 Middle 1/3
Third molar Middle 1/3 Cervical 1/3 Middle 1/3 Middle 1/3

Figure 13-49: Height of contour Figure 13-50: Facial and lingual contours
274 Essentials of Operative Dentistry

Figure 13-51: Interproximal space and related structures:

(1) Marginal gingiva, (2) gingival line, (3) interdental papilla,
(4) gingival embrasure, (5) contact area, (6) clinical crown,
(7) incisal/occlusal embrasure, (8) anatomical crown,
(9) interproximal space, (10) cervical lines, (11) alveolar bone

These embrasures serve: Figure 13-52: Embrasure forms

• Makes spillway escape of food during mastication.
• Prevents food from being forced through contact area.
• For self cleaning purposes.
• In anterior teeth it also forms esthetic part also.
If an imaginary line is drawn between the embrasures
the two halves should be symmetrical.

General Considerations in Embrasure Form Figure 13-53: Mesial contact of a tooth is more
(Figure 13-52) occlusal in position than distal contact
• From the facial aspect the incisal or occlusal embrasure
increase in size from anterior teeth to posterior teeth.
• From facial aspect the gingival embrasure decrease in
size from anterior teeth to posterior teeth.
• From occlusal aspect the incisal embrasure of both buccal
and lingual are of equal size—anterior teeth.
• In posteriors—lingual embrasure is larger except for
maxillary 1st molar.
• Incisal embrasures may be missing in mandibular Figure 13-54: Anterior teeth—contact areas
anterior teeth. are centered faciolingually
• In maxillary anteriors—lingual embrasure is greater
than facial embrasure.
• In mandibular anteriors—facial embrasure is larger.

Design of Contact Areas, Interproximal Spaces,

Embrasures Varies with Form, Alignment of
Various Teeth (Figures 13-53 to 13-55)
• From the labial aspect the contact areas are at the height
of contour and mesial contact is usually more occlusally Figure 13-55: Posterior teeth—contact areas
present than distal contact. are placed more in buccal 1/3rd
 Amalgam Class II Preparation and Restoration 275
• From occlusal aspect the contact areas of anterior teeth massaging effect of the food being deflected away (Figure
are centered faciolingually and in posterior teeth its 13-57).
present on the buccal 1/3rd .
• Contact areas usually recede from incisors to the molars. Facial and Lingual Concavities
• Proper maintenance of concavities occlusal to height of
Marginal Ridges contour is essential for it acts as pathways for occlusal
• The linear elevations which are convex in cross-section relationships.
and are found at the mesial and distal terminations of • Apical to height of contour the concavities play role in
the occlusal surface of posterior teeth. They are also protection of gingival tissues.
found on anterior teeth, but are less prominent.
• Their location also differs, since on anterior teeth they Interproximal Spaces
form the lateral (mesial and distal) margins of the lingual Proper restoration of this form is essential, improper
surface. restoration of this area results in overhangs or underhangs
• Marginal ridges of adjacent teeth must be of same height. results in food impaction and impingement on periodontal
• In conjunction with their heights, adjacent marginal tissues.
ridges are normally shaped so that they create a small
occlusal embrasure for posterior teeth or lingual Marginal Ridge
embrasure for anterior teeth. The heights and shapes of Following faults can occur (Figure 13-58):
the adjacent marginal ridges directly affect the • Absence of marginal ridges.
embrasure form. • Marginal ridge with exaggerated occlusal embrasure.
• Dentist’s responsibility to reproduce symmetrical • Adjacent marginal ridges not compatible in height.
embrasure form by establishing marginal ridges on • Marginal ridge with no triangular fossa.
adjacent teeth which are similar in height and shape. • Marginal ridge with no occlusal embrasure.
• One plane marginal ridge.
• Thin marginal ridge can be susceptible to fracture.
Hazards of Faulty Reproduction
of Physioanatomical Features of Intraoral Procedures for Creation
Teeth in Restorations of Contacts and Contours
Contact Size Two operative procedures are essential and precede
• Increase in size leads to impingement on gingival restoration of teeth, they are:
tissues and inflammation. 1. Tooth movement
• Broader contact also leads to increase in caries suscep- 2. Matricing.
tibility.
• Creating contact smaller in size leads to food impaction. Tooth Movement
• An open contact can also lead to food impaction and
microbial growth. It is an act of bringing two teeth closer or apart. This is
done in order to facilitate the creation of physiologically
functional contact and contour (Figure 13-59).
Contact Configuration
Creating a contact with too much concavity (flatness) or
Objectives
convexity also leads to inflammation of gingival tissues
(Figure 13-56). • To bring the teeth to physiologic position for proper
reproduction of proximal surfaces.
Contour • To close space between two teeth not amenable to
restoration.
Facial and Lingual Contours • To move the teeth to periodontal acceptable position.
An overcontoured tooth can lead to food accumulation at • To move the teeth in direction so that there is increase
gingival margins and deprive gingival tissues of in dimension of available tooth structure.
276 Essentials of Operative Dentistry

Figure 13-56: Contact configuration

Figure 13-57: Correct, over and under contours

 Amalgam Class II Preparation and Restoration 277

Figure 13-58: Common faults in marginal ridge

Two principal tooth movements are:

1. Rapid or immediate tooth movement.
2. Slow or delayed tooth movement.

Rapid Tooth Movement

Indications
• Used as preparatory to slow movement.
• This type of movement should not exceed thickness of
periodontal ligament thickness (0.5 mm).

Advantages
• Quickness
• Ability to produce steady tooth movement during
operative procedure.

Disadvantages
• Rupture of periodontal fibers.
• Pain if too rapid separation.
Figure 13-59: Tooth movement
Slow or Delayed Tooth Movement
• To create space sufficient for thickness of matrix band
interproximally.
Indication
When teeth has drifted or moved considerably.
This procedure is done:
• For forming proper proximal contact and contour.
• Facilitating access to proximal lesions.
Advantages
• To detect proximal decay. • Absence of soreness of tooth.
• For polishing proximal restorations • Less danger of tearing of periodontal fibers.
• To remove foreign bodies lodged proximally. • To retract gingival tissues.
278 Essentials of Operative Dentistry

Disadvantage • Wedge is used in conjunction with application of

Slow and time consuming. matricing.
Rapid method has more advantages and frequently • Wedge perform following function:
used. • Assure close adaptation of matrix band to tooth
structure preventing accumulation of restorative
material between tooth and band.
Methods
• They define gingival extent of contact area.
Wedge method: Separation is accomplished by pointed • Create separation to compensate for thickness of
wedge shaped device. matrix band.
Elliot separator (Figures 13-60A and B) • Establish atraumatic retraction of rubber dam septa
• Is used for short duration and no stabilization is and gingiva from gingival margins of the tooth
required. preparation.
• Useful for examining proximal surfaces and polishing • Assure immobilization of matrix band during
restorations. insertion of restorative material.
• Protect interproximal gingival from operative trauma.
Procedure: Two opposing wedges of the device is engaged Wedges are supplied in various forms and shapes but
in interproximal spaces and knob turned clockwise to
custom trimmed wedges are best (Figures 13-61A and B).
move wedges close together and desired separation is got.

Figures 13-61A and B: Wedges

Main advantage of wooden wedge is it can be easily

trimmed and absorb water intraorally to swell up and
increase retention of wedge.
Main advantage of plastic wedge is it can be easily
molded or bend.
Traction method: This is done by a mechanical device in
which holding arms separate the teeth held.
Examples:
a. Noninterfering true separator
• It is indicated when continuous stabilization is required
during operative procedure.
• Advantage is that the separation can be increased or
decreased even after stabilization.
Procedures
• Ensure that the jaws are close to each other and can
Figures 13-60A and B: Elliot separator be easily inserted into interproximal portion of teeth.
• Jaw closest to bow is employed on tooth to be
Wooden or Plastic Wedges operated.
• They are usually triangular in cross-section. • Moving jaw is engaged on other tooth.
• Base of triangular wedge be on gingiva, two sides of • Softened modeling compound is used to cover the
triangle face two proximal surfaces of tooth and apex of separator without interfering on the bow or the
triangle faces contact area. moving screws (Figure 13-62).
 Amalgam Class II Preparation and Restoration 279

Figure 13-62: Noninterfering true separator

available in three sizes

b. Ferrier double bow separator (Figure 13-63)

Figure 13-64: Separating wires
• Separation is stabilized throughout the procedure.
• Here separation is shared by the contacting teeth also
unlike in previous model. • Orthodontic appliances: Fixed orthodontic appliances
Procedures are most effective way of tooth movement of any
• Four arms are adjusted so that they hold four corners magnitude.
of proximal surfaces.
• Wrench is applied labially and lingually to make
desired separation. Matrices for Two and Three
• Compound is applied for stabilization.
Surface Restorations
• First use of matrix in dentistry is by Dr Louis Jack in
1871.
• Matricing is a procedure by which a temporary wall is
created opposite to axial walls and surrounding areas
of tooth structure that were lost during preparation.
• When placing the amalgam its aim is to reproduce the
contacts and marginal ridges and at the same time have
smoothest possible junction between tooth and
restoration.
• In dentistry there is no satisfactory matrix system.
• Primary function of matrix system is to restore the
Figure 13-63: Ferrier double anatomic contour and contact areas.
bow separator
• Matrix is always a two component system:
1. The band a piece of metal or polymeric material
Slow or Delayed Tooth Movement which give support and form to restoration.
Methods 2. A retainer a device by which the band is retained in
its position and shape. This could be a mechanical
• Gutta-percha: It could be heated and softened or it could
device, a wire, dental floss or compound.
be softened in eucalyptus oil and packed into proximal
cavity and left for days to attain separation. Qualities of good matrix are (Figure 13-65)
• Separating wires: Thin wires can be introduced thru • Rigidity
the contacts of teeth and twisted and tightened • Establishment of proper anatomical contour.
periodically to attain desired separation (Figure 13-64). • Restoration of correct proximal contact.
• Oversized temporaries: Oversized resin temporaries • Prevention of gingival excess.
(mesiodistal dimension) are employed and periodically • Convenient application.
resin material is added to attain desired separation. • Ease of removal.
280 Essentials of Operative Dentistry

Figure 13-65: A good adapting

matrix and wedge

Objectives of Matrix
• Displace rubber dam and gingiva away from cervical
part of preparation.
• Assure dryness and noncontamination of the
preparation.
• Provide proper form and contour for restoration.
• Maintain its shape during hardening of restoration.
• Confine the restoration within the preparation
preventing overhanging margins.
Matrices can be of three types (Figures 13-66A to C): Figures 13-66A to C: Types of matrices
1. Band encircles the tooth and is held by a retainer either
on buccal side or lingual side. This is the most Types of Matrices for Class I Restoration
commonest type and various types are available in this
Matrix for Class I Restoration
category.
2. Band encircles only 3/4th of tooth and is held by a jaw
(Occlusolingual Preparation)
impinging on the band in free interproximal space. This Technique—Double banded Tofflemire (Figures 13-68A
type is employed where contact points are very tight. and B)
3. In this type the matrix band is held without a retainer. • Tofflemire retainer is used to retain a matrix band but
Here band is retained by ligature wire, compound or this does not allow intimate adaptation of matrix to
spring mechanism. Advantage here is there is no lingual portion of tooth.
interference from presence of retainer. • An additional step here is to cut a piece of stainless
Matrix bands are made up of stainless steel, celluloid, steel matrix (0.0002 inch thick, 5/16 inch wide) that
copper (Figure 13-67). will be used to fit in space between tooth and matrix band.
Metal band—used for amalgam restorations and are • Break off a round tooth pick holding it in No.110 plier.
firm. • Heat a greenstick compound cover this with end of a
Mylar strip (celluloid band)—allows light to pass tooth pick, now insert the tooth pick with heated
through used in composite and GIC restorations. compound between tooth and matrix band.
• In additions these bands are available in straight, curved • Now using a burnisher the matrix band is contoured
and contoured. with firm pressure.
• Bands are available in various occlusogingival height • This was suggested by Barton.
smaller ones are used in pediatric cases. • Condensation of amalgam is started from the gingival
• Uncontoured bands are available in two thickness 0.002 end of lingual portion.
inches (0.05 mm) and 0.0015 inches (0.038 mm). • As the condensation is finished the matrix band is
• Contoured bands are preferred as they reproduce removed using No. 110 plier by slightly moving it
contour better but are expensive. lingually and then occlusally.
 Amalgam Class II Preparation and Restoration 281

Figure 13-67: Types of matrix band

Figures 13-68A and B: Matrix band adaptation for buccal and palatal
extensions of class I preparations

Matrices for Class II Preparations • With varying occlusogingival heights of bands it could
Universal matrix (Tofflemire matrix) (Figures 13-69A and B) be used in various situations.
• Designed by BR Tofflemire. • Smaller sizes available for pediatric cases.
• Used both for two surface proximal cavity and single • It is one of the stable retainers.
surface proximal cavity. Disadvantage
Advantages Restorations produced with this retainer requires more
• Can be used both facial and lingual sides. carving than produced by a compound supported matrix.
• Lingual application requires usage of contrangled Bands
tofflemire retainer. • Uncontoured bands comes in three shapes, No. 1,
• It is easy to apply and remove No. 2, No. 3 (Figure 13-70A).
282 Essentials of Operative Dentistry

Figures 13-69A and B: Tofflemire band can be applied both buccally and lingually

Parts of Retainer (Figure 13-71)

Head : This is the part that has a open end. It is U-shaped
with two slots for matrix band positioning. Open side of
the head faces gingivally when applied on tooth. Based
on angulation of head two types of Tofflemire retainer are
available. Contrangled is for lingual application.
Slide: This element has a diagonal slot and the band extends
1-2 mm beyond the slot, depending on size of tooth being
treated. Slide is kept close to head when the band is engaged
to retainer and also during application onto the tooth. This
slide is adjustable up and down the retainer.
Figure 13-70A: Uncontoured bands
Rotating spindle: This is used to adjust the distance between
the head and slide by this way the diameter of the band
loop could be adjusted.
Set screw: It tightens the threaded shafts to lock and unlock
the bands onto the slide.

Figure 13-70B: Precontoured bands

• Available in thickness of 0.002 inches (0.05 mm) and

0.0015 inches (0.038 mm).
• By far the No. 1 band most commonly used and is the
universal band. Figure 13-71: Parts of retainer: (1) Set screw, (2) rotating
spindle, (3) slide, (4) head, (5) band
• No. 2 band has two gingival extensions and is used for
MOD preparations in molar.
Application (Figures 13-72A to D)
• No. 3 band is used in premolars it also has two gingival
• Flat bands are placed on a paper pad and burnished
extensions.
with a egg shaped burnisher to get a contoured surface
Precontoured bands (Figure 13-70B): One such example is and thinner surface to be easily engaged into the contact
Dixie-Land bands (Tele Dyne Getz). area.
Amalgam Class II Preparation and Restoration 283

Figures 13-72A to C: Application of retainer

Figure 13-72D: After placement

of band onto tooth there should
be 1 mm of band above marginal
ridge of concerned tooth
284 Essentials of Operative Dentistry

Figure 13-73: Wedge placement

• In a precontoured band this is unnecessary. Wedging Techniques (Double Wedging

• Loop can be extended from the retainer in three Techniques)
ways straight, left or right. Straighter is for anterior tooth Piggyback wedging (Figures 13-74A and B): Here if the
where there is no interference of cheeks. wedge is significantly apical to gingival margin of
• The band is folded to form a loop, when formed it forms preparation due to gingival recession a smaller wedge
a smaller diameter in gingival end and larger diameter could be applied over the existing applied wedge.
on the occlusal end.
• After the band has been applied onto tooth its again
burnished.
• Width of the band be 1 mm above the marginal ridge so
that the amalgam could be overpacked and carved.
• The matrix band with retainer is applied onto tooth
with open end of retainer facing gingiva.
• Narrower end of loop is adapted over the cervical part
of preparation.
• When one of the gingival margins is shallower in a two
surface proximal preparation band may be trimmed to
prevent gingival damage. Figures 13-74A and B: Piggyback wedging
• Evaluation of band is done both from proximal view
and occlusal view.
Double Wedging (Figures 13-75A and B)
Wedge Placement (Figure 13-73) • It is done when access allows and proximal box is wide
• Wedge can be wooden or plastic and is usually inserted faciolingually.
on side with widest embrasure usually lingual. • Here on wedge inserted from lingual and other from
• Wedge should be tightly applied to compensate for the buccal.
matrix band thickness.
• Wedging should be applied slightly gingival to gingival Wedge-Wedging (Figure 13-76)
margin of the restoration. • Occasionally a concavity may be present on the
• Wedging should not be too far down leading to proximal surface (like in max 1st premolar) to adapt the
overhanging margins. band to this concavity this technique is employed.
 Amalgam Class II Preparation and Restoration 285

Figures 13-75A and B: Double wedging supported by

compound

Figures 13-77A to D: Triangular wedge and

round wedge application

• Sometimes in clinical situation a wedge may not be

applied in those situations it must be seen that the matrix
band is tightly adapted against the tooth. And there is
bound to be some gingival excess of amalgam removed
by suitable carvers (Figure 13-78).
Figure 13-76: Fluting or mesial root concavity in upper first
premolar requires application of wedge-wedging

• A second pointed wedge may be applied between the

first wedge and the band.
Testing tightness of matrix band is done by explorer tip
on the middle 2/3rd of matrix band.
Also the tightness of the wedge also should be
evaluated.

Cross-section of Wedge (Figures 13-77A to D)

Two types:
1. Triangular wedge (anatomic wedge)
2. Round wedge.
Figure 13-78: Tongue blade
• Round wedge is preferred in shallower cavities as its
application as wedge
wedging action is more closer to the gingival margin of
restoration.
• Anatomic wedge is preferred in deeper gingival Matrix Removal (Figures 13-79A and B)
extension restoration as its base is wider. • Now the retainer is removed from the band.
• To maintain gingival isolation during operative • Next after it is determined that amalgam has set
procedures the anatomic wedge may be applied before reasonably with a No. 110 plier the band is slowly teased
the commencement of tooth preparation. and removed from one contact area and then the next.
• A suitably trimmed tongue blade could be used to secure • It is never pulled straight up as it can fracture the
a matrix band if interproximal spacing is too large. marginal amalgam.
286 Essentials of Operative Dentistry

Figures 13-79A and B: Matrix removal first done by band

removal followed by wedge removal

• Wedge is left in place as it can provide slight tooth

separation which can prevent amalgam fracture during
band removal also aid in evaluation of interproximal Figure 13-81: Ivory No. 8
portion for amalgam excess.

Ivory Matrix No. 1 (Figure 13-80)

• Band encircles posterior proximal surface used in single
proximal surface class II preparations.
• Band is attached to the retainer via a wedge shaped
projection which engages the tooth at embrasures of
proximal surfaces of unprepared tooth surface.
• Mainly used in areas where there is tight contact Figure 13-82: Siqveland matrix retainer
between teeth.

Prewelded Bands (Figure 13-83)

• For example, Denovo systems.
• Prewelded bands of various sizes are available and are
engaged onto the tooth without any retainers.

Figure 13-80: Ivory No. 1

Figure 13-83: Prewelded bands

Ivory No. 8 (Figure 13-81)

Sectional Matrix
Band encircles entire crown of the tooth. Indicated in mesio-
occlsaldistal preparations. • For example, Palodent system.
• Here a sectional dead soft matrix band is engaged onto
tooth a ring retainer is engaged onto tooth both to adapt
Steele’s Siqveland Self-adjusting Matrix Retainer band and also wedges and aids in separation of tooth
(Figure 13-82) (Figure 13-84).
• It forms two diameter at the same time in band loop. • Main advantage is only one proximal needs to engaged
• Anatomic adaptation is possible without wedges. by matrix band.
 Amalgam Class II Preparation and Restoration 287

Figure 13-84: Sectional matrix Figure 13-86: Making of matrix band, burnishing and
applying onto tooth

Omni Matrix System (Figure 13-85) • Soften a piece of low fusing compound and apply onto
• It is a disposable Tofflemire retainer. the facial and lingual sides without encroaching upon
• Here the band is preassembled onto tooth. the occlusal side of tooth.
• Once condensation and carving of occlusal amalgam
is done compound is broken off and matrix band is
removed by slowly teasing off and wedge being in place.
• Both wedge and matrix band can be removed off with a
Figure 13-85: Omni matrix retainer No. 110 plier.

Compound Supported Matrix Automatrix Systems (Figures 13-88 and 13-89)

(Anatomic Matrix) • Is a retainer less system available in four sizes to fit all
• It is described by Sweeney. teeth.
• It provides most essential qualities of good matrix. • Band vary in height from 4.7-7.9 mm and thickness of
0.038-0.002 mm.
Procedure (Figures 13-86 and 13-87) • Indicated in class II preparation especially teeth
requiring rebuilding of cusps.
• Using 8 mm wide. 0.002 inch (0.05 mm) stainless steel
matrix material to cover 1/3rd of facial and lingual Advantages
surfaces and covering the proximal surface is used. • Autolock loop can be either be placed on facial or lingual
side.

Figure 13-87: Application of softened compound to stabilize the band

288 Essentials of Operative Dentistry

Figure 13-88: Automatrix with tightening device holding the

matrix band on the left

Figures 13-89A to C: Application of automatrix system onto tooth

• Convenience. Black’s Matrix for Gingival Extension

• Improved visibility because of lack of retainer. (Figure 13-91)
• Decreased time for placement of matrix band. Same as above except it has greater occlusogingival
Disadvantages extension for gingival coverage.
• Bands are not precontoured and development of
physiologic contour is difficult.
• Can be unstable.

Black Matrices
Black’s Matrix for Simple Cases
Recommended for majority of small and medium
cavities.
Figure 13-91: Black’s matrix with
Procedure (Figure 13-90) gingival extension
• A metallic band is cut to slightly cover over the buccal
and lingual surfaces of the tooth. S-shaped Matrix
• A ligature wire or a dental floss could be used to wrap
Used in class II and facial and lingual extensions (Figure
around the band to tooth to prevent slipping of wire
13-92).
gingivally the corners of band is bend occlusally.

Figure 13-90: Black’s matrix Figure 13-92: S-shaped matrix

 Amalgam Class II Preparation and Restoration 289

Figures 13-93A to D: Application of T-matrix band

T-shaped Matrix
• Made of T-shaped brass or stainless steel.
• Long arm of T is bend and encircles the tooth and
overlap the short horizontal arm of T.
• Compound placement and wedging is done to stabilize
the band (Figures 13-93A to D).

Matrices for Class III Tooth Colored

Restorations
• A clear polyester strip or mylar strip is used.
• The matrix strip is usually contoured before application.
Figure 13-95: Transparent crown form
• If lingual approach is employed then labial side of
matrix strip is pulled over and covered.
Anatomic Matrix (Template)
Matrices for Class IV Restoration • Study model can be poured and tooth is restored on the
Mylar strip or transparent polyester strip could be used model using wax or resin to expected contour (Figure
(Figure 13-94). 13-96).
• Then a template can be made of thermoplastic resin or
be made of rubber base putty material.
• This template could be used for restoration.

Figure 13-94: Mylar strip application

for class III restoration

Transparent Crown Form Matrices

Plastic transparent stock crowns are available which can Figure 13-96: Fractured area is built-up with wax and a
be adapted to tooth (Figure 13-95). vacuform sheet is used to construct the matrix
290 Essentials of Operative Dentistry

Matrices for Class V Preparations Condensation of Amalgam

Window Matrix (Figure 13-97) Condensation is started in the proximal portion of cavity
preparation first, and also the proximal locks and
• Can be made in Tofflemire band or in copper band.
grooves are also condensed carefully continue the conden-
• Wedges or compound can be placed to stabilize the
sation until preparation is overfilled (Figures 13-100 and
band.
13-101).

Procedure for Carving the Occlusal Portion

After precarve burnishing carving is started. With matrix
still in place a special attention is given to the marginal
ridges with use of an explorer or Hollenback carver occlusal
embrasure and height of marginal ridge is defined (Figures
13-102 to 13-107).

Removal of Matrix Band

• After removal of the matrix band and wedges (Figures
13-108A and B).
Figure 13-97: Window matrix • Proximal wall is evaluated.
• Minimal carving may be necessary to carve out the
excess amalgam.
S-shaped Matrix • Gingival excess may be removed using amalgam knives.
This can also be employed (Figure 13-98). • Postcarve burnishing is started after this procedure.
• Occlusal relationship is evaluated and any high points
or high points in marginal ridges are noticed.
• Articulating paper may be used to study for centric and
lateral excursion interferences.
• Also after the patient has closed the shininess on the
restoration may indicate the presence of high points.
• Before patient is dismissed a dental floss may be
passed through the contact to evaluate the contact
(Figure 13-109).

Figure 13-98: S-shaped matrix

Finishing and Polishing
• Same as that in class I restoration.
Anatomic Matrix • Accessible areas of proximal portions are finished and
• Can be done by use of study models. polished.
• Can be made of plastic strip or compound to be applied • Dental tape may be utilized to finish the proximal
during restorative procedure (Figures 13-99A to C). portion.

Figures 13-99A to C: Anatomic matrix

 Amalgam Class II Preparation and Restoration 291

Figure 13-102: Precarve burnishing

Figure 13-100: Condensation is

done in step-wise manner

Figure 13-101: First condensation increment

is placed in proximal box Figure 13-103: Removal of excess amalgam

Figures 13-104A and B: Create occlusal embrasure using an explorer

Figures 13-105A and B: Contour facial and lingual embrasure

292 Essentials of Operative Dentistry

Figures 13-106A and B: Develop occlusal anatomy

Figure 13-110: Quadrant dentistry

• When two or more proximal cavities are to be restored

alternate tooth could be matriced and wedged.
• Smaller proximal cavity is restored followed by larger
Figure 13-107: Correct proximal contour and marginal ridge cavity as it allows for more access and proper marginal
height configuration.
• Posterior most cavity is restored followed by anterior
restorations if lesions are of same size.

Designs of Cavity Preparations

Design 1
Indication
A moderate to large size proximal lesion with occlusal
surface of similar size (Figure 13-111).
Figures 13-108A and B: First matrix band is removed
followed by wedge removal

Figure 13-111: Design 1

Design 2: Modern Design

Figure 13-109: Dental floss should be able
to pass through the contact Indication
A moderate to small size lesion (Figure 13-112).
• Sufficient smoothness has been imparted by the
application of matrix band itself.
Design 3: Conservative Design
Quadrant Dentistry (Figure 13-110) Indication
• When more number of teeth are to be operated its best to Lesion involving primarily the proximal surface and a
perform quadrant dentistry. very limited part of occlusal surface (Figure 13-113).
 Amalgam Class II Preparation and Restoration 293

Figure 13-112: Design 2

Figure 13-115: Design 5

Design 6
Indications
• Occlusal, proximal and part of the facial or lingual
surface also involved (Figure 13-116).
• Cusp is undermined.

Figure 13-113: Design 3

Design 4: Simple Design

Indications
• Lesion involving only proximal surface.
• Decay involving proximal surface without involving
the marginal ridges (Figure 13-114).
Figure 13-116: Design 6

Design 7: Combination of Class II with

Class V
Indications
• Shape A—junction of class V and class II via proximal
surface (Figure 13-117).
• Shape B—junction of class V and class II via facial or
lingual surface.
Figure 13-114: Design 4

Design 5
Indications
• Part of the proximal surface and very limited facial or
lingual surface may be involved.
• Design can have dovetail or may not have it (Figure
Figure 13-117: Design 7
13-115).
294 Essentials of Operative Dentistry

Figures 13-118A to C: Design 8

Design 8
Indication
Two or more surfaces of endodontically treated tooth that
does not require post (Figures 13-118A to C).

Figure 13-119: Reverse curve on buccal wall

Features of Class II Preparation
Occlusal Portion (Figures 13-119 and 13-120)
• Tooth preparation should be in the center of tooth.
• Preparation should be smooth flowing with no abrupt
curves. With dovetail form present on occlusal portion
of cavity opposite to proximal portion involved.
• Marginal ridges walls should follow the external
contour of tooth. Figure 13-120: Facial and lingual wall should follow the
external contour of tooth
• Width of cavity should be no more than 1/4th inter-
cuspal width and depth being 1.5-2 mm of which
0.5 mm into dentin. • Pulpal floor be flat and smooth unless until residual
• Uninvolved marginal ridge width in premolar is caries has been excavated.
1.5 mm and molar is 2 mm. • Cavity form should be occlusally converging without
• All defective pits and fissures are involved in danger of undermining the enamel.
preparation. • No unsupported enamel should be present.
 Amalgam Class II Preparation and Restoration 295
Proximal Portion (Figures 13-121 and 13-122)
• Buccal and lingual proximal walls should be
convergent and follow the external contour of tooth
without danger of creating unsupported enamel.
• Axial wall is slightly convex from occlusal view
following external contour of tooth.
• Axial wall is 0.5-0.8 mm into dentin. Axial wall height
should be just below the caries extent or beyond gingival
contact whichever is greater.
• Reverse curve should be present on the facial wall which
prevents too much cutting the tooth structure.
• Occlusal and proximal portion should be continuous Figure 13-123: Contact area
with each other smoothly.

• Matrix band should be closely adapted to tooth and

should have been well contoured by burnishing.
• Wedge should be placed in correct position not too far
below and too occlusally. Wedge should be tightly in
place.
• Excess band material protruding from retainer be cut
off.
• After retainer has been removed matrix band is removed
in an angular fashion either buccally or lingually and
never occlusally.

Figure 13-121: (1) Presence of reverse curve, (2) Gingival

clearance of proximal box from adjacent tooth Restoration (Figures 13-125A to C)
• No underfilling or overfilling should be there.
• A tight positive contact with adjacent tooth no open
contacts.
• No gingival overhangings should be present. Gingival
overhang presence can be tested by-passing floss
through the contact if it comes out smoothly no gingival
overhangs are there.
• Restoration should be well carved and polished.

Figure 13-122: Axial wall of proximal box should

follow the external contour of tooth Common Pitfalls
Contact Area (Figure 13-123) • Preparation not centered.
• Cavity depth and width being too much or too narrow.
Buccal, lingual and gingival contacts should be broken
• Cavity form not in smooth flowing curves.
and prepared proximal portion should clear adjacent tooth
• Proximal portion too large or small.
by 0.5 mm just enough for explorer tip to enter.
• Contact form is not properly broken or too much open.
• Matrix retainer applied in wrong way and wedge
Matrix Retainer Application (Figure 13-124) placement is not tight.
• Tofflemire retainer should be applied in proper direction • Restoration not properly carved and gingival
with slot in the head portion of retainer facing gingivally. overhanging is present.
296 Essentials of Operative Dentistry

Figure 13-124: Matrix retainer and band removal: Step 1—Matrix retainer removal, Step 2—After removal of matrix
retainer, Step 3—Band in removed from one embrasure and then from other embrasure gradually, Step 4—Removal
of wedge, Step 5—After removal of matrix retainer. Band and wedge. Restoration still requires carving and finishing

Armamentarium • Enamel hatchet

• Gingival marginal trimmer (both right and left)
From Left to Right • Amalgam well (Dappen dish)
• Mouth mirrors • Amalgam carrier
• Explorers • Tofflemire retainer and matrix band No. 8
• Tweezers • Ivory No. 1 retainer and band
• Chip syringe • Wedges (round and triangular)
• Cotton holder with cotton • Amalgam condensers (parallelogram and round)
• Spoon excavator • Amalgam burnisher (football or ovoid)
• Cement spatula • Amalgam carvers (cleiod-discoid carvers, hollenback
• Plastic filling instrument carver)
• Enamel chisel • Articulating paper and articulating forceps.
 Amalgam Class II Preparation and Restoration 297

Fig. 13.125A Fig. 13.125B

Figure 13-125C: After finishing of restoration occlusal

contacts not present in restoration
298 Essentials of Operative Dentistry

Rotary Cutting Instruments •

•
Wedges
Separators
• Airotor handpiece, slow speed handpiece. • Embrasure form
• Burs (tungsten carbide burs No. 330, 245) (diamonds • Cuspal capping
round ½, pear shaped 245, straight fissure 271, inverted • Marginal ridge
cone 33½ ). • Types of wedging
• Amalgam finishing stones.
• Rubber cup.
• Pumice. Questions to Think About
1. What are the indications and contraindications of
Miscellaneous
class II amalgam restorations? Discuss about
• Gauze cotton fundamentals in class II cavity preparation.
• Rubber dam kit. 2. What are the factors that govern the outline form of
class II amalgam cavity preparation?
3. What are the resistance features in class II amalgam
Key Terms cavity preparation?
• Occlusal step 4. Discuss about retention features in class II amalgam
• Gingival bevel cavity preparation.
• Contacts 5. Write in detail about the class II cavity preparation
• Proximal ditch cut 6. Elaborate about the cuspal capping procedure.
• Axiopulpal line angle bevel 7. Discuss about tooth separation methods.
• Height of contour 8. What are the different types of matrix retainers and
• Proximal box explain in detail about Tofflemire retainer?
• Dovetail 9. Explain about different features in class II amalgam
• Matrix retainer cavity preparation.
• Proximal lock 10. Write about common pitfalls in class II amalgam
• Gingival and occlusal clearance tooth preparation.
• Matrix band 11. Discuss about failure in amalgam restorations.
 Amalgam Class III Preparation and Restoration 299

14
Amalgam Class III
Preparation and
Restoration

Class III Amalgam Restoration • Size and position of carious lesion

• Esthetics
Class III amalgam restoration has been greatly replaced • Age of the patient
by tooth colored restorations which are stable and wear • Economics
resistant.
Tooth Location
Indications • Most common area for amalgam class III res-
Mainly used for distal surfaces of canine because of its toration is distal surface of maxillary and mandibular
low esthetic potential compared to other anterior teeth. canines.
• Preparation is minimally extended into facial margin • Proximal surfaces of anterior teeth because of visibility
• Lesion is primarily on cementum. zone are restored with tooth colored restoration.
• Moisture control is difficult.
Most of the preparations for amalgam class III are Service
approached from lingual aspect.
Amalgam restoration provides more long restoration than
tooth colored restorations.
Contraindications
Not usually indicated in areas of esthetic importance. Size and Position of Carious Lesion
Advantages Amalgam is used only when the facial enamel is intact
and carious lesion is approached through lingual
• Usually stronger restorations. surface.
• Less expensive to patients.

Disadvantages Esthetics
• Metallic in color and less esthetic. Tooth colored restorations are preferred in areas where
• Preparation is less conservative; cavity form needs to visibility is high.
have 90° marginal enamel, uniform axial depth all
resulting in extensive tooth preparation. Age of the Patient
Selection of Restorative Material Amalgam can be chosen irrespective of age of patient.

Selection of restorative material for class III restoration

depends upon: Economics
• Tooth location Amalgam restorations are one of the most economical
• Service restorations.
300 Essentials of Operative Dentistry

Occlusion
Centric and lateral excursions has to be marked by
articulating paper. Proper considerations has to be given
for these contacts.

Local Anesthesia
• Is given to anesthetize to both soft tissue and tooth, it
reduces patient apprehension and also reduces
salivation.
• Not required in preclinical exercises.

Isolation of Operating Site

Rubber dam isolation is a mandatory step for isolating
operating site.
Figure 14-2: Lingual wall meets axial
wall in obtuse angle
Distal Cavity Preparation for the
Maxillary or Mandibular Canine • It is similar to cavity preparation for tooth colored
Initial Cavity Preparation restoration and it includes only proximal portion of
tooth, lingual dove tail is indicated when extra retention
Outline Form (Figures 14-1 and 14-2) is required.
It is influenced by five factors: • Enter the tooth with a No. 2 or No. ½, 1 round bur in the
1. Esthetic concern: Lingual access is preferred over labial distolingual marginal ridge. Bur is held perpendicular
access. Labial wall should be convex and present only to long axis of the tooth and entry will penetrate slightly
0.2-0.3 mm into facial embrasure. incisal to carious lesion. Depth of penetration is
2. Extension for access: To instrument in proximal limited to a depth of 0.5-0.6 mm into dentinoenamel
region it may be necessary to extend the preparation junction.
lingually. • Preparation is extended into facial embrasure of 0.2-
3. Stress consideration: Incisal extension of preparation 0.3 mm into facial embrasure. Facial margin of prepara-
should be minimally into incisal embrasure to prevent tion should be curved from incisal to gingival margins.
overload on restoration. • Lingual outline blends with the lingual surface of tooth
4. Enamel rod direction: Lingual margin extension most with little or no lingual proximal wall. Cavosurface
often include lingual marginal ridge. angle and all walls should meet axial wall in right
5. Incisal access: If incisal slopes are undermined by caries angles, except for lingual wall which meets the axial
then access to proximal portion can done through wall in an obtuse angle or may be continous with axial
incisal region. wall. Axial wall contour should follow the contour of
the tooth.
• Incisal extension should be as minimal as possible to
remove caries. It may be necessary to remove incisal
contact.
• Gingival extension is done as far as caries has extended
and to prevent damage to gingival tissues a wedge
could be placed.
• All line angles are accentuated by using a small No. ½
bur.

Figure 14-1: Bur position should be perpendicular to tooth Final Cavity Preparation
surface, isolating proximal enamel and preserving as much
marginal ridge as possible See Figure 14-3.
 Amalgam Class III Preparation and Restoration 301

Figures 14-4A and B: Placement of gingival retention

groove and incisal cove

Figure 14-3: Prepared class III cavity form

Removal of any Remaining Infected Dentin

Any remaining caries present is removed using a round
bur or excavator.

Pulp Protection
As described in earlier chapters.

Resistance and Retention Form

Figure 14-5: Placement of gingival retention groove and
Resistance form is provided by: axial wall depth
• Enamel margins being 90° and supported by dentin
• Sufficient thickness of restoration Incisal Retention Cove
• No sharp line angles. Prepare incisal retention cove at the axioincisal point angle
Distal surface of cuspid is an area of considerable stress with No. ¼ bur into dentin carefully not undermining
concentration. It is one of the few areas in mouth where enamel (Figures 14-4 amd 14-5).
three types of stresses compression, shear and tensile acts
together.
Lingual Dovetail (Figures 14-6A to E)
Retention form given by:
• Gingival retention groove • It is usually given in preparations where there is
• Incisal retention cove. extensive incisal extension and large sized prepa-
rations.
• Preparation of lingual dovetail is done only after the
Gingival Retention Groove
proximal portion has been finished.
• It is done using a No. ¼ bur by rotationg it at slow speed • Dovetail should not be extended beyond mesiodistal
and placing the bur at axiofaciogingival point angle and midpoint of tooth.
extending it through axioginigval line angle and • It is usually given by No. 245 bur, position the bur in
direction of cutting is mostly gingival than pulpally. proximal portion into a depth of 1 mm pulpally and
• Width of groove is 0.25 mm into dentin. Dentin sup- extend the preparation mesially till midpoint of tooth.
porting enamel should not be removed (Figures 14-4 • Now extend the bur incisally and gingivally to form a
and 14-5). dovetail of dimensions 2.5 mm.
302 Essentials of Operative Dentistry

Figures 14-6A to E: Extensive class III preparation requiring lingual dovetail form

• Now smoothen the walls of the dovetail using No. ½

bur or gingival marginal trimmer to smoothen axio-
pulpal line angle.
• Lingual dovetail retention is increased by convergence
of walls.

Procedures for Finishing External Walls

• Unsupported enamel is removed, enamel walls are
smoothened, cavosurface margin is refined.
• This procedure is usually done by hoe.
• If gingival extension is extensive, gingival wall may be Figure 14-7: Matrix band cutting lingual portion
bevelled.

Finishing and Polishing of Restoration

Final Procedures: Cleaning, Inspecting, and
Varnishing • Finishing is done using small fine grit pointed stones.
• Polishing is started with a tapered rubber polishing
Using air/water spray cleans the cavity for any debris.
point run in slow speed.
Cavity varnish is applied in two coats before matrix band
• Final high gloss is given by fine grit polishing rubber
application.
point.
Cavity preparation for mandibular incisor is similar
• Alternative method will be to use rubber cup and
to maxillary canine.
pumice.

Matrix for Class III Preparations

Features in Class III Preparation
• Has been described under class II preparation.
• Compound supported matrix is best suited with lingual • Cavity preparation is started from lingual aspect from
portion of band is removed so that restoration could be distal marginal ridge.
done from lingual aspect (Figure 14-7). • Cavity outline is triangular with rounded corners.
• Cavity form should extend 0.2-0.3 mm into facial
Procedures for Inserting, Carving and embrasure.
• Facial margin should be curved in direction from incisal
Polishing the Restoration
aspect to gingival aspect.
• Is same as in posterior teeth. • Axial wall should be follow contour of the tooth (Figures
• Restoration on proximal portion of canines are less 14-8A and B).
conspicuous if properly prepared and restored. • Lingual wall meets the axial wall in obtuse angle.
 Amalgam Class III Preparation and Restoration 303
• Gingival marginal trimmer
• Hoe
• Amalgam carrier
• Amalgam condenser (Round and Parallelogram)
• Amalgam carver (Hollenback)
• Amalgam burnisher (Round)
• Stainless steel matrix band
• Low fusing compound

Rotary Cutting Instruments

• Airotor handpiece
Figures 14-8A and B: Axial wall should follow
the contour of external surface of tooth • No. ½, 1, 2 round burs, No. 245 fissure bur
• Amalgam finishing kit
• Rubber dam kit
Common Pitfalls
• Axial wall will be flat.
Miscellaneous
• Too much extension into facial embrasure. • Cotton
• Complete removal of lingual wall. • Gauze
• Amalgam polishing kit (stones and rubber points)
Armamentarium
Key Terms
From Left to Right • Gingival retention groove
• Mouth mirror • Incisal cove
• Explorer
•
•
Tweezer
Cotton
Question to Think About
• Spoon excavator 1. Discuss about factors influencing outline form of
• Glass slab class III amalgam tooth preparation and steps in class
• Agate spatula III tooth preparation.
304 Essentials of Operative Dentistry

15
Amalgam Class V and VI
Preparations and
Restorations

• Cervical caries usually develops because the affected • Uncontrollable sensitivity

tooth surface is unclean and patient has caries inducing • Deep enough endangering the pulpal health
diets. • Deep enough that it may weaken the tooth
• Incipient smooth caries appears as a ‘milky white’ line • Deep enough acting as food retentive areas.
just occlusal or incisal to crest of marginal gingiva.
• This lesion could be remineralized if surface is not Sensitive Areas
broken.
• If there is root exposure or cemental exposure and
• If enamel surface is broken or softened then a class V
sensitive teeth, amalgam is chosen over composite
cavity has to be prepared and restored.
restoration, as composite bonding to cementum is weak.
• When a large number of cervical caries is present it
• Unless it is an esthetic zone, amalgam could be chosen.
indicates high caries susceptibility.

Service
Indications and Contraindications Amalgam restorations offer longer service than any other
Selection of class V amalgam restoration depends upon type of restoration, provided basics of cavity preparation
following factors: and restoration is adhered.
• Caries
• Erosion or abrasion of teeth Economics
• Sensitive areas Amalgam is an economic restorative treatment compared
• Service to other restorative materials.
• Economics
• Abutment teeth
Abutment Teeth
• Esthetics.
When involved teeth is used as abutment amalgam
restoration is preferred over composite restoration.
Caries
• If caries is susceptibility is high then amalgam resto-
Esthetics
ration is preferred.
• Once the caries susceptibility has been brought down • Patients objecting to metallic appearance are restored
then more esthetic materials could be chosen. with composite restorations.
• Increasing use of composite materials are used in class
V caries.
Erosion or Abrasion If class V lesion is extensive and involves whole of tooth
These lesion occurring on cervical areas of tooth, as surface or an existing class II caries is there then it is
notched out areas should be restored when: preferred to give a full crown.
 Amalgam Class V and VI Preparations and Restorations 305
Local Anesthesia
• It is given both for pain control and salivation control.
• Not required in preclinical exercises.

Isolation
Salivary control inaddition to gingival hemorrhage,
gingival sulcular fluid has to be controlled.
Isolation is done by:
• Cotton roll
• Gingival retraction cord with hemostatic agents
(Figures 15-1A and B)
• Rubber dam with cervical retainer (Figures 15-1A and B)
• Surgical gingival exposure
Figure 15-2: Outline form is determined
by caries extension

Mandibular Canine
Initial Cavity Preparation
Outline form given by:
Figures 15-1A and B: Isolation using rubber dam,
gingival retraction cord • A tapered fissured bur or a round bur is used into
enter into the caries lesion of depth of 0.5 mm from the
dentinoenamel junction (1-1.25 mm total depth) to
0.75 mm from cementum (root) (Figure 15-3).
Principles of Outline Form • Bur entry should be done in center of the tooth.
• It involves extending the preparation to sound tooth • Using the edge of bur for entry will be easier than using
structure, and a limited depth of 0.5 mm into dentino- flat end of bur.
enamel junction and 0.75 mm from cementum in root • All walls of preparation should be perpendicular to the
external tooth surface.
surface.
• Extend the preparation in all directions till sound
• Outline form of class V preparation is primarily
enamel, dentin are reached.
determined by location and size of the carious area
(Figure 15-2). • Axial wall should follow the contour of the tooth (Figure
As far as possible the occlusal margin should be 15-4).
placed below or at the height of contour and gingival
margin should be placed supragingivally.

Resistance and Retention Form

• Class V restoration may not be under direct occlusal
load, but during lateral excursions of mandible the tooth
flexes causing V-shaped gap between restoration and
tooth margin (abfraction).
• Many instances gingival margin may be placed on
cementum which can weaken the tooth.
• When occlusal margin is close to cusp and marginal
ridges no grooves are placed on the occlusal margin as
it may weaken the cusp and marginal ridge. Figure 15-3: Cavity form
306 Essentials of Operative Dentistry

Figure 15-5: Retention groove placement and position

Figure 15-4: Axial wall contour should

follow the external surface of tooth

Final Cavity Preparation

It involves removal of any remaining infected dentin, pulp
protection, retention form, finishing external walls and
final procedure of cleaning, inspecting.

Removal of any Remaining Infected Dentin

It is usually done with No. 2 or 4 bur.

Pulp Protection
Same principles as in other preparations.
Figure 15-6: Retention groove can be angular or rounded
Retention Form by use of inverted cone bur or round bur
• Mesial, distal, gingival and incisal walls of the cavity
preparation being perpendicular to external tooth
surface diverge outward. Thus, retention form has to be
provided.
• No. 1/4 bur is used to prepare two retention grooves
one along the incisoaxial line angle and the other
gingivoaxial line angle.
• Alternatively four retention coves are given on four axial
point angles. Figure 15-7: Axial wall should follow the contour of the tooth
• Depth of groove is 0.25 mm which is half the diameter
of bur. Final Procedures: Cleaning, Inspecting
• Retention groove placement should not undermine the Using air/water spray the cavity is cleaned and debris
dentin support for enamel. Grooves could also be placed removed.
with angle former or 331/2 inverted cone bur (Figures
15-5 to 15-7).
Extended Restoration Involving the
Transitional Line Angles
Finishing Enamel Walls
• Caries on the facial surface of molar teeth can also
It is done with chisels and marginal trimmers to achieve
extend around the transitional line angles and involve
smooth enamel margins (Figures 15-8A to D).
mesial and distal surfaces.
 Amalgam Class V and VI Preparations and Restorations 307
Carving and Contouring the Restoration
(Figure 15-10)
• Carving is done parallel to margins with a Hollenback
carver. Edge of the instrument should rest against the
external tooth surface margin.
• Carving should remove excess amalgam incisally,
mesially, distally and gingivally.
• Proper contour of the tooth should be reproduced.
• Gingival extension carving should be done after
removing of isolation technique.

Figures 15-8A to D: Chisels, marginal trimmers or hoe can

be used for finishing enamel margins

• In distal surface extension a round bur is used extend

the cervical preparation distally.
• Retention grooves are placed along the entire length of
the occlusoaxial and gingivoaxial line angles ensures
retention. Retention grooves are placed using a No. ½ Figure 15-10: Carving cervical amalgam restoration
round bur.
If a tooth has both class II and class V lesion it is best to
restore class II restoration first as restoring class V Designs of Class V Preparation
lesion first prevents matrix and wedge application (Figure
15-9). Design 1: Conventional Design
Indications
• Lesion is confined to gingival third of tooth crown.
• Axial angles are intact (Figure 15-11)
• No furcation or root involvement.

Design 2
Indications
• Lesion approaching the axial angles.
• Axial extension places the restoration in gingival
Figure 15-9: Extended class V lesion
embrasure (Figure 15-12).

Insertion of Amalgam
• Class V restoration with amalgam is usually done
without any matrix band application.
• Amalgam is first condensed into the retention grooves
followed by condensing in the mesial, distal walls and
then the center of preparation.
• When restoring preparation extending around the
transitional line angles a stainless matrix strip could
be placed on both mesial and distal contacts. Figure 15-11: Design 1 Figure 15-12: Design 2
308 Essentials of Operative Dentistry

Design 3 • Definite occlusal, gingival, mesial and distal walls be

This cavity form has occlusal moustache extension. present and meet the axial wall at 90° (Figure 15-16).
• Occlusal cavity margin be below to height of contour
and gingival margin be present supragingivally.
Indications
Lesion on gingival third is continuous with caries present
above height of contour (Figure 15-13).

Figure 15-16: Sites of mesial, axial and distal walls

Common Pitfalls
Figure 15-13: Design 3
• Axial wall will be flat.
• Definite walls are missing because of crawling out of
Design 4 bur while preparing cavity.
Called as multiple isolated boxes.

Armamentarium
Indications
Multiple decalcifications are present with intervening From Left to Right
sound tooth structure (Figure 15-14). • Mouth mirror
• Explorer
Design 5 • Tweezer
• Cotton
Indications • Spoon excavator
Caries occurring on root surface or in furcation area of • Glass slab
root (Figure 15-15). • Agate spatula
• Gingival marginal trimmer
• Amalgam carrier
• Amalgam condenser (Round and Parallelogram)
• Amalgam carver (Hollenback)
• Amalgam burnisher (Round)
• Stainless steel matrix band
• Low fusing compound
• Rubber dam kit.

Rotary Cutting Instrument

Figure 15-14: Design 4 Figure 15-15: Design 5
• Airotor handpiece
• No. ½, 1, 2 round burs, No. 33½ inverted cone bur
Features of Class V Preparation • Amalgam finishing kit.
• Outline form is determined by extension of caries. In
intact tooth for preclinical exercises it is of ‘half moon Miscellaneous
shape’. • Cotton
• Axial wall follows the contour of the tooth. • Gauze
 Amalgam Class V and VI Preparations and Restorations 309
Key Terms • Such preparation is frequently indicated where
attritional wear has removed enamel and exposed
• Gingival retraction cord underlying dentin.
• Cervical retainer • Such lesions are usually cupped out in shape. Patient
• Surgical gingival removal complains is mostly of food impaction and sensitivity.

Questions to Think About Tooth Preparation

• Is done using a small tapered fissure bur extending to
1. Write in detail about preparation of class V amalgam sound dentin.
preparation. • Esthetic areas may be restored with composite
2. Discuss about different designs in class V amalgam restorations.
tooth preparation. • Carving and finishing of restoration is done same as
class I restoration.
Amalgam Class VI Preparation
• Class VI cavity preparation is used to restore the incisal
edge of the anterior teeth and cuspal tip of posterior
teeth.
310 Essentials of Operative Dentistry

16 Bonding

Adhesion: Attraction between two unlike molecules. Surface Energy (Figure 16-2)
Cohesion: Attraction between two similar molecules.
The energy at surface of solid is higher than interior
The material/film used to cause adhesion is adhesive,
because the atoms at the surface with their energies are
the material to which its applied is adherent.
unbalanced.
In liquids, its surface tension and is measured in
Types of Bonding (Figure 16-1) dynes/cm. In general, as temperature increases surface
tension decreases.
Mechanical Bonding Detergents such as sodium lauryl sulfate or ingredients
Strong attachment to one another accomplished by of soap, including sodium stearate are effective in reducing
mechanical retention rather than by molecular attraction. surface tension. These are surface active agents these
Most dental adhesion is based on this. agents occupy position between water molecules
preventing their cohesion. This increases the wettability
of liquids and solids.
Physical Bonding
Here weak van der Waals forces are developed.

Chemical Bonding
Chemisorption, a chemical bond is formed. An example,
is oxide layer over metallic surface.

Figure 16-2: Surface energy and

Figure 16-1: Types of bonding surface active agents
 Bonding 311
Wetting
To force two solid to adhere a thin layer of liquid is required
between them, this liquid should flow easily over the solid.
This is called as wetting.
The ability of adhesive to wet is influenced by:
• Cleanliness of surface.
• Surface energy, waxes have low surface energy and
prevent wetting.

Contact Angle of Wetting (Figure 16-3)

• Extent to which adhesive wets the adherend is
determined by the angle between adhesive and
adherend.
• If adhesive spreads completely over the adherend then
the ø = 0 and as ø increases the wetting is decreased
(Figure 16-3).

Figure 16-4: Adhesive joint

Table 16-1: Composition of enamel and dentin

Enamel Dentin
Wt% vol% Wt% vol%
Mineral 97 92 70 45
Organic 1 2 20 33
Water 1 6 10 22

Figure 16-3: Contact angle

Adhesion to Tooth Structure

(Figure 16-4)
• Composition of tooth is not homogeneous and the
organic content of both enamel and dentin varies (Table
16-1 and Figure 16-5).
• So adhesive must bond both to organic and inorganic
component.
• After tooth preparation a tenacious smear layer is
formed of microscopic debris which reduces wetting.
• Greatest problem with adhesion to tooth is smear layer
and contamination by saliva.
• Dental adhesives should be able to displace water, react
with it, or wet the surface more effectively. And bonding
must be long standing in aqueous environment. Figure 16-5: Enamel and dentin structure
312 Essentials of Operative Dentistry

Enamel
Formation of optimally bonded surface requires (Figure
16-6):
• Surface be clean.
• Intimate approximation with low contact angle.
• Should have sufficient physical, chemical, mechanical
strength.
• Adhesive be well cured.

Figure 16-7: Uses of bonding

In dentistry, bonding systems has been of historically

of two different systems, viz.
• Enamel bonding systems
• Dentin bonding systems
• Combination enamel/dentin bonding systems.

Enamel and Dentin Bonding

1951—Dr Oscar Hagger developed acidic glycerophos-
phoric acid. Dimethacrylate that permitted resin adhesion
to dentin.
1955—Buonocore used phosphoric acid to etch enamel
Figure 16-6: Good bonding surface.
1962—Bowen introduced BIS-GMA monomer which
polymerize under oral conditions.
Mechanism of Interfacial Debonding
• Occurs by crack formation, propagation of crack and 1979—Fusiyama introduced ‘total etch concept’ with 40%
joint failure. phosphoric acid.
• For example, defects includes sites of interfacial 1982—Nakabayashi introduced concept of hybridization.
contamination, excess moisture, trapped air, voids, poor
wetting, curing shrinkage. 1992—Kanca - Gwinett introduced concept of wet bonding.
• Failures can be cohesive, adhesive, mixed. 2001—McCafe and Lee introduced concept of moist enamel
bonding.
Clinical Applications of Adhesion
(Figure 16-7) Enamel Bonding
• Pit and fissure sealant • Achieved through acid etching of highly mineralized
• Bonded amalgam tissue.
• Composite restorations • Etching of enamel results in etch pits through which
• Orthodontic brackets resin (unfilled or lightly filled) can flow and form resin
• All ceramic restorations luting tags.
• Repair of ceramic restorations. • Bond strength of enamel is in the range of 15-25 MPa.
 Bonding 313
Goals of Enamel Etching • Micro tags are formed at cores of enamel prism where
• To clean enamel. multitude of individual crypts formed due to removal
• To remove enamel smear layer. of hydroxyapatite crystals. This is more important for
• To increase microscopic roughness. bond strength. Because of larger number and greater
• To increase surface free energy from 28 dynes/cm to surface area 0.2 microns. These form basis of micro-
72 dynes/cm. Removes 10 µm of enamel surface and mechanical bonding.
creates a microporous layer of 5-50 µm deep. Effect of acid etching depends upon:
• Kind of acid used.
• Acid concentration.
Patterns of Etching • Form of etchant - gel is more preferred for its control.
Gwinett and Silverstone, 1975. • Rinsing time.
Type I: Predominate dissolution of prism cores and • Chemical composition of enamel.
peripheries left intact—Honeycomb appearance most • Primary or permanent tooth.
common. • Fluoridated enamel.

Type II: Predominate dissolution of prism peripheries and

Etching Procedure (Figure 16-9)
core left intact—Cobblestone appearance.
Concentration of acid
Type III: Surface loss without exposing underlying enamel • Usually 30-50% of phosphoric acid is used commonly
prisms, more common. On etching of enamel turns dull 37% is preferred.
and appear Frosty white. • Concentration above 50% results in formation of
monocalcium phosphate monohydrate which can
Resin Tags (Figure 16-8) inhibit further dissolution but can be rinsed off.
Resin tags are resinous extensions into microporosities of • Concentration below 27% results in dicalcium
enamel. These tags become interlocked (on polymerization) phosphate monohydrate which cannot be easily rinsed
with surface irregularities created by etching—Micro- off.
mechanical bonding.
Two types
1. Macrotags are formed circularly between enamel
prisms—3-5 microns.

Figure 16-9: Etching procedure

Etching time
• Glaspole and Ericsson (1986) suggested 15 secs of
etching.
• 15 secs of etching conserves enamel.
• Primary and fluorosis teeth require greater time.
Rinsing time
• Rinsing time should be done for about 20 secs to remove
dissolved calcium phosphate.
Drying of enamel with air or using ethanol can
improve bond strength. Etching procedure increases
surface energy but momentary contact with saliva can
Figure 16-8: Tag formation reduce this energy.
314 Essentials of Operative Dentistry

Form • This resin penetrates into the microporosities created

Gels are preferred they are made by adding colloidal silica by etching forming resin tags, also potential chemical
or polymer beads, while applying gel with brushes interaction with etched enamel, carbon-carbon double
trapment of air should be avoided (Figure 16-10). formation with matrix phase of composite resin.
If by anyway contamination of saliva occurs, enamel • These separate agents for enamel were used before
should be rinsed and re-etched for 10 secs. introduction of ‘Total etch concept’ (Figure 16-12).
• Nowadays these agents has been replaced by dentin
bonding agents that has ability to wet etched enamel
surface and to simplify the process.

Figure 16-10: Etching gel

Alternative Enamel Etchant (Figure 16-11)

EDTA
Low bond strength.
Pyurvic acid
Has low stability.
Figure 16-12: Total etch concept
Sulphuric acid
At higher concentration inhibit bonding. As effective as
phosphoric acid.
Dentin Bonding

Other inorganic acid 2.5% nitric acid Challenges in Dentin Bonding

• Organic acid 10% maleic acid and 10% citric acid. • Dentin is a heterogeneous structure with 50% vol
• Lasers. inorganic content, 30% organic content (type I collagen)
• Air abrasion. and 20% fluid.
• Its high fluid content places stringent requirements on
the materials.
• Tubular structure of dentin provides variable area for
fluid to traverse to surface and affect bonding (Figures
16-13 and 16-14).
• Formation of smear layer plugging the tubules.
• Three steps involved are etching, priming, bonding
(Figure 16-15).
• Mainly dentin bonding concentrated on etching,
priming, bonding.

Figure 16-11: Other inorganic and organic acids

Enamel Bonding Agents

• Early systems consisted of polymethylmethacrylate, but
these were discontinued because of curing or thermal
shrinkage.
• Todays agents composition is same as that of composite
resin with BIS-GMA, UDMA, TEGDMA this can be either
unfilled or slightly filled. Figures 16.13A and B: Dentin structure
 Bonding 315
Organic compound bonding to ions in mineral apatite
in dentin are (Figure 16-16):
• Phosphate-based adhesives
• Amino acid or amino alcohol-based adhesives
• Dicarboxylates-based adhesives.
Compounds bonding to collagen are:
• Isocynate group
• Carboxyl group
• Amino group
• Aldehyde group.
Chemistry of adhesive agent-based on type of adhesion
to collagen (Munksgaard 1985).
• Adhesion-based on ionic polymer.
Figure 16-14: Dentinal tubules • Adhesion-based on coupling agents.
• Grafting to collagen.

Figure 16-15: Bonding steps

• On acid etching dentin the smear layer is removed

exposes the collagen increases dentin permeability.
• On etching dentin is converted from a hard mineralized
surface to a very soft mineral free collagen rich surface
that collapses when air dried.
• Surface becomes porous with inter- and intrafibrillar
pores through which low viscosity monomers penetrate
polymerize to form hybrid layer.
• Dentin etching changes the surface energy, high protein
content exposed after etching is responsible for low
surface energy (44.8 dynes/cm) different from enamel. Figure 16-16: Bonding mechanism
• This surface energy has to be increased by surface active of different agents
primer application.
• Objective of priming is to transform the hydrophilic Adhesion-based on Ionic Polymer
dentin surface into a hydrophobic surface, also to wet
• Basically proteoelectrolytes
the surface, entangle with collagen fibers on poly-
• For example, GIC (Glass Ionomer Cements), Zn poly-
merization, if possible react with functional groups of
carboxylate.
dentin for chemical bonding.
• Achieved by ionic bonding with Ca++ ions and hydrogen
• Dental priming molecules has been mainly concentrated
bonding also occurs (Table 16-2).
on bifunctional molecules that bond to one end on tooth
tissue and other end to composite resin.
Bonding agent—an agent when applied to surface of Adhesion-based on Coupling Agents (Figure 16-17)
substances can join them together and resist separation • These are materials coupling resin to tooth structure.
(Kinloch 1987). • They are bifunctional in nature.
316 Essentials of Operative Dentistry

Table 16-2: Chemical design of dentin adhesives

with potential chemical bonding

Potential Ca2+ bonding dentin adhesives

M-R-POYZ Phosphate group
M-R2-NZ-R3-COOH Amino acid
M-R2-OH Amino alcohol
M-R4-COOH-COOH Dicarboxylic acid

Potential collagen-bonding dentin adhesives

M-R-NCO Isocyanate group
Figure 16-17: Adhesion-based M-R2-COCl Acid chloride
on coupling agents M-R4-CHO Aldehyde group
M-R4-CO-COOH Carboxylic acid anhydride
Basic Formula, M-R-X (Figure 16-18)
M—metha-acrylic group bound to resin by co- Etchants
polymerization.
Also called as conditioners. A wide range of organic and
R—reactive group interacts with tooth surface.
inorganic acids are used.
X—is linking and spacing group.

Primers
Hydrophilic monomers carried in a solvent.
Acidic primers containing carboxylic acid group are
used in self-etching primers.
Solvents are usually, acetone, ethanol or water, e.g.
HEMA, BPDM, NTG-GMA, PENTA.

Adhesives
Adhesives are hydrophobic dimethacrylate oligomers, that
are compatible with monomers used in primers and
composites, e.g. BIS-GMA, TEGMA.
Figure 16-18: HEMA
Initiators and Accelerators
Most bonding agents are light cures and contain activators
Grafting to Collagen (Table 16-2) auch as camphorquinone and an organic amine.
• They graft to organic collagenous component of dentin.
• Bonding sites of collagen include, hydroxyl group Other Ingredients
• Carboxyl group
• Fluoride, antimicrobial agents.
• Amido group
• Glutaraldehyde as desensitizers.
• Amino group.
These combine with compounds containing reactive
groups of: Fillers
• Aldehyde Ranging from 0.5-40% by weight includes nanofillers
• Isocynates submicron glass. They aid in easier to place on tooth and
• Carboxylic acid derivatives higher in vitro bond strength. Provide some elasticity.
• Carboxylic acid anhydrides.

Scientific Classification of Modern

Dentin Adhesive System Adhesives
Dentin adhesive system consists of:
• Based on smear layer treatment.
 Bonding 317
• Based on number of steps. • They partially demineralize the smear layer and
• Based on generations. underlying dentin without removing dissolved smear
layer remnants.
Van Meerbeek Scientific Classification Moderate self etching groups (Clearfil SE, Unibond GC): pH
• Etch and rinse adhesive of 2, shallow hybrid layer 0.5-1 µm.
• Self-etching adhesive
Aggressive self etching group (Prompt - L - Pop 3M, Prime
• Glass ionomer adhesive.
and Bond, NT-non-rinse conditioner) pH less than 1,
Hybrid layer thickness 2-3 µm.
Based on Smear Layer Treatment
• Smear layer modifying. Based on Number of Steps (Figure 16-20)
• Smear layer dissolving.
• Smear layer removing. Three Step
Here primer, adhesive, etchant are in three separate bottles
Smear Layer Modifying (Figure 16-19) and involve three steps. This is two bottle system, e.g. All
Bond - 2, Scotchbond multipurpose.
• Based on concept that smear layer form a natural barrier
to pulp and prevent outflow of pulpal fluid that might
impair bonding efficiency. Two Step
• Efficient wetting and in situ polymerization of monomers Here primer and adhesive or primer and etchant are
infiltrated smear layer, reinforce the smear layer to combined in single step and involve two steps. This one
dentin, e.g. compomers, poly acid modified composites. bottle system, e.g. Prime and Bond, Single Bond.

Single Step
Here etchant, primer, adhesive are all combined. This is
all-one system, e.g. Clearfil liner 2, Prompt -L-Pop.

Figure 16-19: Smear layer modifying

Figure 16-20: Based on number of steps
Smear Layer Removing
• Many of today’s adhesive agents opt for complete Based on Generation (Flow Chart 16-1)
removal of smear layer based on ‘Total etch concept’ First Generation
(Figure 16-12).
• Early dentin bonding agents were based on model of
• Their mechanism is based on combination effect of
silane coupling agents.
hybridization and formation of resin tags.
• The formula for this is M-R-X.
M—Methacrylate group.
Smear Layer Dissolving R—Spacer group.
• Self-etching adhesives use slightly acidic primers so X—Acidic group to reat with mineral portion of dentin
called ‘self etching primers’. especially, Ca2+.
318 Essentials of Operative Dentistry

Box 16-1: Dentin bond strengths associated with

several generation of adhesives

Second generation adhesives 2 to 4 MPa

Third generation adhesives 3 to 8 MPa
Fourth generation adhesives 13 to 30 MPa
Fifth generation adhesives 3 to 25 MPa

• The first product marketed was active agent glycerol-

phosphoric acid dimethacrylate (Buonocore 1950s). The
disadvantage was high polymerization shrinkage and
coefficient of thermal expansion, degradation in
aqueous environment.
• Also in this category is NPG-GMA (Bowen 1960s) which
chelate with Ca2+ ions of hydroxyapatite crystals.
• Bond strengths achieved were 2-3 MPa as evidence
pointed out no chemical bonding (Box 16.1).

Second Generation
• In 1978, Clearfil Bond system F (Kuraray, Japan) was
introduced.
• Based on phosphate ester material (phenyl P-HEMA in
ethanol).
• Mechanism of action based on interaction between
negatively charge PO4 groups and positively charged
Ca2+ of smear layer.
Disadvantages
• Smear layer was weakest link.
• Resins were hydrophobic and had large contact angle,
not able to penetrate dentin bond strengths achieved
were only 1-5 MPa, e.g. scotchbond 3M, bondlite Kerr,
prisma universal bond 3M.

Third Generation
• Also based on acidic group to react with Ca++ and a
methacrylate group to copolymerize with unfilled resin.
• It also included attempt to deal with smear layer through
conditioning of dentin.
• Two approaches used were:
1. Modification of smear layer to improve its properties.
2. Removal of smear layer without disturbing occluded
plugs.
• Concept of phosphoric acid etching before application
of phosphate ester bonding agent was introduced by
Fusiyama 1979. But this concept created criticism of too
aggressive to pulp.
• Procedures involved were:
Flow Chart 16-1: Evolution of bonding adhesives • Application of dentin conditioner
 Bonding 319
• Application of primer (dentin bonding agent)
• Application of adhesive (unfilled resin)
• Placement of resin composite
• Most of this generation bonding agent were designed
to modify smear layer to allow penetration of acidic
monomers such as phenyl-P, PENTA.
• Another approach in this generation was removal of
smear layer by EDTA and bonding agent containing
glutaraldehyde in HEMA to bond with collagen. But
no evidence of bonding to collagen, e.g. Gluma system
Bayer.
Disadvantages
Acidic conditioners/primers used created precipitates on
dentin surfaces preventing resin penetration.
• Treatment of smear layer with 2.5% maleic acid
Scotchbond 3M and a trace of methacrylic acid effectively
combined etching philosophy of Japan and
conservative approach of US and Europe.
• Other agents used were 2% aqueous nitric acid Tenure
Dentmat.
• Clearfil Kuraray in 1984 contained HEMA and a
10 carbon 10 MDP which includes long hydrophobic
and short hydrophilic component which continued Figure 16.21: Steps in total etching
dentin etching philosophy.
• It was during this period in 1982, Nakabyashi, et al.
gave reliable higher bond strength with use of MMA- • Dry thoroughly to remove solvent in primer.
TBB (4 META/methylmethacrylate-tri-n-butyl borane) • Apply adhesive to enamel and dentin. It should be of
and explained about hybrid layer formation. sufficient thickness of 50 µm to prevent oxygen
inhibition of primer layer. Cure adhesive and primer
Fourth Generation layers.
• Apply composite resin over the adhesive and cure.
Fourth generation based on total etch where by both enamel
• Primer should contain solvent as dentin contains water
and dentin are etched by phosphoric acid. ‘Total etch
and dentinal fluid which can inhibit polymerization,
concept’ removal smear layer by etching improves bond
so a solvent is required to evaporate this water.
strength.
• Adhesive system must have low surface tension and
Fourth generation agents are all bond - 2 Bisco, Optibond
substrate have high surface energy for adequate inter-
FL Kerr, Scotchbond multipurpose 3M.
facial contact. But after etching of dentin low surface
They basically composed of:
energy collagen is exposed this is converted to high
• Acid etching gel that is rinsed off.
energy by primers.
• Solution of primers that are hydrophilic monomers in
ethanol, acetone, water. Major components (Tables 16-3 to 16-5)
• Unfilled/filled bonding agent (BIS GMA, HEMA). Etchant—phosphoric acid 32-37%, citric acid 10%,
Calcium chloride 20%, oxalic acid, aluminium nitrate.
Steps (Figure 16-21)
Primer—NTG-GMA/BPDM, HEMA/GPDM4 META/
• Etch both enamel and dentin for 15 secs. Then rinse
MMA, Glutaraldehyde Adhesive - BIS - GMA, TEGMA.
with excess water to remove precipitate and gel.
Solvent—Acetone, ethanol, water.
• Dry enamel to determine etching.
• Slightly moisten the surface.
• Absorb excess water with cotton. Fifth Generation
• Apply primer according to manufacturer’s instructions • Developed as a result of recognition that clinical success
1-6 layers. should be more successful if fewer steps involved.
320 Essentials of Operative Dentistry

Table 16-3: Representative compositions of major Table 16-6: Composition of One-step (Bisco)
components of bonding agents adhesive system
Component Composition of major components Monomers
BPDM (hydrophilic resin)
Fourth generation
HEMA (hydrophilic resin)
Etchant Phosphoric acid (32-37%)
BIS-GMA (hydrophobic resin)
Citric acid (10%)/calcium chloride
Photoinitiator
(20%)
Tertiary amine
Oxalic acid/aluminium nitrate
Camphorquinone
Primer NTG-GMA/BPDM, HEMA/GPDM
Solvent
4-META/MMA, glutaraldehyde
Acetone/ethyl alcohol (60-65%)
Adhesive Bis-GMT/TEGMA
Solvent Acetone, ethanol/water
Table 16-7: Composition of Optibond (Kerr)
Fifth generation adhesive system
Etchant Phosphoric acid
Primer-adhesive PENTA, methacrylated Primer
phosphonates HEMA (hydroxyethyl methacrylate)
Solvent Acetone, ethanol/water, solvent- GPDM (glycerylphosphate dimethacrylate)
free PAMM (phthalic acid monoethyl methacrylate)
CQ (camphorquinone)
Sixth generation Ethanol
Acidic primer-adhesive Methacrylated phosphates Water
Solvent Water Adhesive
Seventh generation Resin
Acidic primer-adhesive Methacrylated phosphates BIS-GMA
Solvent Water HEMA
GDM
Table 16-4: Composition of tenure quik (Den-mat) Filler
adhesive system Barium-aluminium-borosilicate glass
(average particle 0.6 µm)
Resins
Fumed silica
BIS-GMA (hydrophobic)
Disodium hexafluorosilicate
HEMA (hydrophilic)
Photoinitiator
NTGGMA (hydrophilic)
CQ (camphorquinone)
Water
Photoinitiator
Acetone (46%) Sixth Generation
Self etching primers
Table 16-5: Composition of prime and bond • Contain a phosphonated resin molecule which perform
(dentsply-caulk) adhesive system
two function simultaneously etching and priming of
Resins dentin and enamel, e.g. clearfil liner Bond 2.
Resin (R-5-62-1) (elastomeric urethane resin) • This eliminates steps of drying and rinsing.
UDMA (urethane dimethacrylate)
• Two other products are Prompt-L-Pop 3M, is a self
BPA-DMA (phenol A dimethacrylate)
Penta (adhesion promotor by wetting, etching adhesive this is all in one with no rinsing step.
crosslinking) Non-rinse conditioner NRC dentsply this is a
Photoinitiator conditioner which requires no rinsing but separate
Acetone (75-80%) adhesive prime and bond is applied.
• Most manufacturers have combined primer and Major components
adhesive this is one bottle system. • Acidic primer-adhesive—methacrylated phosphonates.
• For example: One step Bisco, Prime and Bond Dentsply, • Solvent—water.
Single Bond 3M, Optibond Solo Kerr.
Major components (Tables 16-6 and 16-7)
• Etchant—phosphoric acid.
Hybridization
• Primer-adhesive—PENTA, methacrylated phospho- • Process of formation of hybrid layer (resin interdiffusion
nates. zone or interpenetration zone). Usually of 5-8 µm thick-
• Solvent—acetone, ethanol, solvent free. ness.
 Bonding 321
• This layer forms following initial demineralization of
dentinal surface with an acidic conditioner exposing a
collagen fibril network with inter fibril microporosities
that subsequently become intediffused with low
viscosity monomers. This zone in which resin adhesive
system interlocks micromechanically with dentinal
collagen is termed hybrid layer or zone.
• Three different layers in hybrid zone are:
– Top layer amorphous electron dense phase.
– Middle layer cross-sectioned and longitudinally
sectioned collagen fibrils separated by electron
lucent spaces.
– Base layer is characterized by a gradual transition to
underlying unaltered dentin.
• Hybrid layer act as stress breaker or stress reliever with
young’s modulus of 3Gpa.
• Perdigao et al advocated removal of demineralized
collagen and exposing hydrophilic underlying collagen Figure 16-22: Dentinal tag formation
for better penetration of bonding agents. He advocated
use of 2% sodium hypochloride. He suggested that • Dentin should be kept with thin film of water and
formation of hybrid layer is not essential for good glistening appearance. No pooling of water as it can
bonding. This process is called deproteinization. dilute the primer.
• But others refuted this finding stating that hybrid layer • This thin film of water will be driven off by solvent in
as stress breaker is necessary from preventing pulling primer.
away of composite during polymerization shrinkage.
• Also partial dissolution of collagen fibrils and desta- Disadvantages
bilization of molecules that compose dentin structure
• Acetone-based bonding agent if kept open for some time
during deproteinization, may compromise reliable
solvent can evaporate and monomer ratio in bonding
bonding interface.
agent increases.
• Oxygen released from sodium hypochloride also
• Having cavity wall wet prevents to see frosted etched
inhibits polymerization.
enamel surface.
• If resin monomers do not completely penetrate dentinal
• Water-based adhesive are recommended to be used after
tubule the basal zone of demineralized dentin can lead
slight air drying of etched tooth surface.
to nanoleakage and decrease in bond strength.
• Rewetting agents like Aquaprep Bisco HEMA/ water
• Hybridoid layer is the region of demineralized dentin
can be used as postconditioning agent.
into which resin failed to penetrate. Concurrent to hybrid
layer formation is penetration of primer into the open
dentinal tubules (Figure 16-22). Glass Ionomer Adhesives
Microtags—formed within intertubular dentin. • These are cements with powder consisting of acid
Macrotags—within dentinal tubules. soluble aluminosilicate glass and aqueous solution of
Macrotags are generally of little value as these are under polyacrylic acid.
cured. • Short pretreatment of polyalkeonic acid with tooth
removes smear layer of 0.5 µm. It is less severe than
etching and do not denude completely off hydroxy-
Wet vs Dry Bonding apatite.
• Polyalkeonic acid infiltrates and soften tooth surface
• Wet bonding introduced by Kanca and Gwinett. displacing Ca++ and PO4+ ions.
• Keeping dentin moist after etching prevents collapse • An intermediate layer of Ca and Al phosphates and
of collagen which can prevent resin monomer pene- polyacrylic acid is formed as glass ionomer cement
tration. (GIC) tooth interface.
322 Essentials of Operative Dentistry

• A direct primary chemical bonding of carboxyl group Surface Treatment

of polyalkeonic acid to Ca of hydroxyapatite could be Roughening and cleaning of ceramic surface requires
proved. adequate surface activation.
Common methods employed are:
Amalgam Bonding (Figure 16-23) • Grinding
• Amalgam traditionally retained by proper cavity design. • Abrasion with diamond rotary instruments
• Nowadays amalgam are being bonded to cavity wall • Airborne abrasion with aluminium oxide particles
using agents having Formulas M-R-X. • Acid etching
• One system which uses 4 META (both hydrophobic • Combination of these methods.
and hydrophilic group). Acid etching with 2.5-10% hydrofluoric acid and
• Attachment of amalgam to bonding agent is not ammonium bifluoride applied for 2-3 minutes seems to be
completely understood but its due to interlocking of most successful. This etching process creates surface
amalgam into bonding agent which occurs due to roughness, removes glassy matrix exposes crystalline
condensing of amalgam over the uncured bonding resin. structures.
• Bond strength up to 20 MPa. These systems have to be Adhesive resin flows into this irregularities interlocks
self-cured. to form micromechanical bond. Number, size, distribution
• Repair of amalgam with bonding agents not successful. of leucite crystals influence formation of microporosities
• Amalgabond plus Parkell, Panavia Kuraray. during acid etching.
Current ceramic repair systems utilize combination of
airborne (50 µm Al2O3), etching with HF acid.

Silane Coupling Agents (Figure 16-24)

Thorough rinsing followed by ultrasonic cleaning is
recommended, chemical bonding is achieved by
silanization with a bifunctional coupling agent.
Most commonly used silane coupling agent used is
γ-methacryloxypropyltrimethoxysilane.
Here silane group reacts with OH group in silica
particles and methacrylate groups polymerize to the
adhesive resin group.

Figure 16-23: Amalgam bonding

Ceramic Bonding
• Increasing number of metal ceramic and all ceramic
restorations are becoming available.
• A strong durable resin bond to tooth structure is
necessary for high retention, improved marginal
adaptation, prevents marginal leakage.
• Intraoral repair of these systems also rely on strong resin
bond to composites.
• Bonding resin to ceramic surface whether porcelain or
glass ceramic is based on combined effects of micro-
mechanical bonding and chemical bonding. Figure 16-24: Silanization
 Bonding 323
For silane agents to be reactive it must be hydrolyzed • Ineffective resin penetration due to collapse of collagen
and acidified. layers leads to so called hybridoid layer formation
Silane agents are available either in single component observed ultramorphologically.
or two component solutions—containing aqueous acidic • Nanoleakage (Sano et al, 1993): Used to describe small
solution to activate the agent. porosities within the hybrid layer or at transition
Bond strength—20-40 MPa. between hybrid and mineralized dentin that allow
penetration of miniscule particles of silver nitrate dye
Resin-Metal Bond here even though gap between restoration and tooth
may not be observed microscopically.
Resin composite (indirect) are required to be bonded to • Water trees: Described by Tay et al (2003) since
metal substrate, generally it can be classified as mechanical contemporary dentin adhesives are very hydrophilic
or chemical. they tend to attract water lead to water sorption, which
forms interconnecting channels with adhesive resin
Mechanical layer this is termed as ‘Water Trees”.
• Macromechanical—Beaded metal, metal mesh, pitted • This residual water has been shown to degrade the
metal. bonding efficiency on long-term basis, this problem is
• Micromechanical—Sandblasting, etching. seen only with newer generation bonding agents.

Biocompatibility
Chemical
• Potential for acid penetration and interaction is within
Here an intermediate layer of tin coating or ceramic coating
only superficial layer of about 1.9-5.8 microns buffering
is fused to metal surface, e.g. silicoating (Kulzer), rocatec
ability of hydroxyapatite and collagen are excellent.
(ESPE), co-Jet. • HEMA is a very volatile substance can act as allergen.
Recently liquid primers composed of thiophosphate • Dental adhesives are well tolerated by dentin-pulp
monomers are available they achieve bond strength complex provided a hermetic seal is achieved.
18-30 MPa to metal alloys, silane coupling agents are also
of importance for bond of resin to metal, especially Ni-Cr. Uses
For effective bonding surface conditioning of metal is • Changing shape of anterior teeth
required. • Restoring Cl - I, II, III, IV, V
• Bonding amalgam
Rocatec (ESPE): Based on silica abrasive particles • Luting metallic or porcelain crown
(50 microns) roughens the surface also provides increased • Bonding in-direct resin restoration
silica content on substrate this is called tribochemical • Pit and fissure sealant
method. Followed by silane agents application. • Bond orthodontic brackets
Silicoater MD (Kulzer): Here pyrochemical layer of silica • Bond periodontal splints
formed onto metal substrate followed by silane agent • Repair existing restorations
application used with Co-Cr alloy. • Desensitizing root exposures
• Bonding posts
Co-Jet (ESPE): Here noble metal alloys are roughned by • Seal exposed pulp.
co-Jet sand followed by silanization.

Microleakage HEMA, META (Figure 16-25)

• It is defined as the passage of bacteria and their toxins
HEMA (Figure 16-26)
between restoration margins and tooth preparation
walls. • 2-hydroxyethyl methacrylate. Found to enhance
• Clinically microleakage is of importance as pulp bonding by Fusiyama et al, 1979.
irritation in restorative procedures are more commonly • Key ingredient for priming in many dentin bonding
due to bacteria than due to chemical toxicity of agents has both hydrophobic and hydrophilic groups.
restorative materials. • This molecule is analogous to methyl methacrylate
• Occurrence of gap between restoration and tooth does except that pendant methyl ester is replaced by an ethoxy
not immediately result in debonding of restoration. ester group to make it hydrophilic.
324 Essentials of Operative Dentistry

• HEMA can polymerize only by linear polymerization

so in high concentration can produce weakened
polymerization.
• HEMA enhances water sorption from host dentin also
from mouth fluids deteriorating the bond efficiency.

META (Figure 16-27)

• 4-methacryloxyethyl trimellitate anhydride.
• MET-4-methacryloxyethyl trimellitic acid.
• This monomer contains both hydrophobic and
Figure 16-25: HEMA and META having hydrophilic ends. It easil penetrates dentin substrate
hydrophilic component with MMA monomer to polymerize.
• Developed by Takeyama et al, 1978, as META/MMA-
TBB (tri-n-butyl borane).
• These are available in powder liquid form with powder
containing polymethylmethacrylate (PMMA) and liquid
contains MMA, META, TBB. TBB liberates free radicals
on contact with moisture and enhances polymerization.
• Suzuki et al with Raman spectroscopy has showed
that 4-META molecules were hydrolyzed to 4-MET
Figure 16-26: HEMA molecules which were than copolymerized with MMA
molecules to form resin and resin reinforced dentin zone.
• Probable mechanism of bonding to tooth structure is
• It aids in enhancing the wettability of hydrophobic by:
agents (surface active agents) and also it has low • Excellent infiltration property
molecular weight enhancing the infiltration into • Chelating with Ca++ ions as coupling agent (through
dentinal tubules. hydrogen bonding).
• It also helps in binding hydrophobic and hydrophilic • It has been used as amalgam bonding agent, also in
components into one single solution. resin luting cement.
• Other typical monomers of this nature are NTG - GMA
(N-polyglycineglycidylmethacrylate), PMDM (Pyro-
mellitic acid dimethacrylate), BPDM (biphenyl
dimethacrylate), PENTA (dipentaerythritol penta
acrylate monophosphate).
HEMA adhesion as prescribed by N Nishiyama et al.
• Facilitates restoration of collagenous layer in which the
collagen fiber arrangement has collapsed during air
drying process and ester carbonyl group in HEMA forms
hydrogen bond with carboxylic group in collagen.
• Hydrogen bonded HEMA species promotes hybridiza-
tion of adhesive resin dentinal collagen fibers, thus
enhancing bonding at the resin-dentin interface.
Conventional adhesives contain HEMA in conc of
35-55 vol%.

Disadvantages
• HEMA has potential immunotoxic effect on monocyte.
• HEMA will retain water within adhesive formulations
be detrimental to bonding efficiency. Figure 16-27: META
 Bonding 325

Figure 16-28: Pit and fissure sealant penetration

Pit and Fissure Sealant

Figure 16-29: Clinical case preoperative
(ADA No. 39) (Figure 16-28)
• Primarily used in children with recently erupted molar
tooth. Adults can also benefit if he/she experiences
change in caries susceptibility.
• Sealants are usually filled or unfilled resin of
polyurethane, cyanoacrylates and BIS-GMA. BIS-GMA
are cure by amine-peroxide chemical activation or light
activation.
• They can be:
• Unfilled resin—Colorless/tinted/transparent.
• Filled resin—Opaque/tooth colored/white.
• Success depends on intimate contact into pits and
fissures.

Indication
• Children with increased caries susceptibility.
• Used as a prevention of caries rather than treatment. Figure 16-30: Postoperative

Clinical Technique (Figures 16-29 and 16-30)

• Isolation of tooth done in quadrants. Key Terms
• Area cleaned with polishing brush and pumice.
• Liquid etchant is preferred as it can easily flow into • Surface energy
pits. • Contact angle
• Tooth is rinsed with water for 20 secs and dried. • Wetting
• Sealants is teased into pits and fissures. • Enamel bonding
• If there is any caries remnants its justified to place • Resin tags
sealant over the caries. • Etching
• Dentin bonding
• Smear layer
Preventive Resin Restoration • Total etch concept
If there is a potential carious lesion a conservative cavity • Hybrid layer
can be prepared on tooth and composite restoration with • Hybridoid layer
sealant application is employed. • Wet bonding
326 Essentials of Operative Dentistry

• Amalgam bonding Questions to Think About

• Ceramic-metal bonding
• Resin-metal bonding 1. What are different types of bonding? Write about clinical
• Silanization application of bonding in dentistry.
• Microleakage 2. Elaborate about enamel etching.
• Nanoleakage 3. Classify various classification of dentin bonding agents.
• Pit and fissure sealant Explain about any one classification in detail.
• HEMA 4. Elaborate about different generations of dentin bonding
• META agents.
 Resin Composite Restorative Material 327

17 Resin Composite
Restorative Material

Introduction methacrylate) a dimethacrylate resin and an organic

silane coupling agent to bond filler particles and resin
During the first half of 20th century, silicates were the matrix.
only tooth-coloring esthetic materials available. • In dentistry term “resin composite” generally refers to a
reinforced polymer used for restoring enamel and
Disadvantages of Silicate Cements dentin. Proper term (material science) is polymer matrix
composite or particulate-reinforced polymer matrix
• Becomes severely eroded
composite.
• Dissolution in oral fluids
• Most biological materials including enamel, dentin,
• Surface crazing
bone are composite material.
• Lack of adequate mechanical properties.
• In general, composite is a physical mixture of materials.
Acrylic resins similar to denture base resins (PMMA)
The parts of the mixture are generally chosen with
were introduced later (powder/liquid).
averaging the properties of the parts to achieve
intermediate properties.
Advantages of Acrylic Resins Composites typically involve a dispersed phase of
• Tooth colored fillers within a continuous phase-matrix phase (Figure
• Insolubility in oral fluids 17-1).
• Ease of manipulation
• Low cost. Historical Development

Disadvantages of Acrylic Resins

• Poor wear resistance
• Shrinkage leading to marginal leakage.

Evolution and History of Composites

Later quartz powder (filler) were added to form a composite
structure. This addition of filler having coefficient of
thermal expansion similar to tooth reduced curing
shrinkage. This was not successful as filler particles were
not bonded to resin matrix.
• Major advancement was made when Dr Ray L Bowen
(1962) developed Bis-GMA (Bisphenol—A glycidyl
328 Essentials of Operative Dentistry

Figure 17-1: Composites

Components of a Composite Resin

Figures 17-2A to C: Structure of BIS, GMA,
• Organic resin component that forms matrix. UDMA, TEGDMA
• Inorganic fillers.
• Coupling agent to unite filler and matrix.
• Bis-GMA, UDMA has high molecular weight which
• Initiator and activator system to activate setting
reduces polymerization shrinkage and increased
mechanism.
mechanical properties.
• Inhibitors.
• Strictly speaking Bis-GMA UDMA are oligomers.
• Pigments and other components.
• Lower molecular weight TEGDMA are used to reduce
viscosity of Bis-GMA.
Composition and Function of Components • Bis-GMA is a difunctional monomer formed by reaction
Dental composites properties are greatly influenced by filler product of Bis-phenol A and glycidyl dimethacrylate.
content. • Dimethacrylate monomers produce extensive cross-
Dental composite are highly crosslinked polymer linkage resulting in rigid resin matrix highly resistant
materials reinforced by a dispersion of glass, crystalline to softening and degradation.
or resin filler particles or fibers bound to matrix by silane • Trade-offs in polymerization shrinkage, wear resistance
agents. and manipulation properties place severe limits to
optimize an universal composites.
Uses and Applications
• Anterior restorations Fillers
• Posterior high stress restorations Incorporation of fillers into resin matrix greatly improves
• Pit and fissure sealant material properties, provided that filler particles are
• Cementing fixed partial dentures bonded to polymer matrix or otherwise it may actually
• Bonding ceramic veneers. weaken the resin.

Resin Matrix Benefits of Filler

• Most use a blend of aromatic/aliphatic dimethacrylate • Increased hardness, strength and decreased wear.
monomers as Bis-GMA, TEGDMA (triethylene glycol • Decreased polymerization shrinkage.
dimetharylate) and urethane dimethacrylate (UDMA) • Decrease in thermal expansion and contraction.
(Figures 17-2A to C). • Improved workability.
• Mostly shrinkage occurs as these monomers are • Decrease in water sorption, softening and staining.
converted to polymers, as weak van der Waals forces • Increased radiopacity.
between them are converted to strong covalent forces. Filler particles are commonly produced by grinding
This shrinkage leads to gap formation between tooth or milling quartz or glasses to produce particles ranging
and restoration. in size from 0.1-100 µm.
 Resin Composite Restorative Material 329
Pure silica exists in several crystalline form
(crystobalite, tridymite, quartz) and noncrystalline form
glass.
Since crystalline form are stronger and harder
difficult to polish most composite use silicate glass.
Filler particle size greatly influences the fluidity of
composite as filler particle size decreases surface area
increases which decreases fluidity.
Figure 17-3: Pyrogenic silica
Also affect roughness of restoration.
Filler compositions are modified by additions of Li,
Al to make glasses easier to crush. space exists between filler particles these can be filled
Ba, Zn, B, Zr, Y are added to filler to increase opacity. up with smaller fillers. Maximum filler packing fraction
• Nonsilicate compositions are being developed, can be for closely packed structure is 74% vol.
used for nanofilled composites. • Amount of filler that can be incorporated into a resin is
• Fiber reinforced systems are also being used main greatly influenced by total filler surface area, which is a
advantage is their excellent strength in primary fiber function of particle size, with size of particle decreasing
direction. Fibers less than 1 micron causes carcino- the surface area increases. Colloidal silica have
genecity. extremely large surface area also it increases viscosity
• Single crystals having symmetrical shapes are used even with very small amounts, because this effect
behaving as fibers. They are much stronger than non- microfilled composites contain only 20-59% of colloidal
crystalline or polycrystalline fibers. silica. The remainder is pulverized pre-cured resin the
• SiC crystals are being used but they are not very esthetic. so called ‘organic filler’. With particle size between
• Crystalline polymer fillers are also being used but they 5-30 µm (Figure 17-4).
are not as strong as inorganic fillers. • Degree of filler addition is represented in terms of weight
Microfillers utilize silica manufactured from different percent or volume percent of filler. Because silica fillers
procedures. are approximately 3 times as dense as monomer 75%
weight is equivalent to 50% vol. Properties of compo-
Colloidal Silica sites are proportional to vol percent.
• For proper translucency of composites to enamel, the
• It is chemically precipitated from a liquid solution as
refractive index of composites and in turn fillers should
amorphous silica particles.
closely match that of tooth.
• Submicron silica particles of colloidal size (0.04 µm)
referred to collectively as microfiller are obtained by
pyrolytic or precipitation process. Here a silicon
compound, e.g. SiCl4 is burned in a oxygen and hydro-
gen environment to form macromolecule chains of SiO2.
These macromolecule are of colloidal size and
constitute inorganic filler phase.

Pyrogenic Silica (Figure 17-3)

Pyrogenic silica is precipitated from a gaseous phase as
amorphous particles. The properties of each form are
different.
In addition to filler volume level, other factors that
determine the properties of composites are filler size, size
distribution, index of refraction, radiopacity and hardness
of filler.
• A distribution of particle size is necessary to incorporate
a maximum amount of filler into a resin matrix. If
uniform particle size is used, even with close packing Figure 17-4: Pulverized precurved resin
330 Essentials of Operative Dentistry

Quartz extensively used as filler in earlier version of Activator-initiator System

composites, its chemically inert, very hard making it Both methacrylate and dimethacrylate are polymerized
abrasive and hard to polish. by addition polymerization initiated by free radicals. Free
• Pure silica exists in several crystalline forms, e.g. radicals can be generated by chemical activation or by
cristobalite, tridimite, quartz. Noncrystalline form- external energy (light, heat, microwave).
glass.
• Amorphous silica has same composition and refractive
index as quartz and its not crystalline and not as hard. Chemically Activated Resin
• Most of today’s composite have modified silicate glass.
These are supplied in 2 paste system, one paste contains
• Radiopacity of fillers are given by number of glasses
benzyl peroxide (initiator) and other contain tertiary amine
and ceramics that contain heavy metals such as barium,
(activator), e.g. N, N dimethyl-p-toluidine. When 2 parts
strontium and zirconium.
are mixed together, tertiary amine reacts with peroxide to
form free radicals.
Coupling Agents (Figures 17-5A and B)
• It is essential that filler particles be bonded to resin
matrix. This allows the more flexible polymer matrix to Light Activated Resin
transfer stresses to higher modulus filler particles. This First light activated systems were formulated with UV
is provided by a coupling agent. system.
• Most commonly used is γ methacryloxypropyltri-
methoxysilane.
• During deposition of silane on the filler the methoxy Disadvantages
groups hydrolyze to hydroxyl groups to react with • Lack of penetration depth.
adsorbed moisture or OH groups of filler. They can also • Damage to eye.
condense with OH groups on an adjacent hydrolyzed • Now its replaced with blue light activated systems, with
silane to form a homopolymer on the filler surface. improved penetration depth.
• Methacrylate groups form covalent bonds with resin Light curable dental composites are supplied as single
when it is polymerized. pastes. The free radical initiating system, consisting of
• This bond degraded when water is absorbed by photosensitizer (diketone-camphorquinone) and an amine
composite intraorally. activator (dimethyl amino ethyl methacrylate - DMAEMA).
• Also titanes and zirconates also employed. On exposure to light (blue-470 nm) produces an excited
state of photosensitizer which interacts with amine to form
free radicals that initiate addition polymerization (Figure
17-6).
• Camphorquinone absorbs light (blue) in wavelength
between 400 and 500 nm, this is added in 0.2 weight %
or less. This causes slight yellowish tint in uncured
composites.
Figure 17-5A: Coupling agents • Amine activators are present at levels approx 0.15 wt%.
• Other initiators are phenyl propane dione - PPD, lucirin
TPO.

Inhibitors
• They are added to prevent or minimize spontaneous
and accidental polymerization. Inhibitors have strong
affinity with free radicals. A typical inhibitor is butylated
hydroxy toluene (BHT). In conc. of 0.01 weight %.
• They are useful in extending working time and storage
Figure 17-5B: Bonding of coupling agents lifetime.
 Resin Composite Restorative Material 331
According to Anusavice
• Particle size
• Traditional composite 1-50 µm glass
• Hybrid (large) 1-20 µm glass 0.04 µm silica
• Hybrid (midifiller) 0.1-10 µm glass 0.04 µm silica
• Hybrid (minifiller/SPF) 0.1-2 µm glass / 0.04 µm silica
• Packable composite midi/mini filler hybrid but with
lower filler fraction
• Flowable composite midi hybrid, with finer particle size
distribution
• Homogeneous micro fill 0.04 µm silica
• Heterogeneous micro fill 0.04 µm silica prepolymerized
resin particles containing 0.04 µm silica.

According to Sturdevant
(Figures 17-7 and 17-8)
• Homogeneous: Composite contains only filler particles
and uncured matrix material.
• Heterogeneous: Includes precured composite or other
unusual filler particles.
Heterogeneous Heterominifill
Heteromidifill
Heteromicrofill
Homogeneous Megafill
Macrofill
Midifill
Microfill
Figure 17-6: Light polymerization of resin composite
Nanofill
Hybrid Midimicrohybrid
Optical Modifiers Minimicrohybrid
Modified Fiber reinforced homogeneous midifill
Composites should be able to match tooth color, which is
Macrofillers—10-100 µm
achieved by adding minute amounts of metal oxide
Midifill—1-10 µm
particles. To increase opacity manufacturers add titanium
Minifillers—0.1-1 µm, microfillers—0.01-0.1 µm,
dioxide and aluminum oxide (0.001-0.007 wt %). Darker
nanofillers—0.001-0.01 µm
shades and greater opaque shades have decreased
light transmission and depth of light curing ability. This
requires an increased exposure time and thinner layer
when cured.

Classification of Composite Resin

• This can be done on basis of filler content, filler particle
size and method of filler addition, (or)
• Matrix composition (Bis-GMA, UDMA, etc.) (or)
• Method of polymerization (selfcure, lightcure, dual
cure)
• Most commonly used classification is based on filler
particle size and distribution. Figure 17-7: Classification of resin composites
332 Essentials of Operative Dentistry

Traditional Composites
• This category was developed during 1970’s and
modified slightly over the years.
• Referred to as conventional or macrofilled composites.
• Most commonly used fillers are finely ground
amorphous silica or quartz.
Figure 17-8: Filler particle size distribution • Average particle size is 8-12 µm but particles as large
as 50 µm are also present.
• Filler loading is 70-80% weight or 60-70% vol.
According to ISO 4049/ANSI/ADA # 27
Type I : Polymer-based material suitable for restoration
involving occlusal surfaces.
Properties
• Compressive strength improved by 300-500% to unfilled
Type II : Other polymer-based materials resins.
Class 1 : Self cured material • Elastic modulus is 4 - 6 times greater, tensile strength is
Class 2 : Light cured material doubled.
Group I : Energy applied intraorally
• Water sorption, polymerization shrinkage and thermal
Group II : Energy applied extraorally
expansion are reduced from unfilled resin.
Class 3 : Dual cured material.
• Suffer from roughening of surface as a result of abrasion
of softer resin matrix.
Lutz and Phillips (1983) • Radiolucent composites.
Type I: Macrofilled composite resin
Type II: Microfilled composite resin Clinical Consideration
Homogeneous • Major disadvantage is rough surface during abrasive
Splintered prepolymerized particles
wear.
Spherical prepolymerized particles
• Tend to discolor because of rough surface.
Agglomerated microfiller complexes
• Fracture is not a common problem.
Type III: Hybrid composite resin.

Willems Classification Small Particle Filled Composites

• To improve surface smoothness and improve physical
• Densified composites: Midway
and mechanical properties of traditional composites
Ultrafine midway filled
inorganic fillers are ground to a size range of 0.5-3 µm.
Fine midway filled
• It has broad size distribution aiding in increased
• Densified composite, compact filled
inorganic filler content 80-90% weight and 65-77%
Ultrafine compact filled
weight.
Fine compact filled
• These composites use amorphous silica as fillers, but
• Homogeneous microfine composites
most incorporate glasses containing heavy metals for
• Heterogeneous microfine composites
radiopacity.
Splintered prepolymerized fillers
• Colloidal silica is added in approx 5 wt% to adjust the
Spherical prepolymerized fillers
viscosity of the paste.
Agglomerated prepolymerized fillers
• Misc. composites
Splintered prepolymerized fillers Properties
Agglomerated prepolymerized fillers • Most of the mechanical and physical properties are
Sintered agglomerates improved.
Spherical prepolymerized fillers • Radiopaque.
• Traditional composites. • Heavy metal fillers are soft and prone to hydrolyze and
• Fiber reinforced composites. leach in water.
 Resin Composite Restorative Material 333
Clinical Consideration Properties
• Used in high stress and abrasion prone sites Cl-IV. • Final inorganic filler content may be only 50 wt%, but if
• These are not as smooth as newer composites. composite particles are counted as fillers it does increase
to 80 wt%.
Microfilled Composites • Major shortcoming is the bond between composite
particles and clinically cured matrix is weak and results
• Problems of surface roughening and low translucency
in chipping.
associated with traditional and small particle
• They have inferior physical and mechanical properties
composites can be overcome through use of colloidal
to traditional composites because of greater 40-80
silica particles as fillers. The individual particles are
vol % of resin.
approx, 0.04 µm in size.
• Provide smoothest finish possible.
• These tiny colloidal silica particles tend to agglomerate
• Preferred choice for Cl—III, V preparation.
colloidal silica filler would have to be added in large
amounts, however as these fillers have large surface
area that must be wetted by monomer and formation of Clinical Consideration
polymer like chains among colloidal particles, it leads • Should not be used in stress bearing areas Cl—II,
to increase in viscosity and undue thickening. IV sites.
Two methods to circumvent this problem is: • Restoring cosmetic zones and subgingival areas.
1. Sinter the colloidal silica particles which results in
particles with sizes of several tenths of micrometer, Hybrid Composites
this larger agglomerate results in a reduced surface
• Hybrid composites was developed in an effort to obtain
area, allowing more filler to be added. This sintering
even better finish than small particle composites while
results in porous fillers—Homogeneous Microfills.
still maintaining desirable properties of the latter.
2. Preparation of prepolymerized filler involves adding
• It contains two kinds of fillers, this bimodal distribution
60-70 wt, (50 vol%) of silane treated colloidal silica
of filler aids in higher filler loading and better surface
to monomer at a slightly elevated temp to lower its
finish.
viscosity. When filler is thoroughly mixed into the
• Fillers are colloidal silica and ground particles of glass
resin, the composite paste is heat cured using benzyl
containing metals.
peroride initiator. The cured composite is then
• Glasses have average particle size about 0.4-1.0 µm.
ground into particles of size larger than quartz
Colloidal silica represents 10-20 wt% of total filler
particles in traditional composites. These
content. These has been known as minimicrohybrids.
prepolymerized particles are often called ‘Organic
• Smaller filler particle size and greater amount of micro-
fillers’—heterogeneous microfill (Figure 17-9).
fillers increase surface area and thus filler loading will
not be as high as small particle filled.

Clinical Consideration
• Physical and mechanical properties in between
traditional and small particle filled.
• Filler particles contain heavy metal, they have sufficient
radiopacity.
• Because of this surface smoothness and good strength
widely used for anterior restoration including Cl - IV.

Nano Composites
• Most recently developed with nanofillers in range of
0.005-0.020 µm.
• Nano sized fillers are produced for sol—gel processing
of silica, polyhedral oligomeric silsequixanes, metal
Figure 17-9: Manufacture of prepolymerized particles oxide nano particles.
334 Essentials of Operative Dentistry

• Nano particles can also be clustered or aggregated into • Their characteristics derive from inclusion of elongated,
large units that can be blended with nano particles to fibrous, filler particles of about 100 µm in length/
produce hybrids. textured surfaces tend to interlock and resist flow.
• They take twice the time required for amalgam
Fiber Reinforced Composites placement.
• No advantageous properties over hybrid resin.
• Here fibers are added as fillers.
• Mean filler particle size often may not correspond to
• Main advantage is that they have excellent strength
any actual particle size because of polydispersed
along primary direction of fibers.
distribution.
• Most fibers have diameter of 5-10 µm and effective length
• For posterior composite its also possible to insert 1-2
of 20-40 µm.
large glass inserts (0.5-2 mm particles) into the
composites at a points of occlusal contact or high wear.
Ceramic Whiskers They have been referred to as mega inserts. Technique
• Single crystals generally have symmetric shape and are is more cumbersome.
commonly long plates, behaving similar to fibers.
• They are much stronger than noncrystalline or poly-
crystalline fibers. Curing of Resin-based Composite
• Commonly used is silicon carbide crystals, crystals are
colored and not very esthetic. Chemical and Light Curing
Chemical Curing
Flowable Composites
• Chemical curing also referred to as cold curing or self
First Generation curing.
Posses particle size and distribution similar to those of • Activated by mixing two pastes just before use.
hybrid, but decreased filler content, to give desired • Impossible to avoid incorporating air into the mix
viscosity. Mechanical properties inferior to those of hybrid. thereby forming pores and traps oxygen which inhibits
polymerization.
• No control over working time.
Second Generation
They have higher filler content and properties are similar
Light Activation
to that of traditional composites.
In general, they provide a consistency that enables the • To overcome problems with chemically cured resin,
material to flow readily spread uniformly and intimately these were developed where no mixing was required.
adapt to cavity. • A exposure of 40 secs or less is required to light cure a
2 mm thick layer only.
• Not as sensitive to oxygen as chemically cured resin.
Indications
• Conservative Cl—I, II, III, IV, V
• Used to repair resin restoration Disadvantages
• Can be used as a sealant • Cured only in thickness of 2-3 mm layers.
• In gingival areas of Cl—I, II. • Cost of light curing units and other factors associated
with light curing.
Packable Composites
• It is because of highly plastic like consistency of the Photo Curing with Visible Blue Light
precured composites, its difficult for the material to be
Advantages
condensed in a cavity and allow it flow laterally. This
is particular in tooth with proximal contact restoration. • No mixing
• This allowed introduction of packable composites of • Aliphatic amine can be used instead of aromatic amine
two categories—Packable/Condensable of hybrid as in chemically cured resin giving better color stability
composites. • Control over working time.
 Resin Composite Restorative Material 335
Disadvantages • Light passes through UV and band pass filters eliminate
• Build-up in layers of 2 mm or less. significant amounts of unnecessary light and convert it
• Relatively poor light penetration in certain posterior into heat within the unit.
and interproximal locations. • Light pass through fiber optic bundle and is emitted
• Variable exposure times due to shade variation. from tip of curing unit.
• Sensitivity to room illumination. • Curing light output can be monitored by in-built or
portable radiometer or by trial curing composites.
• Commonly lamp emanate radiant power density of
Curing Lamps approx 300-1200 mw/cm2 and it should be never less
Types of lamp used: than 300 mw/cm2 with wavelength of light between
• QTH : Quartz tungsten halogen lamp (ADA No. 48) 400-500 nm.
• LED : Light emitting diode
• PAC : Plasma arc lamp
LED (Figure 17-12)
• Argon laser source
• Solid state light emitting diodes (LED) use doped semi-
conductors (p-n junctions). Based on gallium nitride to
QTH (Figures 17-10 and 17.11) emit blue light.
• QTH has a power supply that heats a tungsten filament • Spectral distribution between 450-490 nm and requires
in a quartz bulb containing halogen gas. no filters.
• Typical bulb has 80-100 hrs of life. • It can be battery operated no heat and no cooling fan
required.

Figure 17-12: Light emitting diode unit

Figure 17-10: Light curing lamp (Halogen)
PAC Lamps
• Uses xenon gas that is ionized to produce a plasma.
• High intensity white light is filtered to remove heat and
to allow blue light to be emitted.

Argon Laser Lamps

Highest intensity and emit a single wavelength.

Depth of Cure and Exposure Time

(Figure 17-13)
• Depth of cure is usually 2 mm thick for composites
• This thickness is limited by light scattering effect of
composites, accessibility of light to composites and
Figure 17-11: Light curing unit (Halogen) penetration depth of light.
336 Essentials of Operative Dentistry

has not polymerized, but at least one of the two

methacrylate groups could have reacted and formed
covalent bonds to polymer structure.
Conversion of monomer to polymer depends on:
• Light transmission through the material.
• Conc of sensitizers, initiators, and inhibitors.
• No difference between chemically cured and light cured
resin.
Light transmission through the material depends on:
• Lamp intensity.
• Absorption and scattering of light by filler particles and
opacifiers.
• Tooth interposed between composite and light source.
Total degree of conversion does not differ significantly
Figure 17-13: Depth of cure between chemical cure and light cure composites.

• Any thickness more than 2 mm requires unusually

long exposure times.
Reduction of Residual Stresses
• Increasing the intensity of lamp leads to rapid (Polymerization Shrinkage)
polymerization stresses and a polymer network
formation that is completely different. • In chemically cured resin internal porosities acts as
• Restorative material-based on Bis-GMA generally can stress relievers and also slow curing time acts as to
be converted only to 65%. relieve shrinkage stresses by internal flow of material
(gel stage) during curing.
• These two events do not occur in light activated resins
Dual Curing Resin and Extraoral Curing
which can lead to substantial stress build-up.
• One way to overcome limits on cure depth is to combine Two general approaches to overcome this problems
chemical cure/heat cure with light cure materials. (polymerization shrinkage) are:
• Available in two light curable pastes that contain benzyl • Altering chemistry/composition of the resin system to
peroxide and other containing a aromatic tertiary reduce shrinkage
amine. • Clinical techniques to offset shrinkage
• When two pastes are mixed and then exposed to light, • First approach is more desirable
light curing is promoted by the amine/CQ combination • During conversion of monomer to polymer in the initial
and chemical curing is promoted by amine/ stages, there are only few polymer chains and are not
benzylperoxide interaction. well connected, in the range of approx 20% conversion
• This material is intended for any situation that does the polymer chain is in a gel state. At this stage, any
not allow sufficient light penetration. shrinkage stresses that occur are relieved by materials
• Another option is to produce inlay on a tooth or die, ability to flow. After the gel point (post gel), polymeri-
followed by additional extraoral curing which may be zation shrinkage produces internal stresses within the
in light or heat form. system and along the tooth-resin interface.
• Composites undergo substantial polymerization
Degree of Conversion contraction during setting, approx volumetric
• Degree of conversion is the measure of percentage of contraction for macrofilled composites is 1-2.5% and
carbon-carbon double bonds that have been converted for microfilled composites 2-2.5%. This shrinkage
to single bonds to form a polymeric resin. The higher, creates polymerization stresses as high as 13 MPa.
the degree of conversion, the better the strength, wear
resistance, etc. Incremental Build-up and Cavity
• A conversion 50-60% implies that 50-60% of metha- Configuration
crylate groups have been polymerized. However, this • One technique is to reduce C-factor (configuration
does not mean that the remaining methacrylate groups factor) introduced by Feiltzer and others.
 Resin Composite Restorative Material 337
• C-factor is the ratio of the bonded surface to the
unbonded surface. Residual polymerization stresses
increases as this ratio increases (Figure 17-14).
• Curing composites in thin layers results in less bonded
surface and large unbonded surface for the stresses to
be dissipated (Figures 17-15A to C).

Figure 17-16: Ramped curing

Precaution for Using Curing Lamps

• Light emitted by curing lamps can cause retinal
damage.
• Protective eyeglasses various types of shields are
Figure 17-14: C-factor
available to filter the light (Figure 17-17).

Figures 17-15A to C: Incremental curing

Figure 17-17: Protective wear during curing of resin composites

Soft Start, Ramped Curing
and Delayed Curing (Figure 17-16) Other Methods to Reduce Residual Stresses
Here offsetting polymerization stress build-up is to follow • BIS-EMA with reduced curing shrinkage is proposed.
the example of chemical initiation by providing an initial • Ring opening reactions with spiro-orthocarbonates to
low rate of polymerization, thereby extending the time produce expansion.
available for stress relaxation before reaching the gel point. • More recently oxirane and oxitane as a method of
designing controlled shrinkage composites, that
undergo little curing shrinkage.
High Intensity Curing
• Increased lamp intensity allows for shorter exposure
time for a given depth of cure in a particular shade and Other Properties of Composites
type of resin.
• However, increased lamp intensity cause accelerated Marginal Leakage
rates of curing and substantial residual stresses because When gingival margin of restoration is located in dentin/
of insufficient stress relaxation. cementum, whereas other margins are in enamel, the
• Polymer network formed is also greatly different. composite tend to pull away from gingival margins.
338 Essentials of Operative Dentistry

Radiopacity
Most of today’s composites today have glass fillers with
metals so they have sufficient radiopacity. But still flowable
composites are radiolucent.

Wear
• Another frequent problems have been occlusal wear.
• No lab test can accurately simulate oral conditions.
• Posterior composites tend to wear at a rate of 10-20 µm/
year.

Two Principal Modes of Wear

Two-body wear
Direct contact of restoration with opposing cusp or with
adjacent proximal surface of tooth leading to high stress
development.
Three-body wear
Caused by contact with food bolus as its forced across the
occlusal surface.
• This type of wear is controlled by toughness, porosity,
stability of silane coupling agent, degree of monomer
conversion, filler loading and size and type of filler Figure 17-18: Wear in resin composites
particles.
• Clinically loss of material caused by direct wear in areas Microfracture Theory
of tooth-tooth contact is more.
Higher modulus filler particles are compressed into weaker
• Composites where filler particles are highly loaded, well
matrix during occlusal loading leading to microfracture
bonded to resin matrix are more resistant to wear.
and exfoliation of composites.
Smaller restoration resist wear better than larger
restoration.
Hydrolysis Theory
Silane particles becomes unstable and becomes debonded.
Some Contraindications for Composites This bond failure allows surface filler particles to be lost.
• Patient with bruxism. This usually occurs in basic environment.
• Patient with high caries activity.
Chemical Degradation
Other Types of Wear Pattern (Figure 17-18) Material from food and saliva are absorbed into the matrix
causing matrix degradation and sloughing from the
• Wear by food.
surface.
• Impact by tooth contact in centric contacts (occlusal
contact area wear).
• Sliding by tooth contact in function (functional contact Protection Theory
area wear). Weaker matrix is eroded between the particles.
• Rubbing by tooth interproximally.
Microprotection theory
• Wear from oral prophylaxis.
If filler loading is high and closely packed the intervening
matrix is protected. So in microfilled composites even
Mechanism of Wear though filler loading is low but closely packed helps in
Wear is associated with fracture of composites. resistance to CFA wear.
 Resin Composite Restorative Material 339
Macroprotection theory • First resins were bonded to metal surfaces by using wire
If composite restoration is narrow enough all stresses are loops/retention beads. Recent improvements include
taken up by tooth structure. chemical bonding systems using 4-META, phos-
phorylated methacrylate, epoxy resins, ‘silicoating’—
silicon dioxide that’s flame sprayed to metal surface.
Selection Criteria for Composites
• When patients esthetic need is high Advantages (Over Ceramics)
• Should not be used for cuspal coverage • Ease of fabrication
• Used when conservative preparation is required • Predictable intraoral repair
• To minimize thermal conduction. • Less wear of opposing teeth and restoration.

Indirect Composites
Disadvantages
Problem areas in composites are—high stress situation,
• Distortion on occlusal loading.
mechanical and physical degradation, polymerization
• Wear during brushing.
shrinkage, technique sensitivity, reliable bond to dentin
Resin composite veneers can be used to mask tooth
and cementum. These problems raise major concerns in
discoloration.
Cl—II restorations, these are overcome by indirect
The preformed laminate, veneers are adjusted by
composites or resin inlay.
grinding and luted on to the tooth using resin cement.
Different approaches to resin inlay construction:
• Use both indirect and direct fabrication method.
• Application of light, heat, pressure, or a combination of Finishing of Composites
these curing systems. • Residual surface roughness can encourage bacterial
• Combined use of hybrid/microfilled composites. growth which can lead to secondary caries, gingival
Fabrication process for direct composite inlays: inflammation and surface staining.
• Separating medium applied to tooth. • Best possible surface finish is obtained when composite
• Restoration resin pattern is formed light cured and is cured against mylar strip this also prevents oxygen
removed from preparation. inhibited layer. However, its often difficult to adapt
• Rough inlay is then exposed to additional light for mylar strip in all areas.
approx 4-6 min or heat activated at approx 100°C for • Three significant factors playing a role in finishing and
7 min. polishing of composites are:
• After this process inlay pattern is luted on the tooth i. Environment
surface. ii. Delayed vs immediate finishing
iii. Type of material.
Indirect Resin Inlays
Finishing: Adapting restoration over the tooth, e.g. removing
• Require an impression and dental technician to overhangs and occlusal adjustments.
fabricate inlay.
• In addition to conventional light and heat curing, Polishing: Removing surface irregularities to achieve-
laboratory processing may employ heat (140°C) and smoothest possible finish.
pressure (0.6 Mpa for 10 min).
• These resin inlays can be repaired intraorally and are Environment
not as abrasive as ceramics. • Refers whether the process is done in dry/wet field.
• Dry field environment allows for better visualization of
Composites for Resin Veneers restoration margin.
• They used originally heat polymerized PMMA. • Dry field has been proposed to cause/increase marginal
• Microfilled materials today used are Bis-GMA, UDMA, leakage due to increased heat production also structural
4, 8-di(metha-acryloxymethylene) - tricyclodecane. and chemical changes in composites have been
• These resin in addition to blue light polymerization are proposed.
polymerized further by a combination of heat and • Excessive heat results in smearing/depolymerization
pressure. of composites.
340 Essentials of Operative Dentistry

• Grinding and polishing to be done in moderation where Biocompatibility of Composites

margins are clearly visible with minimal heat gene-
ration. • Concerns about biocompatibility of restorative materials
usually relate to effects on pulp from two aspects:
Delayed vs Immediate Finishing 1. Inherent chemical toxicity of material.
2. Marginal leakage of oral fluids.
• Delayed finishing can actually increase marginal
• Adequately polymerized composite do not leach any
leakage and has no effect on surface characteristics as
unreacted species, even when they leach they are in
compared to immediate finishing.
very small quantities. Uncured composites at basal layer
• Therefore, composites should be finished and polished
of restoration can leach unreacted molecules but these
immediately after placement and can be delayed for
has not yet been proved.
15 mins.
• Bisphenol-A (BPA) precursor of Bis-GMA has been
shown to be xenoestrogen, but its complete effect on
Types of Material (Figure 17-19) pulp has not yet been elucidated.
• Second biological concern if marginal leakage leading
• Scalpel blade has been advocated to remove proximal to bacterial growth may cause secondary caries and
flash, but it is a risky affair. pulpal reactions. Therefore, restoration procedures must
• Coarse to fine aluminum oxide has been used in areas be designed to minimize this polymerization shrinkage
with difficult access. effect.
• Tungsten carbide burs and fine diamond tips used to
adjust occlusal surface.
• Other devices are fine - extra fine polishing pastes, Repair of Composites
silicon-based systems, silicon carbide impregnated
• New composite material can be added over existing old
brushes and points.
composite material to aid in repair or altering surface of
old composite restoration.
• A newly placed composite has a layer of oxygen
inhibited layer which can readily bond with new layer.
• Even when composite is cure and polished it has
50% unreacted methacrylate groups to co-polymerize.
• As restoration ages fewer and fewer methacrylate
groups remain and greater crosslinking reduces the
ability of monomer to penetrate into matrix. Also
polished surface expose filler particles free of silane
coupling agent.
• Under ideal conditions silane bonding agent has to be
applied before placement of new composite layer.
Mean survival rate for composite in permanent teeth
after 7 years was about 67.4% compared to amalgam 94.5%.

Figure 17-19: Finishing and polishing

materials for resin composites Key Terms
Rebonding • Acrylic resin
• Composite
• Finishing process removes highly polymerized areas • Fillers
of restoration and introduces microcracks. • Colloidal silica
• Application of surface sealer, bonding agent, low • Coupling agents
viscosity resin ensures that surface porosities are filled • Camphoroquinone
and microcracks sealed. This process decreases • Hybrid composites
marginal leakage and improves marginal seal. • Microfilled composites
 Resin Composite Restorative Material 341
•
•
Packable composites
Fiber reinforced composites
Questions to Think About
• Visible light cure unit 1. What are composites? Explain in detail about compo-
• LED light cure unit nents, properties and their clinical application.
• Polymerization shrinkage 2. Elaborate in detail about various classifications of resin
• Depth of cure composites. Discuss about microfilled composites.
• Degree of conversion
• C-factor
• Soft/start/Ramp start
• Indirect composites
342 Essentials of Operative Dentistry

18 Composite Restoration
Class I to VI

Introduction Disadvantages
• Very technique sensitivity.
• With advent of composites and adhesive bonding to
• Polymerization shrinkage.
tooth structure tooth preparation can be done as
• Higher coefficient of thermal expansion.
conservatively as possible, maintaining the structural
• Low modulus of elasticity.
integrity of the tooth.
• Biocompatability issue.
• Search still continues for a tooth colored material to
• Limited wear resistance.
withstand high occlusal stresses.
Newer formulation of composites has these general
features: Indications
• Radiopaque fillers. • Classes I, II, III, IV, V and VI restorations.
• Smaller filler particles. • Foundations or core build-ups.
• Increased amount of fillers. • Sealants and conservative composite restorations
• Greater strength. (preventive resin restorations).
• Reduced porosity. • Esthetic enhancement procedures:
• Reduced water sorption. • Partial veneers
• Polymerization with visible light. • Full veneers
Some of the other esthetic or tooth colored restorative • Tooth contour modifications
materials are: • Diastema closures
• Ceramics • Cements (for indirect restorations).
• Silicate cement • Temporary restorations.
• Glass ionomer cement. • Periodontal splinting.

Advantages Contraindications
• Esthetics. • Operating site cannot be isolated.
• Conservation of tooth structure. • All occlusal contacts will be on the composite
• Improved resistance to microleakage. restoration.
• Strengthening remaining tooth structure. • Heavy occlusal stresses.
• Low thermal conductivity. • Deep subgingival areas that are difficult to restore.
• Completion in one appointment. Shade matching in posterior teeth is not critical as
• Economics. slight shade mismatch can aid in revaluation of the
• No corrosion. restoration.
 Composite Restoration Class I to VI 343
Preoperative Evaluation Tooth preparation form differs from amalgam pre-
paration by:
• A brief overview of patient’s needs and complaints has
• Less outline extension (adjacent suspicious or at-risk
to be evaluated.
• Proper diagnosis and treatment plan is to be assessed. areas [grooves or pits]) may be “sealed” rather than
restored.
• An axial and/or pulpal wall of varying depth (not
Local Anesthesia uniform).
• Not required in preclinical exercises. • Incorporation of an enamel bevel at some areas (the
• Proper profound local anesthesia has to be given. width of which is dictated by the need for secondary
• It is needed both for patient comfort and moisture retention).
control. • Tooth preparation walls being rough (to increase the
surface area for bonding).
Preparation of Restorative Site • Use of a diamond abrasive instead of tungsten carbide
• Tooth has to be cleaned with slurry of pumice to remove burs (to increase the roughness of the tooth preparation
superficial stains, debris and calculus. walls).
• This step is necessary for making the tooth receptive for • Unsupported/undermined enamel could be left
bonding. behind, this could be strengthened by composite
bonding:
Shade Selection • The tooth preparation should include removing (outline
form) all of the caries, fault, defect, or old restorative
Proper shade selection is necessary and most of the tooth material (when necessary) in the most conservative
is white color with varying degrees of gray, yellow and
manner possible.
orange tints.
• The composite material must be retained within the
tooth (retention form), but this primarily results from the
Occlusal Evaluation micromechanical bonding of the composite to the
Both centric and eccentric contacts has to be marked and roughened, etched, and primed enamel and dentin. In
properly restored and consideration has to be given these some instances, a dentinal retention groove or enamel
contacts. bevel may be prepared to enhance the retention form.
• Resistance form, which keeps the tooth strong and
Moisture Control protects it from fracture, is primarily accomplished by
Adequate moisture control is mandatory for successful the strength of the micromechanical bond but may be
and long-term survival of composite restoration than when increased, when necessary, by usual resistance form
compared to amalgam restorations. features such as flat preparation floors, boxlike forms,
This could be done either by: and floors prepared perpendicular to the occlusal
• Rubber dam forces.
• Cotton rolls • The composite is bonded to the prepared tooth and the
• Gingival retraction cord. composite material is insulative, there is no need for
any bases under composite restorations. However, a
calcium hydroxide liner is still indicated when a pulpal
Tooth Preparation for Composite Restorations
exposure (or possible pulpal exposure) occurs.
Basic tooth preparation principle for composite restoration
includes:
• Removing the fault, defect, old material, or friable tooth
Basic Preparation Designs
structure. • Conventional design
• Creating prepared enamel margins of 90° or greater • Beveled conventional design
(greater than 90° usually preferable). • Modified design.
• Creating 90° (or butt joint) cavosurface margins on root
surfaces. Conventional Design (Figure 18-1)
• Roughening the prepared tooth structure (enamel and • These are box like cavities have slightly converging
dentin) with a diamond abrasive. walls, flat floors, undercuts in dentin (if required).
344 Essentials of Operative Dentistry

Figure 18-1: Conventional design Figure 18-2: Beveled conventional

for class III restoration (Class III) preparation

• Here design of cavity preparation is same as in portion of posteriors as the cavity becomes more
amalgam restorations, outline form is the necessary extensive rather than conservative. Therefore,
extension of external walls at an initial, limited, beveled conventional preparations are rarely
uniform dentinal depth, resulting in the formation of employed in posterior teeth.
those walls in a butt joint junction (90°) with the
restorative material. Modified Preparation
Indications for this preparation design • Modified tooth preparations for composite restorations
• Replacing an old restoration like amalgam. have neither specified wall configurations nor specified
• Root surface lesion butt cavosurface margin provides pulpal or axial depths; preferably, they have enamel
better configuration. margins.
• For moderate to large size class I or II where increased • Outline form is solely guided by extension of caries
resistance form of restoration is needed. lesion (Figure 18-3).
• Emphasis here is more on the conserving tooth structure.
Beveled Conventional Preparation Design Characterized by:
• Bevel is prepared using flame shaped diamonds of • Conservative removal of tooth structure.
approx 0.5 mm width and at an angle of 45° to external
surface.
• This design is preferred when there is a requirement for
increased resistance form (Figure 18-2).
Indications
• Replacing an old amalgam restoration whose cavo-
surface margin is in enamel.
• This design is typical for class III, IV, V lesions.
Need to bevel
• To increase the surface area for etching, therefore to
improve the bond strength.
• For esthetic reasons by beveling the restoration blends
with tooth structure masking any discrepancy in shades
between restoration and tooth.
• Beveling is not given in posterior teeth with heavy Figure 18-3: Modified preparation
occlusal contacts and also not given in proximal (Class III) preparation
 Composite Restoration Class I to VI 345
• Establishment of beveled margins on all cavosurface • Now the bonding agent is light polymerized according
margins. to manufacturer’s instructions which usually are
20-40 seconds.
Indications
Each bonding agent has specific requirement with
• Initial smaller carious lesions surrounded by enamel
regard to etching and bonding agent application which
margin.
should be strictly followed.
• Correcting any enamel faults.
All these preparations are done with diamond
abrasives so that preparation walls are rough to enhance Matrix Band Application
the bonding to tooth structure. • Usual matrix preferred for class II is Tofflemire matix or
sectional matrix.
Restorative Technique • For class III or IV restorations polyester strips or Mylar
Etching strips are preferred (Figure 18-5).
• Restoration with composites requires acid etching of
the tooth followed by bonding agent application, then
composite restoration.
• Etching is usually done with 37% phosphoric acid.
Etchant are available in gel and liquid form.
• It is applied using an applicator tips, brushes or cotton.
Gel type is preferred over liquid type.
• Etching is done for both enamel and dentin for 15 secs.
Tooth to be etched is properly isolated. After etching Figure 18-5: Mylar strip application
the tooth, acid is removed off using water from air for anterior tooth
syringe for 5 secs. There are two options available either:
• If only enamel has been etched then tooth is dried with
1. Matrix band can be applied prior to etching and
air from air syringe and a frosted appearance of enamel
bonding of tooth, or
should be seen, if not tooth is re-etched.
2. Matrix band applied after etching and bonding to tooth
• If both enamel and dentin has been etched then tooth is
to prevent pooling of etchant and bonding agent.
left in slight moist condition without drying it.
• If after etching or during etching the tooth becomes Preferred technique is matrix band applied prior to
contaminated by saliva the tooth again has to be etched. etching and bonding of tooth, advantage here are:
(Not required in preclinical exercise). • Provides better isolation of tooth for bonding procedure.
• Prevents the bonding and etching of adjacent tooth.
Bonding Agent Application
• Most contemporary bonding agents combine the primer Insertion of Composites
and adhesive in single bottle. • Insertion of composite is two stage procedure with first
• This bonding agent is applied onto the etched tooth step being bonding of tooth and second step is composite
surface by using an applicator tips (Figures 18-4A and
placement.
B). The dentin bonding agents should be applied
• Usually, light cured composite is preferred and it can
thoroughly and tooth should have a glistening
be placed onto tooth using either with hand instrument
appearance by the presence of bonding agent.
or by syringe. The material thickness to be placed is
only 1-2 mm.
• Advantage with hand instrument (plastic filling instru-
ment) placement of composite is it is easy and fast. Teflon
coated plastic instrument is preferred it prevents sticking
of composite material to instrument.
• With syringe application of composite minimal voids
are incorporated, better infection control as the
Figures 18-4A and B: Applicator tips for bonding agent composites applied for syringe comes in capsules which
application are disposed after one patient usage.
346 Essentials of Operative Dentistry

• For class II restorations composite placement is first • But these materials are given for the purpose of enhan-
placed on gingival margin with slight extension up the cing the bonding to gingival margin of the restoration.
facial margin and thickness of about 1-2 mm. Then the
next increment and follows on (Figures 18-6 and 18-7). Retention in Class V Lesion
• Composite bonding to cementum in root surface is still
not as strong on enamel margins.
• Therefore, additional retentive grooves are required for
class V preparations.

Wear
• Composites placed under heavy occlusal loads and
Figure 18-6: Incremental build-up composite restoration
composite restorations having centric occlusal contacts
wear faster.
• Wear resistance of composite is poorer compared to
metallic restorations.

Marginal Gap
• Because of polymerization shrinkage the composites
shrink leading to gap formation between composite and
the tooth margin.
• This can lead to staining or secondary caries.

Figure 18-7: Applicator gun and capsule Armamentarium

for composite placement
Tray Instrument Set-up
Contouring Composite From left to right
• Mouth mirrors
• Usually for light cure composites, it is done immediately
• Explorers
after polymerization.
• Tweezers
• Good skill in placement of composite requires minimal
• Chip syringe
contouring.
• Cotton holder with cotton
• Coarse diamond rotary instruments are available in
• Spoon excavator
various shapes and sizes for the purpose of contouring
• Cement spatula
the composite restoration.
• Plastic filling instrument or composite placing
• A proper knowledge of tooth morphology is essential
instrument
for proper contouring of the tooth.
• Enamel chisel
• Enamel hatchet
Polishing • Tofflemire retainer and matrix band No. 8 (for palatal
It is done with rubber disks, abrasive disks and strips. extension in upper molar)
• Polyester strip (Mylar strip).
Problem Areas in Composite Restorations
Rotary Cutting Instruments
Liners and Bases Under Composite Restorations
• Airotor handpiece, slow speed handpiece.
• Many newer materials like resin modified glass ionomer • Burs ( tungsten carbide burs No. 330, 245) (diamonds
cements (GIC) and its modification has been proposed round ½, pear shaped 245, straight fissure 271, inverted
as liners and bases for composites. cone 33½, flame shaped diamond).
• Since composites are nonmetallic restoration they do • Composite finishing kit (abrasive disks, abrasive strips).
not need bases and liners in traditional sense of • Rubber cup.
preventing thermal conduction. • Pumice.
 Composite Restoration Class I to VI 347
Miscellaneous Conventional Preparation (Figures 18-8 and 18-9)
• Gauze cotton • For the large class I composite tooth preparation, enter
• Rubber dam kit the tooth in the distal pit area of the faulty occlusal
• Acid etchant surface, with the inverted cone diamond, positioned
• Dentin bonding agent parallel to the long axis of the crown.
• Resin composite material • Prepare the pulpal floor to an initial depth of 1.5 mm.
• Applicator tips. This results in cavity preparation into dentin of about
0.2 mm.
• Move the preparation from distal towards the mesial
Key Terms aspect of the tooth.
• Conventional design • Marginal ridge and cuspal strength should be preserved
• Beveled conventional as much as possible.
• Modified preparation • Any remaining caries or old restorative material is
• Etching removed at this stage.
• Bonding • If there any groove extensions these grooves are prepared
• Matrix application and cavosurface margin should have bevel. Bevel is
• Incremental insertion given by flame shaped diamond.
• Applicator gun

Questions to Think About

1. What are the various designs of composite tooth
preparation?
2. Explain about restorative technique of composite
material.

Class I and II Composite

Restoration Figure 18-8: Depth of preparation for conventional preparation

Class I Cavity Preparation

• Three types of preparation—conventional, beveled
conventional and modified preparation can be used for
class I restoration depending on the indication.
• A more box like conventional preparation is necessary
when restoration will be subjected to heavy occlusal
forced or in large restorations.
• A small to moderated lesion will be restored with
modified design which will not have uniform depth,
preparation will be more rounded and smaller cutting
instruments are used.
• An inverted cone bur is used for cavity preparation and Figure 18-9: Buccal groove extension
size of the bur depends upon the size of caries lesion, where margin is beveled
advantage with inverted cone bur is:
• Result in flat floor. Modified Preparation (Figures 18-10 to 18-13)
• Enhance retention form because of cavity margin • These preparation will have scooped out appearance.
converging occlusally. • When restoring small pits and fissures a ultracon-
• Conservation of tooth structure. servative modified preparation is recommended.
348 Essentials of Operative Dentistry

• Ultraconservative preparation is done using No. ½ bur

and bevel by flame shaped diamonds.
• Depth of cavity is done till the caries has been removed.
• For deep cavities CaOH liner and light cure GIC base is
recommended.
• No. 245 bur and beveled conventional preparation may
be employed when extensive preparation is entitled or
a large faulty restoration is present.
• An undermined marginal ridge (enamel) can be left in
Figure 18-10: Modified preparation extensive preparation and can be strengthened by
composite bonding.

Class II Composite Restorations

Certain precautions have to be taken:
• Cavity periphery should be on enamel, if it is on the
root special precautions be taken for good isolation and
bonding procedures.
• Preoperative occlusion must be checked to verify for
heavy occlusal stresses.

Tooth Preparations
Figure 18-11: Various sizes of • Preparation can either be modified or conventional.
inverted cone bur
• Modified form is for smaller lesion and less round like,
unequal depth.
• Conventional preparation is same as that of amalgam
preparation—more box like and uniform in depth. But
it is not as extensive as amalgam preparations.
Both preparations have some same objectives:
• Remove faults, caries and old restorative materials.
• Remove friable enamel not undermined enamel.
• Have occlusal cavosurface margins 90°.
Only the affected portion of tooth is involved in the
preparation.

Conventional Class II Preparation

Figure 18-12: Undermined enamel • This is the most recommended design.
could be left behind • Occlusal step preparation is same as that of the
amalgam preparation (Figures 18-14A and B).
• Primary difference is in proximal portion preparation.
• No. 245 or No. 330 bur is used for preparation of occlusal
step.

Proximal Box Preparation (Figures 18-15 to 18-18)

• Same as in amalgam preparation it is initiated with
proximal ditch cut.
Figure 18-13: Conservative class I • If caries in not extensive then proximal contact could be
composite preparation left intact.
 Composite Restoration Class I to VI 349

Figures 18-14A and B: Conventional class II composite preparation

Figures 18-15A and B: Proximal box extension gingivally is

not as extensive as in amalgam preparation—A and done just
to remove caries—B

Figures 18-17A and B: Difference between amalgam

preparation: (A) Composite preparation, (B) it is not as extensive
as amalgam preparation

• Bevels are given if proximal boxes are wide or additional

retention are necessary.
Differences between amalgam preparations and
composite preparations are:
• No secondary retentive features required.
• Less extensive.
• Proximal axial wall depth is only 0.2 mm into dentin.
Figure 18-16: Contacts can be left in contact if
• Proximal box extension gingivally is not as deep as in
unaffected by caries
amalgam preparation and done just to remove caries.
• Here no secondary retentive features are given as in
amalgam preparations as its retained by bonding Final Cavity Preparation (Figure 18-19)
mechanisms. • Usually no bevels are given, but if proximal box is
• No occlusal bevel is given as it can lead to thin already wide faciolingually bevels can be give. Also
composite which can fracture. bevels are given in facial or lingual groove extensions.
350 Essentials of Operative Dentistry

Figure 18-20: Round preparation—Modification 1

Figure 18-18: Any remaining caries is removed

Figure 18-21: Box preparation—Modification 2

Figure 18-22: Slot preparation—Modification 3

Figure 18-19: Final cavity form for conventional class II • A round shape of preparation if a round bur is used
preparation and a box like preparation if a inverted cone is utilized.
Modification 2
• If remaining caries is there after initial cavity pre– • This facial or lingual slot preparation.
paration its removed at this stage and if it is deemed • Here lesion is on the proximal surface but can be
caries is close to the pulp a calcium hydroxide lining accessed through the facial or lingual embrasure.
could be given. • Usually a round bur is used for preparation.
• Depth is 0.2 mm into the dentin.
Modified Class II Preparation
(Figures 18-20 to 18-22) Restorative Technique
Indicated in small initial lesions. Involves etching, priming, bonding, matrix band
• A small round or inverted cone bur is used to remove application (Figures 18-23 to 18-27).
the caries. Matrix band is usually applied before priming and
• A diamond bur with straight edges may be required for etchant procedure as it can:
proximal box extensions. • Aid in evaluating the margin if it has fractured due to
wedge placement.
Modification 1
• Prevent etching and priming of adjacent tooth.
• Box only preparation it is indicated in lesion involving
only the proximal surface and not the occlusal part. Disadvantage: It can cause pooling of the bonding
• Axial depth in proximal box is 0.2 mm into dentin. agents.
 Composite Restoration Class I to VI 351

Figure 18-23: Etchant application

Figure 18-27: Light application – light polymerization

Finishing and Polishing (Figure 18-28)

• It is initiated with a round bur or 12-fluted carbide burs.
• Finishing diamonds can also be utilized.
• Excess composites on proximal walls are finished with
a flame shaped burs or 12 fluted carbide bur or diamond
disks can be used.
Figure 18-24: Bonding agent application
• Amalgam knife or gold knife or BP No. 12 blade can be
used to remove overhanging margins.
• Finishing strips are used.

Figure 18-25: Matrix band application

(sectional matrix)
Figure 18-28: Composite finishing

Extensive Class II Preparations

(Figures 18-29A to E)
A very large restorations usually requires:
• Most of the occlusal contacts on the restorations.
• Extensions will be on root surface.
• Isolation will be difficult.
In these situations composite is selected for as foun-
dations or patients not able to afford indirect restorations.
Figure 18-26: Incremental application of composite In these situations amalgam is material of choice, it could
also be bonded and provide:
Matrix band applied is usually Tofflemire or sectional • Good dentinal support.
matrix band. Composite material placement is done in • Additional retention form.
incremental manner. • Reinforcement of weakened enamel.
352 Essentials of Operative Dentistry

Figures 18-29A to E: Extensive class II

composite preparation

• Additional retentive and resistance features must be

given in these type of composite restorations.
• Cuspal capping may also be indicated. It is done same
as that of amalgam cuspal capping.

Internal Occlusal Fossa (Tunnel Preparation)

When enamel lesion is atleast 2.5 mm apical to marginal
ridge, the simplest and most effective method will be a
conservative approach through the occlusal surface
proximal to marginal ridge using tunnel approach.

Tunnel Restoration
• Tunnel restorations was described by Jinks in 1963 as
an alternative to conservative class II preparation in
primary molars.
• Original restorative material was sodium-silicate
fluoride cement containing silver alloy admix.
• Tunnel restoration is best done under magnification
(intraoral video camera and caries detecting solutions)
(Figures 18-30 to 18-33).
Advantages
• Retention of marginal ridge.
• Maintenance of interproximal contacts. Figure 18-30A: Steps in tunnel preparation and restoration

Disadvantages • This is done under fiber-optic illumination and

• Difficulty in ensuring complete removal of caries. especially useful in elderly patients who have gingival
• Difficulty in locating proximal caries. recession and exposed root surface.
Alternative to tunnel restoration Technique
• An alternative to tunnel preparation will be lateral A preoperative bite wing radiograph is essential to measure
tunnel or slot preparation through buccal or lingual the depth of proximal caries from marginal ridge this is
embrasure. done using a periodontal probe.
• Described by Morand and Jones done either with burs Isolate the tooth and dry the tooth using rubber dam.
or ultrasonic preparation. Place a wooden wedge into the contact of involved tooth.
 Composite Restoration Class I to VI 353

Figure 18-30B: Steps in tunnel restoration

Using a No. 2 round bur enter 2 mm inside from the

marginal ridge to the predetermined depth. Using caries
detecting solutions and transillumination evaluate for
remaining caries.
If caries is remaining after predetermined depth use
spoon excavator or slow speed bur.
If needed another radiograph could be taken to evaluate
the preparation.
Place a sectional matrix band and remove the old wedge
and place a new wedge.
Fill the proximal cavity up till dentinoenamel junction Figure 18-31: Various preparation designs
with autocure glass ionomer cement. Fill the occlusal
portion with composite. Evaluate for any occlusal
interferences.
Finish and polish the restoration.

Sandwich Restoration (Laminate Technique)

(Figures 18-34A and B)
• It has been proved that glass ionomers could be bonded
to both dentin and composites.
• So glass ionomers could be used as a dentin substitute
as an intermediate layer in sandwich restorations.
• Sandwich restorations may be ‘open’ when GIC is
exposed to external environment and ‘closed’ when GIC
is internal.
• Etching of GIC in not necessary and it may adversely
affect the maturation of cement, composite could be Figures 18-32A and B: (A) Slot preparation,
placed over it after etching only the enamel part. (B) Proximal preparation

Figure 18-33: Tunnel approach

354 Essentials of Operative Dentistry

Figures 18-34A and B: Sandwich restoration

Class VI Composite Restoration Class III Tooth Preparation

• Class III by definition are located on the proximal
• Modified preparation design best suites this type of surface of anterior tooth which necessitates greater use
restoration. of composites because of esthetic reasons.
• Enter the faulty pit with a small round bur (No. ½, ¼) • Mostly lingual approach to the lesion is preferred.
oriented perpendicular to tooth surface and depth is
determined by the extent of caries. Advantages of Lingual Approach
• Small bevel is placed using flame shaped diamond.
• Facial enamel is conserved.
• Color matching is not so critical.
Key Terms
• Discoloration or deterioration of restoration is not very
• Slot preparation conspicuous.
• Box preparation
• Tunnel preparation Indications for Facial Approach
• Sandwich restoration.
• Carious lesion is present more facially.
• Irregular alignment of teeth making lingual approach
Questions to Think About
difficult.
1. Elaborate the steps in preparation and restoration of • An existing restoration is present facially.
class I composite.
2. Discuss about preparation and steps in class II com-
Conventional Class III Cavity Preparation
posite preparation and its modification preparation.
3. Enumerate the differences in preparation design for • This design is utilized in where caries is present in the
amalgam restorations and composite restoration for Cl- root with no enamel margins.
I and Cl-II. • Cavosurface margin is butt joint with 90°.
• Axial wall depth be 0.75 mm into dentin, grooves may
be necessary in portions where there is no enamel.
Class III and IV Composite • Cavity portion in tooth crown have cavosurface margins
Restoration beveled.
Remainder of design and preparation and technique is
Indication same as in class III amalgam cavity preparation (Figures
Almost all cases of class III and IV esthetic restorations 18-35 and 18-36).
can be satisfactorily restored with composites.
Beveled Conventional Class III Cavity
Contraindications Preparation
• Any tooth that cannot be properly isolated from moisture. • Is primarily indicated for replacing an existing
• Extensive caries or broken down teeth. restoration.
 Composite Restoration Class I to VI 355

Figures 18-37A and B: A small class III lesion with the

required outline form

Figures 18-35A to C: For caries extending onto the root

structure a conventional preparation is indicated

Figures 18-38A and B: Initial angle of bur entry preserving

as mush facial and lingual structure as possible

Figure 18-36: Conventional preparation is indicated for

lesions extending onto the root surface of tooth

• Also used where the extent of caries is extensive.

• Cavosurface margins in enamel is beveled.
• Axial wall depth is varied.
• Retention grooves can be placed in gingival or incisal
line angles if cavity is large.

Lingual Access
Initial Cavity Preparation (Figures 18-37 to 18-39) Figure 18-39: Enamel walls are smoothened
• Mostly done under indirect vision so clean and using a triple angled chisel
unscratched mouth mirror is mandatory.
• A round carbide bur No. ½, 1 or 2 depending on size of
• Proximal contact area is left intact unless otherwise it is
caries is used. For preclinical exercises a No. 1 bur could
involved by caries.
be used.
• Enamel wall in the incisal and gingival areas are planed
• Bur entry is done within the incisogingival dimension
with hoe or chisels.
of caries close to adjacent tooth without contacting
adjacent tooth.
• Axial wall depth is kept fixed at 0.75-1.25 mm. Axial Final Cavity Preparation
wall should follow the contour of the external surface Removal of remaining caries and old restorative material
of the tooth. Cavity preparation into dentin will be • Any remaining caries left after the prescribed depth into
0.2 mm into dentin. preparation is removed at this stage and any old
• Cavity preparation is extended dictated by caries extent defective restorative material is also removed at this
and presence of old restorative material. stage.
356 Essentials of Operative Dentistry

Pulp protection
If required a calcium hydroxide cement is applied if caries
excavation is close to pulp.
Secondary retention form
• Retention groove along the gingivoaxial line angle and
retention cove in the incisal region is placed using a
No. 1/4 round bur.
• Depth of the groove being 0.25 mm into dentin without Figures 18-42A and B: Finished beveled
undermining the enamel portion of cavity. conventional preparation design

Finishing the enamel wall Facial Approach (Figures 18-43 to 18-46)

• Cavosurface margin is beveled to provide more surface • With few exceptions the cavity preparation is same as
area for noding. lingual approach.
• This bevelling is done with flame shaped diamond • Usually in this approach the caries is extensively present
instrument (Figure 18-40). on the facial area, therefore, a larger round bur is used
• Bevel width of 0.25-0.5 mm is sufficient. for initial cavity preparation.
• All accessible enamel margins are beveled (Figures • Bevel is again placed on all accessible enamel margins
18-41 and 18-42). of the preparation.
Beveling is not indicated in:
• Cavity preparation on root surface.
• Lingual areas where the cavity margins extend onto
centric tooth contacts.

Figures 18-43A and B: Caries involvement into facial

embrasure requiring facial approach for cavity preparation

Figure 18-40: Beveling is done using flame

shaped diamond rotary instrument

Figure 18-44: A large unesthetic restoration

requiring a beveled conventional preparation

Figure 18-41: Final cavity form with beveled enamel Figure 18-45: Beveled conventional preparation
margins and retention groove placement done here contacts are broken
 Composite Restoration Class I to VI 357

Figure 18-46: Composite restored teeth, contacts are Figure 18-49: For cavitated lesions preparation is extended
reconstructed and proper contour has been established into the dentin and contact left intact

Modified Class III Cavity Preparation

(Figures 18-47 to 18-52)
• It is usually indicated for small to moderate sized lesion.
• Cavity design is entirely dictated by the caries extent,
usually no specific cavity shape or form is prescribed.
• This type cavity preparation is not routinely extended
into dentin, and mostly is confined to enamel portion
itself unlike in conventional cavity preparation.
• Most initial caries restoration is in the form of a scooped
out appearance.
Figure 18-50: Small discolored enamel into facial embrasure
requiring modified cavity preparation from facial aspect entry

Figure 18-47: Modified cavity preparation Figure 18-51: Modified scooped out cavity
with no definite walls or angles preparation with lingual contact left intact

Figure 18-48: For initial enamel lesions as much as possible

preparation should be confined in the enamel and contact left
intact Figure 18-52: Composite restoration done
358 Essentials of Operative Dentistry

Figure 18-53: Steps in restoring a class composite restoration (Mylar strip can also be
left intact while polymerizing composite resin)
 Composite Restoration Class I to VI 359
Initial Cavity Preparation Stage
• Initial entry into lesion is same as in conventional cavity
preparation.
• No specific cavity walls are defined they may diverge
outwards and have a scooped out appearance.
• In a larger caries lesion the cavity preparation has a
definite shape with definite axial wall and cavity walls
do not diverge from the axial wall.
• But in smaller caries lesion the cavity preparation
should be as minimal as possible. Possible outline form Figure 18-54: An extensive class IV lesion requires tooth
preparation and beveling of enamel margins
be:
• Not include the entire contact area.
• Minimal or no extension into facial embrasure.
• Not to extend preparation subgingivally.

Final Cavity Preparation Stage

It involves following stages same as in conventional cavity
preparation:
• Removal of any remaining caries or old restorative
material.
• Pulp protection.
• Beveling the accessible enamel margins.
• Cleaning and inspecting of the cavity. Figure 18-55: Beveled conventional preparation

Class IV Cavity Preparation

(Figures 18-53 to 18-57)
• Class IV by definition in tooth affected both proximally
and incisally.
• Class IV composite restoration has provided with
alternative for porcelain full crown in following clinical
conditions:
• Fractured teeth.
• Caries involved teeth.
• Conventional class IV preparation utilized very rarely
unless caries extension into root surface.
• Beveled conventional preparation is used in situation
where the caries is extensive. Figure 18-56: Dovetail extension in
class IV preparation
• Modified preparation is routinely utilized.

Figures 18-57A to C: Beveled conventional preparation

360 Essentials of Operative Dentistry

Beveled Conventional Preparation

• It is indicated for restoring large proximal caries lesion
involving the incisal edge.
• Gingival retention grooves, incisal retention coves,
threads, pins, dovetail extensions or combination of
these could be utilized for additional retention.
• A dovetail extension onto the lingual surface of the tooth
may increase the retention of restoration but is less
conservative preparation.

Initial Cavity Preparation

• Class IV beveled preparation are characterized by an Figure 18-59: For fractured tooth no preparation is
outline when the cavity walls are prepared as much as required except for beveling of enamel margins
possible perpendicular or parallel to long axis of the
tooth, this design gives greater resistance of restoration
to bite forces.
• Initial cavity depth is 0.5 mm into dentin.

Final Cavity Preparation

• Removal of any remaining caries or old restorative
material and if necessary pulp protection provided by
calcium hydroxide.
• Beveling of cavosurface margin is done by flame shaped
diamond. The width of the bevel being 0.25-2mm
depending on the extent of cavity preparation.
Figure 18-60: Modified class IV cavity preparation
• Inaddition gingival retention groove is placed as in
class III conventional cavity preparation.

Modified Cavity Preparation

(Figures 18-58 to 18-61)
• It is indicated for small to moderate size cavities and
fracture tooth.
• Objective here is to remove as little tooth structure as
Figures 18-61A and B: Fractured tooth requiring no specific
possible and at same time provide retention and preparation except for beveling of enamel margins
resistance for restoration.
• Remove the caries and any old restorative material with
no specific shape for cavity preparation.
• In fractured tooth no preparation is required except for
beveling of the enamel margin to provide retention of
composite through bonding.

Restorative Procedures
• Etching of enamel using gel etchant and dentin bonding
agent application is followed by composite placement.
• To confine the composite placement to prevent gingival
overhangs and to form proper contour matrix
Figures 18-58A to C: Labial and incisal views application is essential.
 Composite Restoration Class I to VI 361
Matrix Application Insertion of Composite (Figures 18-64 to 18-67)
Two types of matrix are being employed: • Usually light cured composite is preferred. The
1. Polyester strip. composite is inserted into the preparation while the
2. Compound supported metal matrix. strip is still in between the two teeth (Figure 18-67).
• After placement of composite the strip is pulled over
Polyester Strip Matrix
the labial surface of the tooth and material is cured
• Most common type of matrix for class III and IV
through the strip.
restorations.
• Placement of composite in done in an incremental build-
• Polyester strips are contoured since these are flat, by
up. For smaller restorations composite is placed in one
drawing across the blunt back end of tweezers. Several
layer.
pulls across the back end of tweezer may be required to
obtain the desired contour (Figure 18.62).
• Strip is placed between the prepared tooth and adjacent
tooth.
• A wedge is placed subsequent to matrix strip placement,
wedge may be placed facially or lingually. If cavity
preparation is lingual it is placed facially and vice
versa (Figures 18.63A and B).
Figure 18-65: Composite placement
using hand instrument

Figure 18-66: Composite placement where the strip is opened

and composite inserted, followed by closing of the strip to
establish the contour and contact form

Figure 18-62: Polyester strip is contoured

using the back end of tweezer
Contouring and Finishing of Composite
(Figures 18-68A to F)
• Skilful placement of composite does not require excessive
contouring and finishing.
• Finishing is done with fine grade diamonds or abrasive
stones.
• Polishing of composite restorations are done with
diamond disks. Polishing strips are used for proximal
regions finishing and polishing.

Class V Composite Restoration

Figures 18-63A and B: Strip and wedge in place for Wide Variety of Materials is Available for
composite to be inserted
Class V Restorations
Nonesthetic Materials
• Amalgam
• Gold foil (direct) (not widely used)
Figure 18-64: Composite placing hand instrument • Gold inlay (not widely used).
362 Essentials of Operative Dentistry

Figure 18-67: Steps in restoring class IV composite restoration (Mylar strip can be
left intact while polymerizing composite resin)
 Composite Restoration Class I to VI 363

Figures 18-68A to F: Using various grades of abrasive disks and abrasive strips for
contouring and finishing of composites

Esthetic Materials Contraindications: Same as class III and IV except

• Resin composite (with dentin bonding system). restorations extending onto the root surface must be
• Resin composite (with glass ionomer base—sandwich restored with guarded prognosis. As bonding to cementum
technique). is still questionable (Figure 18-69).
• Flowable resin composite.
• Glass ionomer.
• Resin-modified glass ionomer.
• Compomer.
• Porcelain inlay (not widely used).
• Material of choice in class V esthetic materials will be
glass ionomer cement.
Indications: All class V lesions requiring esthetic restora-
tion can be satisfactorily restored with composite Figure 18-69: Composite bonding to root surface can lead to
restorations. marginal gap formation
364 Essentials of Operative Dentistry

Tooth Preparation Beveled Conventional Class V Preparation

Definition of class V preparations are located in the (Figures 18-71 and 18-72)
gingival 1/3rd of the facial and lingual surfaces of tooth. • Beveled enamel margin preparation is indicated for:
• Replacing an existing old restoration or
Conventional Preparation • Restoring large class V preparation.
• Is mainly indicated for preparation that is partly or full • Cavosurface margin is 90° and axial depth is uniform
extended into the root surface of tooth. of 0.5–0.6 mm into dentin.
• Features of cavity preparation are same as amalgam • Enamel margin of preparation is beveled.
preparation with 90° cavosurface angle, uniform axial
depth of cavity and grooves for additional retention.

Initial Cavity Preparation

• A tapered carbide fissure bur (No. 700, 701 or 271) is
used for entry into tooth surface.
• As preparation is extended the cavosurface margin
should have 90° angle.
• Axial depth in this stage is 0.75 mm. Axial wall should
Figures 18-71A and B: Cavity outline form for
follow the contour of the external surface of tooth. beveled conventional preparation
• Outline form and extension of cavity preparation is
determined by the extent of caries or any old defective
restoration.
• A hand instrument like angle former can be used to
define the walls of preparation.

Final Cavity Preparation Stage

It consists of following steps (Figures 18-70A to C):
• Removal of any remaining caries or old restorative
material.
Figures 18-72A and B: Completed cavity
• Application of calcium hydroxide liner is caries removal form with beveled enamel margins
is close to pulp.
• Preparing retention groove.
Retention groove preparation is done using No. 1/4 Advantages over Conventional Preparation
round bur along the full length of gingivoaxial and inciso- • Increased bonding because of beveled margins.
axial line angle. • Decreased need for retention grooves.
Retention groove depth is 0.25 mm deep. Beveling is done by flame shaped diamond.

Modified Class V Preparation

• This design is primarily employed for restoring small
to moderate sized lesions.
• Objective here is to restore the tooth as conservatively
as possible.
• Usually the cavity form is scooped out and no groove
retention is indicated.

Initial Cavity Preparation

Figures 18-70A to C: Conventional class V preparation
• Preparation is started by using a round or elliptical
design for lesion occurring on the root surface diamond rotary instrument.
 Composite Restoration Class I to VI 365
• No effort is made extend the preparation into dentin
unless otherwise the caries or defect has extended into
dentin.
• Outline form is dictated by the extent of caries.

Final Cavity Preparation

Any remaining caries is removed at this stage and if
required a calcium hydroxide liner in indicated (Figures
18-73 and 18-74).
Figures 18-75A and B: Class V abrasive lesion restored
with composite

b. Gingival health: If gingival health has been adversely

affected by the presence of defect.
c. Esthetics: If defect is affecting the esthetics of the
patient.
d. Sensitivity: If persistent sensitivity is present due to
occurrence of the defect.
e. Pulpal health: If pulpal health is being affected by the
deep extension of the defect.
f. Tooth strength: Strength of the tooth has been affected
by presence of defect.
Figure 18-73: Cavity outline form is determined by the extent Whenever any of these conditions are present it is best
of caries to restore the tooth. If otherwise no restoration is required.
Abrasion or erosion lesion is prepared by just beveling
the enamel margins and if required retention groove could
be placed.

Insertion of Composite (Figure 18-76)

• Usually no matrix application is required.
• Contouring of the composite is done with hand
instrument while placing the material.
• Polishing of restoration is done by abrasive disks and
strips.

Figure 18-74: Modified class V preparation design

Class V Preparation for Abrasion/Erosion

Lesion
Modified cavity preparation design could be used for this
condition occurring on the cervical region of tooth (Figures
18-75A and B).
Decision to restore these defects are determined by
following factors: Figure 18-76: Resin composite is
a. Caries: If caries is present in the defect. placed in incremental manner
366 Essentials of Operative Dentistry

Common Pitfalls in Composite Restorations Key Term

• Too extensive cavity preparation than needed. Mylar strip.
• Incomplete removal of caries lesion.
• Improper isolation. Questions to Think About
• Improper etching and bonding procedure.
1. Elaborate about steps in preparation of class III
• Composite placed in bulk rather than in increments
composite restoration.
leading to shrinkage and marginal gap formation.
2. Describe about various designs in class IV composite
• Improper shade selection.
tooth preparation.
• Voids in composite placement.
3. Discuss about factors influencing restoration of class V
• Improper finishing and polishing of restoration.
composite restoration.
 Direct Filling Gold Restoration 367

19 Direct Filling
Gold Restoration

Introduction 3. Granulated gold (encapsulated gold powder): With the

exception of platinized foil and alloyed electrolytic
• Direct filling gold still remains the standard by which precipitate most types of direct filling gold are pure
technique sensitivity of restorative materials is judged. 99.99%.
• Because of high demand of technical excellence and
increased demand for esthetic restoration and prosthesis Cohesive and Noncohesive Gold
direct filling gold are rarely used in clinical practice.
• As noted previously ability of gold surfaces to cohere
• High quality gold restorations can be ensured only when
by welding at oral temp as dependent on an atomically
four principal conditions are satisfied:
clean surface.
• Appropriate gold form is used for each specific
• Gold like most metal attracts gases to its surfaces and
situation.
any adsorbed gas film prevents the intimate atomic
• Material is used only when its indicated.
required for cold welding.
• Perfectly dry/clean field.
• For this reason the manufacturer can supply foil to the
• Material is properly manipulated with correct
dentist essentially free of surface contaminants and
instruments.
therefore inherently ‘cohesive’.
• However, most gold sheets are provided with an
Forms of Direct Gold adsorbed protective gas film such as ammonia. This
substances minimizes adsorption of other less volatile
It is divided into three categories: agents and prevents premature cohesion of sheets. The
1. Foil—Fibrous gold ammonia treated foil is called ‘noncohesive foil’. This
2. Electrolytic precipitate—Crystalline gold volatile film readily removed by heating to restore
3. Granular gold—Powdered gold cohesive character of foil. Figures 19-1A to C show
1. Foil (Fibrous gold) various heating devices currently in use in the field of
• Sheet dentistry.
• Cohesive
• Noncohesive
• Ropes
• Cylinders
• Laminated foil
• Platinized foil
2. Electrolytic precipitate (crystalline gold):
• Mat gold
• Mat foil (mat gold + gold foil) Figures 19-1A to C: Heating devices: (A) Open flame,
• Gold—calcium alloy (B) Mica over flame, (C) Electric desorption
368 Essentials of Operative Dentistry

Compaction of Direct Filling Gold • Instruments have a series of small pyramids or serra-
tions on face. That exert lateral forces on their inclines
• Direct gold materials can yield conservation and long in addition to direct compressive force as load is applied.
lasting restoration. The technique for placing direct gold • Serrated pyramidal configuration performs three
restoration is quite demanding. functions:
• Two of the main processes that control the quality of • Acts as swaggers.
the final direct gold restoration are ‘welding’ and • Establish triangular indentation on gold surface so
‘wedging’. Cold welding refers to process of forming that succeeding increments are locked into it.
atomic bonds between pellets, segments or layers as a • Increase surface area of condenser face.
result of condensation. Wedging refers to the pressurize • Densest structure occurs directly under the face of
adaptation of the gold form within the space between condenser, to ensure a densest mass in corners and at
tooth structure walls or corners that have been slightly line angles/point angles, the line of force must be
deformed elastically. directed to bisect/trisect the angles.
• Retention points are cut in the prepared cavity and first
pieces of gold foil are wedged into these areas.
Pressure Application
• Increments of gold must be of a proper size and
atomically clean condition for condensing and Hand condensation
compacting. Condensation energy produced by this method is not
• Compaction of the gold segments will seal the cavity always sufficient to fulfill the objective of condensation.
and securely locked in place if the compacting force is This can be used as a initial step to confine the material
applied in appropriate direction and is of sufficient within the cavity.
magnitude. Pneumatic condensation
• A systematic action must be followed. Involves use of vibrating condensers energized by
compressed air. Although a efficient way, but not always
Condensers controllable.
• Instruments can be straight, curved, angled, round, Electronic condensation
square or rectangular (Figure19-2). • Most efficient and controlled way of condensing.
• Vibrating condensers heads have an intensity or
amplitude from 20 oz-15 lbs and a frequency of 360-
3600 cycles/min. Condensers with mallet, e.g.
electromallet (Mc Shirley products).

Compaction Method (Figures 19-3A and B)

• Direction of force, amount of applied force and
compaction pattern are critical for obtaining direct gold
restoration.
• Condenser penetration depth be less than thickness of
increment.
• Condenser tip be stepped in controlled overlapping
motion.
• Porosity is likely to occur in all direct gold restorations.
Each type of gold requires a slight variation in
condensation technique. For mat gold best results are
obtained by using condenser of larger tip and finer
serration pattern.
• A small amount of excess material is provided to ensure
Figure 19-2: Hand condensers proper contour and surface finish.
 Direct Filling Gold Restoration 369

Figures 19-3A and B: Method and mechanism of compaction

Principles of Condensation gold can be found within restoration which are actually
gold foil portion of mat gold. For this reason mat gold
• Forces must be at 45° to cavity walls.
restorations should always be veneered with cohesive gold
• Forces of condensation must be 90° to previously
foil.
condensed gold.
• Proper overlapping stepping motion be followed.
Metallurgical Consideration of Powdered Gold
• Use of minimal thickness of pellet possible, that
condenser will not penetrate it • Here also its same as mat gold.
• Here also surface of restoration be veneered with gold
foil.
Energy of Condensation
• Energy in condensing direct gold restoration should
only be dissipated fulfilling objectives of condensation.
General Steps for Insertion of
Additional energy used may deform tooth structure and Direct Gold Restoration in
adjacent investing tissues.
• When inserting pieces of direct gold material, the
Cavity Preparation
condensation be started from one periphery to other, or • Three steps for build-up of restoration (Figure 19-4):
preferably from center two the peripheries. Tie formation: Involves connecting two opposing point
angles or starting points filled with a transverse bar of
Metallurgical Consideration gold. This forms foundation for any direct gold
restoration.
Metallurgical Consideration of Cohesive Gold Foil Banking of walls: Accomplished by covering each wall
Cross-section of properly condensed gold foil will from its floor or axial wall to the cavosurface margin
demonstrate: with direct gold.
• Superficial 400-600 µm are formed almost completely Shoulder formation: To connect two opposing walls with
of solid gold with no voids. Due to action of burnishing. direct gold material.
• Deepest 200 µm in contact with floor also is composed • Paving of restoration: Every area of cavosurface margin
of solid gold with no voids. Due to resistant nature of be individually covered with excess cohesive gold foil.
walls or floor against which gold is being condensed. For this ‘Foot Condenser’ is used.
• Serrated portion in bulk of restoration with isolated • Surface hardening: Utilizing highest condensation
areas of solid gold ranging from 3-4 µm corresponding energy go over the surface of restoration in all directions,
to thickness of serrated condenser faces. so as to strain harden the surface of gold.
• Remainder of restoration is full of voids. • Burnishing
• Major act in creating a solid gold sheet marginally
and on surface.
Metallurgical Considerations in Mat Gold
• Helps in adapting more material over the margin
There will be no areas of solid gold, i.e. voids is spread and eliminate marginal voids. done from gold to
throughout the restoration. Only portions/strips of solid tooth surface.
370 Essentials of Operative Dentistry

• Nobility of material
• Strength of strained gold.
• Insolubility in oral fluids.
These are the reasons why microleakage is least in
dimension of all restorative material and decrease over-
time.

Principles of Cavity Preparation for

Direct Gold Restorations
Fundamentals of Cavity Preparation
• Gold restorations require meticulous attention to
details.
• Margins of outline form must not be ragged.
• They are established on sound areas of tooth that can
be finished and polished.
• Outline form includes initial depth into dentin ranging
from 0.5 mm in coronal dentin to 0.75 mm in root
dentin.
• Resistance form is established by pulpal floor being flat
and perpendicular to occlusal forces.
• All enamel walls must be supported by dentin.
• Retention form is established by parallelism of walls
and converging the walls. Sharp line angles are
necessary to resist movement of gold.
• Optimal convenience form requires rubber dam isolation
and in classs V tooth preparation a gingival retractor
and in class III restoration a minimal separation
Figures 19-4A to C: Metallurigcal considerations: (A) Cohesive
gold foil, (B) Gold foil with mat gold, (C) Powdered gold between teeth.

Indications
• Margination • Class I direct filling gold are one option for treatment of
• Use sharp instruments moving from gold surface to small carious in posterior teeth and lingual surfaces of
tooth to eliminate small excess at a time. anterior teeth.
• Necessary to alternate between margination and • Direct filing gold is also indicated in treatment of small
burnishing, because margination may expose soft
cavitated class V carious lesions.
gold/voids.
• Class III gold restorations where the lesion is small and
• Contouring: To recreate proper anatomy of tooth.
can be treated esthetically.
• Finishing and polishing: Minimal finishing /polishing
• Class II gold restorations are indicated where the tooth
is required with a properly surface hardened, margi-
arte not subjected to heavy occlusal forces on marginal
nated and contoured restoration.
ridges as in mandibular premolar.
• Final burnishing: To ensure closure of marginal voids
and other surface discrepancies.
Contraindications
Sealability of Gold Restorations • Teeth with very large pulp chamber.
• Most efficient sealing permanent restorative material. • Severely periodontal weakened teeth.
• Reasons for this are: • Handicapped and elderly persons who cannot tolerate
• Method of condensation creates elastic deformation long chair time.
of the underlying and surrounding dentin. • Root canal filled tooth.
 Direct Filling Gold Restoration 371

Figure 19-5: Class I cavity preparation outline form

Class I Tooth Preparation and Restoration Instrumentation

Design • For description a mandibular premolar is selected.
• Outline is extended to include the lesion on the tooth • No. 330 or 329 bur is used for establishing outline form
and also the fissured enamel. and initial depth.
• Preparation margins are placed beyond the pits and • A small hoe can be used to establish desired smoothness
fissures of the tooth. in pulpal floor.
• Outline is kept as small as possible with acceptance for • Using a 33½ inverted bur or angle former chisel an
condensation and manipulation of restorative material. undercut may be given in the pulpal floor.
• Pulpal wall is of uniform depth and established at • Round burs may be used to remove any remaining caries.
0.5 mm into the dentin. • Angle former or finishing bur (7802) or flame shaped
• Small undercuts are placed in pulpal floor to aid in stone may be used to finish the cavosurface margins.
beginning of condensation of gold.
• A very slight cavosurface bevel is placed about: Restoration (Figures 19-6A to C)
• 30-40° of marginal metal to aid in ease of finishing of • The restorative phase begins with insertion of a pellet
gold. of E-Z gold or gold foil.
• To remove rough remaining enamel. • The gold is first degassed in the alcohol flame, cooled
This bevel is not more than 0.2 mm in width. momentarily in air, and inserted into the preparation.
• The gold is pressed to place with the nib of a small
General Shape round condenser.
Outline form is similar to class I cavity preparation for • Next, compaction of the gold begins with a line of force
amalgam with three modifications (Figure 19-5): directed against the pulpal wall.
• Instead of round corners here its angular corners. • Hand pressure is used for E-Z gold; malleting is used
• Extensions in facial and lingual grooves will end in for gold foil.
spear shaped form. • The line of force is changed to a 45° angle to the pulpal
• Whole outline form will look more angular than and respective external walls (to best compact the gold
amalgam preparations. against the internal walls).
372 Essentials of Operative Dentistry

• A cleoid-discoid carver is used to continue the burni-

shing process and remove excess gold on the cavo-
surface margin.
• After use of the cleoid-discoid, a small round finishing
bur (No. 9004) is used to begin polishing.
• It is followed by the application of flour of pumice and
tin oxide or white rouge.

Class II Direct Filling Gold Restoration

Class II direct filling gold are an option for restoration of
small cavitated proximal surfaces lesion in posterior teeth
in which marginal ridges are not subjected to heavy
occlusal forces (e.g. mesial and distal surfaces of mandi-
bular first premolar and mesial surfaces of some maxillary
premolars).
There are three designs of class II direct filling gold
restorations:
Figures 19-6A to C: (A and B) Class I outline shape, 1. The conventional design.
(C) Undercut placed on floor of preparation to retain gold foil 2. The conservative design.
3. The simple design.
• If E-Z gold is to be the final restoration surface,
compaction is continued until the restoration is slightly Conventional Design (Figures 19-8 to 19-11)
overfilled. • Very similar to class II amalgam design.
• If gold foil is selected to veneer this restoration, then • Angles of cavity preparation are more angular.
pellets of suitable size are selected. • Cavosurface bevel of 45° is established.
• The pellet is degassed and carried to the preparation. • Width of occlusal portion of cavity be no more than
First, hand pressure compaction is used to secure the 1/5th intercuspal width.
pellet against the compacted E-Z gold and spread it
over the surface; then mallet compaction is used.
The first step in the finishing procedure is to burnish
the gold (Figure 19-7).
• A flat beaver-tail burnisher is used with heavy hand
pressure to harden the surface gold.

Figure 19-8: Class II conventional design outline form

Figure 19-7: Finished class I gold restoration Figures 19-9A to C: Line angles are angular in shape
 Direct Filling Gold Restoration 373
Simple Design (Figure 19-14)
Indications
• Lesion involving only proximal surface.
• Decay involving proximal surface without involving
the marginal ridges.
• Junctions are more angular.

Figures 19-10A and B: Finished class II conventional design

Figure 19-14: Class II simple design

Restoration
Figures 19-11A and B: Clinical case on conventional
class II gold restoration in maxillary premolar
It is necessary to use a matrix in class II restoration it can
be:
• Compound supported matrix (Figure 19-15)
Conservative Design (Figures 19-12 and 19-13) • Tofflemire matrix
• Any other matrix system.
Indications • Pieces of alloyed filling gold or encapsulated
• Lesion involving primarily the proximal surface and a powdered gold are placed in the proximal box and
very limited part of occlusal surface. thoroughly condensed with heavy hand pressure
and condensers.
• Gold is added and pressure is directed towards
proximal walls and matrix.
• Proximal box is filled till pulpal floor of occlusal step
then the dovetail in occlusal step is condensed with
gold.
Contouring and finishing
• Burnishing is done with discoid-cleiod carver.

Figures 19-12A to C: Class II conservative design in

mandibular premolar

Figures 19-13A and B: Clinical case of class II conservative

design in mandibular premolar Figure 19-15: Compound supported matrix
374 Essentials of Operative Dentistry

Figure 19-16: Ferrier design – shape is triangular

• After matrix removal inter-proximal areas are finished

with abrasive disks and strips.
• Occlusal portion is finished with stones and finishing
burs.

Class III Direct Filling Gold Restoration

Class III gold tooth preparation is the most difficult to
master as it has to be prepared with adequate access for
instrumentation and also must be inconspicuous so as
gold is placed in an esthetic manner.
There are three basic designs in class III preparation
Figure 19-18: Ingraham design–with bulky incisal and
they are: gingival tooth structure
1. The Ferrier design (Figure 19-16)
• Indicated after removal of all tooth structure, bulky • After removal of diseased and undermined tooth
labial, lingual and incisal walls remain. structure, this preparation design will accommodate
• General shape is triangular, involving about two- bulky gingival and incisal walls.
thirds to one-half of the proximal surface.
• Access is usually done from lingual aspect of tooth.
Tooth Preparation (Figures 19-19A to D)
2. Loma-Linda design (Figure 19-17)
• Indicated for a combination of powdered gold build- • Lingual tooth structure is penetrated with a small round
up with a cohesive gold foil veneer. bur (No. ½, 1).
• Usually done in tooth where the marginal ridge or • A tapered fissure bur (No. 169 or 170) can then enter
lingual surface is lost or undermined by caries. through this penetrated tooth structure and extend the
• General shape of the cavity is triangular with cavity incisally and gingivally.
rounded corners. • Labial wall is curved in continuation with labial tooth
3. The Ingraham design (Figure 19-18) structure.
• Indicated primarily for incipient proximal lesions in • There is no lingual wall.
anterior teeth where esthetics is the main concern. • Walls are refined with appropriate instruments like hoe.
• Two retentive points are placed one at linguogingival
and other at the incisal.

Restoration (Figures 19-20A to C)

• Compound supported matrix is placed for restoration
onto the tooth.
• A separator may be employed at this stage or will be
used during finishing of restoration.
• Annealed pieces of alloyed filling gold or pellets of
Figure 19-17: Loma-Linda design–lingual wall is missing encapsulated powdered gold are placed in gingival area
 Direct Filling Gold Restoration 375

Figures 19-19A to D: Preparation of tooth (Class III filling gold)

of preparation and condensed using heavy hand Class V Direct Gold Restoration
pressure. (Figures 19-22A to D)
• First pieces of gold is condensed onto the linguo-
gingival retention point and followed by into the axio- Cavity Preparation Design
labial accentuated point angle.
There are four basic designs:
• More gold is condensed till the gingival area is filled
1. The Ferrier design: General shape of this cavity is
followed by condensation incisal retention area.
trapezoidal with short arm gingivally and long arm
• Once the gingival and labial areas are filled with gold
occlusally.
rest of the areas is filled-up.
2. Class V cavity with proximal pan handle extension: Cavity
consists of two portions, i.e. a facial or a lingual part,
Contouring and Finishing (Figures 19-21A and B) whose outline is exactly like the previous design, and a
• After removal of matrix band, a Ferrier double bow proximal part, parallelogram in shape.
separator is used to separate the tooth by 0.5 mm. 3. Class V with unilateral or bilateral moustache extensions:
• Abrasive disks or strips are used to finish the proximal Sometimes surface defects occlusal to height of contour
portion, also cleiod-discoid carver be used to contour may be continuous with gingival third defects
the restoration. employing this design.
376 Essentials of Operative Dentistry

Figures 19-20A to C: Restoration of tooth

(Class III filling gold)

Figures 19-22A to D: Designs of class V: Cavity preparation

Tooth Preparation (Figures 19-23A to E)

Figures 19-21A and B: Ferrier separator used to separate • No. 33 ½ bur is used to establish the outline form.
teeth apart to aid in access to proximal surface of tooth • Acute line angles of the cavity are established by the
hand instruments like hoe.
4. Partial moon (crescent) shape cavity • Axial wall follows the contour of the tooth preparation.
• Sometimes due to the very apical location of height Axial wall meets the occlusal wall of preparation in an
of contour or because of esthetic reasons the classical acute angle.
trapezoidal shape will be unacceptable. • Axial wall meets the mesial and distal walls in an obtuse
• Here s curved shape cavity with gingival margin angle to prevent undermining of the enamel.
curved like a part of circle. • Acute axiogingival line angle provides the retentive
• General shape will look like a ‘semilunar’. point for gold.
 Direct Filling Gold Restoration 377

Figures 19-23A to E: Preparation of tooth (Class V)

378 Essentials of Operative Dentistry

Restoration (Figures 19-24A and B)

• Alloyed filling gold is started with an annealed piece of
gold the size of axial wall.
• Gold is condensed onto axial wall first, heavy hand
pressure is employed.
• Alloyed gold filling fills up 95% of the cavity before a
gold foil veneer is placed.

Figures 19-25A and B: Contouring and finishing

Figures 19-24A and B: Restoration of class V tooth (Class V gold)

• Compaction
Contouring and Finishing (Figures 19-25A and B) • Tie method
• A beaver tail burnisher is used to work harden and • Banking
smoothen the surface. • Shoulder formation
• A cleiod-discoid carver is used to remove excess of gold. • Margination
• Fine cuttle disks are used to smoothen the gold surface. • Ferrier design
• Pumice or tin oxide or whit rouge applied with rubber • Loma-Linda design
cup is used to give final polish to the restoration. • Ingraham design

Key Terms Questions to Think About

• Cold welding 1. What are indications and contraindications for direct
• Desorption /annealing filling gold. Explain in detail about principles of cavity
• Cohesive and noncohesive gold preparation for direct filling gold restoration.
• Gold foil 2. Explain class III direct filling gold tooth preparation
• Mat gold and restoration.
• Electrolytic precipitate gold 3. Explain in detail about various designs of class V direct
• Powdered gold filling gold preparation and restoration.
 Pin Retained Amalgam Restoration 379

20 Pin Retained Amalgam

Restoration

Complex Restorations Occlusion, Esthetics and Economics

• Whenever drastic occlusal changes has to be done
Complex restorations are defined as restorations that
complex amalgam restorations like pin retained
replace a severely broken down teeth or replacing two or
amalgam restorations are of good choice.
more cusps.
• When esthetics is of primary concern amalgam
restorations cannot be used.
Factors to be Considered • Complex amalgam restoration are more cost effective
than cast restoration.
Complex restorations are determined by following
factors.
Definition
Resistance and Retention Form • Pin retained amalgam restoration may be defined as
• Severely broken down teeth are often best restored with any restoration requiring placement of one or more pins
cast restorations. in dentin to provide adequate resistance and retention
• Sometimes amalgam restorations with the help of pins forms.
or slots could be also used. • Pins are rarely used in anterior teeth because of smaller
size of the tooth.

Status and Prognosis of Tooth

• Teeth with pulpal involvement may require root canal
Advantages
treatment prior to restorations. • Conservation of tooth structure: Preparation more
• Periodontally weakened teeth may be restored with conservative than cast tooth preparation
complex amalgam restoration like pin-retained • Appointment time: Pin retained restoration can be
amalgam restorations prior to fabrication of cast completed in one appointment unlike cast restoration.
restoration. • Resistance and retention form: Both are significantly
increased by use of pins.
• Economics: Compared to cast restorations these are very
Role of Teeth in Overall Treatment Plan inexpensive.
• For periodontal and orthodontic patients complex
amalgam restoration may be the choice prior to final
cast restorations.
Disadvantages
• Teeth that are to be used as abutment in denture • Dentinal microfractures: Drilling pin holes in dentin can
treatment are also best restored with complex amalgam create craze lines that can eventually lead to fracture of
restorations. dentin.
380 Essentials of Operative Dentistry

• Microleakage: Microleakage can occur around pins. • Pin is retained by the threads in pins as it is inserted
• Decreased strength of amalgam: Pins do not reinforce into dentin, elasticity of pin helps in this retention.
amalgam therefore strength both compressive and • It is 3-6 times more retentive than cemented pins.
tensile strength of amalgam is decreased. • Lateral and apical stresses can develop when pins are
• Resistance form: Resistance form of tooth preparation is threaded into dentin.
more difficult to prepare. • Thread Mate System (TMS) is most widely used system.
• Perforations: Pin increases the chances of perforations
through external surface of the tooth. Friction Locked Pins (Figure 20-1B)
• Tooth contour: Exact contour of tooth may be difficult to
• Goldstein in 1966 described about this system of pins.
reproduce.
• Diameter of pin hole is 0.001 inch smaller than diameter
of the pin.
Indications • Pins are tapped into dentin and the resilience of dentin
helps in retaining the pin.
• Auxiliary means of retention in badly broken down
tooth.
Cemented Pins (Figure 20-1C)
• Indicated in young patients with relatively large pulp
chamber and gingival lines are high making tooth • Markley in 1958 described this system of pins.
preparation for cast restoration difficult. • Pin holes are 0.001 to 0.002 inch larger than diameter of
• Pin retained restorations are indicated as foundations pin.
for cast restorations. • Cementing medium can be either zinc phosphate or
• In teeth with questionable periodontal or endodontic polyacrylate cement.
prognosis these restorations are advisable.
• As an alternative to costly cast restorations. Mechanical Aspects
Stressing Capabilities of Pins
Types of Pins Stresses are always induced when pin is introduced into
Most frequently used pin is self threading pin: dentin.
• Self threading pins When stresses exceed the plastic limit of dentin micro-
• Friction locked pins fracture can occur.
• Cemented pins Factors increasing or decreasing stresses are (Figures
20-2A to G:
• Type of pins:
Self Threading Pins (Figure 20-1A)
• Maximum stress is introduced by placement of
• These pins were described by Going in 1966. friction grip pins.
• Diameter of pin hole is 0.0015 to 0.004 inch smaller • Least stress is introduced by application of cemented
than diameter of pin. pins.

Figures 20-1A to C: Types of pin: (A) Self threading pins, (B) Friction grip pins, (C) Cemented pins
 Pin Retained Amalgam Restoration 381

Figures 20-2A to G: Factors influencing stressing capabilities of pins

• Intermediate stress is introduced by application of d. Bulk of dentin: Greater bulk of dentin lesser will be
self threading pin. stresses produced.
• Diameter of pins: Greater the diameter of pin greater will e. Type of dentin: In sclerotic dentin and root canal filled
be the induced stress. teeth dentin greater will be stress produced leading to
• Pin depth and dentinal engagement: Greater the depth microfracture. In root canal filled tooth cemented pins
of dentinal engagement greater will be the stress are the choice of pins.
introduced. Therefore, manufacturer’s produce smaller f. Inter-pin distance: When inserting pins inter-pin distance
pins. be minimum of 4 mm.
382 Essentials of Operative Dentistry

• Loose pins: Loose pins inside pin channels result in stress • Ratio of dentinal engagement of pin to their protruding length
formation inside dentin. in cavity preparation: Ideal ratio will be 2 : 1 any lower
• Ratio of depth of pin in dentin to that protruding into the than this ratio affects the retention.
cavity preparation: Ideal ration of pin depth and pin • Mode of shortening pins after insertion: Ideally, pins should
extrusion is 2:1. Any ratio lower than this could increase not be disturbed after insertion into dentin.
stress production in dentin. Least disturbing method of reducing height of pin
• Number of pins in tooth: Fewest pins that will help retain after pin insertion is by using cutting plier.
the restoration are placed. • Bulk of dentin around pin: Greater the bulk of dentin
• Overthreading or overdriving the pins: These situations around the pins placed greater will be the retention
can greatly magnify the stress produced in dentin. because lesser microcracks appearing in dentin.
• Bending of pins: After placement bending of pins leads
to increased stress formation in dentin. Effect of Pin on Amalgam
• Retentive features in remaining portion of cavity: Other Strengths of Pins
retentive features in other portions of cavity can greatly
Pins will not increase the compressive strength of amalgam.
reduce stress production in dentin. Pins should be used
Infact there is a drop in strength whenever:
only as an auxiliary means of retention.
• Pins are closer than 2 mm apart.
• Inserting pin in critical areas of tooth: Stress concentration
• Less than 1.5-2 mm of restorative material is present
areas like axial angles or junction between clinical
between the pin and exterior surface.
crown and root will exacerbate production of stress.
• There is incomplete wetting of restorative material to
pins, i.e. voids present in the restorative material.
Retentive Capabilities of Pins in Dentin • Reduction of tensile strength of restorative material
occurs if the pins are placed right angles to tensile
Main objective of pin is to improve or acquire retention of
stresses occurring in restoration.
restoration to dentin. Following factors determine the
retentive capabilities:
Retention of Pins to Restorative Material
• Type of pins: Self threading pins will be 5-6 times more
• Type of pin: Friction grip pins are least retentive to
retentive than cemented pins.
restorative material because of smooth surface.
Friction grip pins will have 2-3 times the retention of
Cemented pins and self threading pins because of
cemented pins.
serrated surface have maximum retention to restoration.
• Depth of pin engagement in dentin: Usual depth of pin • Pin length in restorative material: Usually a protruding
engagement of 2 mm any increase in depth will not length of 1.5-2 mm into restoration is ideal for retention
increase the retentive capabilities. of pin to restorative material (Figure 20-3A).
• Pin channel circumference shape relative to that of pin: • Pin diameter: There is a gradual increase in pin retention
Ideally, there should be minimum discrepancy between to restorative material up to a diameter of pin size
pin channel diameter and pin diameter to increase the 0.035 inch.
retentive capability. Any diameter larger than this will not increase the
• Number of pins: Pins placed less than 2 mm apart greatly pin retention.
reduce the retentive capability. • Inter-pin distance: Ideal inter-pin distance be 2 mm.
This is due to microcracks appearing in the dentin. • Proximity of restorative material to pin surface: Greater the
• Type of cement: Retentive capability in cemented pins is wetting ability of restorative material to pin surface better
most when zinc phosphate cement is used followed by will be retention of pin to restorative material (Figure
20-3B).
polyacrylate and zinc oxide eugenol.
• Surface material of pin: Silver coating found on stainless
• Type of dentin involved: Young resilient dentin is the
steel pins can react with mercury in amalgam restoration
most retaining type of dentin.
to increase the retention of pin to amalgam.
Hypermineralized and scelerotic or dehydrated
Bending of pin after insertion will not increase the
dentin has minimum retentive capabilities for pins. retention potential but can complicate the stress pattern
• Surface roughness of pins: Pins with serrations or threads induced and also increase the chances of formation of
have maximum retentive capabilities. microcracks in dentin.
 Pin Retained Amalgam Restoration 383

Figures 20-3A and B: (A) Ideally there should be at least

2 mm of restorative from pin surface, (B) Voids in restorative
material leads to incomplete wetting of restoration with pins

Anatomical Aspects of Pin Retained

Restoration
Pins placement be confined to dentin portion of the
tooth.
To facilitate the placement of pin following factors has
to be assessed:
• Knowledge of anatomy: Full three dimensional aspect of
the tooth anatomy and its investing tissues need to be Figures 20-4A and B: (A) Outer surface tooth contour can
known. help in placement of pin parallel to long axis of tooth, (B) Tilted
• Radiographs: Properly exposed radiograph of concerned tooth requires greater care while pin placement
tooth will help in placement of pin.
• Outer surface of the tooth: Outer surface of the tooth will
serve as a guide in placement of pin parallel to long
axis of tooth without risk of perforation (Figure 20-4A).
• Abnormal anatomical features: Abnormal anatomical
factors like grooves or fossa can complicate the
placement of pin.
• Tooth alignment: Tilted or rotated tooth can complicate
the placement of pin and individual assessment of tooth
in necessary (Figure 20-4B).
• Cavity extent: More the extent of cavity gingivally greater
the chances of perforation to occur.

Pin Placement
Figures 20-5A to D: Four sizes of TMS pins: (A) Regular,
Pin Size (B) Minim, (C) Minikin, (D) Minuta
Four sizes of pins and pin drills are available with color
coding (Figures 20-5A to D and Table 20-1). They are: Factors determining selection of pin sizes are:
• Regular—0.031 inch – Gold color • Amount of dentin available to receive dentin
• Minim—0.024 inch – Silver • Amount of retention required.
• Minikin—0.019 inch – Red For posterior teeth pins of choices will be:
• Minuta—0.015 inch – Pink Minikin (0.019 inch) and Minim (0.024 inch).
384 Essentials of Operative Dentistry

Table 20-1: TMS pin design and diameter

Name Illustration Color code Pin diameter Droll diameter Total pin Pin length
(Not to scale) (In/mm) length (mm) extending from
dentin (mm)
Regular Gold 0.031/0.78 0.027/0.68 7.1 5.1
(standard)
Regular Gold 0.031/0.78 0.027/0.68 8.2 3.2
(self-shearing)
Regular Gold 0.031/0.78 0.027/0.68 9.5 2.8
(two-in-one)
Minim Silver 0.024/0.61 0.021/0.53 6.7 4.7
(standard)
Minim Silver 0.024/0.61 0.021/0.53 9.5 2.8
(two-in-one)
Minikin Red 0.019/0.48 0.017/0.43 7.1 1.5
(self-shearing)
Minuta Pink 0.015/0.38 0.0135/0.34 6.2 1.0
(self-shearing)

1 mm = 0.03937 in.

Number of Pins • Pin holes are located on flat surface of tooth not inclined
Factors deciding number of pins will be: surface.
• Amount of tooth structure remaining. • Once pin hole position has been determined a “pilot
• Amount of dentin available. hole” be drilled using No. ¼ bur to allow more accurate
• Amount of retention required. placement of pin hole.
• Size of pins.
As a rule one pin per missing axial line angle, one pin Pin Hole Preparation (Figures 20-7
per missing cusp, one pin per missing wall should be used. and 20-8)
Minimum number of pins must be used to achieve the
• Kodex drill (twist drill) is used for drilling pin holes.
desired retention.
• Drill is color coded to match the pin size.
• Depth limiting drill is available is used to prepare pin
Location of Pins hole of depth of accurately of only 2 mm.
Factors aiding in placement of pins (Figures 20-6A to D) • Omni depth gauge can be used to measure accurately
a. Knowledge of tooth anatomy the depth of pin hole.
b. Radiograph of tooth. • Drill is engaged onto a contrangle handpiece and used
c. Periodontal condition. at speeds of 300-500 rpm or can also be used with hand
• Age of patient. wrench.
• Pins be placed in area of greatest bulk of tooth structure • Twist drill is an end cutting revolving instrument with
and restoration. Most preferred location of pin place- two blades. The drill is made of steel.
ment will be in line angles of posterior tooth. Five rules in using this drill are:
• Areas of direct occlusal contacts the pins should not be 1. Drill should be used at ultra-low speed 300-350 rpm.
placed. 2. Drill should be used in direct cutting motion and
• Pin hole should be positioned no closer than 1 mm to should not be used in lateral cutting direction as this
dentinoenamel junction and no closer than 1.5 mm to can lead to widening of pin hole.
the external surface. 3. Drill should be revolving both while placement of
• A 0.5 mm clearance be present around the pin to aid in pin hole and removal from tooth structure.
condensation of amalgam. 4. Drill should not be used in pumping strikes.
 Pin Retained Amalgam Restoration 385

Figures 20-6A to D: Pin hole and pin placement

Figures 20-7A to C: (A) Standard drill, (B) Depth limiting Figure 20-8A: Close-up view of drill with end cutting tip and
drill, (C) Omni depth gauge two blades
386 Essentials of Operative Dentistry

Figure 20-8B: Pin placement be ideally 2 mm away from

dentinoenamel junction

Pin Design
In each size of pins design available are (Figures 20-9A to I):
• Standard: Approx 7 mm in length with a flattened head
and is engaged in a hand wrench or contrangle
handpiece.
• Self shearing has a varied length that varies with dia-
meter of pin. This could also be engaged in a contrangle
handpiece or hand wrench. When the pin is engaged
into dentin till its bottom the head of pin shears off,
leaving a length of pin extending from the dentin.
• Two-in-one is actually two pins in one with one pin being
shorter than standard pin. When the pin is engaged
onto dentin it shears off in half leaving the remaining
portion in handpiece or wrench itself to be engaged in
another pin hole.
• Link series is contained in colour coded plastic sleeve
that fits in handpiece or wrench. When the pin is
engaged onto dentin the top portion shears off leaving
a length of pin protruding from the tooth. The plastic
sleeve is then discarded.
• Link plus is a self shearing pin available in single pin or
two-in-one pin in various color coding. The pin design
has a sharper head, a shoulder stop at 2 mm and a
tapered tip to engage into pin hole.
All the pin designs could be engaged with conventional Figures 20-9A to I: Various designs of pins. (A) Standard,
latch type handpiece or hand wrench. (B) Self shearing, (C) Two-in-one, (D) Link series, (E) Link
plus, (F) Link series pin, (G) Link series plus pins, (H) Link
series depth limiting drill, (I) Link series pin with a plastic sleeve
Pin Insertion
Friction Grip Pins
• Two instruments for insertion of pins are (Figures 20- • In a latch type handpiece the link series or link plus
10A to D): pin is engaged onto handpiece and placed into pin hole.
• Conventional latch type handpiece. The handpiece is rotated until the plastic head shears
• TMS hand wrench. off from the pin leaving the pin engaged into dentin.
• Once the location of pin hole is determined a “pilot • Once the pin is engaged into dentin it should be
hole” of 0.2 mm depth is prepared with No. ½ bur (Figure protruding no more than 2 mm into cavity preparation
20-10E). and any excess length be removed off (Figure 20-10F).
 Pin Retained Amalgam Restoration 387

Figures 20-10A to K: Techniques of pin insertion: (A) Hand wrench, (B, C) Latch type handpiece, (D) Hand wrench, (E) Pilot hole
preparation, (F,G) TMS bending tool, (H,I) TMS bending tool used to bend pins, (J,K) If any other instrument is used for bending pins
may fracture
388 Essentials of Operative Dentistry

• Occasionally, a placed pin may be required to be bend Matrices

to allow space for amalgam condensation and it is to be Universal matrix band or compound supported matrix
done with “TMS bending tool”(Figures 20-10G to K). band or automatrix could be used.

Cemented Pins Inserting and Carving of Amalgam

• Pin holes are prepared into dentin 3-4 mm deep using a Restoration
twist drill.
• Proper condensation of amalgam around the pins is
• Pins are cemented using zinc phosphate or polyacrylate
necessary to prevent any voids formation.
cement.
• Spherical or admixed amalgam alloy is recommended.
• Once condensation of amalgam is completed define the
Tooth Preparation for Pin occlusal embrasure and marginal ridge using explorer.
• Discoid carver is used to define the occlusal features in
Retained Amalgam Restoration amalgam restoration.
• Matrix band is removed as in class II restoration
Initial Cavity Preparation followed by evaluation of the contour of restoration and
Perform initial cavity preparation as in conventional proximal overhangs.
amalgam preparation.
Finishing and Polishing (Figures 20-11A to G)
Final Cavity Preparation It is done same as in conventional amalgam restoration.
• After initial cavity preparation any remaining caries is
removed in accordance with conventional amalgam
preparation and pulp protection if needed is advocated. Failure of Pin Retained
• Any additional retentive or resistance features are given Restorations
in tooth preparation.
Failure of this type of restoration can occur in five different
Class II Pin Retained Restoration locations (Figures 20-12 and 20-13):
• Within the restoration (restoration fracture)
Design Feature
• Interface between the pin and the restoration material
• Pins should be an auxiliary retention feature with other • Within the pin (pin fracture)
modes of retention like slots, locks, grooves be present. • Interface between pin and dentin
• Most of the pin retained restoration tooth requires cuspal • Within dentin (dentin fracture).
capping which may involve one or two cusps. Cuspal
capping procedure is same as in cuspal capping for
cast restorations. Mishaps During Pin Retained
• As mush as possible pin placement be apically as
possible and as much peripherally present.
Restorations (Figures 20-14
• Pin placement is done in facio- or linguoproximal and 20-15)
corners avoiding the acute axial line angles.
• Pin placement is avoided in cuspal capping table. • Broken drills or pins.
• Flat planes should be present around the pins. • Loose pins—if this happens a new pin hole be prepared
• Avoid placing the pins in gingival floor of preparation. 2 mm from original pin hole.
• Try to place minimum number of pins. • Perforation into pulp:
• Rest of the cavity design is same as in conventional • If there is hemorrhage into prepared pin hole it
class II amalgam preparation. indicates perforation.
• Radiographs are used to verify the perforation.
• If pin perforation into pulp of an asymptomatic tooth
Pin Placement (Table 20-2) it is treated by direct pulp capping procedure.
Pins are placed in accordance to principles described • Most of the times pulp perforation requires root canal
above. therapy.
 Pin Retained Amalgam Restoration 389

A B

C D

E F

G
Figures 20-11A to G: Class II cavity preparation: (A) Cavity preparation, (B) Pin placement,
(C) Pin placement from axial angle, (D) Matrix band application, (E) After matrix band application,
(F) Amalgam condensation, (G) Carved pin retained amalgam restoration
390 Essentials of Operative Dentistry

Table 20-2: Location of pin placement

Teeth Location of pin Area to be avoided

Maxillary
Incisors 1. Gingival floor 1. Middle of lingual floor
2. Incisal region when atleast 2. Incisal in absence of dentin
2 mm of dentin is left
Canine 1. Facio- or linguoproximal corners 1. Middle of lingual gingival floor
2. Gingival floor 2. Close to root concavities
3. Incisal edge if more than
2 mm of dentin is left
Premolars Close to proximofacial and 1. Mesial gingival floor
lingual corner of tooth 2. Middle of gingival floor buccally
and lingually
Molars Gingival floor distolingual corner, 1. Gingival floor at mesiobuccal corner
distobuccal, mesiolingual corner of 2. Close to furcation
tooth
Mandibular
Incisors Pins are usually avoided because
of thin nature of tooth structure
Canine Very similar to upper canine
Premolars Close to proximofacial and proximolingual Middle of gingival floor buccally and lingually
corner of gingival floor
Molars Distolingual, distobuccal and mesio- 1. Mesiobuccal corner of gingival floor
lingual corner of gingival floor 2. Any cusp tip.

• Pin is removed and the pin hole enlarged and the

hole is restored with amalgam.
If it is below gingival attachment it is treated by:
• Reflect the gingival tissue surgically and restore the
pin hole with amalgam.
• Perform crown lengthening procedure.

Other Alternative to Pins for

Additional Retention in Amalgam
Restorations
Horizontal Pins
Figure 20-12: Five possible modes of failure in • Horizontal pins are described by Burgess.
pin retained restorations • Horizontal pins should be placed 0.5-1 mm from
dentinoenamel junction.
• It should not be placed too near to the surface of
• Perforation into external surface of tooth (Figure 20-14):
amalgam (Figure 20-16).
Perforation into external surface of tooth can be either
above gingival attachment or below the gingival
attachment. Circumferential Slots
If it is above gingival attachment it is treated by: Described by Outhwaite and others, he introduced a
• Pin can be cut-off flush to external surface and tooth circumferential slot prepared with No. 33 ½ inverted cone
restored. bur (Figure 20-17).
 Pin Retained Amalgam Restoration 391

Figure 20-14: External perforation of pin

Figures 20-15A to D: Mishaps in pin retained restoration

Figures 20-13A to E: Failures in pin retained restorations

Slots
• Slot is a retention groove whose length is in a transverse
Amalgapins plane and in dentin.
• Shavell described about preparation of amalgapins • Slots are prepared with No. ¼ bur.
• Here a channel was prepared with No.1157 or No.1156 • Gingival slots are placed in adjunct with pins in
bur and had a depth of 3 mm. amalgam restorations.
• The entrance of channel was beveled to reduce the stress • Gingival slots are placed with 33½ bur or 169 L bur.
concentration (Figure 20-18). • Slot dimension be at least 0.5 mm in depth (Figure 20-19).
392 Essentials of Operative Dentistry

Figure 20-17: Circumferential slot

Figure 20-16: Horizontal pins

Figure 20-18: Amalgapins with entrance being beveled

Key Terms
• Pins • Slots
• Locks • Amalgapins
• Circuferential slots • Horizontal pins
• Pilot hole • Craze lines and
• Self threading pins microfracture
• Friction grip pins • Cemented pins
• Twist drill

Questions to Think About

Figure 20-19: Slots and coves
1. Explain about various types of pin available. Explain
in detail about self threading pin and its placement.
Locks
2. Write about stressing capabilities of various types of
• Lock is a retention groove whose length is in a pins and various factors controlling it.
longitudinal plane and in dentin. 3. Discuss about factors affecting the retention of pin to
• Slots and locks are used in preparation with more dentin and in restoration.
number of longitudinal walls, whereas pins are used 4. Elaborate about various failures and mishaps in pin
where there is lack of longitudinal walls. retained restoration.
 21 Class II Inlay
Restoration

Cast Metal Restoration 4. Pinlays

5. Full crowns.
• Cast restoration was first introduced in dentistry by
Taggart. Before Taggart it was explained by D Philbrook
in 1897. Definition
• Cast restorations traditionally involve fabrication of a • Inlay involves the occlusal and proximal surfaces of
wax pattern followed by investment of wax pattern and posterior tooth and may cap one or more but not all of
burn-out process to remove the wax and casting the the cusps.
pattern in metal. • Onlay involves proximal surface of a posterior tooth
and caps all of the cusps.
There are two techniques of cast fabrication (Figure 21-1):
• Pinlay are cast intracoronal or extracoronal restorations
1. Direct technique: Here wax pattern is taken directly
where pins are cast along with the restoration, here
from cavity preparation in the mouth, invested and cast.
pins acts as auxiliary means of retention.
2. Indirect technique: Here wax pattern is fabricated from
• Full crown is an extracoronal restoration which covers
the model poured from either with alginate or rubber
the whole tooth surface (Figures 21-3A and B).
based impression.

Advantages
Direct Technique vs Indirect Technique
• Better physical properties like strength.
• Direct technique is more technically difficult than
• Casting techniques and carving of wax pattern allow
indirect technique.
precise and controlled reproduction of tooth details.
• Indirect technique, wax distortion could be more
• Metals used for cast restorations are biocompatible.
because of difference between mouth temperature and
• Since cast restorations are build in one bulk rather than
room temperature.
in increments as in direct restorations they have fewer
• In indirect technique fabrication of wax pattern is given
voids or imperfections.
to a qualified dental technician.
• Cast restorations are finished and polished extraorally
• In indirect technique postoperative model allows for
so maximum surface smoothness can be imparted.
extraoral evaluation of preparation.
• In indirect technique control of proximal contour and
contact could be better established outside the mouth Disadvantages
in dental lab. • Being a cemented restoration there is cement tooth
There are basically five general designs to accommodate interface which can lead to microleakage.
cast restorations (Figures 21-2A to D): • Cast restorations necessitate extensive tooth pre-
1. Inlays paration.
2. Onlays • Can lead to galvanic phenomenon if used with amalgam
3. Cast restorations with surface extensions restorations.
394 Essentials of Operative Dentistry

Figure 21-1: Direct and indirect techniques

• Procedure for cast restoration is lengthy. 1. Control of plaque and caries: Before planning cast
• Ceramic cast restorations can abrade the natural teeth. restorations caries and plaque status has to be stabilized
Procedure is done in two appointments. First for tooth so that there is no recurrence of caries.
preparation, impression taking and second for delivering 2. Control of periodontal problem: Most of the cast
the restoration. This type of restoration is referred to as restorations involve the proximal surface of tooth,
‘indirect restoration’. therefore periodontal health status of tooth must be
sound before placing final restoration.
Materials used for Cast Restorations 3. Proper foundation: A badly broken down teeth has to
be build by a foundation before placement of final
Are classified as:
restoration.
• Class I—Gold and platinum based alloys. These are
4. Control of pulpal condition: Pulpal health should be
type I, II, III, IV gold alloys.
evaluated and if necessary endodontic treatment be
• Class II—Low gold alloys containing gold less than
initiated.
50%.
• Class III —These are nongold palladium based alloys.
Principle of Cavity Preparation for
• Class IV—Nickel-chromium based alloys.
• Class V—Castable or moldable ceramics.
Cast Restorations
• Cast restorations can be intracoronal or extracoronal.
Nowadays indirect or direct composite resin inlays and
• Here we are mainly concerned with intracoronal cast
onlays are also fabricated.
restorations.
• Intracoronal restorations are mortise shaped, having
Mouth Preparation Prior to Cast definite walls and floors joined by line angles and point
Restorations angles.
Single tooth cast restorations are the ultimate and final • General principles of tooth preparation can be applied
restoration; therefore, every precaution should be taken to to intracoronal preparation with slight modification for
insure the longevity of restoration. the extensiveness of the preparation.
 Class II Inlay Restoration 395

Figures 21-2A to D: General designs of cast restoration

396 Essentials of Operative Dentistry

2. Need for retention: If a preparation requires

additional retention then divergence of preparation
is reduced.

Preparation Features of the Circumferential Tie

• Weakest link in cast restoration is the tooth-restoration
interface or the cement link.
• Margins of preparation or cavosurface margin is
Figures 21-3A and B: Inlay (intracoronal) has an retention of
otherwise called as circumferential tie. This margin
mortise type, while full crown (extracoronal) has sleeve type should be smooth; enamel supported by dentin, proper
retention beveling configuration is established.

• Compared to amalgam restorations cast restorations Types and Designs of Occlusal and
have more extensive surface involvement. Gingival Bevel in Cavosurface Margin
Following are specific features: (Circumferential Tie)
There are six types of bevels (Figures 21-5A to F):
Preparation Path A. Partial bevel: This bevel involves only part of the enamel,
• Preparation will have single path of insertion and not exceeding 2/3rd dimension of enamel. This is not
withdrawal and this is usually parallel to long axis of used in cast restoration but only used to cover for any
tooth or parallel to direction of occlusal loading. faulty fissures (enameloplasty).
• This prevents micro tooth movement during function B. Short bevel: Includes entire enamel wall not dentin,
and aids in better retention. usually used for class I alloys or gold alloys.
C. Long bevel: Includes the entire enamel wall and up to
one-half of dentinal wall. Most frequently used bevel
Apicocclusal Taper of a Preparation for intracoronal cast restorations.
(Figures 21-4A and B) D. Full bevel: It involves whole of enamel wall and dentin,
• Cast restorations require materials like wax pattern to it is not used because it deprives preparation of retention
be inserted and taken out smoothly, which requires the form.
preparation walls to be parallel to each other. E. Counter bevel or reverse bevel: This is usually done
• But to prevent formation of any undercuts the walls are in preparation where capping of cusp is done, it is
diverged by angle of 2-5° for each wall. This angle of usually given facial or lingual surface of cusp.
divergence depends on. F. Hollow ground or concave bevel: This feature is in form
1. Length of preparation walls: Greater the length of of concavity. Not used nowadays. Used for materials
preparation walls greater is the degree of divergence. with low castability.

Figures 21-4A and B: Taper in an inlay restoration is essential both for retention and for
removal and path of draw for wax pattern
 Class II Inlay Restoration 397

Figure 21-7: Gingival bevel

Figures 21-5A to F: Types of bevels Proximal Box Margin (Cavosurface Margin)

Types and Design Features of Facial and
Angulation and width of bevel depends on various
Lingual Flare
factors like material of restoration, caries presence, location
of margin, retention and resistance from required, etc. Flares are present on the proximal box of the intracoronal
cast preparations.

Function of Occlusal and Gingival Bevel Two types of flare (Figure 21-8):
(Figures 21-6 and 21-7) 1. Primary flare
• It is present both on the facial and lingual wall of
• Bevels help in establishing strong enamel margins well
proximal box, it is very similar to long bevel.
supported by dentin.
• It has an angluation of 45° to inner dentinal wall.
• Produces an acute marginal metal of 30-40° which aids
burnishability of alloy and marginal fit. Functions: In addition to function of bevel, they bring
• Bevels especially gingival bevel aid in close adaptation the proximal portion of restoration to self cleansable
of restoration to tooth surface. areas.
• Bevels can be used to extend the cavity preparation 2. Secondary flare: It is a flat plane superimposed peri-
without any drastic tooth reduction especially surface pherally to a primary flare.
defects or faulty grooves.

Figure 21-8: Proximal box in class II inlay should have

Figure 21-6: Occlusal bevel flares and result in metal of 40°
398 Essentials of Operative Dentistry

Function and indications Slot

• In addition to function of bevels. • This is placed on the floor of the preparation.
• This is used in wide proximal box restorations • They are different from internal box preparations in
superimposing over primary flare. that the slot walls are continuous with slot walls
• In wide proximal boxes secondary flare brings without any definite angles.
margins to self cleansable areas. • Bur No. 169L is used for slot preparation.
Pins
Mechanical Design Features Pins can be threaded, cemented or cast onto the cast
(Figures 21-9 to 21-20) restoration.
• Cast restorations are usually indicated for teeth with
Collar
compound and complex caries process.
• To increase the retention and resistance form of
• In addition to primary form of retention like parallelism
preparation a shoulder of 0.8 mm width and a height
in preparation walls, dovetail and friction between res-
of 2-3 mm occlusogingivally should be prepared on
toration and tooth, other auxillary means of retention
the facial or lingual surface of the cusps. This is
are:
mainly employed in onlays.
Luting cement
• This is usually given by No. 271 carbide bur.
• Their action is primarily, locking the cast to tooth
• On the gingival margin of shoulder a bevel is placed
structure by filling the space between them and
to result in marginal metal of 30°.
wetting the details of both the restoration and tooth
• All the margins should be rounded and no junction
preparation.
should be sharp.
• Some cements also bonds to tooth structure but their
Skirt
primary mode of retention is friction between
restoration and tooth preparation. • Are thin extensions of the facial or lingual proximal
Grooves margins of cast restorations inlay or onlay that extend
• Grooves should be placed only on dentin without from secondary flare to a termination just past the
undermining enamel. transitional line angle of the tooth.
• It could be placed on proximal box, axial wall or on
the gingival wall.
• In addition to auxillary form of retention they also
prevent the rotation of restoration.
Reverse bevel
• This is usually placed at the gingival floor, locking
the restoration and preventing proximal displace-
ment of restoration.
• It should be used only if there is sufficient gingival
floor and there is no danger of undermining of dentin. Figure 21-9: Groove extensions
Internal box
• This is one of the most efficient way of locking the
cast restoration.
• Box should consist of definite walls, floors.
• It is placed near the marginal ridge of caries
uninvolved side.
• Usually done using 169L bur.
External box
• It is placed on the axial surface of preparation on the
external surface of the tooth.
• It is prepared in box shaped form with definite walls
and floors.
• They are prepared with No. 169L bur. Figure 21-10: Reverse bevel
 Class II Inlay Restoration 399

Figure 21-14: Slot

Figures 21-11A to C: Capping cusp

Figure 21-12: Internal box

Figure 21-15: Post

Figure 21-13: External box Figure 21-16: Skirt preparation

400 Essentials of Operative Dentistry

Figures 21-17A to F: Collar preparation

Figures 21-18A to F: Slot preparation

 Class II Inlay Restoration 401
Posts
For a badly broken down teeth and endodontically
treated tooth posts can aid in retention of the cast
restoration.
Reciprocal retention
• In cast restoration every portion of cavity preparation
should be retentive.
• If one side of preparation is retentive while other
side is not it can lead to failure of the restoration.
• Therefore placing auxiliary and primary retentive fea-
tures should ideally be opposites of the preparation.
Figures 21-19A and B: Slice preparation Etching of tooth and restoration
• Tooth preparation surface could be etched with
phosphoric acid and metal cast restoration could
electrolytically etched to create a rough surface for
aid in retention by luting agents.
• Ceramic cast restoration is etched by hydroflouric acid.
• In both these instances the luting agent is resin
cement.

Class I Inlay
Indications
Figure 21-20: Pins • Used when other teeth have been restored with gold
restorations.
• This skirt extension gives resistance form thereby
• Used when rest should be prepared on the restoration
preventing tooth fracture and also increases retention
for removable partial dentures.
form.
• This feature is usually employed only when facial or Occlusal Portion of Class I Inlay is Same as
lingual walls of proximal box are not sufficient for
Class II Inlay
retention.
• This preparation is placed entirely in enamel. Tooth Preparation (Figures 21-21A to C)
• This preparation is done by fine grit flame shaped • Preoperative occlusion has to be checked, local
diamond, provding marginal metal of 40°. anesthetic administered not required in preclinical
• This preparation is not only done to aid in retention exercises followed by rubber dam application.
form but also to change the proximal contour of tooth. • Preparation must allow for placing and removal of cast
Both skirt and collar preparations are not done in restoration and margins must be designed to close the
maxillary premolars because they cause unesthetic interface between tooth and restoration.
metal display. • Preparation is started with bur No. 171 and taper of
Slice preparation preparation be 6-10°. The pulpal floor has to be flat.
• It is similar to flare given in proximal box preparation, The buccolingual width of preparation be not more than
its given using a disk, this is seldom used nowadays. 1/3rd intercuspal width.
• Two types of slice preparation are: • All the grooves are included in the preparation. Occlusal
1. Slice preparation bevel is given by flame shaped diamond.
2. Auxiliary slice preparation. • Marginal ridge has to be left intact without too much
Capping of cusp undermining of the ridge.
• This procedure can increase the retention form and • Cavity margins near mesial and distal margins must be
resistance form. away from the ridges by 1.6-2 mm.
• But usually this procedure reduces the retention form • Whenever there is remaining caries after initial cavity
because it shortens the cuspal height. preparation it is removed and base should be placed.
402 Essentials of Operative Dentistry

Features in Class I Inlay

• Width of preparation should not be more than 1/3rd
intercuspal width.
• Occlusal bevel should result in 40° marginal metal.
• Depth of cavity preparation should be 0.5 mm into dentin.
• No undercuts be present in the preparation.

Tooth Preparation for Class II

Cast Restorations
Class II Inlay (Figures 21-21A to 21-22B)
Indications and Contraindications
• Cast metal restoration is preferred over amalgam
restoration because of its superior strength and better
control of contour and contact of restoration.
• Cast restoration is treatment of choice for tooth greatly
weakened by caries or failing restoration.

Figures 21-22A and B: Class II inlay in premolar

Other Indications
• Biocompatibility of alloy: Both high noble alloys and low
noble alloys have excellent biocompatibility, making
them to be used ideally in intraoral environment.
• Extent of proximal caries: When proximal caries is
extensive and gingival extent of caries is more then cast
restorations are preferred.
• Diastema closure or occlusal plane correction: Often cast
restoration could be used to close gap between teeth
and also to correct occlusal plane which may have been
altered for some pathological reason.
• Removable prosthodontic abutment: When tooth to be
selected for abutment usage then cast restoration is
preferred over amalgam restoration.

Contraindications
• Extent of facial or lingual caries or previous restorations:
Facial or lingual surface is affected by caries inaddition
Figures 21-21A to C: Occlusal bevel is given by flame to proximal surface involvement, then a full crown is
shaped diamond suggested.
 Class II Inlay Restoration 403
• Root canal filings: Root canal filled tooth are often restored
with full crown.
• Economics: Cast restorations are expensive compared to
amalgam restoration, which may prevent its usage.
• Age of the patient: In younger patient amalgam or
composite restoration for class I or II cavities are
preferred. The reason being pulp chamber might be
higher preventing extensive tooth preparation.
• Esthetics: Patient concerned with metallic display may
prevent its usage in patients.

Indications for Inlay Restoration

• Cavity preparation more than 1/4th intercuspal width
but less than 1/3rd.
• Strong self resistant cusps remain.
• Occlusion need not be changed. If occlusion needs to be
changed an extensive preparation like onlay or full Figure 21-23: Burs No. 271, 169L, flame shaped diamond
crown is indicated.

• Suggested burs are No. 271 and No. 169L (Figure 21-23).
Occlusion
• Marginal bevels are placed with a slender, fine grit,
Preoperative occlusal relationship should be evaluated flame shaped diamond No. 265-8F or No. 8862.
which includes both static and dynamic relations. • Throughout the cavity cutting process the cutting
instruments used to develop the longitudinal walls are
Local Anesthesia oriented to a single draw path, so that the final
• Has to be administered to the tooth being operated upon preparation does not have any undercuts.
for both pain control and control salivation. • Gingivocclusal divergence of cavity walls ranges from
• Not required in preclinical exercises. 2-5°. In short cavity walls the degree of divergence in
only 2°. As the cavity walls height increases the degree
of divergence increases.
Consideration for Temporary Restoration
• This procedure as such is not required to be done in Outline form, retention form, and resistance form
preclinical exercises. • A No. 271 carbide bur is used to enter near the involved
• Before tooth preparation, an alginate or rubber base marginal ridge (distal marginal ridge) of depth pulpally
impression is taken. about 1.75 to 2 mm (Figures 21-24A and B).
• If preoperatively tooth has a large defect it can be filled • Bur should be rotating as it enters the tooth and also as
up with utility wax. it leaves the tooth.
• This impression is poured and cast is later used for • At all times bur should be kept parallel to long axis of
temporary restoration fabrication. tooth.

Cavity Preparation for Class II Cast Metal

Inlays
Maxillary premolar is taken as an example.

Initial Cavity Preparation

Convenience form
• Carbide burs used for cavity preparations are plane cut
and tapered fissure burs. So that the walls of preparation
will be smooth. Figures 21-24A and B: Outline form
404 Essentials of Operative Dentistry

Figures 21-25A to D: Class IInd inlay preparation

• Cavity preparation is extended along the central • At this stage if high speed handpiece was employed
fissure to opposite triangular fossa of same depth of the enamel wall would break-off if remaining enamel is
1.75-2 mm. Ideally facioligual width of preparation is there its broken off with a spoon excavator.
1 mm when there is minimal or no caries. • Proximal box at this stage might have ragged edges.
• Marginal ridge that is not involved by caries should be • Planing of distofacial, distolingual and gingival walls
kept as strong as possible. is done using hand cutting instruments like hatchet,
• Faciolingual extension of cavity preparation of the bin-angle chisel or hoe.
unaffected mesial marginal ridge is done to give dovetail • Facial and lingual wall of proximal should ideally clear
form which resists displacement of restoration (Figures off from the adjacent tooth by 0.5 mm.
21-25A to D). • Diamond rotary stones could be employed to finish the
• Continuing at same depth the preparation is extended enamel walls instead of hand instruments, if this be the
to distal marginal ridge to expose the proximal dentino- case then is done after:
enamel junction. As preparation is extended distal • Removal of any remaining caries and old restorative
marginal ridge the faciolingual width of preparation is material.
widened in anticipation of proximal box to clear • Application of base.
adjacent tooth by 0.5 mm. Reason being when rotary instruments are used there
• Facial and lingual walls should go around the cusps in are chances of gingival bleeding which may obscure
graceful curves. the above mentioned procedures.
• Retentive grooves are placed on the facioaxial and
Proximal Box (Figure 21-26A) linguoaxial line angles especially if the tooth is short.
• Continuing with bur No. 271 carbide bur, isolate the These are prepared by bur No. 169L and placed fully in
distal enamel by cutting a proximal ditch. Allow harder dentin (Figure 21-26B).
enamel to guide the bur.
• Mesiodistal width of proximal ditch be 0.8 mm of which Final Cavity Preparation
2/3rd in dentin and 1/3rd in enamel. Removal of infected carious dentin and application of base
• Extend the preparation gingivally so that the gingival (Figure 21-27):
wall clears the adjacent tooth by 0.5 mm. • This step of removal of remaining caries is not done in
• Make two cuts on the proximal ditch one at facial limit preclinical exercises.
and other at lingual limit. Extend these cuts until the • Use a slowly revolving round bur (No. 2 or No. 4) or
bur emerges through the enamel surface. spoon excavator to remove the carious infected dentin.
 Class II Inlay Restoration 405

Figure 21-26A: Class II inlay proximal box preparation

406 Essentials of Operative Dentistry

Figure 21-26B: Class II inlay proximal box preparation

• Light-cured glass ionomer cement may be mixed and Preparation of Bevels and Flares
applied with a suitable applicator to these shallow (or (Figures 21-28A to G)
moderately deep) excavated regions to the depth and • After the cement base (where indicated) is completed,
form of the ideally prepared surface. the slender, flameshaped, fine-grit diamond instrument
• Placement of base in these excavated areas is mandatory is used to bevel the occlusal and gingival margins and
as it prevents formation of undercut areas. to apply the secondary flare on the distolingual and
• Glass ionomer cement is placed with a plastic filling distofacial walls.
instrument or periodontal probe. Any excess cement is • Also No. 169L bur or if access permits fine sandpaper
trimmed off after cement has set using No. 271 bur. disk or cuttle disk may be employed for preparation of
• If remaining caries is close to pulp then calcium flares.
hydroxide cement is applied which is overlaid with • While preparing gingival bevel, tilt the rotating instru-
glass ionomer base. ment mesially so that a marginal metal of 30° is
• Sometimes, if it is deemed that additional retentive achieved. The gingival bevel should be of 0.5-1 mm
areas are necessary then retentive coves using ¼ bur wide.
could be utilized. • This should result in 30-40° marginal metal on the inlay.
• With regard to good resistance form pulpal form should • This cavosurface design helps seal and protect the
not entirely be of base, but atleast two points of sound margins and results in a strong enamel margin with an
dentin be there (Tripod effect). angle of 140-150°.
• Remaining old restorative material on the internal walls
should be removed if any of the following conditions Gingival bevel serves following purpose:
are present: • Weak enamel is removed and enamel wall is in
• The old material is judged to be thin and/or confluence with enamel rod direction.
nonretentive. • Bevel results in marginal metal of 30° which is
• There is radiographic evidence of caries under the burnishable.
old material. • A lap sliding fit is ensured because of bevel at gingival
• The pulp was symptomatic preoperatively. margin which greatly reduces marginal discrepancy.
• The periphery of the remaining restorative material • Gingival bevel should uninterruptedly continue with
is not intact. the secondary flare of proximal box.
• Petroleum jelly or vaseline is applied over the glass • Using the flame-shaped diamond instrument,
ionomer base to prevent adherence of temporary rotating at high speed, prepare the lingual secondary
material and impression material. flare.
 Class II Inlay Restoration 407

Figure 21-27: Removal of carious dentin and applying base

408 Essentials of Operative Dentistry

• Proximal walls facial and lingual extends in two plane • 40° of marginal metal is burnishable.
first is primary flare and second is secondary flare. • More stronger enamel margin is created.
This flaring should result in marginal metal of 40°. Occlusal bevel is given using a slender flame shaped
While preparing gingival bevel it is necessary to retract diamond rotary instrument, it provides:
the marginal gingival or gingival sulcus using gingival • More enamel strength.
retraction cord. • Burnishable marginal metal of 40°.
Secondary flare is given for following reasons: Desirable angle of marginal metal is 40° for all surfaces
• Proximal margins extend into self cleansing embra- except the gingival margin which has marginal metal of
sures. 30°.

Figure 21-28: Contd...

 Class II Inlay Restoration 409

Figures 21-28A to G: Final cavity preparation: Bevels and flares

410 Essentials of Operative Dentistry

Bevels could also be given with hand instruments like

gingival marginal trimmer and angle former.

Mesiocclusal-distal Cavity Preparation

Marginal ridge uninvolved by caries in class II lesion must
be carefully evaluated for its integrity and strength. If it is
weakened then this proximal surface has also to be
prepared (Figure 21-29).

Mandibular Premolar
Because of its small lingual cusp and a large facial pulp
horn, the pulpal floor has to slant slightly lingually.
Occlusal cavity preparation should be more at the expense Figure 21-29: Mesiocclusal-distal inlay preparation
of facial cusp than lingual cusp (Figures 21-30A to C).

Maxillary Premolar
Proximal especially on mesiofacial wall is given minimal
flare to minimize the exposure of metal (Figure 21-31).

Facial or Lingual Groove Extension

• Sometimes facial groove and mandibular molars or
distal oblique groove in maxillary molar will be involved Figures 21-30A to C: Mandibular premolar cavity preparation
which should be included in the cavity preparation
(Figures 21-32A and B).
• This groove should be done by No. 270 carbide bur, depth
of preparation should be 1.75-2 mm. The axial wall should
follow the contour of external surface of tooth.
• With flame shaped fine grit diamond a bevel is given
on the mesial and distal walls of the groove extension.
This bevel should provide for 30° marginal metal and
be continous with occlusal bevel.

Class II Preparation with Gingival Extension

to Include Root Surface Lesions
Gingival extension should primarily be accomplished by
Figure 21-31: Maxillary premolar with minimal
lengthening the gingival bevel, especially in treating teeth extension into facial embrasure
with gingival recession (Figures 21-33A and B).

Figures 21-32A and B: Facial groove extension in class I inlay

 Class II Inlay Restoration 411
• Guarding against lingual surface groove extension
close to proximal box preparation.
• Preparation started with No. 271 carbide bur, first
reduce the distolingual cusp by 1.5 mm.
• Then prepare the occlusal portion and proximal box
preparation.
• Lingual groove extension is done after establishment
of proximal box as a minimum of 3 mm tooth
structure has to be there between proximal box and
lingual groove extension.

Figures 21-33A and B: Gingival extension is done by Increased retention form is given by No. 169L bur by
extending the gingival bevel preparing:
• Mesioaxial and distoaxial grooves in the lingual surface
extension.
Maxillary Molar with Unaffected Oblique Ridge • Facial and lingual retention grooves in proximal box.
(Figures 21-34A and B) A lingual counter bevel is given on the distal cusp which
should result in marginal metal of 30°, bevel should be
If oblique ridge in maxillary molar is unaffected by caries
0.5 mm. Gingival bevel on lingual groove surface extension
then a mesiocclusal restoration or distocclusolingual
should also be of same dimension.
restoration with capping of small distal cusp be enough.
Retention form in distocclusolingual cavity preparation Capping Cusps (Figures 21-36A to D)
is given by:
• When cavity preparation is extended up the cusp slope
• Creating a minimum of 2° divergence.
and in more than half way distance from primary
• Accentuating certain line angles.
occlusal to cusp tip, then capping should be considered.
• Extending the lingual surface groove of at least 2.5 mm
When cavity preparation is more than 2/3rd inter-
occlusogingivally.
cuspal width capping of cusp is mandatory.
Resistance form is given by: • This procedure is mainly done to strengthen the
• Routine capping of distal cusp (Figures 21-35A to C). weakened cusp and prevent placing occlusal cavity
margin under heavy occlusal stress.
• But cuspal capping greatly reduces the retention form
of preparation because of reduced cuspal height.
Therefore, additional features like grooves and skirts
are employed.
• Cuspal reduction when indicated is done as a first step
as it greatly improves the vision and accessibility.
• Cuspal reduction is started with ‘depth gauge grooves’
Figures 21-34A and B: Mesiocclusal class II inlay in with side of No. 271 bur of about 1.5 mm. This depth
maxillary molar with unaffected oblique ridge
gauge grooves provide uniform cuspal reduction. In
maxillary premolar because of esthetics the reduction
is only of 1 mm.
• A bevel is prepared on the facial margin of reduced
cusp with flame shaped fine grit diamond. This bevel is
called as reverse bevel or counter bevel. This should
provide marginal metal of 30°. This counter bevel is not
given on facial cusp of maxillary premolar because of
its presence in esthetic zone.
Figures 21-35A to C: Distocclusal class II inlay in upper • Once the cuspal reduction is completed all the corners
molar with capping of distopalatal cusp are rounded.
412 Essentials of Operative Dentistry

Figures 21-36A to D: Capping cusp

• Occlusal bevel should have enamel margin of 140° or

Features of Class II Inlay Preparation
marginal metal of 40°.
• Intercuspal width of occlusal preparation should no • Proximal box should clear from adjacent tooth by 0.5 mm.
more than 1/3rd. Occlusal preparation should include • Proximal box should have primary flare if required
dovetail form. secondary flare.
• No undercuts in preparation be there. With one eye • Gingival bevel should result in marginal metal of 30°.
shut the preparation should be surveyed for any • All the bevels should be of width 0.5-1 mm.
undercuts (Figure 21-37). • Pulpal floor should be flat (Figures 21-38A to D).
• Taper of prepration be 2-5°. • All the line angles and point angles be rounded.
 Class II Inlay Restoration 413

Figure 21-37: Presence of undercut is evaluated with one eye shut

Figures 21-38A to D: Sequence in preparation of inlay cavity in mandibular molar

• Cement spatula
Common Pitfalls • Plastic filling instrument
• Tooth preparation too narrow or wide. • Enamel chisel
• Proper width and angle of bevel not given. • Enamel hatchet
• Preparation has undercut. • Gingival marginal trimmer ( both right and left)
• Tooth preparation is not cleared from adjacent tooth. • Tofflemire retainer and Matrix band No. 8
• Preparation not smooth. • Wedges (round and triangular)
• Articulating paper and articulating forceps.

Armamentarium Rotary Cutting Instruments

Tray Instrument Set-up • Airotor handpiece, slow speed handpiece
• Burs (tungsten carbide burs No. 170,171,169L) (Fine
From left to right
grit flame shaped diamond)
• Mouth mirrors
• Sandpaper or cuttle disk.
• Explorers
• Tweezers
• Chip syringe Miscellaneous
• Cotton holder with cotton • Gauze cotton
• Spoon excavator • Rubber dam kit
414 Essentials of Operative Dentistry

• Gingival retraction cord Temporary restorations are required for all cast
• Lubricant (Vaseline) restorations as the final restoration is placed on the tooth
• Inlay wax only the second appointment.
• Hollen back carver While the cast inlay is being constructed, an accurate
• Cleiod-discoid carver temporary restoration is needed for the following reasons:
• PKT wax dropper and carvers. • To protect the pulp
A preclinical conservative dentistry student is expected • To prevent ingrowth of gingival tissues
to prepare class II inlay cavity preparation and fabrication • To prevent alteration of occlusal and approximal
of wax pattern directly. contacts
• To prevent fracture of weakened cusps
Fabrication of Wax Pattern • To restore appearance and comfort.

Direct Method (Figure 21-39) Direct Method

• Fabrication of direct wax pattern requires high degree • The cavity is lightly lubricated with Vaseline and a
of skill to produce an accurate casting. matrix band is fitted to the tooth. The band is burnished
• Matrix band is adapted onto tooth and correct and to obtain accurate approximal contacts, and wedges
contour is formed by burnishing the matrix band. are placed to ensure good cervical adaptation. The self-
• Tooth is lubricated using Vaseline with cotton. cure resin is mixed and when it has a putty consistency
• A stick of hard inlay wax is heated and dropped onto it is firmly placed into the band.
cavity preparation and the wax is allowed to cool. • As the resin sets it loses its plasticity and the temporary
• With a hot egg burnisher contour the occlusal wax inlay can now be removed. It should be replaced gently
portion. and withdrawn a number of times until it has set. Excess
• Remove the matrix band and pattern will come out with resin is now trimmed off the inlay outside the mouth
matrix band, inspect the pattern for internal details and with a bur or stone in a laboratory handpiece. Finally,
replace onto cavity preparation. the inlay is inserted and the occlusion is checked with
• Carve the occlusal portion and the embrasures with articulating paper and adjusted until it is correct in
Hollenback carver. intercuspal position and in lateral excursions. The
• Pass a floss through the contact and smoothen the inter- temporary inlay is finally smoothed with a rubber wheel
proximal contact bypassing a fine soft silk through the before cementing it with a zinc oxide and eugenol
contact. temporary luting cement.
• Smoothen the wax pattern with cotton pellet soaked in
acetone. Indirect Method
• Remove the wax pattern by attaching a sprue (formed
by a copper wire) to the bulkiest portion of pattern. Advantages
• Inspect the wax pattern for any voids or defects. • Avoids placing polymerizing self cure resin on exposed
• Then the pattern is invested (Figure 21-39). dentin.
• Prevents accidental locking of temporary resin into the
Indirect Method cavity preparation if there is any undercut in the
• An impression is taken either with alginate or rubber preparation.
based material. A model is poured. • Provides an opportunity to inspect the cast before final
• Upper and lower model are mounted in an articulator. restoration fabrication.
• A wax pattern is fabricated in the model, the pattern is • Fabrication of temporary can be delegated to a qualified
invested and cast into metal. dental mechanic.

Method (Figure 21-40)

Temporary Restoration • A preoperative impression prior to preparation of tooth
which was already taken is needed if it was taken with
It can be fabricated either by direct method or by indirect alginate it should have been wrapped in a moist paper
method. towel or cotton.
 Class II Inlay Restoration 415

Figure 21-39: Preparation of wax pattern (Direct method). Step 1: Matrix band adapted tooth. Step 2: Separating media is applied
to tooth. Step 3: Wax is placed into tooth preparation. Step 4: Hot egg shaped burnisher is used to burnishing. Step 5: Burnishing
done with egg shaped burnisher. Step 6: Occlusal portion is carved. Step 7: Dental floss is passed through the contact to establish
the tightness of contact. Step 8: Final burnishing done. Step 9: Wax is cleaned with acetone. Step 10: Finished wax pattern.
Step 11: Sprue is attached to wax pattern. Step 12: Wax pattern is invested

• A postoperative impression after preparation of tooth the prepared tooth in the model and pressed against
is taken and gypsum model is poured. the preoperative impression and the model is held onto
• The preoperative impression’s gingival sulcus the impression by a rubberband.
extensions are cut away, and this impression is made • Once the resin sets it is removed from the model and its
to fit over the postoperative model. The fit should be excess is trimmed off using small acrylic burs.
verified so that there is no discrepancy in the fit. • Then the temporary is tried onto the mouth and any
• Once the fit is satisfied a separating agent like cold occlusal adjustment is done with No. 271 carbide burs.
mould seal can be applied onto the prepared tooth in The temporary is finished and polished.
the model. • The temporary is luted onto the teeth using a zinc oxide
• A tooth colored self cure resin is mixed and placed over eugenol cement.
416 Essentials of Operative Dentistry

Figure 21-40: Preparation of temporary (Indirect method). Step 1: A postoperative impression is checked for accuracy like bubbles,
voids and proper gingival retraction. Step 2: A postoperative model is taken. Step 3: Preoperative impression gingival sulcus
extensions are cut away. Step 4: Preoperative impression is fitted and tried on the postoperative model. Step 5: Cold mold seal is
applied onto the prepared tooth. Step 6: Tooth colored self cure resin is placed onto the preoperative impression in the required
tooth. Step 7: Impression is pressed against the model and held in place by rubber band. Step 8: Temporary is tried onto the tooth.
Step 9: Temporary is trimmed and polished

Armamentarium for Temporary • Various different impression materials are utilized

Restoration it can alginate, gar or rubber based impression mate-
rials.
• Preoperative impression.
• Before taking impressions it is mandatory for tissue
• Postoperative model.
control, this is done by utilizing gingival retraction cord
• Self cure tooth colored acrylic resin.
which is placed around the gingival sulcus of prepared
• Dappen dish and spatula for mixing resin.
tooth, left there for 3–4 mts. Then it is taken out, the
• Vaseline.
purpose of this procedure is to move away the free
• Cold mould seal.
gingiva surrounding the preparation so that exact
• Explorer.
impression could be got.
• Burs (No. 271, acrylic trimmer, carborundum disk).
• Before the impression is poured it is inspected for voids,
• Cloth wheel for polishing temporary.
bubbles or any other defects. The impression should be
• Zinc oxide eugenol cement.
disinfected as per manufacturer’s instructions before
pouring.
Final Impression • Model is poured and articulated in patient’s maximum
• For fabrication of wax pattern by indirect method this intercuspal position (Figure 21-41).
impression is utilized. • Wax pattern is made from this model.
 Class II Inlay Restoration 417
• Now using a rubber wheel the casting is polished, the
casting is placed on the articulated model and checked
for occlusion (Figure 21-44).
• Using Tripoli or Rouge and cloth wheel the casting is
polished to get the final gloss (Figure 21-45).
• Place the casting in a solvent solution to remove traces
of polishing agent before placing in patient mouth.

Figure 21-41: Articulated model

Adjusting and Polishing the Casting

• Once the casting has been done, it is examined under
magnification for any blebs, defects or voids. If there are
any projections they should be removed with a small
bur.
• With sprue still attached to the casting try the casting
onto the prepared tooth in the model. If casting fails to
seat it should be inspected where it fails to seat and any
metal projections if found should be removed.
• Now the sprue is removed using carborundum disk
(Figure 21-42).
• Once the casting seat onto the model it is hand Figure 21-44: Using a rubber
wheel for finishing
burnished along the margins using ball burnisher to
improve the marginal fit (Figure 21-43).

Figure 21-42: Cutting off sprue using

a carborundum disk

Figure 21-45: Using cloth wheel and Tripoli

for imparting luster to casting

Trying in Mouth
• Casting is now removed from model and tried on
patient’s mouth.
• Temporary inlay is removed from tooth using a hand
scalar and any remnant temporary cement is removed
Figure 21-43: Hand burnishing of margins
of casting using a burnisher carefully without damage to preparation.
418 Essentials of Operative Dentistry

• 3 × 3 inch gauze is used as a throat screen while casting Checking for Occlusal High Points
is tried on mouth to prevent aspiration of casting.
• After evaluation of the fit and proximal contacts of
• Casting is fitted onto the tooth and its margins are
casting.
evaluated and it is determined whether the casting is • The patient is asked to bite in maximum intercuspation
satisfactory or should be repeated (Figure 21-46). position and a articulating paper is used to evaluate for
• Proximal contact tightness is evaluated using a dental any high points.
floss, most of the tight proximal contact prevents proper • Any high points are evaluated by holes on the
seating of inlay.
articulating paper or heavy marking on the casting. Also
• To properly seat the casting masticatory pressure of
shiny areas due to occlusal contact of cusp is also taken
patient is utilized, by asking the patient to bite on a as high points.
Burlew disk which is kept over the inlay. Cotton is not • These high points are reduced on the casting with
advised for applying bite pressure to inlay as it is too abrasive stones.
soft (Figures 21-47 and 21-48). All high points are reduced until:
• Heavy markings are no longer produced when
patient bites.
• Contacts are placed on optimal position and form
• There are even distribution of contacts.
Occlusal high points are also evaluated for lateral
movement and protrusion movement of mandible (Figures
21-49 and 21-50).

Figure 21-46: Casting is fitted onto tooth

using a firm pressure with burnisher

Figure 21-49: Articulating paper utilized

for evaluation of high occlusal points

Figure 21-47: Biting pressure

using Burlew wheel

Figure 21-48: Explorer should be able to pass Figure 21-50: High occlusal points are
from the restoration to tooth surface smoothly grinded off using abrasive points
 Class II Inlay Restoration 419
Improving Marginal Adaptation (Burnishing) spoon resting against the marginal ridge of the adjacent
tooth. With the tip of the spoon firmly seated against
• This is called as ‘dress down’ the margins.
the metal casting, pivot the spoon using the adjacent
• Here the marginal adaptation is improved using a ball
tooth as a fulcrum (Figures 21-52A and B).
burnisher against the cavosurface margins, also cleiod
instrument be used in areas of grooves.
• Once the burnishing has been finished an explorer tip
Soldering Contacts
should be able to pass throught the margin of restoration When casting is short on the proximal contact with adjacent
to tooth surface uninterruptedly (Figures 21-51A to C). tooth, a solder of 650 or higher is added to the casting. The
diiference between solidus temperature of the inlay and
liquidus temperature of the solder should be 100°F.

Method
• First resurface the proximal area of casting using an
abrasive wheel to remove traces of any polishing agents
as it may act as antiflux.
Figures 21-51A to C: Burnishing of casting margin using • Next cut a piece of strip of solder so that it extends 1 mm
burnisher, cleiod instrument or abrasive points beyond the contact area.
• Apply borax type flux over both the solder and casting.
Removing the Casting from Tooth • Now the casting is held in a plier with the solder in
proper position and heated over a Bunsen burner, until
• 3 × 3 inch gauze as throat screen is essential.
the flux effervescent and water is removed.
• To remove the casting a spoon excavator may be
• Apply the melt solder onto the casting and it will flow.
utilized as, the tip of the spoon is inserted as deep as
• Now the contact is trimmed and polished.
possible in the occlusal embrasure with the back of the
Cementation
Most common cements employed for luting the inlays are:
• Zinc phosphate
• Polycarboxylate cement
• Glass inomer cement
• Resin cements.
Zinc phosphate cement has the advantage of low film
Figures 21-52A and B: Throat screen should be used prior to thickness, good retention, good working time, and easy
removal of casting. Casting is removed using a spoon excavator removal of set cement (Figures 21-53 and 21-54).

Figure 21-53: Cementation of inlay and removal of excess cement

420 Essentials of Operative Dentistry

typodont tooth, procedure of patient biting is omitted and

manual pressure is applied.

Key Terms
• Cast restoration • Full crown
• Bevels • Inlay
• Direct wax pattern • Flare
• Onlay • Indirect wax pattern
• Slot • Pinlays
• Taper • Skirt
Figure 21-54: Postcementation radiograph showing • Collar • Slice preparation
correct contact, contour and no gingival overhangs • Burnishing • Cuspal capping

• Before cementation is attempted, the tooth is isolated Questions to Think About

using cotton rolls and tooth is removed of any saliva
1. What are cast restorations? Write about advantages
using air syringe.
and disadvantages of cast restorations.
• Next the mixed cement is applied onto the tooth surface
2. What are the principles of cast restorations? Discuss
of the casting and carried to the prepared tooth and
about various types of bevels and in detail about
pressed using a ball burnisher.
functions of occlusal and gingival bevel.
• Next the patient is asked to bite tightly on to a Burlew
3. What are flares and types of flares? Discuss about
disk.
functions of flares.
• Any excess unset cement is removed using an explorer.
4. What are the different restorative materials used for
Excess cement present in the interproximal area is
class II inlays?
removed using a dental floss.
5. Write about class I inlay tooth preparation?
• When adaptation and marginal fit on inlay is proper
6. What are the indications and contraindications of
no cement line should be visible.
class II inlays?
7. Discuss about steps in class II inlay preparation.
Repair 8. Write about bevels and flare preparation in class II
If any small portion of inlay is fractured off it could be inlay preparation.
repaired with amalgam or composite. 9. What are the features in class II inlay preparation?
When trying the casting or cementation done on the 10. Discuss about cuspal capping procedure.
 Cast Onlay Restoration 421

22 Cast Onlay
Restoration

• Cast metal onlay by definition caps all of the cusps of a • Cuspal protection of all cusps is necessary.
posterior tooth, can be thoughtfully designed to • In tooth preparation, if the length : width ratio of a cusp
strengthen a tooth that has been weakened by caries or is more than 2 : 1.
previous restorative experiences (Figures 22-1A to C). • When there is need to change the occlusal inter-
• Cast metal onlay restoration spans the gap between relationship between the maxillary and mandibular
inlay which is primarily an intracoronal restoration and teeth.
full crown which is primarily an extracoronal restoration. • Onlays are ideal restorations for abutment teeth in
• It is partly an intracoronal restoration and partly an partial dentures (both fixed and removable).
extracoronal restoration. • When excessive tooth wear of occlusal surfaces include
cuspal tips.
Advantages
• It is designed in such a way to eliminate the dis- Tooth Preparation
advantage of tooth fracture that occurs with cast inlay
Certain basic features in onlay tooth preparations are:
restoration (Figures 22-2A to C).
• All finish lines are beveled.
• It is more conservative than full crown.
• Beveled shoulder is the finish line for centric cusp that
is capped.
Indications • Long bevel or chamfer finish line is used for noncentric
cusp.
Besides general indications for cast restorations that we • Gingival margins are designed like those in inlay
have seen in Chapter 21, specific indications are: preparation with bevels and flares.

Figures 22-1A to C: Onlay covering all the cusps

422 Essentials of Operative Dentistry

Figures 22-2A to C: (A) Inlay restoration experiencing occlusal

forces, (B) Tooth fracturing because of occlusal force in inlay
restored tooth, (C) Onlay restoration protecting the tooth from
fracture
Figure 22-3: Features in class II cast metal onlay preparation
• All these finish lines are blended to form an un-
interrupted finish around entire preparations.
• Any remaining caries or old restorative material is not
removed at this stage.
Initial Cavity Preparation • Throughout the preparation of tooth preparation the
Class II MOD mandibular first molar tooth preparation is bur should be kept parallel to long axis of tooth and
described (Figure 22-3): develop longitudinal walls of preparation with ‘single
• Initial cavity preparation is started with tapered fissure draw path’ so that there are no undercuts.
bur or No. 271 carbide bur. These rotary instruments • After the cuspal reduction an occlusal step depth of
help achieve the necessary taper of 6-10°. 0.5 mm remains.
• First step in preparation sequence is cuspal reduction
as it aids in visibility and access. Proximal Box Preparation
• The bur is held parallel to long axis of tooth and prepares
Proximal box preparation is done in same manner as in
a 2 mm depth cut along the central groove.
inlay tooth preparation.
• With the side of bur depth cut grooves of 1.5-2 mm deep
are made on the functional cusp and 1-1.5 mm depth
cut grooves are made on the non-functional cusps. Final Cavity Preparation
Depth cut grooves serves as template for cuspal Removal of infected carious dentin and/or defective
reduction (Figures 22-4A to C). restorative materials and application of bases:
• After the depth cuts are made a uniform reduction of • Removal of any remaining caries or old restorative
the cusps following the anatomic contour of cusp is material is done in same manner as in inlay tooth
done. preparation.

Figures 22-4A to C: (A) Central groove of 2 mm depth is placed, (B) Depth cut grooves are
placed with side of bur, (C) Cuspal reduction in accordance with occlusal morphology
 Cast Onlay Restoration 423
Preparation of Bevels and Flares
• After the cement base is set, use a slender, flame-shaped,
fine grit diamond instrument to place counter bevels on
reduced cusps, gingival bevel, and secondary flares on
facial and lingual walls of proximal box.
• A gingival retraction cord is placed prior to gingival
bevel preparation.
• Bevels should be of 0.5 mm in width and result in
marginal metal of 30° metal margin.
• Counter bevels placed on reduced cusp so that
cavosurface margin is beyond (gingival to) any contact
with opposing dentition (Figure 22-5).

Figures 22-6A and B: Counter bevel placement on reduced

cusps: (A) Shoulder placement on functional area, (B) Long
bevel placement on the nonfunctional area

• Finished MOD cast metal onlay tooth preparation

((Figure 22-7).

Figure 22-5: Cavosurface margin of counter bevel

be clear of the occlusal contact of tooth

• Counter bevels placed on reduced cusps are of two types

they are (Figures 22-6A and B):
• Shoulder preparation:
• A shoulder is prepared on external surface of
centric cusp to provide a band of metal (ferrule) to
Figure 22-7: Finished MOD cast metal
protect the tooth. onlay tooth preparation
• Bur is held parallel to external tooth surface in
preparing this shoulder it is of dimensions
shoulder height of about 1.0 mm and axial depth Beveling and Flare Preparation
of 1.0 mm.
Beveling and flare preparation is done same as in inlay
• Axial line angles of shoulder in continuation with
tooth preparation.
occlusal step should be rounded.
• Noncentric cusp:
• A chamfer or long bevel is used here instead of Enhancing the Resistance and Retention Form
shoulder. If the tooth preparation height after cuspal reduction is
• Bur is positioned at angle of approximately 45° to low then following things are to be done:
axial surface of tooth. • Minimal amount of taper (2° per wall).
• This provides the necessary ferrule effect. • Incorporation of retention grooves.
424 Essentials of Operative Dentistry

• Preparation of facial and lingual surface groove

extensions like:
Features in Cast Metal Onlay
• Skirt preparation Tooth Preparation
• Collar preparation
• Preparation walls should be 6-10° occlusally divergent.
• Slot preparation.
• Cuspal reduction of 1.5-2 mm in functional cusp and
1-1.5 mm on nonfunctional cusp.
Restoring the Occlusal Plane of Titled Molar • All line angles and bevels are smoothly joined with no
(Figure 22-8) interruption.
• Onlay that covers the entire cusp is an excellent • Gingival, occlusal bevels and flares are prepared in a
restoration for restoring occlusal plane of a tilted molar. manner such that a marginal cast gold metal of 40° is
• Certain modifications in basic design like extending obtained.
the counter bevel placement, line angles and surfaces
on the side where tooth is tilted is extended to obtain Common Pitfalls
the desired contour.
Wax pattern fabrication, impression taking, cementa- • Too much reduction of cusps leading to reduced tooth
tion of casting are essentially same as in inlay restorations. height preparation and loss of retention.
• Preparation is not smooth and all bevels and line angles
are not joined smoothly.
• Undercut in tooth preparation.

Armamentarium
Same as in cast inlay tooth preparation.

Key Terms
• Counter bevel
• Shoulder
• Functional cusp
• Nonfunctional cusp

Question to Think About

Figure 22-8: Mesially tilted maxillary molar to restore the 1. Define onlay. Explain about tooth preparation sequence
occlusal plane cast metal onlay will be an ideal restoration for cast metal onlay on a mandibular molar.
 Tooth Colored Inlays and Onlays 425

23 Tooth Colored
Inlays and Onlays

Introduction bridges, sound occlusal surfaces has to be preserved

even when they are not supported by dentin.
Esthetic restoration for class I and class II tooth prepara- • Resistance form is incorporated in the form of rounded
tion apart from direct composites are (Figure 23-1): proximal boxes with no grooves or locks.
• Indirect composite inlay and onlay • Walls of preparation are smooth and internal line angles
• Ceramic inlay and onlay are rounded.
• CAD/CAM or CAD/CIM (Computer Aided Designing/ • Resistance and retention form is mainly provided by
Computer Assisted Machining) bonding to tooth structure.
Tooth colored inlays/onlays are also called as “Esthetic • Occlusal reduction be as anatomically close as possible
inlays/onlays”. and have minimum reduction of 2 mm.
• Bevels are not placed and butt joint (90°) configuration
is advocated.
• Bases and liners are usually not indicated but is placed
only to block the undercut in preparation. Preferred
choice of liner will be glass ionomer cement.
• Preparation walls should diverge by minimum of 10°.
Greater divergence is required in direct resin inlay
preparation.
• Temporary restoration is usually difficult as most of
time the preparation design will be nonretentive.
Figure 23-1: Classification of esthetic tooth colored
Conventional acrylic temporary can be used either by
posterior restorations direct method or indirect method as explained for cast
restoration.
• Light curable resin temporaries like Protemp (3M ESPE)
General Considerations could also be used.
• Preliminary procedure like local anesthetic admi- • Dual cure resin cements is choice of cement for luting
nistration and isolation with rubber dam are composite and ceramic inlays and onlays because it
mandatory. can bond both to tooth structure and restoration.
• Preparation for indirect composite and ceramic inlays • Prior to luting ceramic inlays or onlays are etched with
and onlays are same. hydrofluoric acid and silane coupling agent applied
• Preparation design for CAD/CAM restoration varies followed by luting with resin cements.
slightly and it is described in last section. • For indirect composite restorations the interior surface
• As in all adhesive restorations conservation of tooth could be air abraded with alumina particles prior to
structure is mandatory, marginal ridges, enamel bonding with reisn luting cement.
426 Essentials of Operative Dentistry

Tooth Preparation Design • Pulpal floor be relatively smooth and flat. Glass ionomer
base could be placed to provide a flat pulpal floor.
(Figures 23-2 to 23-4) • Cuspal capping principle and procedure is same as in
cast restorations but should be reduced of 1.5-2 mm
• Tooth preparation is same as in cast restoration without
and all angles be rounded.
any bevel or flare placement.
• Proximal box preparation is same as in cast restoration
• Occlusal reduction be 2 mm and axial reduction be
without bevels or flares.
1.5 mm.
• All the internal line angles are rounded to prevent stress
formation. Luting Procedure
• A tapered carbide bur or diamond bur is used. Diamond
abrasive has the advantage of producing a rougher • Enamel and dentin in tooth preparation is etched for
preparation to aid in bonding of the final restoration. 15-20 secs, then dried.
• Occlusal divergence of tooth preparation should be • Followed by bonding agent application for tooth
minimum of 10°. structure and light cured for 30 sec.
• Occlusal step be minimum of depth 1.5-2 mm. Groove • Then silane applied ceramic restoration or air abraded
extension be minimum of width 1.5 mm to prevent composite resoration is applied with dual cure resin
fracture of restoration. luting cement and placed onto tooth preparation and
seated properly. Followed by removal of excess cement
and light curing according to manufacturers
instructions.
• Today self etching dual cure resin cements are available
which do not require the steps of etching or bonding
agent applicant to tooth structure, e.g. Rely X (3M ESPE).

Resin Composite Inlays and

Onlays
Figures 23-2A and B: (A) Conventional onlay preparation,
(B) Modified onlay preparation with rounded walls and angles Materials for Indirect Resin Inlays/Onlays
• Problem areas in composites are, high stress situation,
mechanical and physical degradation, polymerization
shrinkage, technique sensitivity, reliable bond to dentin
and cementum. These problems raise major concerns
in Cl - II restorations.
• These are problems are circumvented to a great deal in
using indirect composite resin systems.

Figures 23-3A and B: Rounded internal line angles widened

First Generation Indirect Composite Resin Systems
isthmus and cavity design without any interlocking design
These were introduced in late 1980’s. They include:
• SR isosit system:
• This is microfilled composite.
• Inlays are fabricated on die system and subjected to
heat and pressure polymerization at 120° C and
6 bar pressure in processing unit (Ivomat) for
10 minutes.
• Coltene Brilliant system:
• It contained fine hybrid composite resin.
Figures 23-4A and B: MOD inlay with cuspal capping in • It is polymerized in a special light curing or heat
maxillary premolar oven at 120° C for 7 minutes.
 Tooth Colored Inlays and Onlays 427
• Kulzer system: merized in an oven, heat or pressure pot under intense
• This system employs coarse hybrid composite resin. heat or pressure to ensure complete polymerization of
• Secondary curing is done in a special light box the material. This second polymerization is called as
(Translux) for 6 minutes. “secondary polymerization”.
These first generation composites did not perform any • Modern day indirect composite resins are cured in
better than conventional direct composite restoration. They special postcure unit specifically made for this purpose
had poor physical properties and bonding to resin cements. (Figure 23-5).

Second Generation Indirect Composite Resin Systems

• These were introduced in late 1990’s .
• They are called by term “Ceromers” or Ceramic
Optimized Polymers.
• They have higher strength properties, better wear
resistance and durability.
Some of Ceromers are:
• Artglass (Kulzer)
• Belle Glass HP (Kerr)
• Targis (Ivoclar)
• Skulptor Fiberkor (Jeneric/Pentron).

Resin system Composition Physical properties Figure 23-5: Special postcuring unit

First generation Matrix resin 49%, Flexural strength—

indirect composite filler 72% 7-75 MPa, compressive
Materials for Direct Resin Inlays/Onlays
strength—400-430 MPa, • After inlay/onlay tooth preparation a water soluble
Vickers hardness—34.
separating medium and a matrix band is placed onto
Second generation Matrix 42%, Flexural strength—
tooth.
indirect composite filler 72% 120 MPa, Compressive
strength—447 MPa, • The preparation if bulk filled with direct composite
Hardness—590/n/mm 2 material (direct hybrid resin composite) and light cured.
• After light polymerization the composite is teased out
• Microfilled materials today used are Bis-GMA, UDMA,
form the preparation and if there are no undercuts the
4, 8-di(metha-acryloxymethylene)-tricyclodecane.
composite material should come out easily (Figure 23-6).
• These resin in addition to blue light polymerization are
• The inlay is then cured again extraorally (secondary
polymerized further by a combination of heat and
polymerization).
pressure.
• Then it is finished and polished extraorally. Finally,
• First resins were bonded to metal surfaces by using wire
luted onto tooth.
loops/retention beads. Recent improvements include
chemical bonding systems using 4-META, phosphory-
lated methacrylate, epoxy resins, ‘silicoating’ - silicon
dioxide that’s flame sprayed to metal surface.
There are basically three techniques available:
1. Direct resin inlays/onlays
2. Semidirect inlays/onlays
3. Indirect resin inlays and onlays.

Secondary Polymerization
• Superior properties of indirect composites over direct
composite are due to secondary polymerization.
Figure 23-6: Preparation design should not have any
• Indirect composites are light cured conventionally in interlocking so that resin restoration can be easily removed
the initial stage but after this procedure its further poly- from tooth structure
428 Essentials of Operative Dentistry

Tooth Preparation Design (Figures 23-7A and B) • Some currently used ceromers are, Art Glass ( Heraeus
• Technique mainly adapted to one and two surface Kulzer), Targis (Ivoclar Vivadent), Belle Glass (Kerr).
cavity restorations. • These materials are polymerized in special curing units
• There should be sufficient taper of preparation of to ensure high degree of polymerization.
minimum 15°.
• Preparation walls should be smooth with interlocking. Tooth Preparation Design
• A proper separating medium is to be used. • Same as in cast restoration.
• A tapered carbide bur or diamond bur is used. Diamond
abrasive has the advantage of producing a rougher
preparation to aid in bonding of the final restoration
(Figures 23-10 and 23-11).

Advantages of Resin Composite Inlay and

Onlay Over Direct Composite Restoration
Figures 23-7A and B: Clinical case of direct inlay
• Open contacts and improper proximal contours with
direct composite restoration is negated.
Direct/Indirect Resin Inlays and
• Marginal leakage or gap formation due to polymeriza-
Onlays (Semidirect) (Figures 23-8A to D) tion shrinkage with direct composite is not a problem
• When direct/indirect method is used an impression is here as polymerization of indirect composite is done
made of the tooth preparation a master cast is fabricated. extraorally.
Impression is usually made of rubber based material. • Superior physical properties of indirect composites
• Direct hybrid resin material is used to build-up the because of more complete polymerization occurring
restoration in cast made and light cured and additional extraorally.
secondary polymerization is also done.
• Followed by finishing and polishing and placement in
Disadvantages of Indirect Resin Inlays and Onlays
mouth.
• Increased cost and time factor.
Tooth Preparation Design • Dental laboratory skill in making accurate restorations.

Same as in direct resin inlay only difference being that

some amount of undercuts could be tolerated. Indications
• Esthetics requirement of patients.
Indirect Resin Inlays and Onlays • Large cavities or teeth with large restorations requiring
(Figure 23-9) tooth colored restorations.
• These are available through commercial laboratories.
They are fabricated on die prepared from the impression Contraindications
taken of tooth preparation. • Heavy or abnormal occlusal forces or parafunctional
• They are either microfilled or hybrid composites. habits.
• Newer generation indirect composite materials are • Inability to obtain moisture free environment.
called as ceromers or ceramic optimized polymers. • Deep subgingival preparations.

Figures 23-8A to D: Clinical case of semidirect (extraoral) inlay

 Tooth Colored Inlays and Onlays 429

Figure 23-9: Types of indirect resin inlay/onlay

Figure 23-10: For direct resin inlay an occlusal divergence of

minimum 15° is required whereas for extraoral technique 10°
divergence is only necessary
Figure 23-11: Diamond abrasive produces rougher pre-
paration walls which could aid in bonding and is used in in-
direct resin inlays/onlays
Laboratory Process in Fabrication of Indirect
Composites (Figures 23-12A to C)
• Composite restoration is initially formed on the die.
• Composite is initially light cured for 1 minute with hand
held light cure unit.
• Final curing (secondary polymerization) is accomp-
lished by placing the restoration in curing oven that
exposes the restoration to additional light and heat for
7 minutes.
• Cured composite is removed and allowed to cool. Then
it is finished and polished. Figures 23-12A to C: Clinical case of indirect resin onlay
430 Essentials of Operative Dentistry

Figures 23-13A to D: Direct composite restoration

Figures 23-14A to D: Direct resin inlay/onlay or semidirect resin inlay/onlay

Figures 23-15A to D: Indirect resin inlay/onlay

Indications for Direct/Semidirect/Indirect

Composite Restorations
Size and number of cavities
• Direct composite restoration is indicated for small to
medium cavities (Figures 23-13A to D).
• Wide coverage restorations that cap the cusps are best
restored with indirect composite restorations.
• A single tooth or limited number of tooth with wider
restorations can be best restored with semidirect resin
inlay/onlay (Figures 23-14A to D).
• If several teeth are to be restored it is best restored with
indirect composite restorations as occlusal and
proximal contours are best reproduced by this technique Figure 23-16: Tooth already restored is ideally restored with
(Figures 23-15A to D). direct composite rather than indirect composite which may
• If a tooth has been already restored with amalgam require excess tooth removal
restoration it is best replaced with direct composite
restoration (Figure 23-16). Ceramic Inlays and Onlays
Location of margins • Modern generation ceramic restorations where intro-
• For all type of composite restorations presence of enamel duced in 1983 by Horn JR.
all around the preparation is ideal. • Ceramic materials employed for ceramic inlays and
• If less than 0.5 mm enamel is remaining in the cavo- onlays are all ceramic materials, these include:
surface of tooth preparation then it is best restored with • Aluminous porcelain, e.g. Hi-Ceram.
indirect composite resin restoration (Figure 23-17). • Glass ceramics, e.g. DICOR (Dentsply)
 Tooth Colored Inlays and Onlays 431
Tooth Preparation Design
Same as in indirect resin tooth preparation.

Fabrication of Ceramic Inlay/Onlay

It involves impression taking either with rubber-based
material or alginate.
Ceramic restoration is fabricated using any one of
following techniques:
• Firing
• Pressing
• Casting
• Machining.
The finished and glazed cermic inlay/onlay is etched
Figure 23-17: When less than 0.5 mm of enamel only remains with hydrofluoric acid and luted onto preparation using
then it is an indication for indirect composite restoration dual cure resin cement (Figures 23-18A to E).

CAD/CAM Restorations
• Pressable glass ceramics, e.g. IPS Empress, IPS
Empress 2 (Ivoclar-Vivadent). • Most widely used CAD/CAM system is CEREC
• Slip casting ceramics, e.g. In-Ceram. (ceramic reconstruction system) which was developed
• CAD/CAM ceramics, e.g. Procera, Cerec. in 1980.
• Another system is CELAY system, here a resin wax
Indication pattern is fabricated the external surface of the pattern
is traced mechanically with a probe and dimensions
Same as in indirect composite restorations.
are input to computer and ceramic restorations are
fabricated to these dimensions (Figures 23-19A and B).
Contraindication
Same as in indirect composite restorations.
Advantages
• Time saving procedure and restoration is completed in
Advantages single appointment.
• Adhesion of resin luting cement to ceramics is far better • Ceramics are of high quality with excellent esthetics,
than to composite. strength and minimum voids as ceramics are made from
• It has long-term occlusal stability, i.e. better wear industry manufactured blocks.
resistance than composites.
• Better physical properties compared to composites. Disadvantages
• Better shade matching capability.
• Marginal adaptation mostly these restorations have a
marginal gap of about 52 micron which is greater than
Disadvantages gold casting which can made with minimum gap of
• Repair of fractured ceramic restoration is difficult. 25 micron.
• Time consuming laboratory process and definite two • Minimum staining can be applied externally.
appointment treatment procedure. • Costly procedure and special equipments like optical
• Expensive restoration. scanner are required.

Figures 23-18A to E: Clinical case of ceramic onlay restoration

432 Essentials of Operative Dentistry

Figures 23-19A and B: CAD/CAM process

Cerec System (Figures 23-20 and 23-21)

• Consists of an intraoral camera, video monitor,
computer and a milling chamber.
• Tooth preparation is scanned by camera and data is
fed to computer, where computer analysis the pre-
paration and designs the restoration, the milling unit
with instructions from computer cuts a ceramic block
to the design.
Figures 23-20A and B: Acquitted image on computer monitor
and design of restoration by computer software creates three
dimensional image to be reproduced onto ceramic blank
Inlays/Onlays
Tooth preparation Computer Assisted Design (CAD)
• Tooth preparation is similar to conventional indirect • A dry field is necessary for proper scanning with
ceramic inlay/onlay restoration. precision and accuracy.
• The occlusal aspect is reduced to atleast 2 mm of • After tooth compeletion the tooth preparation is scanned
clearance. using intraoral camera-optical impression.
• All cavosurface margins are prepared to 90° butt joint. • Prepared tooth surface is coated with a reflective material
• Bevels and chamfers are avoided. for better scanning.

Figures 23-21A to C: Clinic case of cerec onlay

 Tooth Colored Inlays and Onlays 433
Computer Assisted Machining (CAM) • Special curing unit
• Once the optical impression has been done, software • Semidirect inlay/onlay
designs the restoration and is transferred to milling • Interlocking
unit. • CAD/CAM
• The milling unit consists of diamond disk and a • Cerec
cylindrical diamond which cuts a ceramic block. • Milling unit

Try-in and Cementation Questions to Think About

• Once the ceramic block has been done milling, it is
1. What are the different types of indirect composite
removed from milling unit.
restoration? Explain in detail about the indication and
• The ceramic restoration is etched and silanated and
advantages, disadvantages of indirect composite
luted to tooth preparation using dual cure resin cement.
restoration.
2. Elaborate about tooth preparation design for indirect
Key Terms composite restoration.
3. Discuss about ceramic inlay its advantages, disadvan-
• Esthetic inlays/onlays tages and about tooth preparation design.
• Secondary polymerization 4. Explain about CAD/CAM restorations.
434 Essentials of Operative Dentistry

24 Glass Ionomer
Restoration

Introduction • Originally the liquids for GICs were aqueous solutions

of polyacrylic acids in concentration of 40-50%, this
• Glass ionomer cement was developed in early 1970’s was quite viscous and tended to gel overtime. In most of
by Wilson and Kent who combined technology of zinc the current cements the acids is in the form of a copoly-
polycarboxylate and silicate cement. Earlier these were mer with itaconic acid, maleic acid, or tricarboxylic acid.
called as ‘alumino silicate polyacrylate’ (ASPA). • Tartaric acid is also present in the liquid which
• Conventional glass ionomers contain ion leachable improves handling characteristics and increases
fluoroaluminosilicate glass of silicate cement but avoid working time but it shortens the setting time.
their dissolution by substituting of carboxylic acid from • As a means of extending working time of GICs freeze
zinc polycarboxylate for phosphoric acid. dried polyacid powder and glass powder are placed in
• The type of application depends on the consistency of same bottle. Liquid consist of water/water with tartaric
cement which ranges from a very high viscosity to low acid. When water liquid is added the acid powder
viscosity by adjusting the particle size distribution and dissolves and reconstitute liquid acid and this process
P/L ratio. is followed by acid-base reaction, this is called as water-
• Maximum particle size for restorative cement is 50 μm settable GIC or anhydrous GIC.
and for luting agents 15 μm. Another name for this
cement is ‘glass polyalkanoates cement’. Chemistry of Setting
• The chemistry of GICs have evolved overtime incor-
poration of metal particles results in metal reinforced • The setting reaction of glass ionomer cement has been
GIC. Replacing part of polyacrylic acid with hydrophilic characterized as a acid-base reaction.
monomers results in light curable/chemical curable • When powder and liquid are mixed to form a paste, the
material called ‘Resin modified GIC or hybrid ionomer acid etches the surface of glass particles and calcium,
cement’. aluminum, sodium and fluoride ions, etc.
• Acid-base curing process is part of the setting reaction, • Polyacrylic acid chains are cross-linked by calcium ions
therefore, they are called ‘dual cured GIC’. If all these that are replaced by aluminum ions in the next 24 hrs.
three reactions are involved it called ‘tricured GIC’. This process is called ‘maturation’.
• Sodium and fluorine ions do not participate in cross-
Composition linking and uniformly dispersed within the set cement.
• Thus, the set cement consists of an agglomerate of
• Glass ionomer powder is an acid soluble calcium unreacted powder particles surrounded by a silica gel
fluoroaluminosilicate glass. in an amorphous matrix of hydrated calcium and
• Raw materials are fused to a uniform glass by heating aluminium polysalts. This framework is porous that
them to a temperature of 1100-1500°C. small ions like fluoride are free to move through the
• Lanthanum, strontium and barium/ZnO are added to material. A silica gel - formed by leaching of Al and Na
provide radiopacity. from powder when acid is mixed.
 Glass Ionomer Restoration 435
• Water plays a critical role in the setting of GICs. It serves • Anticariogenic effect because of fluoride release.
as the reaction medium initially and then slowly • Acceptable esthetics.
hydrates the cross-linked matrix, there by yielding a • Biocompatability.
stable gel structure. • Less technique sensitivity compared to composite resin.
• If freshly mixed cement is exposed to ambient air
without any protection surface will crack because of Disadvantages
desiccation. Any water contamination can lead to
dissolution of matrix forming cations and anions. • Low fracture resistance
• This problem can be avoided to an extent if calcium • Low wear resistance
ions are removed from glass surface particles and the • Moisture sensitivity
reaction is speeded up. The resultant material is water • Water solubility.
stable, but this fast setting form lacks translucency.
• Initially, calcium polyacrylate chains formed are highly Modifications
soluble this gives initial hard surface, followed by
maturation over next 24 hrs, where less mobile Metal modified:
aluminum ions become bounded. • Silver cermet cement
• Miracle mix

Classification Resin modified:

• Hybrid glass ionomer or resin modified glass ionomer
Type I Luting • Dual cure
• Tri cure
Use: Cementation of crowns, bridges, inlays and ortho- • Compomer
appliances.
Setting rate: Fast
P/L ratio: 1.5:1. Clinical Application
Type II Restorative • Their clinical application is wide range suiting variety
of clinical situations.
1. Restorative esthetic
• As a restorative material glass ionomers are not used in
Use: Esthetic restoration.
stress bearing areas of posterior and anterior teeth.
Autocure: Slow resistance to water uptake and loss.
Resin modified: Fast setting immediate resistance to water.
P/L ratio: 3:1 or greater. Clinical applications
2. Restorative reinforced
Tooth colored filling materials
Use: Where physical properties are required.
• Abrasion and erosion lesions
Setting rate: Fast • Class III lesions involving exposed root dentin
P/L ratio: 3:1 or greater. • Occlusal lesions on deciduous teeth
• Temporary anterior and posterior restorations
Type III Liners/Bases • Repair crown margins

Lining: Used in thin sections under metallic restorations Cavity liners and bases
• Cement base under composites, amalgams
Setting rate: Fast
• Blocking undercuts
P/L ratio: 1.5:1
Base: Use in combination with composite resins as Luting cements
• Cementation of crowns, inlays, onlays, bridges.
lamination/sandwich technique.
Setting rate: Fast
P/L ratio: 3 : 1 or greater Tooth Preparation
• Adhesive quality of the glass ionomer cements dictates
Advantages that an ultraconservative approach be adopted.
• No undercuts or dovetails are necessary.
• Adhesion to tooth structure • Cavosurface margins be butt joint and not beveled.
436 Essentials of Operative Dentistry

Isolation Finishing and Polishing

A clean dry field is mandatory for both better adhesion of • After the required time for setting of cement, the matrix
glass ionomer to tooth structure and also for strength of if used is removed. The restoration surface is protected
the restoration. by waterproof varnish.
• Gross excess in cement is removed using a BP blade.
Preparation of Dentinal Surfaces • Any removal of excess cement with rotary instrument
is best delayed after 24 hours.
Dentinal surface nature varies in noncarious cervical
• Final finishing delayed after 24 hours, final finishing is
lesions and in carious lesions.
done with fine diamond, 12-bladed tungsten carbide or
flexible finishing disks.
Abrasion/Erosion Lesion
• Dentinal surface is cleaned using pumice and brush.
Surface Protection
• This is followed by conditioning of dentin by polyacrylic
acid for 30 seconds. • Varnish application to restoration surface after the
• This will ensure that the dentin surface is clean and cement has set is essential. Polyurethane varnish or
will also result in dentin tubules opening which would nitrocellulose varnishes are other alternatives.
have sclerosed in abrasion/erosion. • Light activated bonding resin can also be used to protect
glass ionomer surface.
Class III, Class V and Other Carious Lesions • Use of vaseline to protect the glass ionomer surface is
of limited use as vaseline is easily removed by action of
• It is not necessary to clean the dentin with pumice.
lips.
• But dentin smear layer that is formed during tooth
preparation is removed by application of polyacrylic
acid for 10 seconds. Clinical Performance
• Other dentin conditioners like citric acid, EDTA, ferric Advantages of glass ionomer as a restorative material are:
chloride can also be used. • Placement in bulk
• Adhesive bonding ability to tooth structure.
Pulpal Protection • Fluoride release.
• When glass ionomer cement is placed directly over the
pulp it can result in pulp necrosis. Glass Ionomer Modification
• When a layer of dentin remains, dentin bridge can form Metal modified and resin modified glass ionomer
when glass ionomer is placed. application are same as conventional glass ionomer and
• In cases where a layer of caries is left behind calcium tooth preparation is also same.
hydroxide liner could be used to stimulate dentin bridge
formation.
Tooth Preparation Design
Dispensing, Mixing and Insertion
Minimal cavity design classification (Indications for glass
• For the powder/liquid systems, correct powder/liquid ionomer restoration):
ratio should be maintained. • Class I / fissure seal
• Tap the powder bottle to ensure powder is compacted • Class II occlusal , tunnel approach, proximal approach
in the bottle. Any excess powder in scoop is scraped off • Class III buccal, lingual approach, posterior restoration.
with a spatula to ensure correct powder quantity. • Class III anterior restoration
• Mixing could be done either on glass slab or mixing • Class V lesions.
pad using a agate spatula. No cooling of powder or
liquid or glass slab is required.
Class I / Fissure Seal (Figures 24-1 to 24-3)
• Powder is mixed into liquid in two increments in folding
motions. Maximum mixing time is 20 seconds. • This concept was introduced by Simonsen is especially
• In preproportioned capsules it is mixed in an useful for newly erupted tooth.
amalgamator at high speed at about 4000 rpm for • Before a faulty fissure develops caries that has extended
10 seconds. into dentin.
 Glass Ionomer Restoration 437
Tooth Preparation
• Using a small tapered diamond the fissure is opened
and any caries on floor of fissure is removed with hand
instruments or small round burs.
• Use of binocular loupes is recommended during tooth
preparation.
• Do not extend the cavity pulpally.
• If glass ionomer cannot withstand occlusal stress in
particular situation, the part of cement can be cut back
and laminated with composite resin.

Figure 24-1: Diamond abrasives used for tooth preparation

Class II Occlusal Approach
(Figures 24-4A to C)
• In proximal lesion caries usually develops apical to
contact are this is where plaque accumulates. The
contact area itself will be free of caries in the initial
stages.
• The contact area and the marginal ridge will be sound.
• Access to the area of carious lesion is done through
occlusal approach from the fossa present just adjacent
to marginal ridges. This is mainly done to explore the
lesion.
Figure 24-2: Conservative tooth preparation of fissure
opening with tapered diamond abrasive • Carious dentin is removed through this approach taking
care not to break the marginal ridge and the proximal
• With minimal tooth preparation the fissure is sealed surface.
with glass ionomer cement. The cement adheres to the • To protect the adjacent tooth a metal matrix band can
walls of fissure. be placed.
• Affected dentin is left in place to remineralize.
Instruments Required • No retentive features are given as cement can be retained
Small tapered, round diamond abrasives. through it is adhesive qualities.

Figures 24-3A to C: Class I fissure seal approach

Figures 24-4A to C: Class II occlusal approach

438 Essentials of Operative Dentistry

• Cement most suitable for this situation will be dual cure

glass ionomer. If necessary glass ionomer cement could
be laminated with composite resin.

Instrument Required
Small tapered diamond, small round diamond and if
necessary a ling shank bur if access is difficult.

Tooth Preparation
• Tapered diamond is used to enter the occlusal surface
just proximal to marginal ridge. The bur is angulated
towards the proximal surface of tooth and progressed
gingivally. Infected caries dentin is removed. Figure 24-5: Isolated teeth with proximal caries
• Funnel like cavity preparation is necessary with that can be restored through proximal approach
widened area present occlusally. Good illumination and
visibility is necessary. Class II Tunnel Approach (Figures 24-7A to C)
• Use a small round diamond to remove any remaining • It is described in class II composite restoration.
infected dentin. If no more infected leathery dentin is • Same design and technique is followed.
present leave the remaining affected dentin (discolored • If occlusal stresses are heavy then some part of glass
but hard dentin) in place to remineralize. ionomer could removed to be laminated with composite
resin–sandwich restoration.
Class II Proximal Approach
(Figures 24-5 and 24-6) Class III Buccal/Lingual Approach
Here only the proximal surface of tooth is involved with (Class III Tunnel) (Figures 24-8A to C)
occlusal surface being intact. • In some situations the proximal caries may develop well
This can occur when: gingival to contact area.
• The lesion is detected while preparing the adjacent tooth • In this situation the proximal lesion could be
for restoration. approached through buccal or lingual approach like
• The lesion is detected when there are no adjacent teeth. done in class III anterior tooth preparation.

Instruments Required Indications

Same as in class II occlusal approach.
• Patients with gingival recession with gingiva well below
the contact area.
Tooth Preparation • Root surface proximal caries.
• Enter the lesion with small tapered diamond abrasive. • Caries below class II restoration or on proximal margins
• Remove soft caries using small round diamond. of a cast restoration like in crown.
• If necessary use mylar strip and wedge. In these situations it should be carefully evaluated
• Restore the tooth with autocure glass ionomer or dual whether the restoration already present is satisfactory or
cure glass ionomer. But it should be radiopaque. needs replacement.

Figures 24-6A to C: Class II proximal approach

 Glass Ionomer Restoration 439

Figures 24-7A to C: Class II tunnel restoration

Figures 24-8A to C: Class III tunnel approach

Instruments Required • Always try to preserve the enamel wall present opposite
Same as in Class II occlusal approach. to site of entry for purpose better cavosurface margin.
• Use a matrix band (Mylar strip) and wedge. Place a
radiopaque glass ionomer cement.
Tooth Preparation
• Enter the lesion either from buccal or lingual depending
Class III and Class V Restorations
on the location where the caries is present more. Enter
(Figures 24-9 and 24-10)
the lesion with a tapered diamond.
• Using a long shank round diamond remove any • Tooth preparation is same as in resin composite
remaining caries. restoration.

Figures 24-9A to C: Class III gass ionomer restoration

Figures 24-10A to C: Class V glass ionomer restoration

440 Essentials of Operative Dentistry

Figures 24-11A to C: Types of sandwich restorations: (A) Closed sandwich technique,

(B) Open sandwich technique, (C) Centripetal build-up technique

• Because of low modulus of elasticity of glass ionomers • Benefit of tooth adhesion, fluoride release.
it performs better in class V restoration than composite • No need for sophisticated instruments.
resin. • Low cost treatment.
• But esthetically composite resin restoration is far better
than glass ionomer cements.
Disadvantage
• Unlike composite resin restoration there is no need for
bevel placement in tooth preparation. Lack of knowing the extent of caries.

Atraumatic Restorative Technique Glass Ionomers as Liners and Bases

• Modern restorative techniques require electrically Advantages
powered equipments. • Better biocompatibility.
• In remote area of developing and underdeveloped • Tooth surface adhesion.
countries basic restorative procedures should be carried • Fluoride release.
out without basic infrastructure of electricity and water. • Can be used to block out undercuts in indirect tooth
This is where atraumatic restorative technique (ART) is preparation.
useful. • Radiopaque formulation.
• In this technique hand excavators are used to remove • Glass ionomer liner and base application is same as
carious lesion followed by restoration with highly for glass ionomer restoration with regard to cement
viscous glass ionomer cement. manipulation and placement on tooth preparation.
• Powder liquid ratio for base application is 3 : 1 and
Indications for lining purposes it is 1.5 : 1.
• Occlusal caries with adequate tooth structure. • This lining or base cement is used in sandwich
• Physically or mentally handicapped patients. technique. Here glass ionmer cement is laminated
• As a caries control restoration. with composite resin restoration.
There are three types of glass ionomer sandwich
Clinical Procedures restoration they are (Figures 24-11A to C):
1. Open sandwich restoration
• Teeth are isolated with cotton.
2. Closed sandwich restoration
• Undermined enamel is broken off with hatchets.
3. Centripetal sandwich restoration
• Caries excavated with spoon excavators.
• Highly viscous glass ionomer is placed in the cavity
and pressed with gloved fingers.
• Excess material is removed, occlusion evaluated and Key Terms
restoration surface protected with petroleum jelly.
• Aluminosilicate polyacrylate (ASPA)
• Acid-base reaction
Advantages • Metal-modified glass ionomer
• Maximum preservation of tooth structure. • Resin modified glass ionomer
 Glass Ionomer Restoration 441
• Dual cure cement Questions to Think About
• Tri cure cement
• Class I fissure seal 1. Explain about glass ionomer cement, its advantages
• Class II tunnel approach and disadvantages. Elaborate its use in posterior
• Class III tunnel approach restorations.
• ART technique 2. Discuss about various cavity designs for glass ionomer
• Sandwich restorations cement. Mention about types of sandwich restoration.
442 Essentials of Operative Dentistry

25 Minimal Invasive
Dentistry

Introduction
• This is also called as “Minimal Intervention Dentistry
or Preservative Dentistry”.
• This is a conservative opportunity to identify early caries
risk followed by preventive procedures designed to heal
early lesions whilst eliminating the bacterial disease
(Figure 25-1).
• When lesions have advanced and healing is not possible Figures 25-2A to C: Difference in tooth preparation for
then a minimal invasive surgical approach should conventional and minimal invasive preparation
control and eliminate surface cavitation and stimulate
remineralization using a biomimetic restorative • Assessment of individual risk to caries occurrence or
material. recurrence.
• The philosophy of minimal intervention dentistry com- • Remineralization of early incipient caries lesion.
bines the current knowledge of prevention, reminerali- • Reduction of cariogenic bacterial count.
zation and ion exchange adhesion to tooth structure. • Minimal surgical intervention (tooth preparation) of
Practice of minimal invasive dentistry is based on cavitated lesion.
following principles (Figure 25-2): • Repair rather than replacement of tooth structure should
• Accurate caries diagnosis using advanced caries be the goal of restoration of tooth.
diagnostic methods like diagnodent (Kavo). • Periodic follow-up to assess the patient’s caries risk.
• Classify caries according to newer system classification.
General Principles of Cavity Design
• Until recent times cavities were designed along surgical
lines without an understanding of the action of fluoride
ion and for placement of restorative materials that were
difficult to handle, were subject to microleakage, and
were often not esthetic.
• Also in absence of adhesion it was necessary to remove
undermined enamel defeating the purpose of preser-
vation of remaining tooth structure.
• With better understanding of fluoride properties and
adhesion developments it is possible to place restora-
Figure 25-1: A proprietary brand advocating principles of tions in limited size cavities retaining much of tooth
minimal invasive dentistry structure.
 Minimal Invasive Dentistry 443
• By today’s standard cavity design proposed by GV Black • On the other hand replacement of failed restoration
is large and it was necessary to remove additional tooth cavity outline will be already defined and often will be
structure for ‘extension for prevention’. extensive. And here most of Black’s principles hold good.
Tooth preparation is mainly done with high speed
handpieces with special smaller diamond abrasives.
New Cavity Classification But other options for tooth preparation will be:
(Mount and Hume Classification) • Air abrasion
• Sono-abrasion
• Prime objective here is to retain as much as natural tooth • Chemo-mechanical preparation
structure as possible, given by GJ Mount and Hume. • Lasers.
• This is the classification that forms the basis of minimal
invasive dentistry. Restorative Materials
Restorative materials used here are mainly adhesive
Three Sites of Carious Lesion materials like:
• Site 1: Pits, fissures, and enamel defects on occlusal • Glass ionomer cements and its modification
surface of posterior teeth and other smooth surfaces • Composite resin
(Class I). • Pit and fissure sealant.
• Site 2: Approximal enamel immediately below areas in Use of composite is limited by its polymerization
contact with adjacent tooth (Class II, III, IV). shrinkage.
• Site 3: Cervical one-third of crown following gingival Amalgam limitation is its poor esthetic quality.
recession in root (Class V). GIC has excellent adhesion but lacks strength to be
utilized in marginal ridges and incisal edge.
Four Sizes of Carious Lesions
• Size 1: Minimal involvement of dentine just beyond Treatment Procedure
treatment by remineralization alone.
• Size 2: Moderate involvement of dentine. Following Here as an example of site 1 lesion with various sizes is
cavity preparation, remaining enamel is sound, well described here.
supported by dentine and not likely to fail under normal
occlusal load. Site 1 , Size 1 (Figures 25-3A to C)
• Size 3: Cavity is enlarged beyond moderate involvement. • Usually, the extent is limited and most of the fissure
Remaining tooth structure is weakened to the extent system should be free of caries.
that cusps or incisal edges are split if exposed to occlusal • Using very finest tapered diamond point (#200) enter
load. Cavity needs to further enlarged so that the the fissure in region of caries attack, open the enamel to
restoration can be designed to provide support to determine the full extent of caries.
remaining tooth structure. • It is unnecessary to remove the affected demineralized
• Size 4: Extensive caries and bulk loss of tooth structure dentin on floor of cavity but walls of cavity be free of
has already occurred. caries.
Size 1 lesion is most commonly will be a new lesion • Remaining fissure systems are also opened to determine
ideal for adhesive restorations. the presence of caries.
Size 2, 3, 4 lesions may be lesions progressed to consi- • Small round burs (#008 or #012) can be used to clean
derable extent or may be breakdown of a earlier restoration. walls of infected enamel.
• Generally, there is no need to penetrate the full depth of
enamel.
Cavity Design and Preparation Restoration
• When dealing with new lesion cavity design be very • Glass ionomer cement (GIC) is material of choice
conservative, because margins can be remineralized, because of fluoride release and adhesion.
and cavity extent is determined only by the extent of • Use strongest GIC available either autocure or self cure.
caries cavitation. • Condition the cavity with 10% polyacrylic acid.
444 Essentials of Operative Dentistry

Figures 25-3A to C: Site 1 Size 1 (1.1) lesion restoration

• Placement of cement in a syringe is desirable.

• When using an autocure cement positive pressure with • Tungsten carbide bur (#140TC) can be used to remove old
restoration, a tapered diamond or straight diamond (#160
gloved finger may be required followed by protection with
Dia or #156 Dia) is then used to explore the lesion.
a resin sealant to prevent contamination with moisture.
• Small round burs can be used to clean the walls of the
• When using light cure resin modified GIC there is no
cavity.
need for finger pressure and restoration can be imme-
diately finished and no resin sealant required.
• If the occlusal load is heavy GIC may be lamination Restoration
with composite (sandwich restoration) can be performed. • GIC is the best choice of material.
• Also lamination technique with composite can be
Site 1, Size 2 (Figures 25-4A to H) considered.
GV Black classification – Class I.
Site 1, Size 3 (Figures 25-5A to C)
Preparation When cavity reaches this size there will be extensive
• It may be a new cavity or repairing or replacement of an undermining of at least one cusp. It may be a new lesion of
old restoration. old restoration that may be recurrent (recurrent caries).

Figures 25-4A to H: Site 1 Size 2 (1.2) lesion restoration

 Minimal Invasive Dentistry 445

Figures 25-5Ato C: Site 1 Size 3 lesion restoration

Figures 25-6A to D: Site 1, Size 4 lesion restoration

Preparation Site 1, Size 4 (Figures 25-6A to D)

• Tungsten carbide burs (#140) should be used to remove • This is an extensive cavitated lesion there will be one or
any remaining old restorations. more loss of cusps full restoration with direct restoration
• A small diamond straight fissure (#156) is used to is difficult.
explore the lesion. • Preparation is same as for size 3 lesion.
• Round burs (#012 or 016) can be used to remove infected • Amalgam as a restorative material could be used with
dentin from walls of the cavity. mechanical interlocks.
• If it is a new active caries it may be necessary to place an • A full crown is the most ideal restoration.
indirect pulp capping agent then review after minimum For proximal cavities slot preparation, tunnel prepara-
of 12 weeks. tion or box type preparation are advocated.
• If cuspal strength is adequate a conventional restoration
is attempted. Key Terms
• If cuspal strength is weakened grooves may be placed
in cusps to strengthen the cusp with restorations. • Minimal Invasive Dentistry/Minimal Intervention
Dentistry
• Mount and Hume classification
Restoration
• Of various direct filling materials amalgam is the
choice.
Question to Think About
• Most of the time teeth affected will be going in for 1. Discuss about the philosophy of minimal invasive den-
crown. tistry. Describe about the various diagnostic and res-
• Lamination technique with resins could also be done. torative options available in minimal invasive dentistry.
446 Essentials of Operative Dentistry

26 Noncarious Cervical
Lesions

• This type of lesion and restoration comes under class V

restoration.
• Because of unique location of lesion, physical properties
of tooth, long-term retention of restoration is challenging.
• Therefore. some of the lesions of this nature can be left
untreated and in other situations minimal tooth
preparation is required prior to restoration.

Types of Noncarious Cervical

Lesion and Definition
Erosion
Figure 26-2: Abrasion
Erosion is defined as loss of tooth structure due to non-
bacterial chemical action (Figure 26-1).
Abfraction
Abrasion Abfraction is defined as loss of tooth structure due to
Abrasion is defined as loss of tooth structure due to flexural forces. It was first described by Grippo JO (Figure
mechanical or frictional forces (Figure 26-2). 26-3).

Figure 26-1: Erosion Figure 26-3: Abfraction

 Noncarious Cervical Lesions 447
Etiology
Erosion
These can be due to acids from extrinsic and intrinsic
sources.

Extrinsic Sources
• Dietary acids from citrus juices, carbonated drinks, etc.
• Environmental erosion is persons working battery
factory, metal plating due to constant acid fumes
exposure.

Intrinsic Sources
Mainly due to regurgitation of gastric acids.
• Gastric disorders like gastric ulcers, etc.
• Eating disorders like anorexia nervosa, bulimia nervosa.
• Chronic vomiting.
Figure 26-4: Abfraction – due to tooth flexes under occlusal
Abrasion loading leading to microfracture in enamel and dentin in
Most commonly abrasion is due to heavy tooth brushing cervical region
with hard toothbrush.
Abnormal habits like pipe smoking, biting finger nails, Most often teeth with abfraction lesion also has occlusal
opening bobby pins can also cause also lead to abrasion. wear facets.

Abfraction Diagnosis
Teeth flex under occlusal loading in both lateral and axial
direction. The stress on occlusal loading is transmitted to Proper diagnosis involves good clinical examination and
the cervical area of tooth causing cervical enamel rods to history taking to ascertain the cause of lesion and nature
fracture (Figure 26-4). of lesion.
This microfracture leads to formation of V-shaped
cervical notch. Isolation
When these lesions occur supragingivally it is easier to
Clinical Features isolate the lesion and restore (Figure 26-5).
But if lesion is subgingival isolation for tooth
Erosion preparation and restoration is difficult.
Cervical lesion is usually rounded, cupped out defect or
saucer-shaped defect, the surface of lesion appears smooth
and polished.

Abrasion
Cervical lesion appears as sharp V-shaped notch. The
margins of lesions are angular and makes acute angle with
surrounding tooth structure.

Abfraction Figure 26-5: Problem of isolation occurs when part of lesion

V-shaped notch is present with margins being angular. is subgingival
448 Essentials of Operative Dentistry

Methods available for isolation of cervical lesions are: • Esthetics: If present on anterior teeth these lesions could
• Nonsurgical retraction: Rubber dam with cervical clamps be unsightly.
like No. 212 SA, gingival retraction cord and cotton • Tooth fracture: If lesions are deep enough then it may
rolls (Figures 26-6 to 26-8). cause tooth to fracture under occlusal forces.
• Surgical retraction: Gingivoplasty, crown lengthening • Pulpal involvement: Deeper lesion could endanger the
all these procedures are done to remove the gingival integrity and health of pulp.
tissue and expose the lesion. • Caries occurrence: Newer caries lesion could occur
because of plaque accumulation.
• Periodontal damage: Because it affects the oral hygiene
maintainece of patients it could lead to gingival
inflammation.

Treatment Options
Considering the above said need for treating these lesions
it has to be weighed against option of less invasive
procedural options too because cervical restoration are
having the challenge of long-term retention.
Treatment options are as follows:
• Dentin desensitization
Figure 26-6: Clamp No. 212 SA
• Restorations
• Endodontic therapy
• Periodontal therapy.

Dentin Desensitization
Modalities to control or reduce sensitivity are:
• Fluoride varnishes
Figures 26-7A and B: Application of clamp 212 SA onto tooth • Fluoride iontophoresis
• Dentin bonding agents
• Desensitizing toothpastes and mouthwashes
containing potassium nitrate, oxalate.

Restorative Treatment
Restorative treatment is initiated only when:
• Considerable loss of tooth structure
• Esthetics is compromised
• Pulpal health being affected.
• Sensitivity persists.
Figure 26-8: Clamp retraction Restorative material options are:
• Nonesthetic materials
• Amalgam
Treatment • Gold foil (direct) (not widely used)
• Gold inlay (not widely used)
Noncarious cervical lesion requires clinical treatment for • Esthetic materials
the following reasons: • Resin composite (with dentin bonding system)
• Tooth sensitivity: Because of loss of enamel form tooth • Resin composite (with glass ionomer base—
structure the underline dentin is exposed to produce sandwich technique)
hypersensitivity. • Flowable resin composite
 Noncarious Cervical Lesions 449
• Glass ionomer
• Resin-modified glass ionomer
• Compomer
• Porcelain inlay (not widely used)
Amalgam
• Preparation is same as in class V tooth preparation.
• Cavosurface margins be 90°, cavity depth be 0.75-
1.5 mm into dentin.
Composite resin (Figures 26-9A and B)
• For moderate to large size lesions composite is placed Figure 26-11: Retentive groove placement on the gingival
wall of tooth preparation
in an increment layers (Figure 26-10).

• If all the margins are in enamel there is better survival

rate for composite restorations.
• A retentive groove is placed with bur No. 1/4 or 1/8 in
the gingival to increase the retention of composites
(Figure 26-11).
• Microfilled composite with their lower elastic of
modulus is the choice of material.
• If the lesion extends onto root surface there are greater
Figures 26-9A and B: Clinical case of noncaries cervical
chances of microleakage than when lesion is on enamel.
lesion restored with composite restoration
• Flowable composites also with lower elastic modulus
is also being used.
• Some authors prefer the use of resin composite without
any tooth preparation. Long-term studies are awaited
for this type of restorations.
Glass ionomer and its modification (Figure 26-12)
• Glass ionomer cement or resin modified glass ionomer
has been extensively used for restoration of this type of
lesions.
• Tooth preparation is same as for composite restoration.
No cavosurface bevels are required.

Figure 26-10: Composite material is placed in a layered

manner to reduce chances of polymerization shrinkage and Figure 26-12: Tooth preparation for
gap formation noncarious cervical lesion
450 Essentials of Operative Dentistry

• This type of restoration takes advantage of both the

material’s properties.
Compomers
• They are newer category of materials with fluoride
releasing properties.
• They could also be used as a tooth colored restorative
material, tooth preparation is same as in composite
restoration.

Key Terms
• Abrasion
• Erosion
• Abfraction
• Microfracture
• Desensitization
• Iontophoresis
• Sandwich restoration.
Figure 26-13: Sandwich restoration

Question to Think About

Sandwich technique (Figure 26-13)
• Here a glass ionomer base is overlaid with composite 1. What are different types of noncaries cervical lesions?
material. Discuss about the restoration of these type of lesion.
 Esthetic Operative Dental Procedures 451

27 Esthetic Operative
Dental Procedures

Veneers Types
• A veneer is a thin layer of tooth colored material that is • Types of veneers according to design (Figures 27-2A to C):
applied to a tooth for esthetically restoring localized or • Partial veneer
generalized defects of or intrinsic discolorations. • Full veneer
• Veneers are labial partial crowns. • Types according to material:
• Partial veneer: Direct—chair side composite resin
Indications • Full veneer: Direct—chair side composite resin.
Indirect—indirect composite resin, ceramics.
• Fracture of anterior teeth.
• Large noncarious cervical lesion on anterior teeth.
• Discolorations resistant to bleaching. Partial Veneer
• Developmental enamel defects. • These are indicated for localized defects on tooth that
• Closing spaces in anterior teeth. do not extend onto whole surface of tooth.
• Correcting mild malalignment of anterior teeth (Figures • Usually, it is done with direct composite chair side.
27-1A and B).

Contraindications
• Bruxism
• High caries activity
• Poor oral hygiene.

Figures 27-1A and B: Malaligned teeth restored to

alignment with veneers Figures 27-2A to C: Types of veneer according to design
452 Essentials of Operative Dentistry

• This method is time consuming when compared to lab • Removal of 0.5-0.75 mm of enamel is done.
processed veneers. • Round or tapered diamond is used for tooth prepara-
tion.
Full Veneer • With chamfer finish line placed for gingival margin
and bevel placed on other margins to aid in blending of
• Indicated for tooth where the defects are present on the
composite shade with tooth structure.
whole surface of tooth.
• Veneer is usually done either with ceramics or Restoration
composite resin. • This done by acid etching and applying dentin bonding
• Indirect lab processed veneers are two appointment agent to tooth.
procedure. • Followed by placement of composite material, material
Veneer tooth preparation is usually an intraenamel is placed in an incremental fashion.
preparation and tooth preparation is recommended for: • Finishing and polishing of composite veneers is same
• To provide spacing for veneering materials. as in any other direct composite restoration.
• To remove outer most fluoride rich enamel to aid in
bonding of veneer to tooth structure. Full Veneer Tooth Preparation
• To create a roughened preparation to aid in bonding of
Preliminary step: Same as in partial veneer tooth preparation.
veneers.
• To establish a definite finish line gingivally. Tooth preparation: Tooth preparation for veneer restoration
Gingival margin for veneer preparation should termi- should be carried in a manner that will provide optimal
nate where the defects in tooth ends. It can be subgingival function, esthetics, retention, physiological contours and
or supragingival depending upon the extent of defect longevity.
(Figure 27-3). Two basic preparation designs are:
1. Window preparation
2. Incisal lapping preparation
Window preparation:
• This preparation design is recommended for direct
and indirect composite resin veneers.
• This design preparation does not extend into lingual
and incisal surfaces of tooth structure, thereby
protecting the resin veneers from occlusal stresses.
Incisal lapping preparation:
Indications:
• When lengthening of crown structure is needed.
• Incisal defects have to be covered.
• Used for ceramic veneers as it allows accurate seating
Figure 27-3: Gingival margin need not always be subgingival of the restoration.
it can be placed where the defect ends
Window preparation (Direct composite veneer)
• Window preparation is typically made to depth of
Partial Veneer Tooth Preparation 0.5-0.75 mm depth into enamel in the midfacial region
and tapering down to a depth of about 0.2-0.5 mm into
Preliminary step
enamel in the gingival region (Figure 27-4).
• Placement of rubber dam, local anesthetic adminis-
• A coarse round diamond or tapered diamond is used
tration and occlusal analysis are mandatory.
for tooth preparation.
• Assess the extent of defect on the tooth.
• A heavy chamfer gingival finish line is given.
• Examine the esthetic need of the patient.
• Margins are not extended subgingivally unless until
• Select the shade for the composite restoration.
the defects extends so.
Tooth preparation • Proximally, the preparation terminates just facial to
• It involves removal of localized defect area from tooth proximal contact area, unless diastema is present
surface. between two teeth (Figures 27-5 and 27-6).
 Esthetic Operative Dental Procedures 453
Incisal lapping preparation (indirect veneers) (Figures
27-7A to F)
• About 0.5-0.7 mm of the entire labial surface is removed.
• The cervical and proximal margins should have a
smooth chamfer which is approximately 0.5 mm
deep.
• It is recommended that you approach the proximal
contact point as much as possible. But proximal contact
should remain in contact.
• The incisal edge should be shortened by about 1.0-
1.5 mm. The palatal margin should have a rounded
bevel.
Figure 27-4: Window preparation with depth of preparation Restoration
thinning out in the cervical enamel region • An impression of the tooth preparation is taken,
usually impression is taken with elastomeric
impression material.
• Die stone cast is made.
• Cast is send to laboratory along with shade selection
details.
Luting
• Tooth is acid etched and bonding agent applied and
light cured.
• Indirect composite veneers are applied with priming
agent followed by resin cement application to bond
to tooth structure.
Figure 27-5: Proximal margin of preparation should not break • Ceramic veneers are etched with hydrofluoric acid
the contact point and be as much as possible into contact followed by silane coupling agent application and
luted with resin cement.

Clinical Cases (Figures 27-8 and 27-9)

Advantages
• Minimal tooth reduction compared to crowns—tooth
conservation.
• Avoids any occlusal changes in static and functions—
function
• Newer generation ceramics, composites and resin luting
cements aids in strengthening veneers—strength.
• Preserves the health of periodontium.

Disadvantages
• Color and esthetics of full crowns cannot be matched.
Figures 27-6A and B: Proximal margins are placed beyond the • Irreversibility once the veneer has been luted to teeth.
contact area only when there is diastema between the teeth
• More costlier than metal-ceramic crowns.
Restoration
• Usually, provisional or temporary restoration is not Key Terms
required. • Partial veneer
• Same as in partial veneer. • Full veneer
454 Essentials of Operative Dentistry

Figures 27-7A to F: Incisal lapping design preparation

• Direct veneer Questions to Think About

• Indirect veneer
1. What are the indications and contraindications of
• Composite veneer
veneers? Write about partial veneer technique.
• Ceramic veneer
2. Discuss about advantage and disadvantage of veneers.
• Window preparation
Explain about full veneer technique.
• Incisal lapping preparation
 Esthetic Operative Dental Procedures 455

Figures 27-8A to C: Direct composite veneer restoration: (A) Partial veneer design, (B and C) Window preparation design

Figures 27-9A to F: Indirect ceramic veneer: (A) Preoperative, (B) Incisal lapping preparation,
(C) Rubber base impression, (D) Wax up on cast, (E) Ceramic veneers, (F) Postoperative
456 Essentials of Operative Dentistry

Bleaching
• Lightening of the color of tooth through the application
of a chemical agent to oxidize the organic pigmentation
in the tooth is referred to as bleaching.
• Tooth discoloration is a common problem.
• Tooth discoloration has multifactorial etiology.

Types of Stains
Extrinsic Stains Figure 27-10: Tooth discoloration due to fluorosis
• Plaque, chromogenic bacteria, surface protein
Medication:
denaturation.
• Tetracycline stains
• Mouthwashes, e.g. chlorhexidine.
• Other antibiotics use
• Beverages (tea, coffee, red wine, cola).
• Fluorosis stains (Figure 27-10)
• Foods (curry, cooking oils and fried foods, foods with
colorings, berries, beetroot). Posteruptive
• Dietary precipitate. • Trauma
• Illness. • Primary and secondary caries
• Antibiotics (erythromycin, amoxicillins). • Dental restorative materials
• Iron supplements. • Ageing
• Smoking
Intrinsic Stains • Chemicals
• Some food stuffs (long-term use causes deeper intrinsic
Pre-eruptive
staining)
Disease:
• Minocycline
• Hematological diseases
• Functional and parafunctional changes.
• Liver diseases
Table 27-1 describes treatment modalities for various
• Diseases of enamel and dentine
tooth discoloration.

Table 27-1: Various treatment modalities for various tooth discoloration

Color Cause Therapy

White Fluorosis Microabrasion, veneers
Blue-gray Dentinogenesis Veneers
Tetracycline Veneers
Gray Silver oxides from root canal fillings Veneers
Light yellow Fluorosis External bleaching, microabrasion
Age-related discoloration External bleaching
Obliterated pulp Internal bleaching
Tetracycline External bleaching
Dark yellow Age-related discoloration External bleaching
Tetracycline Veneers
Pulp necrosis Internal bleaching
Brown Fluorosis Microabrasion, veneers
Tetracycline Veneers
Caries Restoration
Black Caries Restoration
Fluorosis Veneers, crowns
Amalgam-related discoloration Restoration
 Esthetic Operative Dental Procedures 457
Advantages of Bleaching
• Provides immediate improvement in smile of the patient.
• Incorporating the bleaching as a multitreatment
approach can often lead to crown/veneer shades
selected much lighter than originally required.
• Noninvasive approach to tooth color modification.

Disadvantages of Bleaching
• Long duration of treatment.
• Unpredictable results.
• Sensitivity can occur in some patients.
• Increased cost.

Tooth Color Figure 27-11: Light penetration through tooth structure

• Tooth color is polychromatic.
• The color varies from gingival, middle and incisal thirds This can be further classified as:
of tooth depending on reflectance of different colors, • In-office bleaching
and translucency in enamel and dentin (Figure 27-11). • Home-bleaching.
Color of healthy tooth is primarily determined by
dentin and modified by: Nonvital Bleaching
• Color of enamel • Nonvital in-office bleaching—consists of placing 30%
• Translucency of enamel affected by varying grades hydrogen peroxide and applying heat on external
of calcification. surface of tooth this technique is called as thermo-
• Thickness of enamel which is thicker at incisal edge catalytic technique.
and thinner at cervical region. • Nonvital home bleaching—where usually 30%
Current home bleaching technique employing a custom hydrogen peroxide and sodium perborate is placed
fit tray containing 10% carbamide peroxide was intro- inside the tooth to lighten the tooth color this technique
duced by Klusmier in late 1960’s. Table 27-2 gives a cursory is called as walking bleaching (Figures 27-12A to C).
look on the development made in bleaching therapy. • Inside-outside bleaching introduced by Settembrini
et al 1997, Carrillo et al 1998. This technique consists of
Types of Bleaching Therapy placing bleaching material into pulp chamber and a
It can be classified as: bleaching material in bleaching tray and placing it
• Nonvital tooth bleaching outside the tooth. By this way bleaching is accomplished
• Vital tooth bleaching. both from outside and inside.

Figures 27-12A to C: Bleaching nonvital teeth or endodontically treated tooth with

bleaching material placed inside the access cavity
458 Essentials of Operative Dentistry

Table 27.2: History of bleaching techniques

Date Name Material used Discoloration

1799 Macintosh Chloride of lime is invented; called bleaching powder
1848 Dwinelle Chloride of lime Nonvital teeth
1860 Truman Chloride and acetic acid Labarraque’s solution Nonvital teeth
(liquid chloride of soda)
1861 Woodnut Advised placing the bleaching medicament and
changing it at subsequent appointments
1868 Latimer Oxalic acid Vital teeth
1877 Chapple Hydrochloric acid, oxalic acid All discolorations
1878 Taft Oxalic acid and calcium hypochlorite
1884 Harlan Uses the first hydrogen peroxide (called hydrogen dioxide) All discolorations
1893 Atkinson Three percent pyrozone used a sa mouthwash which also
lightened teeth
Twenty-five percent pyrozone was the most effective
1895 Garretson Chlorine applied to the tooth surface Nonvital teeth
1910 Prins Thirty percent hydrogen peroxide on to teeth Nonvital and vital
1916 Kaine Eighteen percent hydrochloric acid (muriatic acid) and heat lamp Fluorosed teeth
1918 Abbot Discovers a high intensity light that produces a
rapid temperature rise in the hydrogen peroxide to
accelerate chemical tooth bleaching
1924 Prinz First recorded use of a solution of perborate in
hydrogen peroxide activated by a light source
1942 Younger Five parts of 30% hydrogen peroxide heat lamp, anesthetic
1958 Pearson Used 35% hydrogen peroxide inside tooth and Nonvital teeth
also suggested 25% hydrogen peroxide and 75%
ether which was activated by a lamp producing
light and heat to release solvent qualities of ether
1961 Spasser Walking bleach technique Nonvital teeth
Sodium perborate and water is sealed into the pulp chamber
1965 Bouschar Five parts 30% hydrogen peroxide, 5 parts 36% Orange colored
hydrocholoric acid, 1 part diethyl ether fluorosis stains
1965 Stewart Thermocatalytic technique Nonvital teeth
Pellet saturated with superoxyl inserted into pulp
chamber and heated with hot instrument
1966 McInnes Repeats Bouschar’s technique using controlled Predictable?
hydrocholoric acid-pumice abrasion technique
1967 Cohen and Parkins Thirty-five percent hydrogen peroxide and a heating instrument Tetracycline stains
1967 Nutting and Poe Combination walking bleach technique Nonvital teeth
Superoxyl in pulp chamber (30% hydrogen peroxide)
1968 Klusmier Home bleaching concept started-incidental finding Vital teeth
10% carbamide peroxide in an custom fitted
orthodontic positioner Gly-Oxide used
1972 Klusmier Used the same technqiue with Proxigel as it was
thicker and stayed in the tray longer

Contd...
 Esthetic Operative Dental Procedures 459
Contd...

Date Name Material used Discoloration

1975 Chandra and Thirty percent hydrogen peroxide 18% hydrochloric acid Fluorosis stains
Chawla flour of Paris
1977 Falkenstein 1 minute etch with 30% hydrogen peroxide 10% Tetracycline stains
hydrochloric acid 100 watt (104°F) light gun
1979 Compton Thirty percent hydrogen peroxide heat element (130-145°F) Tetracycline stains
1979 Harrington and Reported on external resorption associated with
Natkin bleaching pulpless teeth
1982 Abou-Rass Recommended intentional endodontic treatment Tetracycline stains
with internal bleaching
1984 Zaragoza Seventy percent hydrogen peroxide + heat for both arches Vital teeth
1986 Munro Used Gly-Oxide to control bacterial growth after Vital teeth
periodontal root planning. Noticed tooth lightening
1987 Feinman In-office bleaching using 30% H2O2 and heat from Vital teeth
bleaching light
1988 Munro Presented findings to manufacturer resulting in
first commercial bleaching product: White + Brite (Omnii Int.)
1989 Croll Microabrasion technnique 10% hydrochloric acid Vital teeth, superficial
and pumice in a paste enamel discoloration,
hypocalcification
extrinsic stains
1989 Haywood and Nightguard vital bleaching 10% carbamide peroxide All stains, vital and
Heyman in a tray Nonvital teeth
1990 Introduction of commercial over-the-counter Vital teeth
bleaching products (a controversy)
1991 Bleaching materials were investigated while the
FDS called for all the safety studies and data.
After 6 months the ban was lifted
1991 Numerous authors Power bleaching 30% hydrogen peroxide using a All stains, vital teeth
light to activate bleach.
1991 Garber and Combination bleaching power and home bleaching
Goldstein
1991 Hall Recommends no etching teeth before vital bleaching
procedures
1994 American Dental Safety and efficacy established for tooth bleaching
Association agents under the ADA seal of approval
1996 Food and Drug FDA approve ion laser technology. Argon and CO2
Administration lasers for tooth whitening with patented chemicals
1996 Reyto Laser tooth whitening Vital teeth
1997 Settembrini et al Inside/outside bleaching Nonvital and vital
teeth
1998 Carrillo et al Open pulp chamber 10% carbamide peroxide in custom tray
Present • Plasma arc and light activated bleaching techniques
day • Power gels for-in-office belaching
• Laser activated bleaching
• Home bleaching available in different concentrations and flavors
460 Essentials of Operative Dentistry

Vital Bleaching • The hydrogen peroxide breaks down to oxygen and

• In-office bleaching technique consists of application of water. And this oxygen enters the tooth to lighten the
color of tooth.
bleaching material (hydrogen peroxide) onto tooth
surface with rubber dam application and activated by
heat or light. Nonhydrogen Peroxide Containing Materials
• Home bleaching consists of bleaching material (usually • Most often the active agent in this type of bleaching
carbamide peroxide) in a bleaching tray overnight for material is sodium perborate.
the patient to wear. • These type materials are also reported to contain
Here in this topic main area of discussion is going to be hydroxylite, sodium chloride, oxygen and sodium
about vital tooth bleaching. fluoride.

Constituents of Bleaching Material Thickening Agents

• First generation bleaching materials were in liquid form Carbopol (carboxypolymethylene) is a polyacrylic acid
and could not remain long-time in the bleaching tray polymer is used. Trolamine is added to reduce the pH of
and should be replenished frequently. gels to 5-7.
• Second generation bleaching materials are more viscous This thickening agent helps in:
and in gel form so could remain in tray for longer time. • Retaining the material in bleaching tray.
The ingredients differ by their concentration and active • Helps in slow release of oxygen molecules from
ingredient. bleaching gel prolonging the action of bleaching
• Third generation bleaching materials differ by color and material.
mode of activation. Polyx is a thickener used in Colgate Platinum bleaching
• Carbamide peroxide. kit.
• Hydrogen peroxide and sodium hydroxide (Li, 1998).
• Nonhydrogen peroxide containing materials, i.e. Urea
sodium perborate. It is used in bleaching material to:
• Thickening agent – carbopol or polyx. • To stabilize hydrogen peroxide.
• Urea. • Elevate the pH of solution.
• Vehicle – glycerine, dentifrice, glycol.
• Surfactant and pigment dispersants. Vehicle
• Preservatives.
• Glycerine is most common used vehicle. Other vehicles
• Flavorings.
are glycol or dentifrice based bleaching material.
• Fluoride (in some recent products to reduce sensi-
• Vehicle enhances the viscosity of bleaching gel and ease
tivity). of manipulation.

Carbamide Peroxide Surfactants

• Carbamide peroxide (CH6 N2O3) in 10% aqueous Surfactants enhance the surface wetting ability of
solution is most commonly used in home bleaching bleaching material and to enhance the penetration of
material. hydrogen peroxide into tooth.
• This breaks down to a 3.35% hydrogen peroxide (H2O2)
and 6.65% solution of urea (CH4N2O). Preservative
• 15-20% carbamide peroxide is also available for dentist • Preservative acidic solutions like phosphoric acid, citric
supervised bleaching. This yields 5.4 -7.5% hydrogen acid, sodium stannate are added.
peroxide. • These acidic solutions give bleaching material better
stability and longer durability.
Hydrogen Peroxide
• Most of bleaching agents contains some form of hydro- Flavoring Agents
gen peroxide. These are added to enhance the patient acceptability.
 Esthetic Operative Dental Procedures 461
Over the Counter Bleaching Kits (OTC Kits)
• These are bleaching kits that are available in markets
without any dentists prescription.
These kits contain:
• Acid rinse: These have pH of 1-2 because of presence
of citric acid or phosphoric acid and can lead to
erosion of teeth.
• Postbleach polishing cream: These pastes have titanium
oxide which gives white appearance to tooth which
is a temporary effect.
Problems with OTC kits:
• They can cause severe erosion of teeth.
• They can lead to sensitivity of teeth.
• Patient may misdiagnose his/her tooth discoloration
Figures 27-13A and B: Ionization of hydrogen peroxid:
etiology and may self medicate with these bleaching kits. (A) In acidic medium, (B) In alkaline medium

Mechanism of Bleaching Action radicals, which can react with unsaturated bonds
• Enamel is a semipermeable structure. resulting in change in absorption energy of organic
• Three most important bleaching constituents are molecules in tooth enamel. Simpler molecules that reflect
peroxide, chlorine and chloride. less light results in whitening of teeth.
• Hydrogen peroxide and oxygen radicals because of their • In bleaching process pigmented carbon ringed molecules
low molecular weight are easily permeable into enamel are opened and converted into chains which are lighter
and dentin. in color.
• Hydrogen peroxide acts as an oxygenator and oxidant.
Hydrogen peroxide oxidises the pigment in tooth struc- Saturation Point
ture. The yellow pigments (xanthopterin) are oxidized • As the bleaching process is continued a point is reached
to white pigments (leukopterin). where only hydrophilic colorless molecules exists after
• Predominant mode of action of bleaching agent is by which lightening of tooth color slows down (Figure
oxidation the reaction that takes place in “Redox” 27-14).
reaction. • If allowed to continue the bleaching process enamel is
• In “Redox” reaction the hydrogen peroxide molecule is being broken down resulting in formation of carbon di-
reduced to give free radicals with unpaired electrons oxide and water.
and tooth becomes oxidized by accepting this free
electron and lightens in shade. Carbamide Peroxide Bleaching Process
• Carbamide peroxide is available in concentrations of
Hydrogen Peroxide Bleaching 3-15%.
• Hydrogen peroxide is an oxidizing agent that has the • Carbamide peroxide breaks down to hydrogen peroxide
ability to produce free radicals which are very reactive. and urea (Figure 27-15). Ten percent carbamide
• Hydrogen peroxide breaks down to 2H2O2 → 2H2O + peroxide breaks down to 3.6% hydrogen peroxide.
O2. but this reaction gives out only weak free radical • Carbamide peroxide products are available in glycerine
(Figure 27-13A). base to prolong the duration of bleaching process.
• For more potent free radical HO2 · to be formed hydrogen
peroxide needs to be in alkaline in nature with pH 9.5- Factors that Affect Bleaching
10.8. This can happen only when bleaching agent is • Surface debridement: Thorough scaling and polishing
applied onto teeth which are free of debris and saliva should be performed in order to eliminate all superficial
(Figure 27-13B). debris.
• The free radicals released by hydrogen peroxide react • Hydrogen peroxide concentration: The higher the
with organic molecules in tooth structure resulting in concentration, the greater and effect of the oxidation
462 Essentials of Operative Dentistry

Figure 27-14: Bleaching process

 Esthetic Operative Dental Procedures 463
• Amount of time that bleaching solution is in contact
with tooth structure.
• Viscosity of material.
• Rate of oxygen released.
• Original shade and location of tooth.
• Location and depth of discoloration.
• Etiology of discoloration.
Figure 27-15: Break-down of
carbamide peroxide
Vital In-office Bleaching (Power Bleaching)
process. The highest concentration generally used is (Figures 27-16 and 27-17)
35% hydrogen peroxide. • There are several bleaching techniques most of them
Note: When gelling agents are added to a 35% solution use a concentrated solution of hydrogen peroxide (35%
of hydrogen peroxide, the concentration of H2O2 is then hydrogen peroxide).
reduced to 25%. • Some bleaching agents employ heat, high intensity light
• Temperature: An increase of 10oC doubles the rate of to activate the bleaching solutions.
the chemical reaction. Generally, if the temperature is • Bleaching agents are available in, liquid form, powder/
elevated to a point at which the patient does not feel liquid form or gel forms.
discomfort, then the procedure is taking place at a safe • The soft tissues are protected by rubber dam or soft resin
range of temperature. dam material from concentrated hydrogen peroxide.
• pH: When hydrogen peroxide is stored and shipped, an • This technique is usually employed for patients who
acidic pH must be maintained to extend shelf life. The need rapid result.
optimum pH for hydrogen peroxide to have its oxidation • Bleaching lights are used to rapidly activate the
effect is pH 9.5 to 10.8. This produces a 50% greater result bleaching agent.
in the same amount of time as at a lower pH.
• Time: The effect of the bleach is directly related to the Bleaching Light
time of exposure. The longer the exposure, the greater • These are photo-flood lamps that are focused on labial
the color change. surfaces of tooth and provide both light and heat to
• Sealed environment: Placing the hydrogen peroxide into activate the bleaching agents.
a sealed environment has been shown to increase its • Darker stained tooth can be additionally activated by
bleaching efficiency. heat application using a bleaching wand.

Properties of Ideal Bleaching Agent

Ideal bleaching agent should be:
• Be easy to apply.
• Be nonacidic or neutral in pH.
• Lighten the teeth successfully and efficiently.
• Remain in contact with teeth for relatively shorter
periods of time. Figures 27-16A and B: Resin dam placed prior to bleaching
• Use minimum quantity of hydrogen peroxide to achieve agent application
the desired result.
• Should not damage tooth structures and surrounding
periodontal tissues.
• Be well controlled by dentist according to patient’s
needs.

Rate of Color Change

Rate of color change is affected by: Figure 27-17: Application of in-office
• Frequency that solutions are changed. bleaching agent
464 Essentials of Operative Dentistry

In-office bleaching generally takes generally 2-6

appointments of 45 minutes to 1 hour each appointment.
Manufacturer’s instructions are to be followed with regard
to time duration of bleaching agent application.
Some products change color after prescribed time of
application.
If patient compliant of gingival tissues burning
bleaching agent is washed off with water (with or without
baking soda) to neutralize the peroxide to avoid severe
tissue burning.

Laser Assisted In-office Bleaching

• Dental lasers are useful for bleaching it provides
powerful energy (heat) source to enhance the action of
hydrogen peroxide by promoting a more rapid release
of free radical.
• Argon lasers are recommended by American Dental
Association for bleaching purposes.

Compressive Bleaching Technique

(Figures 27-18A and B)
• Miara (2000), suggests that power bleaching could be
made more efficient by compressing the bleaching
material to tooth structure.
• He suggests that 35% hydrogen peroxide be applied in
Figures 27-18A and B: In-office bleaching: (A) Conventional:
a tray and sealed onto tooth structure followed by heat
1—Light cure dam, 2—bleaching gel, 3—light source,
or light application. (B) Compressive: 1—Gingival protection, 2—light cure dam,
• This technique suggests that there is increased 3—tray, 4—bleacing gel, 5—light source
penetration of oxygen molecules into tooth structure
(Figure 27-18B).
At Home Bleaching
Advantage • More commonly employed technique less expensive for
Provides more rapid and quicker result. the patient.
• It uses a custom fit tray with 10% solution of carbamide
Disadvantages peroxide.
• More concentrated solution can cause sensitivity. • Range of concentration of carbamide peroxide available
• More costlier. are 10-20%. Most common concentration employed is
• Time consuming. 10% carbamide peroxide (Figures 27-19A to C).

McInnes Solution Bleaching Tray Fabrication

(Figures 27-20A and B)
• This is one of older techniques of in-office bleaching.
• McInnes solution consists of 1 part anesthetic ether, • Bleaching tray is a soft polymer of polyvinyl acetate.
5 parts hydrochloric acid (36%), 5 parts hydrogen • It is constructed on a stone cast.
peroxide (30%). The solution is freshly mixed and • Trays can either have scalloped gingival margins or
applied onto tooth using a cotton applicator. Each nonscalloped gingival margins.
bleaching session consisted of application of bleaching • Trays are constructed with reservoirs or foam liners to
solution for 5 minutes with 1 minute interval under hold extra amount of bleaching material (Figures
rubber dam application. 27-21A and B).
 Esthetic Operative Dental Procedures 465

Figures 27-19A to C: Home bleaching kit with tray container and gel syringes and applicator tips

Figures 27-20A and B: Bleaching tray

Figures 27-21A and B: Bleaching tray with reservoir on facial surfaces to hold the bleaching material

Tray Wear Time • Food-related stains due to absorption like coffee and tea.
• Root canal treated teeth that has discolored or
• Patient is instructed to wear the tray for a minimum of
discoloration due to trauma.
continuous 4 hours night/day (Figures 27-22A to C).
• Inherited yellowish stained tooth.
• Bleaching may occur anywhere from 2-14 days.
Contraindications
Indications for Bleaching • Severe tetracycline and fluorosis staining.
• Mild generalized staining. • Hypoplastic teeth.
• Age-related yellow discoloration. • In young patients with large pulp chambers.
• Mild tetracycline staining. • Patients who cannot comply with treatment regimen.
• Very mild fluorosis staining (Figures 27-23A and B). • Teeth with inadequate restorations.
• Acquired superficial staining. • Teeth with surface loss like due to attrition, abrasion or
• Tobacco-related staining. erosion.
466 Essentials of Operative Dentistry

Figures 27-22A to C: Placement of bleaching material in tray and patient wearing the tray

Figures 27-23A and B: Clinical case of bleaching fluorosis staining: (A) Preoperative, (B) Postoperative

• Patients who have sensitive teeth. • Carcinogenicity and mutagenicity in concentrations

• Teeth with large restorations. used for bleaching with hydrogen peroxide has not yet
• Teeth with periapical lesions. been proved even though hydrogen peroxide is a
• Pregnant patients and patients who are hypersensitive carcinogenic agent.
to hydrogen peroxide.
Systemic Effects and Response
Safety Factors (Figure 27-24) Systemic absorption of small amount of bleaching material
Tooth and Pulpal Problems used do not cause any systemic disorders.
• Bleaching can lead to increased sensitivity of teeth in
some patients. Effect on Restoration
• This can be treated either by a passive treatment method • Bleaching has no effect on composite, ceramic or
or active treatment method. amalgam restorations.
• Passive treatment method involves reducing the • If already an esthetic restoration is present before
duration of bleaching agent application or stopping bleaching treatment then after bleaching it may be
the treatment for a while before resuming. necessary to replace the restoration as the surrounding
• Active treatment involves application of desensitizing tooth structure would have lightened in shade.
agents like 3-5% potassium nitrate in gel form in tray. • As bleached tooth has oxygen rich surface it might be
difficult to bond to tooth structure because of oxygen
Soft Tissue Problem inhibition of polymerization of resin. Therefore, the
• More powerful in-office bleaching materials of 35% option is to either delay bonding procedure by one week
hydrogen peroxide can cause burning of oral mucosa or applying drying agent like acetone or reducing agent
turning it into white. But it is a momentary phenomenon like ascorbic acid (Vitamin C) to diminish the oxygen
and tissues return to normalcy. content.
 Esthetic Operative Dental Procedures 467

Figure 27-24: Movement carbamide peroxide through tooth structure

Alternatives to Bleaching Questions to Think About

• In-office bleaching, such as power or laser bleaching 1. What is bleaching? Mention about different types of
• Porcelain veneers bleaching techniques. Elaborate about the indications,
• Composite veneers contraindications, advantages and disadvantages of
• Composite bonding bleaching.
• Crowns: All porcelain crowns or porcelain bonded to 2. Discuss about mechanism of bleaching? Mention about
metal crowns constituents of bleaching material and various factors
• Further restorations that affect bleaching process.
• Combinations of treatments. 3. What are the ideal properties of bleaching materials
and factors that affect the rate of color change in
Key Terms tooth?
4. Explain about in-office bleaching technique.
• Bleaching
• Tooth color
• Nonvital bleaching
• Vital bleaching Microabrasion/Macroabrasion
• Hydrogen peroxide
• Microabrasion and macroabrasion represent conser-
• Carbamide peroxide
vative alternative for the reduction or elimination of
• Saturation point
superficial discolorations.
• In-office bleaching
• These techniques abrade away stained areas and
• Home bleaching
defects on tooth structure.
• Power bleaching
• These techniques are employed only for stains and
• Compressive power bleaching
defects on tooth that do not extend beyond a few tenths
• Laser-assisted bleaching
of a millimeter in depth (0.2-0.3 mm).
• Walking bleaching
• Dony et al in 1992, showed that a dense prismless layer
• Thermocatalytic bleaching
is formed on enamel surface after microabrasion giving
• Bleaching tray
the tooth a glass like luster appearance called as
• Resin dam
abrasion effect.
• Reservoir
468 Essentials of Operative Dentistry

Figures 27-25A to D: Clinical case of microabrasion for mild fluorosis staining: (A) Preoperative, (B) Rubber dam
isolation and hydrochloric acid application, (C) Microabrasion with pumice and acid paste, (D) Postoperative

Microabrasion (Chemical-physical Contraindications

Microabrasion) • Incipient enamel caries white spot.
• Croll in 1986, introduced a technique of using 18% • Developmental enamel hypoplasia.
hydrochloric acid and pumice applied in paste to tooth
surface to remove the defects or stains and termed the
Clinical Technique (Figures 27.25A to D)
procedure as “enamel dysmineralization”. • Teeth are isolated by rubber dam.
• This technique depended on acid to cause surface • Microabrasion paste is applied onto tooth with a rubber
dissolution of enamel and abrasive nature of pumice to cup engaged on a low speed handpiece. By this action
remove superficial stains and defects. superficial stains are removed. The rubber cup appli-
• This technique has been modified by reducing the acid cation onto tooth surface is for only 20-30 secs.
concentration to 11% and increase the abrasiveness of • Hydrochloric acid and pumice paste can also be applied
paste by adding silicon carbide particles and this is by cotton pellet to tooth surface.
• Once the procedure has been done topical fluoride
marketed as Prema©.
application has to be done to neutralize the acid used.

Indications Advantages
• When total tooth color change is not required only • Easy to perform
isolated areas of defects needs to be corrected. • Conservative treatment option
• Developmental discolored spot. • Inexpensive
• Any defects less than a millimeter in depth. • Results are quickly seen.
 Esthetic Operative Dental Procedures 469
Disadvantages
• It removes enamel
• Hydrochloric acid is caustic.
• Patient and dentist protection is mandatory.
Most of often microabrasion is combined with bleaching
treatment “Combination treatment” to achieve the desired
result.

Macroabrasion
• Alternative method to remove superficial stains is
“macroabrasion”.
• Here this technique uses a 12 fluted composite finishing
tungsten carbide bur or microfinishing diamond
abrasive employed in high speed handpiece (Figure
27-26).
• Tooth structure removal is one with light intermittent
pressure and carefully monitored to prevent excess tooth
removal.
• After finishing the procedure the tooth is polished with
rubber points to attain the smooth enamel lustre. Figure 27-26: Microfinishing diamond abrasive
• Macroabrasion can also be done with air-abrasion
(kinetic energy preparation).
Key Terms
Advantage • Microabrasion
• Chemical-physical microabrasion
More easier to remove stains than microabrasion. • Enamel dysmineralization
• Abrasion
Disadvantage • Macroabrasion
Can remove excess tooth structure. • Combination treatment.

Indications/Contraindications Question to Think About

• Same as in microabrasion. 1. Discuss about microabrasion and macroabrasion, it is
• Microabrasion is preferred treatment over macro- indications, contraindications, advantages and dis-
abrasion. advantages.
470 Essentials of Operative Dentistry

28 Additional Considerations
in Operative Dentistry

Dentinal Hypersensitivity Cementum Loss

• Gingival recession
• Dentin hypersensitivity is a common condition of
• Periodontal disease
transient tooth pain caused by a variety of exogenous
• Root planing
stimuli.
• Periodontal surgery
• These exogenous stimuli include thermal (cold or heat),
tactile (touch) or osmotic changes (sweets or sour food).
• Most often dentinal sensitivity is related to dental caries, Mechanisms of Pain Transmission Theories
traumatic injuries, presence of defective restoration, etc. of Dentinal Hypersensitivity
• In some number of patients exact cause of dentinal Several theories that have been proposed include:
sensitivity cannot be pointed out. • Direct innervation theory.
• Odontoblast deformation theory/transducer mecha-
Definition nism.
• Hydrodynamic theory.
• The International Workshop on Dentin Hypersensi-
tivity (1983) has proposed following definition.
• “Dentin hypersensitivity is characterized by short, sharp Direct Innervation Theory
pain arising from exposed dentin in response to stimuli • This was one of the first theory proposed.
typically thermal, evaporative, tactile, osmotic or • According to this theory, nerve fibers present within
chemical and which cannot be ascribed to any other the dentinal tubules initiate impulses when they are
form of dental defect or pathology”. injured and causes dentinal sensitivity.
Shortcomings of this theory
Etiology • Histological studies do not reveal nerve fibers in whole
Several predisposing factors leads to dentinal hypersensi- of dentin, nerve fibers is present only in predentin.
tivity. All the causes that lead to loss of enamel or cementum • Root dentin has been shown to be devoid of nerve fibers
and dentin exposure leads to sensitivity. which are also sensitive.
• Pain inducing substances like potassium chloride,
Enamel Loss acetyl choline, histamine fail to elicit pain response.
• Occlusal wear
• Tooth brush abrasion Transducer Mechanism
• Erosion This theory suggests that odontoblasts or odontoblast
• Abfraction process are damaged when external stimuli are applied
• Parafunctional habits which can stimulate the nerve endings in predentin.
 Additional Considerations in Operative Dentistry 471
Shortcomings of this theory
• Odontoblastic processes extend only partly through
dentin.
• Odontoblastic membrane potential is too low to permit
nerve signal transmission.
• No neurotransmitters like acetylcholine are evident.

Hydrodynamic Theory
• Suggested by Brannstrom M.
• This is the most accepted theory for dentinal hypersensi-
tivity mechanism (Figure 28-1).
• Dentinal fluid is present in dentinal tubules. This fluid
undergoes rapid movement when exposed dentin is
stimulated by stimuli like heat, chemical or osmotic
stimulations (Figure 28-2).

Figure 28-2: Various stimuli causing dentinal fluid

movement and dentin sensitivity

• Percussion evaluation.
Figure 28-1: Hydrodynamic theory causing dentin sensitivity
due to dentinal fluid movement
• Persistence of pain after stimulus is removed.
• Pulp vitality tests to assess the health of pulp.
• Radiographic examination of teeth to rule out presence
This rapid fluid movement causes:
of caries, pulp or periodontal involvement, if restoration
• Direct stimulation of low threshold A-delta nerve fibers
is present its marginal integrity and overhangs.
in the pulp.
• Any defective restorations.
• Indirect stimulation of A-delta nerve fibers due to
displacement of odontoblastic cell bodies.
Differential Diagnosis
Clinical Features of Dentinal Sensitivity • Fractured restorations
• Fracture enamel
• Pain is the predominant symptom of dentinal hyper-
• Dental caries
sensitivity.
• Postrestoration sensitivity
• Pain is of short duration and in sharp nature in response
• Cracked tooth syndrome
to external stimuli.
• Bleaching sensitivity
• Pain is present only as long as the stimuli is present.
• Treatment options for 1, 2, 3 are definitive
restorations.
Clinical Examination • Treatment option for 4 is pulpal condition of teeth
Following tests or observations should be done: has to be re-evaluated.
• Evidence for dentinal exposure like gingival recession, • Treatment option for 5 is complex and endodontic
abrasion, etc. treatment is imitated.
• Sensitivity or pain of concerned tooth to tactile • Treatment option for 6 is stop bleaching treatment
stimulation. temporarily.
472 Essentials of Operative Dentistry

Prevention of Dentinal Hypersensitivity Desensitization by Occluding Dentinal Tubules

• Diet counseling avoiding citrus and acidic foods. • Formation of smear layer over exposed dentin:
• Learning proper brushing technique and usage of softer • This can be achieved by isolation and drying the
toothbrushes. tooth and burnishing the teeth with orangewood stick
• During operative dental procedures proper cooling of to form smear layer.
tooth structure while preparing cavities are necessary. • Provides only temporary relief.
• Care during periodontal procedures like scaling and • Use of topical agents to occlude dentinal tubules:
root planing. • Calcium hydroxide
• Calcium hydroxide powder can be mixed with
Management of Dentin Hypersensitivity distilled water to form a thick paste, this then
(Figure 28-3) applied over tooth for a few minutes to increase
the chances of remineralization.
• Desensitization by occluding dentinal tubules
• Provides only temporary relief.
• Formation of smear layer over exposed dentin
• Calcium phosphate pastes
• Use of topical agents to occlude exposed dentinal
• Application amorphous calcium phosphate and
tubules:
casein calcium phosphate (ACP-CCP) has been
• Calcium hydroxide pastes
shown to reduce dentinal sensitivity by occluding
• Calcium phosphate pastes
of dentinal tubules (Figure 28-4).
• Silver nitrate
• Commercially available as GC Tooth Mousse.
• Strontium chloride
• Silver nitrate
• Fluorides
• Application of silver nitrate solution over exposed
• Fluoride ionotophoresis
dentin precipitates protein formation or silver
• Potassium oxalate
chloride crystal formation.
• Varnishes
• But this procedure stains dentin.
• Dentin adhesives.
• Strontium chloride
• Placement of restorations
• It is incorporated into toothpastes.
• Use of lasers:
• It occludes dentinal tubules by formation of
• CO2 lasers
strontium apatite.
• Nd:YAG, Er:YAG lasers
• He:Ne lasers
• Desensitization by blocking pulpal sensory nerves:
• Potassium nitrate toothpastes.

Figure 28-3: Various treatment options for dentinal Figure 28-4: ACP-CCP paste—
hypersensitivity Tooth Mousse
 Additional Considerations in Operative Dentistry 473
• Fluorides • Hydrodynamic theory
• Agents such as sodium fluoride, stannous • Fluoride ionotophoresis
fluoride, acidulated phosphate fluoride may be • ACP-CCP pastes
present along wash mouthrinses, toothpastes.
• This results in formation of flourapatite to block Questions to Think About
dentinal tubules. 1. Define dentinal hypersensitivity. Explain about various
• Fluoride iontophoresis
treatment option available for treating dentinal hyper-
• Iontophoresis is a procedure in which ions of a
sensitivity.
chosen medicament are driven into specific tissues
2. Discuss about the diagnosis of dentinal hypersensitivity
by means of electric current.
and mention about various differential diagnosis of
• Fluoride iontophoresis transfers fluoride ions into
dentinal hypersensitivity.
dentin for purpose of desensitization.
• The iontophoresis unit consists of a negative
electrode placed onto tooth and positive electrode Management of Gingival Tissues
placed on patient’s arm or face.
• Two percent stannous fluoride is used to transfer Very often restoration impinges upon gingival tissues
fluoride ions. when caries extends subgingivally. In these situations it
• This method is expensive and needs special becomes mandatory to manage the gingival tissues to
equipments. achieve maximum possible properties of the restorative
• Potassium oxalate: Oxalate ions react with calcium material and ensure longevity of restoration.
ions in the dentinal fluids to form insoluble calcium
oxalate crystals that block and prevent dentinal fluid Indication for Gingival Tissue Management
movement. • Subgingival extensions of margins: When cavity prepa-
• Varnishes: Varnishes form protective barrier over ration extends subgingivally, e.g. in class II proximal
dentin to prevent conduction of stimuli. cavity preparation or in class V restoration (Figure
• Dentin adhesives 28-5).
Recently introduced dentin bonding agents micro- • Control of gingival hemorrhage or fluid flow: Whenever
mechanically bond to tooth structure to protect the tooth preparation extends close to gingival margins
dentin from external stimuli. bleeding from gingiva or gingival fluid can contaminate
For example, Gluma desensitizer (Hereaus Kulzer), the preparation.
Desense (Ivoclar Vivadent). • Esthetics: When placing esthetic restorations like ceramic
veneers it may be necessary to place the margins
Desensitization by Blocking Pulpal Sensory Nerves subgingivally for better esthetics. This may necessitate
Potassium nitrate toothpastes gingival management.
Potassium ions from toothpaste can easily pass through • Enhancing retention: Sometimes because of inadequate
the dentin to the pulp. Here they depolarize the nerve tooth structure the margins of preparation has to be
endings, preventing the transmission of nerve impulses. extended subgingivally as in cast restorations.
Recommended treatment approach
• At first conservative treatment option has to be tried
like application of calcium phosphate or potassium
nitrate toothpastes.
• If considerable enamel is lost to expose dentin then
restorations has to be included in treatment plan.
• If severe sensitivity persists then endodontic therapy
has to be initiated.

Key Terms
• Direct innervation theory
• Transducer theory Figure 28-5: Subgingival extension of class V lesion
474 Essentials of Operative Dentistry

• Recording of preparation margins in impression: When • Temporary restorations: Use of zinc oxide eugenol
indirect restorations are taken gingival margins are cements or periodontal packs to push away gingival
better recorded if the free gingiva is retracted away from can be used.
the preparation. • Retraction cords: Plain retraction cord can be placed into
• Removal of gingival overgrowth: If gingival tissues have gingival sulcus to push away gingiva laterally (Figures
overgrown and obscuring the tooth preparation it may 28-6 to 28-9).
be necessary to remove the excess gingiva. They may be made of cotton or synthetic fibers.
Retraction cords can be braided or nonbraided and
Methods of Gingival Tissue Management are available in various sizes – 000, 00, 0, 1, 2, 3 (Figure
• Physicomechanical method 28-6).
• Chemomechanical method • Copper bands and impression copings (Figure 28-10):
• Chemical methods Appropriate size copper bands are selected and placed
• Rotary curettage into gingival sulcus prior to impression taking to
• Surgical methods produce gingival retraction.
• Electrosurgical methods. But this technique because of sharp margins in
copper band can exacerbate the gingival bleeding and
Physicomechanical Method traumatize the gingiva.
This method mechanically displaces free gingiva apically
and laterally away from the preparation margins.
This method is employed only when gingival tissues
are healthy.
Various techniques are as follows (Table 28-1):
• Rubber dam: Heavy weight rubber dam sheet can be used
along with clamp No. 212 for gingival retraction.
• Wedges: Wedges placed interproximally in class II
preparation helps in retracting gingiva.
• Rolled cotton: Cotton can be rolled and placed in gingival
sulcus.
Figure 28-6: Gingival retraction cord

Table 28-1: Comparison between various gingival retraction methods

Application Traumatic Requires Requires Provides Time

method to tissue pressure tray or cap hemostasis taken
Retraction cord Packing Yes No No Yes/No Up to 5 minutes
into sulcus
Copper band Trim and apply band Yes No No Yes, Up to 5 minutes
by isolating site
Rubber dam With clamp/floss No No No Yes, Up to 5 minutes
by isolating site
Rotary curettage Direct Yes No No No Up to 5 minutes
Electrosurgery Direct Yes No No Yes 3 to 5 minutes
Laser surgery Direct Yes No No Yes 3 to 5 minutes
Gingival retraction paste
Expasyl™ Syringe No No No Yes 2 to 4 minutes
Magic FoamCord Syringe No Yes Yes No 5 minutes
GingiTrac™ Syringe No Yes Yes Yes/No 5 minutes
 Additional Considerations in Operative Dentistry 475

Figures 28-7A to I: Retraction cord placement using a cord placer instrument: (A) Two inch piece of cord
is cut-off, (B) Cord is twisted to make it tight enough, (C) Loop of cord is placed around the teeth and held
by fingers, (D to G) Cord is pushed into sulcus, (H) Excess cord material is cut-off, (I) Final piece of cord in
placed into sulcus

Figure 28-10: Copper band and its

application onto tooth

Figures 28-8A and B: Placed retraction cord: (A) Correct,

(B) Incorrect Chemomechanical Method
• Placement of gingival retraction cord impregnated in
chemicals is a popular method.
• Commonly used chemicals in retraction cords are:
• Vasoconstrictors
• Astringents/blood coagulants
Figure 28-9: Cord placer • Tissue coagulants.
476 Essentials of Operative Dentistry

Vasoconstrictors
• Agents include adrenaline or noradrenaline. They act
by hemostasis and local vasoconstriction.
• Thus, reducing gingival bleeding and gingival fluid
seepage.
• They are contraindicated in patients with cardio-
vascular diseases.
Astringents
Following agents are used:
Figure 28-12: Rotary curettage with chamfer diamond abrasive
• Alum 100%
• Aluminium chloride
Rotary Curettage (Figure 28-12)
• Ferric sulphate
• Tannic acid 15-20% • This is called as “gingettage”. This is a troughing
Astringents act by coagulating the blood and gingival technique.
fluid in gingival sulcus. • Here a chamfer diamond abrasive in a high speed
handpiece is used to remove minimal gingival tissues.
Tissue coagulants • But this technique is uncontrollable and can lead to
• Following agents are used: excess hemorrhage.
• Zinc chloride 8%
• Silver nitrate
Surgical Methods
• They act by coagulating the surface layer of sulcular
and free gingival epithelium along with any fluids • This technique is using a BP blade knife.
present in gingival sulcus. • Mainly indicated for gingival hypertrophy or
• These agents can cause ulceration and necrosis of preparation extending deep into subgingival region.
gingival.
Electrosurgical Methods
Chemical Methods (Figure 28-11) Electrosurgery is used to remove hypertrophy gingiva
(Figures 28-13A and B).
• Several caustic chemicals like, sulphuric acid, trichlo-
racetic acid, negatol (a 45% combination of metacresol Advantages
sulfonic acid and formaldehyde), etc. have been used • Causes rapid, atraumatic cutting of tissues.
in chemical cautery of gingival tissues. • Creates a dry, blood less field of operation.
• Many of these tissues produce undesirable side effects. Principles of electrosurgery
• Only trichloracetic acid is still employed this produces It uses alternating high frequency current at high frequency
hemostasis and control of gingival fluid flow. concentrated at tiny electrodes to perform surgical actions.
Four actions produced by this current is (Figures 28-14
and 28-15):
• Cutting: This is a precise, bloodless procedure with
minimal tisuue damage using minimal energy.
• Coagulation: Thermal energy introduced produces
coagulation of blood and tissue fluids.
• Fulgeration: Using a greater energy produces deeper
tissue effect and produces carbonization of tissues.
• Desiccation: This produces massive tissue destruction
and is uncontrolled in action.

Recent Techniques for Gingival Retraction

Figure 28-11: Application of chemical agents for gingival • Lasers
tissue management • Retraction by dilatation of gingival sulcus.
 Additional Considerations in Operative Dentistry 477

Figures 28-13A and B: Electrosurgical unit: (A) Active Figure 28-14: Different electrodes for various purposes like
electrode, (B) Ground electrode coagulation, cutting, desiccation, etc.

Figure 28-15: Electrosurgical removal of excess gingival tissues

Lasers
• Currently, CO2 lasers, Nd-YAG lasers and aron lasers
are used for soft tissue procedures (Figure 28-16).
• Nd-YAG laser is recommended for gingival tissue
retraction and excision.
• Lasers work by photoablation mechanism and produces
bloodless field.
Advantages
• Bloodless, painless procedure
• Controlled tissue removal
• Rapid healing.
Disadvantages
• Slow technique
• Expensive.

Retraction by Dilatation of Gingival Sulcus

(Figures 28-17 to 28-21)
• There are several new products that utilize this
technique. These are mainly consists of polymer pastes
which expands while setting and placed into gingival
sulcus and produce necessary gingival retraction.
• All these pastes after prescribed time are removed prior Figure 28-16: CO2 laser used for
to impression-making. gingival retraction
478 Essentials of Operative Dentistry

Figure 28-20: Retraction of gingival tissues after Expasyl

placement and removal

Figure 28-17: Expasyl retraction system

Figures 28-21A and B: Application of retraction

paste and cap

delivered by gun type dispenser into gingival sulcus to

Figures 28-18A and B: Expasyl placement in
produce necessary retraction (Expasyl TM).
class II preparation
Third system: Third gingival retraction paste system (Gingi-
Trac™) also uses a preloaded syringe to apply the paste
around the margins.
The paste contains an astringent, and if necessary a
hemostatic agent can be applied prior to the application of
GingiTrac™.
For single tooth use, a cap (GingiCap™) is used to apply
pressure for up to 5 minutes after the paste has been
applied. The cap is first filled with the paste, then placed
over the tooth and paste syringed around the margins.

Key Terms
• Gingival retraction
Figure 28-19: Expasyl placement
• Copper bands
around tooth preparation
• Retraction cord
• Rotary curettage or Gingettage
First system: One product consists of modified silicone • Electrosurgery
elastomer (polyvinylsiloxane expandable elastomer)
available as base paste and catalyst paste (Magic foam Questions to Think About
gingival retraction cord system TM). This when mixed and
1. Explain about need for gingival retraction. Discuss in
placed into sulcus produces necessary retraction.
detail about the newer techniques of gingival retraction.
Second system: Another product employs aluminium 2. Elaborate about various methods available for gingival
chloride (hemostatic agent), kaolin and water paste retraction.
 Endodontics 479

29 Endodontics

• Endodontics is concerned with morphology and patho- Proper Diagnosis

logy of human dental pulp and periradicular tissues. Proper diagnostic methods are clinical examination, special
• Endodontic treatment is aimed at saving the tooth when pulpal tests and radiographs. This has already been dealt
injury to pulp and periradicular tissues has occurred. with in Chapter 3:Clinical Decisions in Operative Dentistry.
Treatments involving use of dental materials here are:
• Capping exposed vital pulp. Proper Access Cavity Preparation
• Sealing of root canal space after removing its contents Ideal endodontic accesses are as follows:
(root canal treatment and obturation). • Complete removal of roof of chamber.
• Reconstructing badly broken down tooth (post and core). • Removal of coronal pulp.
• Straight line access to root canal of tooth.
• Conservation of tooth as much as possible.
Root Canal Treatment • Proper retention of restorative material to be placed in
It mainly involves removal and disinfection of the inflamed access cavity preparation.
or infected pulp followed by medication of the root canal
and finally obturation of the root canal space. Working Length Determination
• This involves procedure to confine the instrumentation
Indications of root canal within the confines of the root canal space
• Inflammation of pulp and its contents, causes can be and not extruding into periapical region.
fracture of tooth, caries, etc. • Working length is determined from a coronal reference
• Caries exposure of pulp. point in the crown to root apex (cemento-dentinal
• Infection of pulp and its contents. junction).
There are some of the indications, since pulpal inflam- • This working length is determined by radiograph, apex
mation is irreversible the only solution for the resolution of locators, etc.
inflammation is removal of pulp and its contents in toto.
Root Canal Preparation
Root Canal Treatment Sequence • Once the working length is determined the root canal
Root canal treatment sequence involves following steps: preparation is done using files, reamers, etc. up till the
• Proper diagnosis. measured working length.
• Proper access cavity preparation. • During canal preparation two main objectives are
• Working length determination. fulfilled:
• Root canal preparation (biomechanical preparation). • Mechanical widening of root canal.
• Obturation root canal space. • Debridement of root canal using various types of
• Sealing of access cavity. irrigants.
480 Essentials of Operative Dentistry

Principle involved in root canal preparation is: • This is also used for diagnosis of the pulpal and
• Develop continuously taper funnel shaped preparation periapical condition.
from coronal to root apex. • This radiograph must be evaluated in a systemic
• Maintain the original shape of the root canal. manner, first evaluating crown portion then root portion
• Maintain the apical foramen in same position. followed by periapical region.
• Keep the root apex opening as small as possible.
Working Length Radiograph
Obturation of Root Canal Space • A radiograph is taken during the course of treatment
This step involves creating a tight hermetic seal by filling whereby the an endodontic file is kept inside the root
up the root canal space with an inert material. canal and radiograph is taken.
Most commonly used material for obturation is a type • Working length is determined by estimating the distance
of rubber material called as gutta-percha. from a coronal reference point to the root apex.
Various techniques of obturating the root canal space
are: Master Cone Radiograph
• Lateral condensation. • This is taken during the course of treatment wherein a
• Vertical compaction. mastercone gutta-percha is placed inside the canal to
• Injection method. verify the working length.
• Chemically plasticized gutta percha, etc. • This radiograph is taken prior to obturation of root canal.
This is taken to ascertain that obturation material will
Objectives of obturation are:
be confined within the root canal and will not be
• A tight three dimensional hermetic seal.
extruded out or short of root apex.
• Confine the obturation material to exact working
length.
Postobturation Radiograph
Sealing of the Access Cavity Preparation • This is taken after the obturation of root canal.
Once the obturation of root canal space is done, the • This radiograph is evaluated for the confinement of
access cavity is sealed temporarily mostly with zinc oxide obturation material to working length and quality of
eugenol cement followed by restoration of the teeth the obturation.
permanently.
Access Cavity Preparation
Endodontic Imaging Endodontic cavity preparation can be divided into two
It mainly comprises of radiographs most common parts, viz.
radiograph employed in endodontic practise is ‘Intraoral 1. Coronal cavity preparation (access cavity preparation).
Periapical Radiography’ (IOPA). 2. Radicular cavity preparation (Cleaning and shaping
of root canal).
This radiograph is mainly used for following purposes: Though these two are dealt separately, but radicular
• Diagnosis. cavity preparation is continuation of coronal cavity
• Pulp chamber shape, size and root canal morphology preparation.
and number of roots. • GV Black’s principle of cavity preparation could also
• Working length determination. be applied to both these preparations.
• Master cone accuracy. • Access cavity preparation is accomplished by rotary
• Post-treatment evaluation. instruments.
• For maxillary incisors No. 4 round bur is used for access
Preliminary Radiograph cavity preparation.
• This radiograph is taken prior to any treatment being • For a proper access cavity preparation a thorough
done on the concerned tooth. knowledge of the pulp chamber anatomy should be
• Often called as ‘preoperative radiograph’ this is mainly known. From the preoperative radiograph a two
taken to evaluate the size, shape of pulp chamber, root dimensional picture of a three dimensional structure is
canal morphology and number of roots. obtained.
 Endodontics 481
Principles of Access Cavity Preparation Toilet of the Cavity
GV Black applied his cavity preparation principles for • All caries dentin, debris and old restorative materials
cavity preparation in crown of the teeth. By slightly has to be removed completely before intiation of root
modifying it, this could be applied for endodontic cavity canal preparation.
preparation. • A large round bur or spoon excavator could be used for
this purpose.
Coronal Cavity Preparation Principles
• Outline form.
• Convenience form. Anatomy of Pulp Cavity and Root Canal
• Removal of any remaining caries and old restorative Brief Description About Pulp
materials.
• Toilet of the cavity. Anatomy of pulp
• Pulp is a soft connective tissue consisting of blood
Outline Form vessels, nerves and lymphatic vessels.
• Pulp occupies the central portion of tooth surrounded
• Cavity outline form should be proper to allow straight
by dentin.
access to root canal and root apex.
• External outline form is determined by internal pulpal Pulp is divided into:
chamber shape. This may be accomplished only by
Pulp cavity
drilling into the open space of the pulp chamber and
• It is the entire central space surrounded by dentin in
then working with the bur from the inside of the tooth
both crown and root.
to the outside, cutting away the dentin of the pulpal
• It consists of the pulp tissue.
roof and walls overhanging the floor of the chamber.
Pulp chamber
To achieve optimal preparation three factors has to be
Found in the central portion of the anatomic crown of tooth
considered:
and this portion is larger than the pulp canal in root
1. Size of pulp chamber
portion of tooth.
2. Shape of pulp chamber
3. Number of root canals and curvature of canals. Pulp canal (Root canal)
Pulp space found in the root portion of tooth from cervical
Convenience Form region of tooth to root apex.
Convenience form establishes: Pulpal horns
• Unobstructed access to root apex. These are pointed extensions of pulp present in the tooth
• Proper cleaning and filling of root canal space. crown and confirms to lobes or cusps of tooth.
• Complete control over the enlarging instruments.
Apical foramen
Main objective of the convenience form in cavity
It is the opening present in the root apex through which
preparation is that in preparing the root canal with
pulp of tooth communicates with periapical region.
instruments there should be no obstruction form the walls
of the access cavity and there should be straight line access
to the root apex. Functions of Pulp
Formation of dentin: In response to irritation pulp
Removal of Any Remaining Caries or stimulates the odontoblasts to form secondary dentin.
Old Restorative Material Nutrition: Pulp supplies blood to the teeth and also
This is mainly done: nourishes the odontoblasts.
• To eliminate bacteria present in caries dentin.
Sensory: It provides sensory function to tooth by reacting
• To prevent any future discoloration of tooth structure
to external impulses acting on tooth.
by presence of caries or old restorative material.
• To prevent leakage through caries dentin and defective Defensive function: In response to irritation secondary
restoration. dentin is formed, to protect the pulp from further damage.
482 Essentials of Operative Dentistry

Figure 29-1: Pulp chamber anatomy and components

Pulp Anatomy of Maxillary Incisors

(Figure 29-1)
• In general pulp cavity or chamber resembles the external
outline form of the tooth. For example, in maxillary
incisors the crown form is trapezoidal and internal pulp
chamber is also trapezoidal.
• Pulp chamber is wider mesiodistally than facio-
lingually.
• Here are three pulpal horns in maxillary central incisor
and in maxillary lateral incisor only two pulpal horns.

Labiolingual Section (Figure 29-2)

Pulp chamber: At its incisal extremity, the pulp chamber is
pointed, and gradually thickens to its widest point at about
the mid cingulum level. The labial outline is slightly convex,
while on the lingual there is usually a rounded hump
which corresponds to the external contour of the cingulum. Figure 29-2: Labiolingual Figure 29-3: Mesiodistal
cross-section cross-section
Pulp canal: From approximately the cervical line, the outline
of the single pulp canal tapers evenly to the apical foramen,
generally following the contour of the root. The foramen is line level. The three pulp horns, corresponding to the three
quite constricted, except in young teeth. labial lobes, are prominent and pointed in young central
incisors (laterals have two or none).
Mesiodistal Section (Figure 29-3) Pulp canal: From the cervical line, the pulp canal outline
Pulp chamber: From this aspect, the chamber outline is tapers rather evenly to the constricted apical foramen,
widest at the incisal, and tapers fairly evenly to the cervical again following the external root contour.
 Endodontics 483
Cervical Cross-section
In newly erupted centrals, the pulp outline may be
somewhat triangular like the root outline, but with age,
the outline becomes generally circular. The outline for the
lateral incisor is most often round at all ages (Figure 29-4).

Figure 29-4: Cervical third

cross-section

Mid Root Cross-section

At this level, the pulp outline of both maxillary incisors is
round (Figures 29-5 to 29-7).
Figure 29-7: Maxillary right permanent lateral incisor

Maxillary Anterior Teeth Access

Cavity Preparation
• Initial entry is gained with a round bur No. 4. Point of
entry is on the lingual aspect of the tooth in the center
aspect. Penetrate the enamel and enter into dentin.
• On entering dentin a tapering fissure bur is changed
Figure 29-5: Mid-root cross-section and long axis of bur made almost parallel to long axis
of tooth and continue penetration into the pulp chamber.
• On entering the pulp chamber a drop will be felt by the
operator.
• Access cavity is shaped using a round bur the labial
and lingual walls of the access cavity are smoothened
and any roof of pulp chamber is removed. This
procedure is done by taking the bur from inside the
access cavity to outside.
• Access cavity internally should be funnel shaped and
external appearance should be triangular with apex of
triangle facing cervically.
• When a root canal file is placed into the root canal
through the access cavity preparation the instrument
should not touch any walls of preparation. An incisal
bevel is given to prevent root canal instrument from
touching the incisal edge ((Figures 29-8 to 29-11).

Radicular Cavity Preparation

After completion of coronal cavity preparation radicular
Figure 29-6: Maxillary right cavity preparation is started. Principles of radicular cavity
permanent central incisor preparation are thorough debridement of root canal system
484 Essentials of Operative Dentistry

Figure 29-9: This diagram illustrates the importance of straight

line access and correctly designed access cavities. If root canal
treatment were to be carried out through a class III cavity, as
shown on the left, the file would be deflected and the canal
Figure 29-8: A proper access cavity allows would be transported. However, if the access cavity is cut
unrestrained access to root apex incorrectly in the palatal surface, not giving straight line access,
the same deflection and damage will occur

Figures 29-10A to K: Steps in access cavity preparation

and final shape of access cavity
 Endodontics 485
• Outline form is from the coronal 3rd to the apical 3rd of
the root canal.
Retention form
• In some obturation technique (mostly lateral
condensation) the apical 2-3 mm of root canal space is
made with nearly parallel walls ensuring tight fitting
of the master cone gutta-percha.
• This apical 3rd tight fitting is essential both for tight
seal and prevention of extrusion of gutta-percha.
• Rest of all the preparation starting from coronal access
cavity to radicular cavity preparation it is flared.

Figure 29-11: Incisal bevel given for Resistance form: Apical preparation or root can apex
straight access to root apex preparation should resist the filling material from
extruding out. This necessitates creating an apical stop.
and shaping the root canal to a specific shape to receive Prevention of extrusion of filling material is needed to
the obturation material. prevent:
1. Acute inflammation
Cleaning and Debridement of Root Canal 2. Chronic inflammation.
• This objective is achieved by skilful instrumentation This resistance form loss could be considered analogous
followed by liberal irrigation of the root canal. to class II amalgam restoration being done without a
• The microorganisms inside the root canal are killed by proximal matrix band.
the process of placing intracanal medicament. This Extension for prevention: This principle is mainly
process is akin to removal of remaining caries in cavity concerned with enlarging the root canal as much as
preparation in crown of the tooth. possible so that maximum amount of infected dentin is
removed from the root canal.
Preparing the Root Canal
It involves two techniques:
1. Step-back: Whereby the canal is worked from the root
apex and progressively enlarged, working upwards to
the coronal 3rd.
2. Step-down: Also called as crown-down technique, here
the coronal 3rd of root canal is enlarged followed by the
enlargement of apical 3rd.
All other techniques are modification of these two
techniques.

Principles in Radicular Cavity Preparation

(Figure 29-12)
Same as in coronal cavity preparation the principles are:
• Outline form Figure 29-12: Concept of endodontic cavity preparation
• Convenience form according to GV Black's principle: (A) Radiographic apex, (B)
• Toilet of the cavity Resistance from created (apical stop) to prevent extrusion of
debris and obturating materials, (C) Retention form developed
• Retention form
to retain the obturating material, (D) Convenience form so that
• Resistance form there is unobstructed straight line access of root canal files to
• Extension for prevention. root apex, (E) Outline form dictated by the root canal anatomy
Outline form and toilet of the cavity
• Meticulous cleaning of the root canal until the radicular Working Length
dentin is glassy-smooth accompanied by continous • Most important phase of root canal preparation is
irrigation ensures thorough debridement. working length estimation.
486 Essentials of Operative Dentistry

• Working length is defined as distance from coronal Common methods of evaluating working length are:
reference point to the point where the root canal • Radiographic method
preparation and obturation should terminate. • Specific distance from radiographic apex
• According to studies by Kuttler
Coronal reference point
• Ingle method
• This reference point be on the crown of the tooth
• Grossman method
structure and it should be flat usual reference point is
• Bergman method
cuspal tip or incisal edge.
• Tactile sensation
• This reference point is marked by a silicone stop fitted
• Electronic methods (Apex locators)
on the root canal instrument.
• Apical periodontal sensitivity
Apical reference point: This is one of the controversial issues • Paper point evaluation.
in root canal treatment where should the root canal A preclinical conservative students the radiographic
preparation terminate. apex could be taken as the apical limit for the root canal
preparation (Figures 29-14A and B). Though this is a
Some Terms Used in Apical Reference Point highly inaccurate method.
Anatomic apex: Tip of the root determined morpholo-
gically.
Root Canal Preparation
Radiographic apex: Tip of the root determined radio-
graphically. Cleaning and Shaping of Root Canal
Apical foramen: Main apical opening of the root canal. Objective
Accessory foramen: Opening on the root surface commu- Biologic objective
nicating with lateral canals/accessory canals. • Confine all instrumentation within root canal space
without violating the working length.
Apical constriction (minor diameter): Apical portio of root
• Avoid pushing the debris beyond the confines of root
canal opening having the narrowest diameter.
canal space.
Cementodentinal junction: Histologic structure where • Remove all potential irritants (microorganisms) from
cementum and dentin meets near the root apex. entire root canal system.
According to studies by Kuttler root canal preparation • Create sufficient width of the coronal 3rd of root canal
should stop at minor diameter which closely approximates space to allow for copious irrigation and flushing of
the cementodentinal junction. Minor diameter is the region entire root canal space.
where the apical stop is created (Figure 29-13).
Mechanical objectives
• Prepare a sound apical dentin matrix or apical stop at
the minor diameter or cementodentinal junction.
• Prepare the canal to taper apically with narrowest cross-
sectional diameter at the apical termination.
• Develop a continuously tapering funnel type prepara-
tion in 3-dimensional aspect within entire root canal.
• Confine the cleaning and shaping of canal system
within the working length so that the integrity of apical
foramen is maintained.
• Remove all residue of cleaning and shaping procedures
that could prevent the patency of apical foramen, i.e.
pulp tissue debris and dentin shavings.
• Canal shaping should facilitate cleaning and obturation
of root canal space.
Biologic objective are removal of all pulp tissues, bacteria
Figure 29-13: Minor and major diameter and their endotoxin from root canal.
 Endodontics 487

Figures 29-14A and B: Radiographic working length measurement

488 Essentials of Operative Dentistry

Mechanical objective are intended to fulfill the bio- Step-back technique is where the apical portion of the
logic objective and are additionally directed toward canal is shaped first followed by coronal and middle 3rd
producing sufficient canal shape to achieve 3-dimensional canal shaping.
obturation. Step-down (Crown down) technique here the coronal
Both mechanical and biologic objective are achieved in 3rd of root canal is shaped followed by middle 3rd and
in one single clinical procedure. apical 3rd.
Most of other technique is combination of these two
Concepts and Strategies for Canal Preparation techniques.
• Divide the root canal into coronal, middle and apical
3rd. With each third about 3-5 mm. Step-back Technique
• Canal preparation shape should be flared and funnel • A preclinical conservative student, will be required to
shaped in 3-dimension with largest diameter at the know the details of only step-back technique.
coronal 3rd. • This technique was given by Weine, Martin, Walton
• Direct access to the apical 3rd of root canal should be and Mullaney.
there, no hindrance from access cavity walls. • Also called telescopic or serial root canal preparation.
• Length of root canal instrument should be measured
and silicone stopper be placed at the estimated working
Detailed Technique
length.
• Instruments should be used in sequence from smaller When the root canal instrument is placed into root canal
to larger sizes, with periodic return to smaller size the tactile sensation gained may be, by pinching one
instrument to mainitain the patency of apical foramen index finger between the thumb and forefinger of the
(recapitulation). opposite hand and then rotating the extended finger
• Instruments should be used with a quarter to a half (Figure 29-15).
turn and withdrawn in a pull stroke. Phase I
• Apical portion of a root canal, 3-4 mm should be
• This involves the apical 3rd canal preparation.
enlarged at least three sizes greater than the first size
• Firstly, the canal should be explored with a fine
instrument that binds to apical portion of root canal.
instrument like size 10 or 15 file. Working length be
• Root canal instrument should be checked for deformity
determined and apical binding of the root canal
and discarded at first sign of deformity.
instrument size be noted.
• All instrumentation should be done with copious
irrigation.
• No debris should be pushed out through the apical
foramen.

Guideline for Adequate Shaping

• Apical portion of canal be enlarged three sizes larger
than the first instrument size that binds.
• Enlarge the canal until clean, white dentinal shavings
are obtained.

Techniques of Cleaning and Shaping of

Root Canal
• Step-back technique
• Modified step-back technique
• Passive step-back technique
• Step-down technique
• Hybrid technique Figure 29-15: Tactile sensation when a root canal
• Balanced force technique. instrument is introduced into root canal space
 Endodontics 489
• The motion of the instrument is “watch winding”, two
or three quarter-turns clockwise-counterclockwise and
then retraction. On removal, the instrument is wiped
clean, recurved, relubricated, and repositioned. “Watch
winding” is then repeated. Remember that the
instrument must be to full depth when the cutting action
is made. This procedure is repeated until the instrument
is loose in position.
• Then the next size file is inserted and same motion is
repeated.
• Apical portion shaping is finished when it has been
enlarged to three size file greater than the first file that
binds, and clean white dentinal shavings has been
obtained.
• In all these steps copious irrigation is required and
periodic return to smaller size file is necessary to
maintain the apical patency.
Phase II
Phase II A
• This involves the middle 3rd canal preparation.
• Here a next size larger file that has been used in previous Figure 29-16: Step-back root canal preparation in
stage is used, the length of the file is set 1 mm short of molar tooth
working length. Same shaping motion of file is used
and shaping is finished once the particular file is loose.
Periodic recapitulation to working length with smaller
size instrument is essential.
• This shaping is continued using larger sizes instru-
ments keeping 1 mm short of previous instrument length
used.
• Again in these procedures too copious irrigation is
essential.
Phase II B
Refining the shape of whole root canal is done by the
Figure 29-17: On removal from canal instruments
largest size instrument that was used to full working
are wiped clean with gauze
length. This instrument is used in scraping motion across
the root canal walls, to smoothen the preparation (Figure Different irrigating solutions are:
29-16). • Hot water
With this the preparation is finished and a continuously • Saline
tapering 3-dimensional preparation is obtained (Figure • Thirty percent urea
29-17). • Urea peroxide in solution of glycerine
• Chloramine
Irrigation • Sodium hypochloride
Goals of irrigation • EDTA and sodium hypochloride
• Lavage of debris. • Hydrogen peroxide
• Tissue dissolution • Chlorhexidine.
• Antibacterial action Saline
• Lubrication. • Isotonic saline accomplishes gross debridement.
490 Essentials of Operative Dentistry

• Too mild to thoroughly clean the canal. • Not interfere with repair of periapical tissues.
• Does not have chemical dissolution or antimicrobial • Should not stain tooth.
action. • Not be immunotoxic.
Preclinical students are required to use saline as
Various medicaments are:
irrigating solution.
• Essential oils
• Eugenol
Method of Irrigation • Phenolic compounds
• Usually a 27 gauge needle is bent at obtuse angle is • Phenol
used. • Parachlorophenol
• Needle should bind into the canal and needle should • Camphorated parachlorophenol
be free inside the canal and should be moved up and • Formocresol
down during irrigation (Figure 29-18). • Glutaraldehyde
• The return flow of solution should be caught in a suction • Cresatin
or gauze. • Calcium hydroxide
Other systems for irrigation are: • Most common used medicament.
• Prorinse • N2
• Max I probe • Halogens
• Monoject • Sodium hypochloride
• Endo irrigator • Quaternary compounds
• Sonic and ultrasonic irrigation. • Iodine
• Iodoforms

Mode of Application
These agents are available as:
• Gels
• Powder-liquid
• Liquid
These can be applied either as:
• Medicament applied on a cotton pellet or absorbent
paper point placed inside root canal space.
• Root canal can be flooded with medicament.

Obturation
Figure 29-18: Irrigation with needle Final stage of endodontic treatment is to fill the entire root
canal system and all of its complex anatomic pathways
Intracanal Medicaments completely and densely with nonirritating hermetic sealing
Need for intracanal medication is to decontaminate the agents.
canal of microorganisms this medicament is placed inside
the canal during inter-appointment phase when the root Ideal Requirements of Root Canal
canal has been thoroughly cleaned and shaped and before Filling Materials
obturation of root canal space. As suggested by Grossman:
• It should be easily introduced into a root canal.
Ideal Requirements in Intracanal Medicament • It should seal the canal laterally as well as apically.
• Should be effective germicide. • It should not shrink after being inserted.
• Should be nonirritating to periapical tissues. • It should be impervious to moisture.
• Should be stable. • It should be bacteriostatic or at least not encourage
• Prolonged anti-microbial effect. bacterial growth.
• Active in presence of serum, blood, pus. • It should be radiopaque.
 Endodontics 491
• It should not stain tooth structure.
• It should not irritate periradicular tissue.
• It should be sterile or easily and quickly sterilized
immediately before insertion.
• It should be removed easily from the root canal if
necessary.
Root canal filling materials can be classified as:
• Solids
• Silver points
• Acrylic points
• Semi-solids
• Gutta-percha
• Acrylic cones
• Pastes
• Zinc oxide and synthetic resins
• Epoxy resins (AH 2)
• Polyvinyl resins
• Polycarboxylate cements
• Silicone rubbers. Figure 29-19: Well-obturated canal
Root canal filling materials acts as a piston to propel
the sealer cement.
• Chemically plasticized cold gutta-percha
Characteristic of Ideal Root Canal Filling • Essential oils and solvents
• Eucalyptol
• American Association of Endodontists (AAE) has • Chloroform
published Appropriatness of Care and Quality • Halothane
Assurance Guidelines regarding all aspects of modern • Canal-warmed gutta-percha
endodontic treatment. Here root canal obturation is • Vertical compaction
defined as “the three dimensional filling of the entire • System B compaction
root canal system as close to the cementodentinal • Sectional compaction
junction as possible. Minimal amount of root canal • Lateral/vertical compaction
sealers, which have been demonstrated to be biologically • Endotec II
compatible, are used in conjunction with the core filling • Thermomechanical compaction
material to establish an adequate seal”. • Microseal system, TLC, Engine-plugger, and
• With regard to radiographic assessment of root canal Maillefer condenser
obturation, there should be a ‘radiographic appearance • Hybrid technique
of a dense, three dimensional filling which extends as • JS-Quick-Fill
close as possible to the cementodentinal junction as • Ultrasonic plasticizing
possible, i.e. without gross overextension or under filling. • Thermoplasticized gutta-percha
• Obturated canal should reflect the approximate shape • Syringe insertion
of the root morphology. Also the shape of the obturated • Obtura
canal should reflect a continuously tapering funnel • Inject-R-Fill, backfill
shaped preparation without excessive removal of root • Solid-core carrier insertion
structure at any level (Figure 29-19). • Thermafil and Densfil
• Soft Core and Three Dee GP
Various Obturating Techniques • Silver points
• Solid core gutta-percha with sealants • Apical-Third Filling
• Cold gutta-percha points • Lightspeed Simplifill
• Lateral compaction • Dentin-chip
• Variations of lateral compaction • Calcium hydroxide
492 Essentials of Operative Dentistry

• Injection or “Spiral” Filling • Along the side inserted master cone in the root canal a
• Cements spreader is introduced and its forced apically and
• Pastes pushed laterally the master cone. It is disengaged by
• Plastics rotating half turn between the finger tips.
• Calcium phosphate • An accessory cone is inserted into gap created by the
spreader and this insertion of spreader and accessory
Lateral Compaction of Cold Gutta-percha cone is continued till a well condensed filling is obtained.
• The size of the spreader is determined by master cone
(Lateral Condensation Technique)
gutta-percha size and is usually selected on size smaller
• This is the common technique taught in dental schools than the master cone gutta-percha size.
and standard against which other techniques are • After a well condensed filling has been obtained or no
evaluated. longer accessory cones can be inserted the butt end of
• This technique is done by placing a master cone gutta- the gutta-percha in the pulp chamber is seared off using
percha with sealer into canal followed by lateral a hot instrument (burnisher or spoon excavator). The
compaction using spreader to accommodate additional access cavity is filled with an temporary restoration
accessory cones. This is followed by searing of excess (Figures 29-20 to 29-23).
gutta-percha from the coronal access cavity and using
a plugger to condense the coronal gutta-percha.
Armamentarium
Technique • Mouth mirror
• Explorer
• A primary master cone gutta-percha is selected which
• Tweezer
should correspond in size to last largest instrument
• Spoon excavator
worked till the working length.
• Cement spatula
• This master cone gutta-percha should have a snug fit
• Glass slab
(tug-back).
• A radiograph is taken with gutta-percha inside the root
canal to determine the apical and lateral fit. This is the Root Canal Instruments
master cone radiograph. Master cone should exactly be • K File size 15-40, 45-80
confined within the working length. • Finger Spreader 15-40
• If gutta-percha is short or beyond the working length • Twenty-seven gauge needle and 5 ml syringe
the canal should be re-prepared or gutta-percha point • Metal scale (15 cm)
be cut short. • Sponge for holding root canal files.
• Once the fit of the primary cone has been established
the canal is dried and canal and the master cone are Rotary Instruments
coated with sealer. Sealer mixed should be smooth,
• Airotor handpiece
creamy in consistency with no granules.
• Round bur (No. 2 or 4), tapering fissure bur.

Figures 29-20A to D: Sizes of spreader and gutta-percha

 Endodontics 493

Figures 29-21A to J: Lateral compaction techniques of obturation: (A) Spreader is inserted into canal and it should be set 1 mm
short of working length, (B) Master cone gutta-percha is coated with sealer, (C) Master cone gutta-percha is selected with size
same as last instrument size used. Radiograph taken to verify the fit and working length confinement of the master cone gutta-
percha, (D) A spreader is inserted into the root canal along side master cone gutta-percha and space created for accessory cone,
(E) Accessory gutta-percha cone is inserted into the space, (F) Accessory cone insertion and spreader penetration is done until no
further space is available, (G) Butt end of gutta-percha in the pulp chamber is seared off using a hot instrument, (H) Using a hot
plugger the coronal end of gutta-percha is plugged inside, (I) Coronal access cavity is cleaned and restored with temporary
restoration, (J) Completed obturation

Figure 29-22: Mechanism involved in lateral condensation

and accessory cone insertion Figure 29-23: Completed obturation
494 Essentials of Operative Dentistry

Figure 29-24: Common pitfalls in access cavity preparation

Obturation Materials • Cavity preparation off center to root canal.

• Absorbent points 15-40, 45-80 • Discoloration of pulp chamber because of failure of
• Gutta-percha points 15-40, 45-80 removal of incisal portion.
• Zinc oxide eugenol cements. • No straight access to root apex.

Miscellaneous Root canal preparation (Figure 29-25)

• Cotton • Too wide canal preparation
• Cotton holder • Apical zip
• Mounted maxillary incisor • Ledge
• Radiograph films. • Perforation
• Loss of working length or over instrumentation beyond
Common Pitfalls (Figure 29-24) apex.
Root canal treatment (anterior teeth) Obturation (Figures 29-6A to C)
Access cavity preparation • Incompelete root canal preparation and obturation.
• Perforation—especially in the labiocervical region. • Obturation with voids.
• Failure to remove lingual shoulder or roof of pulp • Obturation short of apex or beyond apex.
chamber. All these errors lead to incomplete root canal prepara-
• Too large cavity preparation tion and failure.
 Endodontics 495
• This procedure is done to promote healing and retention
of the vital radicular pulp.
• Dentin bridging may occur as a treatment outcome of
this procedure depending on the type of medicament
used.

Indications
• Pulpotomies are indicated for cariously exposed
primary teeth when their retention is more advantageous
than extraction.
• Pulpotomy candidates should demonstrate clinical and
radiographic signs of radicular pulp vitality, absence
of pathologic change, restorability, and at least two-
thirds remaining root length.
• Pulpotomy is also recommended for young permanent
teeth with incompletely formed apices.

Contraindications
Figure 29-25: Common pitfalls root canal preparation • Root resorption of more than 1/3rd root.
• Tooth crown is unrestorable.
Pulpotomy • Mobility of tooth.
• Pulpotomy is the most widely used technique in vital • Periapical inflammation of the tooh.
pulp therapy for primary and young permanent teeth
with carious pulp exposures. Treatment Approaches to Pulpotomy
• A pulpotomy is defined as the surgical removal of the
Three categories of treatment approaches are available:
entire coronal pulp presumed to be partially or totally
1. Devitalization approach
inflamed and quite possibly infected, leaving intact the
2. Preservation approach
vital radicular pulp within the canals.
3. Regeneration approach.
• A germicidal medicament is then placed over the
remaining vital radicular pulp stumps at their point of Devitalization approach
communication with the floor of the coronal pulp • Here the intention is ‘mummification’ of the radicular
chamber. pulp.

Figures 29-26A to C: Common pitfalls in obturation: (A) Obturation beyond apex, (B) Incomplete
obtruation with voids and obtruation short of root apex, (C) Too wide preparation and obturation
496 Essentials of Operative Dentistry

• The term “mummified” has been ascribed to chemically

treated pulp tissue that is inert, sterilized, metabolically
suppressed, and incapable of autolysis.
• This mainly involved formocresol pulpotomy
Preservation approach
• This approach involved medication that preserve the
vitality of the radicular pulp.
• Pharmacotherapeutic agents used here are gluco-
corticoids, glutaraldehyde, ferric sulphate.
• Non-pharmacotherapeutic agents are electrosurgery
and lasers.
Regeneration approach
• Here it mainly involves agents that have cell inductive
capacity to either replace lost cells or induce existing
cells to differentiate into hard tissue forming cells.
• For example, here are calcium hydroxide, transforming
growth factor-(TGF-β), MTA, freeze dried bone.
Procedure
• Anesthetize the tooth and tissue (not required in
preclinical exercises).
• Isolate the tooth to be treated with a rubber dam. Figure 29-27: Formocresol pulpotomy
• Excavate all caries.
• Remove the dentin roof of the pulp chamber with a high-
speed fissure bur. Rotary instruments
• Remove all coronal pulp tissue with a slow-speed • Airotor handpiece
No. 6 or 8 round bur. Sharp spoon excavators can • Round bur (No. 2 or 4), tapering fissure bur.
remove residual tissue remnants. Miscellaneous
• Achieve hemostasis with dry cotton pellets under • Cotton
pressure. • Cotton holder
• Apply diluted formocresol to the pulp on a cotton pellet • Mounted molar with caries encroaching pulp chamber
for 3 to 5 minutes. • Formocresol
• Place a ZOE cement base without incorporation of • Zinc oxide eugenol cement
formocresol. • Zinc phosphate cement
• Restore the tooth with a stainless steel crown.
Common pitfalls same as in pulpotomy preparation
Fomocresol (Figure 29-27)
(Figure 29-28)
• Is a combination of formalin and cresol in proportion of
• Over extended preparation
1:2 or 1:2.
• Perforation
• Formalin is a strong disinfectant and fixative it combines
• Access off center to pulp chamber
with albumin (protein) to form an insoluble and
• In complete de-roofing of pulp chamber
indecomposable substance.
• Too deep access cavity preparation into floor of pulp
Armamentarium chamber.
• Mouth mirror
• Explorer Key Terms
• Tweezer
• Spoon excavator • Endodontics
• Cement spatula • Pulp horn
• Glass slab • Working length
• Plastic filling instrument. • Access cavity
 Endodontics 497
• Step down preparation
• Irrigation
• Intracanal medicament
• Master cone
• Lateral condensation

Questions to Think About

1. Define endodontics. What are the treatment procedures
in endodontics? Discuss about steps in root canal
treatment?
2. Discuss about principles in coronal cavity preparation?
Give an account of pulp morphology of maxillary incisor
and access cavity preparation.
3. Different methods in working length measurement.
4. What are the objectives of root canal cleaning and
shaping? Mention various types of preparation
technique. Discuss about steps in stepback preparation.
5. What are the objectives of irrigation? Mention about
Figure 29-28: Common pitfalls in pulpotomy
various irrigation solution.
6. What are the characteristics of ideal obturation filling
• Root canal and ideal requirement of obturation material? Discuss
• Step back preparation about types of different obturating materials.
• Pulp chamber 7. Give an account of various obturation techniques and
• Radiograph discuss about steps in lateral condensation.
498 Essentials of Operative Dentistry

30 Endodontic Materials
and Instruments

• Endodontics is concerned with morphology and • This procedure is called as Indirect Pulp Capping
pathology of human dental pulp and periradicular (Figure 30-1).
tissues.
Various materials employed for this procedure are:
• Endodontic treatment is aimed at saving the tooth when
• Calcium hydroxide—stimulate reparative (secondary)
injury to pulp and periradicular tissues has occurred.
dentin formation.
Treatments involving use of dental materials here are:
• Zinc oxide eugenol
• Capping exposed vital pulp.
• GIC
• Sealing of rootcanal space after removing its contents
• Resin-based composite with dentin bonding agents.
(rootcanal treatment and obturation).
• Reconstructing badly broken down tooth (post and
core).

Vital Pulp Capping

Two main causes of pulp exposure are:
1. Dental decay and tooth wear.
2. Accidental exposure during operative procedures or
trauma.

Indirect Pulp Capping

• According to Sir John Tomes 1859 its better to leave a
layer of discolored dentin rather than risk exposure of
pulp.
• During excavating of caries a small portion of dis-
colored, i.e. demineralized but bacteria free dentin can
be left behind to prevent pulpal exposure.
• It has been shown that this demineralized if placed Figure 30-1: Indirect pulp capping: A—Indirect pulp
under suitable dental material undergoes reminerali- capping material, B—Restorative material
zation.
• Two important criteria here are bacteria free dentin
(caries disclosing soln) and pulp without any patho- Direct Pulp Capping (Figure 30-2)
logical changes. Also required in this procedure is tight • This is a procedure by which exposed pulp is dressed
sealed restoration. (covered) directly by dental material.
 Endodontic Materials and Instruments 499
• The hard-setting cements are either two-paste systems
or are single paste systems consisting of calcium-
hydroxide-filled dimethacrylates, polymerized by light.
• The problem with the non-setting versions is that these
will gradually dissolve.
• The difficulty for the manufacturer is to.
• Achieve a balance between a material that is sufficiently
soluble to be therapeutic and not so soluble as to dissolve
away.
• Although it is arguable if the pulp-capping material
needs to release anything to stimulate dentine-bridge
formation.
• When the paste is brought in contact with the pulp it
causes a layer of necrosis of some 1.0–1.5 mm thick,
that eventually develops into a calcified layer.
• Experiments using radioactive calcium in the paste have
shown that the calcium salts necessary for minera-
lization of the bridge are not derived from the cement,
but are instead supplied by the tissue fluids of the pulp.
Figure 30-2: Direct pulp capping: A—Direct pulp capping
material, B—Base, C—Restorative material • Once the bridge has become dentine like in appearance,
and the pulp has been shut off from the source of the
irritation, the hard tissue formation ceases.
• This procedure is mainly indicated in traumatic or ope- • It is believed that the high pH of the calcium-hydroxide
rative pulpal exposure with no bacterial contamination. cement is responsible for this type of pulpal response,
• This procedure is contraindicated in caries pulpal and that this is also closely associated with its
exposure. antibacterial properties (Figures 30-3A to D).
• Calcium hydroxide is the material of choice for this
procedure but other materials are also used nowadays.
• A direct pulp capping material should be able to:
• Have a superficial effect on the pulp tissue, thereby
inducing a biological encapsulation process that
results in hard-tissue formation.
• Cause no adverse effects, whether systemically or
locally, such that the pulp is kept alive.
• Protect the pulp from the coronal ingress of bacteria.

Pulp Capping Materials

Calcium Hydroxide (Ca(OH)2)
• The first use of Ca(OH)2 was in the form of a slurry.
• Consisting of no more than a mixture of calcium
hydroxide in water.
• This was changed to a paste using methyl cellulose, Figures 30-3A to D: Effect of calcium hydroxide on pulpal
being somewhat easier to handle. and dentine tissues
• In the early 1960s the hard-setting calcium hydroxide
cements were introduced, where the calcium hydroxide Dentin Bonding Agents
reacts with a salicylate ester chelating. • What continues to remain controversial is the practice
• Agent in the presence of a toluene sulfonamide of total-etch direct bonding with dentine bonding agents
plasticiser. and more research needs to be focussed on this area.
500 Essentials of Operative Dentistry

• Some successes have been claimed with direct pulp A wide variety of materials are available to fill the root
capping with dentine bonding agents when the acid- canal space. Most of them are available in root canal
etch step is omitted or with bonding systems not obturating points and sealer cements.
requiring a separate acid-etch step, such as the self-
etching primers. Obturating Points
• Main mode of action is through adhesiveness and tight
• Gutta-percha is a name derived from two words.
seal.
“GETAH”—meaning gum
“PERTJA”—name of the tree in Malay language
Failure after Direct Pulp Capping • Dr William Montogmerie, who was a medical officer in
Failure after direct pulp capping can be due to three reasons: Indian Service, he was the first to appreciate the potential
1. Chronically inflamed pulp: There is no healing effect on of this material in medicine. It was introduced into the
inflamed pulp, and, in such situations, a full pulpec- UK in 1843.
tomy is indicated. • Rubbers are polymers of isoprene (2-methyl-1,3-
2. Extra-pulpal blood clot: Such a blood clot prevents contact butadiene) and isoprene is a geometric isomer, which
between the healthy pulpal tissue and the cement and means that it can have different structural arrangements
interferes with the wound-healing process. despite having the same composition.
3. Restoration failure: If the restoration fails to provide a • Cis-isoprene, is known as natural rubber trans-isoprene
bacterial seal then coronal ingress of bacteria can give (Figure 30-4) polymer is commonly referred to as gutta-
rise to failure. percha (Table 30-1).
• In the cis form, the hydrogen atom and methyl group
prevent close packing such that the natural rubber is
Root Canal Treatment amorphous and consequently soft and highly flexible,
whereas the gutta-percha crystallises, usually about
Ideal Requirements of Root Canal Filling
60% crystalline, forming a hard rigid polymer.
Materials • Gutta-percha is a thermoplastic material and softens at
As suggested by Grossman: 60–65°C and will melt at about 100°C, so it cannot be
• It should be easily introduced into a root canal. heat-sterilized.
• It should seal the canal laterally as well as apically. • If necessary, disinfection can be carried out in a solution
• It should not shrink after being inserted. of sodium hypochlorite (5%).
• It should be impervious to moisture. • The use of solvents such as acetone or alcohol should
• It should be bacteriostatic or at least not encourage be avoided, as these are absorbed by the gutta-percha,
bacterial growth. causing it to swell. Eventually, the gutta-percha will
• It should be radiopaque. return to its unswollen state, thus compromising the
• It should not stain tooth structure. apical seal.
• It should not irritate periradicular tissue. • On exposure to light, gutta-percha oxidises and
• It should be sterile or easily and quickly sterilized becomes brittle.
immediately before insertion. • The gutta-percha is able to take up two distinct
• It should be removed easily from the root canal if conformations.
necessary. • At high temperature, the gutta-percha chains take on
Obturating materials can be classified as solids, an extended conformation, which can be preserved if
semisolids, pastes, plastics, cements. cooled rapidly so that it forms the crystalline β-phase,
Root canal filling materials acts as a piston to propel
the sealer cement.
Table 30-1: Composition of gutta-percha points

Root Canal Filling Materials: ADA No. 78 Constituent Amount (%) Purpose
Objectives of modern root canal treatment procedures are: Gutta-percha 19-22 Rubber
• To provide clean canals. Zinc oxide 59-75 Filler
Heavy metal salts 1-17 Radiopacifier
• To provide apical seal.
Wax or resin 1-4 Plasticiser
• To provide coronal seal.
 Endodontic Materials and Instruments 501

Figure 30-4: Structural arrangement of various

forms of isoprene

whereas when the gutta-percha is cooled more slowly, • The composition of commercially available gutta-
the denser β- phase is formed. percha obturating points (also as pellets) will vary from
• Mostly it is the β-phase which is used. product to product.
• The α-phase gutta-percha has better thermoplastic • The additional ingredients are added to overcome the
characteristics and is therefore preferred for use in hot inherent brittleness of the rubber and to make it
gutta-percha application systems. radiopaque.
• An alternative approach is to dissolve the gutta-percha • Gutta-percha are available in standardized sizes from
in a chemical solvent such as chloroform or xylene. This 15-140 and non-standardized cones available as fine,
softens the gutta-percha and allows it to be adapted extra fine, fine-fine as auxillary cones.
closely to the canal wall and duplicate the intricate
canal morphology.
• However, as the solvent is lost, so the dimensional
Advantages
stability may be compromised and concerns have been • Bioinert
expressed regarding the possible cytotoxic effects of • Nonirritating
using these solvents. • Easily inserted or removed
502 Essentials of Operative Dentistry

• Dimensionally stable
• Radiopaque
• Unaffected by moisture
• Does not discolor tooth.

Disadvantages
• Cannot be sterilized.
• Does not sufficiently seal root canal so a sealer is required.
• Cannot be inserted in narrow canals because of lack of
rigidity.

Metal Points
• Metals, including gold, tin, lead, copper amalgam and
silver, have long been used as root canal filling materials. Figure 30-5: Sealer mixture should be smooth,
• Silver points were at one time extensively used because creamy with no granules
of their bactericidal effect.
• Silver is a more rigid and unyielding material than • When used in bulk, the cements are either too soluble or
gutta-percha and was used when access and instru- shrink excessively on setting (Figure 30-5).
mentation was difficult due to a small cross-section or • Additionally, it is difficult to gauge when, or if, the canal
awkward anatomy. is adequately filled, and there is a danger that the cement
• Unfortunately, the rigidity of silver made it impossible may pass beyond the root apex into the surrounding
to adapt it closely to the canal wall and greater reliance tissues.
had to be placed on the cements used to provide the seal.
Wide variety of sealers are used, they are (Tables 30-2
• Other disadvantages with silver points were that they
to 30-4):
tended to corrode, which could give rise to apical
• Zinc oxide–eugenol cements (e.g. Tubliseal, Kerr).
discoloration of the soft tissues.
• Resins (e.g. AH Plus, Dentsply; Diaket, 3M/ESPE).
• They were problematic to remove.
• Calcium hydroxide-containing cements (e.g. Apexit,
• Acrylic and titanium points are now available as
Ivoclar; Sealapex, Kerr).
alternatives to silver points in order to avoid the
• Glass ionomer cements (e.g. Ketac Endo, 3M/ ESPE;
problems of corrosion and silver points are perhaps
Endion, Voco).
now only of historical interest.
• Polydimethyl siloxanes (e.g. RSA RoekoSeal, Roeko).

Root Canal Sealer Cement: ADA No. 57 Table 30-2: Composition of a zinc-oxide-eugenol
• The ideal properties of a root canal sealer are that it cement based on Rickert’s formulation
should:
Powder % Liquid %
• Be easy to use
• Be free of air bubbles and homogeneous when mixed Zinc oxide 34-41 Oil of cloves 78-80
Silver 25-30 Canada balsam 20-22
• Flow to a thin film thickness Oleoresin 16-30
• Be insoluble Dithymoliodide 11-13
• Adapt well to the canal wall and the obturating point
• Be radiopaque
• Be biocompatible Table 30-3: Composition of Grossman’s scaler
(Grossman)
• Be bacteriocidal, or at least bacteriostatic
• Be easy to remove in case of failure. Powder % Liquid %
• The function of the cement is to fill the spaces between
Zinc oxide 42 Eugenol 100
the obturating point and the wall of the root canal, Staybelite resin 27
producing an antibacterial seal. Bismuth subcarbonate 15
• The use of root canal cements without obturating points Barium sulphate 15
is contraindicated. Sodium borate 1
 Endodontic Materials and Instruments 503
• Biocompatibility is excellent with the formation of a
Table 30-4: Composition of Tubliseal (Kerr Co., USA)
cementum over the apical foramen.
Base % Catalyst • One drawback is their high solubility, which has raised
Zinc oxide 57-59 Eugenol concerns about possible coronal or apical microleakage
Oleoresin 18-21 Polymerized resin after a time.
Bismuth trioxide 7.5 Annidalin
Thymol iodide 3-5 Mechanism of Action of Antibacterial Effect
Oils and waxes 10
• Mainly due to its high pH and ionic dissociation.
• Many bacteria are not able to survive in alkaline
• Mineral trioxide aggregate (e.g. Pro-Root MTA, environment and high pH.
Dentsply). • These OH ions have lethal effect on cytoplasmic
membrane of bacteria.
Zinc Oxide Eugenol
Mainly composed of zinc and eugenol to which many other Glass Ionomer Cements
additives are also added. These additives are mainly added • The glass ionomer cements consist of a fluoroalumino-
to impart: silicate glass, which is reacted with a polycarboxylic
• to impart bacteriocidal properties acid.
• to increase their radiopacity • Since glass ionomer cements show low shrinkage on
• to improve the adhesion to the canal wall. setting and possess the virtually unique ability to bond
directly to dentine and enamel, these materials should
make good root canal sealers.
Resins
• Too short a working time, difficulty in transporting the
• The attraction of resin systems is that these materials material to the root canal, adaptation to the root canal
can readily be formulated in such a way that they have wall, lack of low film thickness, lack of radiopacity and
a rapid setting time and yet maintain a sufficiently long questions about the biocompatibility when in contact
working time. with the apical tissues.
• Also, these products do not contain any coarse powders • These problems have now been largely overcome by
so they have a very smooth texture. incorporating radiopaque agents and reducing glass
• An epoxy-amine resin (AH Plus, De Trey, Germany) particle sizes to less than 25 μm.
and a polyvinyl resin (DIAKE, 3M/ESPE, Seefeld, • Working times still tend to be short and retreatment is a
Germany) are commonly employed ones. problem as the material sets very hard compared to the
• Usually available as paste-paste system. other root canal sealers.
• The resin sets by an addition polymerization reaction
after the two pastes are mixed. Polydimethyl Siloxanes
• The main problem with these resins is the amount of
• This root canal sealer is essentially a variant on the
shrinkage that takes place on setting, which can
addition-cured polyvinylsiloxane impression materials,
compromise the apical seal.
consisting of a polydimethylsiloxane, silicone oil,
paraffin-base oil, a Pt catalyst and zirconium dioxide.
Calcium Hydroxide-based Cements • The delivery system ensures a homogeneous mix, free
• Calcium hydroxide-containing cements are presented of air bubbles and the rheology can be carefully
in the form of a base paste and catalyst paste, which are controlled by the addition of the appropriate amount of
mixed in equal amounts. filler.
• They contain a resin similar to those used in the two- • The small filler particle size ensures that this material
paste resin composites, to which is added calcium has excellent flow properties and can achieve a film
hydroxide as a filler in place of the more usual glass thickness of 5 μm, which allows the sealer to flow into
fillers. tiny crevices and tubules.
• These materials have long working times and a high • As with the impression materials, the root canal sealer
pH, which creates a highly alkaline environment, where is insoluble, dimensionally stable and has excellent
most bacteria will be killed. biocompatibility.
504 Essentials of Operative Dentistry

• One concern is that this root canal sealer has neither the their biocompatibility is of considerable importance. Their
ability to bond to dentine, nor any antibacterial properties. physical properties, relevant to the production of an apical
• It relies for its seal on the ability to adapt to the root seal, are also a major concern.
canal wall and according to the manufacturer undergoes
a slight expansion (0.2%) on setting (Figure 30-6). Biocompatibility
• In general, it is assumed that for a material to be
biologically acceptable it must be as inert as possible.
• In a sense, what is really desired is an interaction
between the material and the biological environment
that is beneficial to the biological environment and has
no adverse effect on the material.
• This is very different from complete lack of interaction
in the case of an inert material. The concern is over the
form of the interaction.
• Does not elicit an inflammatory response in the tissues
Figure 30-6: Silicone sealer as this may induce irritation, pain or tissue necrosis.
• A possibly beneficial response would be the formation
Mineral (Metal) Trioxide Aggregate of an intermediate layer of hard tissue that not only
• Is a cement composed of tricalcium silicate, dicalcium isolates the foreign material from the living tissue, but
silicate, tricalcium aluminate, tetracalcium alumino- also helps to improve the quality of the apical seal.
ferrite, calcium sulphate and bismuth oxide. It is com- • Another feature one seeks in a root canal sealer is the
position is not unlike that of Portland cement except for ability to destroy bacteria.
• In general, materials that show antibacterial properties
the addition of bismuth oxide. The latter is added in
also induce some inflammatory response in the local
order to improve its radiopacity.
tissues, while those that do not elicit an inflammatory
• Very alkaline pH (~12.5) and has biological and
response are, at best, bacteriostatic.
histological properties similar to those of calcium
• Gutta-percha is a highly biocompatible material, having
hydroxide cement.
such a low cytotoxicity that it is the cements that are
• Can induce bone deposition with a minimal inflam-
used with it that will determine the tissue response.
matory response as it is less cytotoxic than reinforced
• The zinc oxide–eugenol-based cements are all inclined
zinc oxide–eugenol cements.
to induce some inflammatory reaction in the tissues,
• The material is mixed with sterile water to provide a
probably due to the presence of free eugenol.
grainy, sandy mixture and then can be gently packed • Some formulations must be avoided because they
into the desired area. The material is difficult to handle contain paraformaldehyde, which may cause a severe
and the powder: Liquid ratio (3 : 1) is critical if one is to inflammatory response, leading to tissue necrosis and
achieve appropriate hydration of the powder. bone resorption.
• It takes an average of 4 hours for the material to • Some cements have an incorporated steroid, and, again,
completely solidify and once the cement has set it has a their use is contraindicated.
compressive strength comparable to that of reinforced • The resin systems should have comparatively excellent
zinc oxide–eugenol cement. biocompatibility, known to be slightly toxic during the
• Metal trioxide aggregate has been recommended for use setting period but that once it has fully set, any
as a root-end-filling material, a retrograde root-filling inflammation rapidly recedes.
material, to seal perforations or open apices, or to cap • Calcium hydroxide-containing resins it is claimed that,
vital pulps. in addition to the excellent biocompatibility, the material
promotes cementum formation.
Clinical Aspects of Endodontic
Sealing Properties
Materials • It should be appreciated that so much depends on the
Root canal materials are in contact with living biological technique adopted that an acceptable result can most
tissue that is not protected by any epithelial layer; therefore, probably be obtained with any of them.
 Endodontic Materials and Instruments 505
• It is probably more important that an antibacterial seal • The post and core system is esthetically compatible with
is achieved than a physical seal, although both would the restoration.
be desirable.
• A physical seal by itself may not be good enough if the Types of Post Systems
sealant does not provide an antibacterial barrier.
Posts are either:
• Prefabricated
Physical Properties
• Custom made (cast) (Figures 30-8A to C)
• Important to choose a material which has the handling
• In the case of the prefabricated post, the core can be
characteristics that most suit the particular individual.
built-up with one of a range of core materials (amalgam,
• The working and setting times and flows of the cements
composite, glass ionomer cement, resin-modified glass
determine their handling characteristics.
ionomer cement).
• While the film thickness, the solubility and the
• For the cast post, the core can be incorporated with the
dimensional.
• Stability are important factors in determining their blank such that the post and core is cast as a single
unit.
sealing ability.
• Custom cast post and core systems act as a single unit
• Preferred sealer is zinc oxide eugenol cement.
and can be cast with a ferrule, which supports the tooth
against wedging forces and helps to prevent tooth
Post and Core
fracture.
• The most commonly used methods for reinforcing badly • Prefabricated post is much easier to fabricate can be
broken down and endodontically treated teeth are pin- done in single appointment.
retained cores or post and core systems (Figure 30-7). • The types of prefabricated posts available are:
• The function of a post and core system is not primarily • Metal posts
to strengthen the tooth but to provide support for the • Fiber-reinforced resin posts
retention of crown or other coronal superstructure. • Ceramic posts.
• Besides these, can be classified as:
• Active
• Passive

Metal Posts
• Metal prefabricated posts are made from stainless steel,
nickel chromium or titanium.
• The posts come in a wide variety of designs, which include:
• Nonthreaded parallel-sided posts (e.g. Parapost,
Whaledent).
• Nonthreaded tapered posts (e.g. Endopost, Kerr).
• Threaded parallel-sided posts (e.g. Kurer Anchor
System, Teledyne).
Figure 30-7: Post and core • Threaded tapered posts (e.g. Dentatus Screw Post,
Dentatus).
The desirable features of a post and core system are • Self-threading posts have excellent retention but are also
that: associated with a high incidence of tooth fracture.
• The system provides maximum retention with minimal • Tapered posts are the least retentive and the greater the
removal of tooth tissue. taper, the greater the possibility of root fracture due to a
• The core provides a means of transferring stress from wedging effect.
the restoration to the post and tooth.
• The post is able to transfer the stresses to the remaining Fiber-Reinforced Resin Posts
tooth structure without creating high stresses that may • Fiber-reinforced epoxy resin composite materials are
otherwise cause the tooth to fracture. increasingly finding a place in restorative dentistry and
• The post is retrievable in the case of failure. endodontics is no exception (Figures 30-9A and B).
506 Essentials of Operative Dentistry

Figures 30-8A to C: Custom made (Cast post) metal post

• Current systems include the Cosmopost (Ivoclar-

Vivadent, Liechtenstein), the Biopost (Incermed,
Lausanne, Switzerland) and the Cerapost (Brassler,
Lemgo, Germany).
• The chemical inertness of zirconia is a potential problem
with regard to retention and these systems must rely on
mechanical means of retention.
Relative to the metal posts, both the fiber-reinforced and
Figures 30-9A and B: Fiber reinforced post ceramic posts are relative new additions for the treatment
of the badly broken-down teeth. Considerably more
knowledge and experience, both in vitro and in vivo, with
• The fibers are aligned in the long direction of the post, the use of these materials is required before they can be
which provides strength and yet does not compromise accepted as readily as the metal post systems.
the flexibility of the post.
• At present there are two types of fiber-reinforced resin
post systems: Root Canal Instruments (Figures 30-10A and B)
• Carbon fiber-reinforced posts (e.g. Composipost and • ADA No. 28—root canal files and reamers of 0.02 mm
esthetipost from RTD, Meylon, France; Carbonite tip.
from Harald Nordon SA, Montreux, Switzerland) • ADA No. 58—Hedstroem files
• Glass fiber-reinforced posts (e.g. Snowpost from • ADA No. 63—Rasps and Broaches
Carbotech, Ganges, France; Parapost Fiber White • ADA No. 71—Spreaders and Condensers
from Coltene/Whaledent, New Jersey, USA; Estheti • ADA No. 78—Obturation points
Plus post from RTD, Meylon, France; Glassix from • ADA No. 95—Mechanical root canal enlargers
Harald Nordon SA, Montreux, Switzerland). • ADA No. 101—Root canal insruments not covered in
• The use of a resin matrix means that the post has the No. 28.
potential to be bonded to the remaining tooth structure
and in turn the core can be bonded to the post.
Classification: ISO Grouping
• The carbon-fiber-reinforced posts are black.
• Glass fiber-reinforced posts have the advantage that, According to method of use
being essentially white or white/translucent, they can • Group I: Hand use only
produce superior esthetic results when used in Files, Reamers, Broaches, Pluggers, Spreaders
conjunction with all ceramic restorations. • Group II: Engine Driven Latch type
Same design as Group I but can be attached to
handpiece. Includes paste carriers.
Ceramic Posts
• Group III: Engine Driven Latch type
• From the point of view of esthetics, ceramic posts would Drills or Reamers. Gates Glidden drill, Peesoreamers,
show considerable promise. [Link],T,M—type reamers, Kurer root facer.
• Such posts is zirconia because of its reputed high • Group IV: Root Canal Points
strength and toughness and white appearance. Gutta-percha, Silver, Paperpoints.
 Endodontic Materials and Instruments 507
Original recommendation for standardized instruments.
• Cutting blades 16 mm in length are of the same size and
numbers as standardized filling points.
• The number of the instrument is determined by diameter
size at D1 in hundredths of millimeters.
• Diameter 2 (D2) is uniformly 0.32 mm greater than D1.
Two modifications were:
Figures 30-10A and B: Root canal instruments: (A) Hand • Additional measurement at D3, 3 mm from D1.
root canal instrument and (B) Rotary root canal instrument • Tip angle of an instrument should be 75°± 15°.

In Cohen pathways of pulp Other modifications are:

• Group I: Hand and finger operated instruments such • Instrument sizes of tip should increase by 0.05 between
as barbed broaches and K, H-type instruments. No. 10-60 and increase by 0.1 mm from No. 60-150.
• Group II: Low speed latch type of instruments. Gates, • Instrument handles have been colored for easier
peesoreamers. recognition.
• Group III: Engine driven of same as Group I. However,
handles are latch type. NiTi rotary files. Barbed Broach and Rasps (Figure 30-12)
• Barb height for broaches should be half the core
In Grossman’s endodontics
diameter, whereas in rasps have barbs equal to 1/3rd
Classified according to their function:
the diameter of tip.
• Exploring instruments, e.g. smooth broach, endodontic
• Greater depth of cut in broaches they are more fragile
explorer.
instruments.
• Debridement, e.g. barbed broach.
• Taper of broach 0.007 mm/mm is slightly less than of
• Shaping, e.g. reamers, files.
rasp (0.015).
• Obturating, e.g. pluggers, spreaders, lentulospirals.
• Broaches used for removing intact pulp and paper
points.
Standardization (Figure 30-11)
• Before 1958, endodontic instruments were manufac-
tured without benefit of any established criteria.
• Put forward by Ingle and Levine.
• Points put forward by them are:
• Formula for diameters and taper in each size
instrument and filling material.
• A formula for a graduated increment in size from
one instrument to the next was developed.
• A new instrument numbering system based on
instrument metric diameter was established.
Figure 30-12: Broaches

Files and Reamers

• The clinician should understand the importance of
differentiating endodontic files and reamers from drills.
• Drills are used for boring holes in solid materials such
as gold, enamel, and dentin.
• Files, by definition are used by rasping.
• Reamers, on the other hand, are instruments that ream—
specifically, a sharp-edged tool for enlarging or tapering
holes.
• Traditional endodontic reamers cut by being tightly
Figure 30-11: Standardization of root canal instruments
specification inserted into the canal, twisted clockwise one quarter-
508 Essentials of Operative Dentistry

to one-half turn to engage their blades into the dentin,

and then withdrawn—penetration, rotation, and
retraction. The cut is made during retraction.
• Reaming is the only method that produces a round,
tapered preparation, and this only in perfectly straight
canals.
• In such a situation, reamers can be rotated one-half turn
before retracting. In a slightly curved canal, a reamer
should be rotated only one-quarter turn. More stress
may cause breakage.
• The heavier reamers, however, size 50 and above, can
almost be turned with impunity.
• The tighter spiral of a file establishes a cutting angle
(rake) that achieves its primary action on withdrawal,
although it will cut in the push motion as well.
Figures 30-13A to D: K-type file and its modification and
• The cutting action of the file can be effected in either a
cross-section of file
filing (rasping) or reaming (drilling) motion. In a filing
motion, the instrument is placed into the canal at the K-type Modifications (Figure 30-14)
desired length, pressure is exerted against the canal
wall, and while this pressure is maintained, the rake of K-flex file
the flutes rasps the wall as the instrument is withdrawn • Cross-section is rhomboid or diamond shaped.
without turning. • Cutting edges of high flutes are formed by two angle
• To summarize the basic action of files and reamers, it (acute) of rhombus which give increased cutting
may be stated that either files or reamers may be used to efficiency.
ream out a round, tapered apical cavity but that files • Low flute formed by obtuse angles gives more area for
are also used as push-pull instruments to enlarge by debris removal.
rasping certain curved canals as well as the ovoid • Increased flexibility and decreases danger of
portion of large canals. compacting dentinal filings.
• Most of early instruments and also nowadays are of Triple-flex file
stainless steel but because they cannot be engaged in • More number of flutes than reamer but less than files.
curved canals they are being replaced by instrument • Made from triangular blank (Figure 30-14).
manufactured from nickel titanium.
Hedstroem files (H-file)
• Cutting spiraling flutes into the shaft of a round, tapered,
K-type Instruments (Figures 30-13A to D) stainless steel wires (Figures 30-15A to C).
• Produced by Kerr Manufacturing Co., in 1915.
• Made from steel that is ground to tapered square or
triangular cross-section.
• The wire is twisted in clockwise direction to produce
spiral flutes.
• There is twice number of flutes in files compared to reamer.
• Instrument with triangular blank has thicker cutting
edge removing more dentin and also because of more
space between flutes.
• K-type and modifications fracture during clockwise
motion after plastic deformation.
• Square blanks resist fracture more efficiently, therefore
smaller instruments are of square blanks.
• Reamer manufactured from triangular blank and file
from square blank. Figure 30-14: K-type modifications
 Endodontic Materials and Instruments 509

Figures 30-15A to C: H-file its cross-section and its modification

• Similar to screw cutting machine.

• Cuts only in retraction. Figure 30-16: U-type file
• More cutting efficiency but more fragile.
• A noncutting pilot tip ensures that the file remains in
H-file Modifications the lumen of the canal, thus avoiding transportation
and “zipping” at the apex.
• McSpadden was the first to modify the traditional
• Files are used in both a push-pull and rotary motion
Hedstroem file.
and are very adaptable to nickel-titanium rotary
• Marketed as the Unifile and Dynatrak, these files were
instruments.
designed with two spirals for cutting blades, a double-
• ProFiles are supplied in 0.04, 0.05, 0.06, 0.07, and 0.08
helix design.
tapers and ISO tip sizes of 15 through 80.
• In cross-section, the blades presented an “S” shape
rather than the single-helix teardrop cross-sectional
shape of the true Hedstroem file. GT Profiles
• Other modifications Hyflex file, S-File. • Developed by Buchanan in the U design, are unusual
• Safety Hedstrom (Sybron Endo/Kerr; Orange, Calif.), in that the cutting blades extend up the shaft only
which has a noncutting side to prevent ledging in 6 to 8 mm rather than 16 mm.
curved canals. • The tapers start at 0.06 mm/mm (instead of 0.02), as
well as 0.08 and 0.10, tapered instruments.
U-file • They are made of nickel titanium and come as hand
instruments and rotary files. GT instruments all start
• A new endodontic classification of instrument, for
with a noncutting tip ISO size 20.
which there is no ISO or ANSI/ADA specification as
yet, is the U-file, developed by Heath (personal
communication, May 3, 1988). Lightspeed Instrument
• Marketed as ProFiles, GT Files (Dentsply/Tulsa Dental; • An unusual variation of the U-shaped design (Figures
Tulsa, Okla.), Lightspeed (LightSpeed Technology Inc; 30-17A and B).
San Antonio, Tex.), and Ultra-Flex files (Texeed Corp.,
USA).
• The U-files cross-sectional configuration has two 90°
cutting edges at each of the three points of the blade
(Figure 30-16).
• The flat cutting surfaces act as a planning instrument
and are referred to as radial lands.
• Heath pointed out that the new U shape adapts well to
the curved canal, aggressively planning the external
convex wall while avoiding the more dangerous internal
concave wall, where perforation stripping occurs. Figures 30-17A and B: Light speed instrument
510 Essentials of Operative Dentistry

• Made only in nickel titanium, it resembles a Gates- • Others of this type are, Control Safe files (Dentsply/
Glidden drill in that it has only a small cutting head Maillefer; Tulsa, Okla.), the Anti-Ledging Tip file
mounted on a long, noncutting shaft. (Brasseler; Savannah, Ga.), and Safety Hedstrom file
• It is strictly a rotary instrument but comes with a handle (Sybron Endo/Kerr; Orange, Calif.).
that may be added to the latch-type instrument for hand
use in cleaning and shaping abrupt apical curvatures Functional Characteristics of Files and Reamers
where rotary instruments may be in jeopardy.
Motions used in cleaning and shaping are:
• The instruments come in ISO sizes beginning with
• Filing
No. 20 up to No. 100.
• Reaming
• Half sizes begin at ISO 22.5 and range to size 65. The • Watch winding
heads are very short only 0.25 mm for the size 20 and
• Balanced force instrumentation
up to 1.75 mm for the size 100.
• Advantages is the ability to finish the apical-third pre- Filing
paration to a larger size if dictated by the canal diameter. • Push and pull motion with instrument (Figure 30-19).
• Inward passage of file can lead to canal damage.
Tip Modification (Figures 30-18A and B) • Efficient with hedstrom file.

• Early interest in the cutting ability of endodontic

instruments centered around the sharpness, pitch, and
rake of the blades.
• By 1980, interest had also developed in the sharpness
of the instrument tip and the tip’s effect
• In penetration and cutting as well as its possible
deleterious potential for ledging and/or transpor-
tation—machining the preparation away from the
natural canal anatomy. Figure 30-19: Filing motion
• By 1988, Sabala, et al confirmed previous findings that
the modified tip instruments exerted “less transpor- Reaming
tation and more inner curvature preparation. • Clockwise rotation of an instrument.
• Tips of file have been modified to have a compound • Best used with reamers because of their cutting angle
angle of 70° and 35° without any active cutting edges. axial orientation.
• The first tip modified files were introduced by Roane et • As instrument in rotated it penetrates into the canal
al as Flex R File (Moyco/Union Broach,Miller Dental; deeper.
Bethpage, NY). • Usually rotation is limited to quarter to half turn (Figure
30-20).

Figure 30-20: Reaming motion

Turn and pull

• It is a combination of filing and reaming motion.
Figures 30-18A and B: These tips are known as noncutting • It is detrimental to prepare apical stop with this
or safe cutting tips technique (Weine et al) (Figure 30-21).
 Endodontic Materials and Instruments 511

Figure 30-21: Turn and pull motion Figure 30-23: Watch winding and pull motion

Figure 30-24: Balance force technique

• This technique extrudes no debris, better canal centering

ability, specifically designed for K-type file and
modifications not with H-type files.
• It involves quarter turn clockwise along with inward
Figure 30-22: Watch winding motion pressure to insert the canal.
• Next it is rotated counter clockwise atleast 1/3rd of
Watch winding motion (Figure 30-22)
revolution with gentle inward pressure maintained.
• It is back and forth oscillation of file (30-60°) right and
(30-60°) to the left.
Circumferential Filing
• This is an efficient technique to remove dentin from
root canals. Used in flaring coronal access and ovoid canals (Figure
• Each cut opens space and frees the instrument for 30-25).
deeper insertion with the next clockwise motion.
• This technique is predecessor to balanced force Anticurvature Filing
technique. • Applying instrument pressure that shaping will occur
• It is effective with all types of K-files. away from inside of root curvature (Figure 30-26)
• Abou Raas, Frank, Glick recommended it.
Watch Winding and Pull (Figure 30-23)
• This technique is used with H file as wriggling motion Mechanical Instrumentation
alone cannot cut dentin.
• Cutting action is initiated only during pulling out action. Classification
Rotary (Figure 30-27)
Balanced Force Technique (Figure 30-24) • 16:1 gear reduction, e.g. NiTi Mac.
• Prescribed by Roane, et al. Reciprocal
• Most efficient way to cut dentin. • Contrarotates through 90°, e.g. Giromatic, EndoCursor.
• Used with Flex R-file. • Kerrs endolift has in addition a vertical motion.
512 Essentials of Operative Dentistry

Figure 30-27: Rotary instrument

• Ledge formation
• Extrusion of debris out of apical foramen.

Power Driven Instruments

Figure 30-25: Circumferential filing • Gates Glidden drill
• Peesoreamer.

Gates Glidden Drill (Figure 30-28)

• Flame shaped head with safe tip
• Flame cuts laterally
• Long shaft is designed to break at the neck
• Used to remove lingual shoulder, enlarge root canal
orifices, clean and shape cervical 1/3rd of canals
• Used in brushing strokes at a speed of 750-1000 rpm
• Available in 32 mm and 28 mm length.

Figure 30-28: Gates glidden drill

Peesoreamer (Figure 30-29)

Figure 30-26: Anticurvature filing
• Long, sharp flutes connected to a thick shaft.
• Used for preparation of postspacing, gutta-percha
removal.
Vertical • It is a stiff instrument
Canal Finder System, Canal Leader.
Random
W and H handpiece—Excalibur.
Disadvantages
• Loss of tactile sensation Figure 30-29: Peesoreamer
 Endodontic Materials and Instruments 513
Both peesoreamer and Gales Glidden drill are made of • Sodium hypochloride used as irrigant.
hardened carbon steel and must be used with caution to • Files used are K-files and diamond files.
avoid over instrumentation and perforation. • Main advantage is in cleaning of canals rather than
shaping.
Gates Glidden Modification (Figures 30-30A to C)
• A hand instrument also designed for apical preparation Nickel Titanium Instruments
is the Flexogates, Handygates (Dentsply/Maillefer; • Discovered in 1960’s by Buchler and Wang as NiTiNol
Tulsa, Olka). (US Navy Ordinal Lab).
• A safe-tipped variation of the traditional Gates Glidden • NiTi (56% Ni and 44% Ti).
drill, the Flexogates. • Zero degree residual deformation compared to 10-18°
in stainless steel file.
• Eight percent strain can be sustained by NiTi compared
to less than 1% by stainles steel.
• NiTi instruments cannot be produced by twisting but
can be only machined.
• Cutting efficiency is low.
• Torsional strength is low.
• Superelasticity due to change in crystalline form from
austentite to martensite.
Rotary NiTi systems available are (Figure 30-32):
• Profile
• Protaper
• Quantec series
• GT
• Light speed
• Hero RACE
Figures 30-30A to C: Gates Glidden modification

Sonic and Ultrasonic Instruments

(Figures 30-31A to C)
Sonic vibration Figure 30-32: Rotary NiTi instruments
• Vibration wave introduced in shank changes from
vertical motion when constrained by root canal walls. Key Terms
• Rispi files—coronal 2/3rd
• Pulp capping • Root canal sealers
• Shaper files—apical 1/3rd.
• Files • Gutta-percha
• Zinc oxide eugenol sealer • Reamers
• Silver points • Posts.

Questions to Think About

1. Describe about pulp capping and in detail about types
Figures 30-31A to C: Sonic and ultrasonic instruments of pulp capping.
2. Discuss about various obturating materials and in
Ultrasonic Instrument detail about gutta-percha.
Piezoelectric and Magnetostrictive 3. Classify root canal instruments and discuss about
• Piezoelectric units are more powerful no water coolant standardization of root canal instruments.
required. 4. What are different types of posts used in endodontics?
 Suggested Reading
1. Adhesive Metal Free Restorations. Current Concepts for Esthetic Treatment for Posterior Teeth. Didier Dietschi, Roberto
Spreafico.
2. Basic Guide to Dental Instruments. Carmen Schuller. Blackwell Munksgard. Oxford OX4 2DQ, UK.
3. Bleaching Techniques in Restorative Dentistry. An Illustrated Guide. Linda Greenwall. Martin Dunitz. New York.
4. Burket’s Oral Medicine Diagnosis and Treatment. 10th edn. Martin S Greenberg, Michael Glick. BC Decker Inc. Ontario.
5. Colour Atlas of Dental Medicine. Aesthetic Dentistry. Josef Schmidseder. Thieme Publishing. Stuttgart.
6. Color Atlas of Endodontics. William T Johnson, WB Saunders.
7. Complete Dental Bleaching. Ronald E. Goldstein, David A Garber. Quintessence Publishing Co. Hong Kong.
8. Compressed Air Operations Manual. The Illustrated Guide to Selection, Installation and Maintanence. Brain S Elliot. Mc Graw
Hill.
9. Concise Dental Anatomy and Morphology. James, Fuller A, Gerald E Denehy, Thomas M Schulein. 4th edn.
10. Delmar’s Dental Assisting. A comprehensive Approach, Phinney DJ and Halstead JH. Delmar Thomson Learning.
11. Endodontics. John I Ingle, Leif K Bakland. 5th edn. BC Decker. Canada.
12. Endodontic Practice. Louis I Grossman, Seymour Oliet, Carlos E Del Rio. 11th edn. Varghese Pub. Mumbai.
13. Endodontic Therapy. Franklin S Weine. 6th edn. Mosby Pub. Missouri.
14. Esthetics in Dentistry. Ronald E Goldstein. 2nd edn. BC Decker Inc. Hamilton. Ontario.
15. Essential of Dental Assisting. Robinson DS, Bird DL. 4th edn. Saunders.
16. Fundamentals of Fixed Prosthodontics. Herbert T Shillingburg, Sumiya Hobo, Lowell D Whitsett, Richard Jacobi, Susan E
Brackett. 3rd edn. Quintessence Publishing. Carol Stream. Illinois.
17. Fundamentals of Operative Dentistry—A Contemporary Approach. 2nd edn. James B Summit, J Williams Robbins, Richard S
Schwartz. Quintessence Pub.
18. Infection Control and Occupational Safety Recommendations for Oral Health Professionals. Anil Kohli, Raghunath Puttaiah.
19. Materials in Restorative Dentistry. I Anand Sherwood. Jaypee Brothers Medical Publishers, New Delhi.
20. Occlusion in Restorative Dentistry. Technique and Theory. Martin D Gross. Churchill Livingstone, NewYork.
21. Operative Dentistry: Modern Theory and Practice. MA Marzouk, ALSimonton, RDGross. AITBS. Chennai.
22. Operative Dentistry: A Practical Guide to Recent Innovations. Hugh Devlin. Springer Pub. Germany.
23. Oxford Handbook of Clinical Dentistry. DA Mitchell, L Mitchell. 2nd edn. Oxford University Press. Oxford OX2 6DP.
24. Pathways of Pulp. Stephen Cohen, Richard C. Burns. 8th edn. Harcourt India Ltd.
25. Pickard’s Manual of Operative Dentistry. Edwina A.M. Kidd. 8th edn. Oxford University Press Oxford OX2 6DP.
26. Pocket Atlas of Endodontics. Rudolf Beer, Michael Baumann, Andrej A. Kielbassa. Thieme, Stuttgart, Germany.
27. Principles and Practice of Endodontics. Richard E Walton, Mahmoud Torbinejad. 3rd edn. WB Saunders Co., Pennsylvania
28. Principles of Operative Dentistry. AJE Qualtrough. Blackwell Pub, Oxford OX4 2DQ, UK.
29. Principles and Practice of Operative Dentistry. Gerald T Charbeneau. 3rd edn. Varghese Pub. Mumbai.
30. Second Generation Laboratory Composite Resins for Indirect Restorations. Bernard Toutati, Nadine Aidan. Journal of Esthetic
and Restorative Dentistry Vol 9, Issue 3, May 1997.
31. Sturdevant’s Art and Science of Operative Dentistry. 5th edn. Elsevier Pub. [Link].
32. Textbook of Operative Dentistry. Baum, Phillips, Lund. 3rd edn. Harcourt Brace and Co., Singapore.
33. Tooth Colored Restoratives Principles and Techniques. Harry F. Albers. 9th edn. BC Decker Inc. London.
34. Wheeler’s Dental Anatomy, Physiology and Occlusion. Major M. Ash. 7th edn. WB Saunders Co.
 Index

A occlusion of restoration 251

occlusolingual cavity preparation and
local anesthesia 259
occlusion 259
Abfraction 133, 446, 447 restoration 251 initial cavity preparation 263
Abrasion/erosion lesion 38, 132, 436, 446, 447 outline form, resistance form, retention form completion of proximal extensions 264
Abrasive cutting 192 247 occlusal outline form (occlusal step) 263
Absorbents and throat shields 62 postcarve burnishing 251 primary resistance form and retention
Abutment teeth 304 precarve burnishing 250 form 266
for partial dentures 259 preparation procedures 251 proximal ditch cut 263
for removable partial denture 270 pulp protection 250 proximal outline form (proximal box) 263
Access and visibility 58 removal of any defective enamel 250 modifications in cavity design 269
Access cavity preparation 480, 481 restoration 257 adjoining restorations 270
Accessory instruments 168 Amalgam class II preparation and restoration rotated tooth 269
Accidents and injuries 17 259 simple box preparation 269
Acidogenic theory 115 cavity preparation 270 slot preparation 269
Acrylic resins 327 abutment teeth 270 unusual outline form 270
Activator-initiator system 330 contact and contours 272 variations of single proximal cavity
Active caries 31 design 274 preparations 268
Adhesion 311 embrasures (spillways) 272 maxillary first molar 268
tooth structure 311 facial surfaces 272 maxillary first premolar 268
Adhesives 316 general considerations 274 Amalgam class V and VI preparations and
Adjoining restorations 270 height of contour 272 restorations 304
Adjunctive special tests 42 interproximal spaces 272 amalgam class VI preparation 309
Adjusting and polishing the casting 417 lingual surfaces 272 tooth preparation 309
Admixed alloys 233, 236 mandibular first premolar 271 armamentarium 308
Agate spatula 168 maxillary first molar 271 from left to right 308
Air abrasives 179 procedure for distal cusp 271 common pitfalls 308
Air emphysema 17 proximal contact areas 272 designs of class V preparation 307
Air turbine handpieces 175 reduction of cusps for capping 271 features of class V preparation 308
Airotor 175 final cavity preparation 266 indications and contraindications 304
Airway protection 15 final procedures 267 abutment teeth 304
Allergic manifestations 23 four characteristics 267 caries 304
Alloy composition 232 old restorative material 266 economics 304
Alloyed metals 233 procedure for finishing enamel walls 267 erosion or abrasion 304
Amalgam 34, 244 pulp protection 267 esthetics 304
blues 34 removal of any remaining caries 266 isolation 305
bonding 322 secondary resistance and retention form 267 local anesthesia 305
carriers 166 general principles of cavity preparation 259 sensitive areas 304
class I preparation and restoration 247 condition of marginal ridge 260 service 304
class II preparation and restoration 259 convenience form 263 insertion of amalgam 307
class V and VI preparations and restorations convexity of proximal surfaces 260 carving and contouring 307
304 design features 261, 262 principles of outline form 305
class VI preparation 309 extension for convenience or access 259 extended restoration 306
waste management 245 isthumus 261 final cavity preparation 306
Amalgam class I preparation and restoration 247 location and condition of gingiva 260 final procedures 306
carving procedure 251 margins 261, 262 finishing enamel walls 306
cavity preparation for extensive caries 250 modifying factors 260 initial cavity preparation 305
common pitfalls 257 occlusal surface 262 mandibular canine 305
conservative cavity preparation 247 outline form 259 pulp protection 306
facial pit of mandibular molar 253 proportional size 259 removal of any remaining infected
final cavity preparation 250 resistance form 260 dentin 306
finishing and polishing procedures 251 retention form 262 resistance and retention form 305
finishing enamel walls 250 two surface cavity preparation 263 retention form 306
from left to right 257 indications and contraindications 259 rotary cutting instrument 308
initial cavity preparation 247, 250 abutment teeth for partial dentures 259 Amalgam restorations 47
insertion and carving procedures 253 age of patient 259 Amalgamation and resulting microstructures
insertion of amalgam 250 economics 259 235
isolation of operating site 247 esthetics 259 Amalgamator 11
lingual pit in maxillary incisors 253 galvanism 259 Amalgapins 391
local anesthesia 247 incidence and extent 259 Amelogenesis imperfecta 133
occlusal pits of mandibular first premolar 253 isolation of operating site 259 Anatomic form 34
518 Essentials of Operative Dentistry

Anatomic matrix (template) 289 enamel and dentin bonding 312 Caries 304
Angle former 163 adhesion-based on coupling agents 315 control restorative treatment 126
Anterior teeth 72, 76 adhesion-based on ionic polymer 315 diagnosis and preventive treatment 119, 121
Anticurvature filing 511 alternative enamel etchant 314 examination 29
Anusavice 331 basic formula, M-R-X 316 Cariology 114
Apicocclusal taper 396 challenges in dentin bonding 314 caries diagnosis and preventive treatment
Argon laser lamps 335 dentin bonding 314 119
Arrested caries 31 enamel bonding agents 312, 314 pit and fissure caries 119
Articulating paper 169 etching procedure 313 root surface caries 119
Aspirating equipment 9 goals of enamel etching 313 caries preventive treatment 121
Atomized powder/spherical particles 234 grafting to collagen 316 armamentarium 129
Atraumatic restorative technique 440 patterns of etching 313 indirect pulp capping 129
Attrition 38, 132 resin tags 313 procedure and armamentarium 129
Automatrix systems 287 HEMA and META 323, 324 restoration 127
hybridization 320 steps 126
pit and fissure sealant 325 classification of caries 120
B clinical technique 325 epidemiology of caries 114
indication 325 hypotheses concerning etiology of caries 114
Balanced force technique 511 preventive resin restoration 325 pathophysiology of caries 116
Barbed broach and rasps 507 scientific classification of modern adhesives changes brought by dentinal caries 118
Basic principles in operative dentistry 3 316 clinical sites for caries initiation 116
accidents and injuries 17 based on generation 317 dentinal caries 118
airway protection 15 based on number of steps 317 histopathology of caries 117
amalgamator 11 pit and fissure 116
based on smear layer treatment 317
aspirating equipment 9 root surface caries 116
fifth generation 319
avoiding air emphysema 17 smooth surface caries 116
basic tenets of four-handed dentistry 14 first generation 317
fourth generation 319 zones of dentinal caries 118
compressor 10 zones of incipient lesion 117
dealing with accidents and accident second generation 318
theories of etiology of dental caries 115
reporting 17 single step 317 acidogenic theory 115
dental chair 3 sixth generation 320 Miller’s chemico-parasitic theory 115
dental handpieces 10 smear layer dissolving 317 proteolysis—chelation theory 115
dental school and practice environment 3 smear layer modifying 317 Carious lesions 443
ergonomics in dentistry 3 Carvers 166
smear layer removing 317
illumination 9 Carving and contouring the restoration 307
operator’s chair 5 third generation 318
three step 317 Carving and finishing 243
operator’s position 5 Carving procedure 251
other small equipment 10 two step 317
van Meerbeek scientific classification 317 Cast onlay restoration 421
phantom head or patient position 8 advantages 421
principles of four-handed dentistry 13 surface energy 310
contact angle of wetting 311 armamentarium 424
protection from infection 17 common pitfalls 424
sink 10 wetting 311
types of bonding 310 features in cast metal onlay tooth preparation
soft tissue protection 16 424
some ergonomic facts 9 chemical bonding 310
mechanical bonding 310 tooth preparation 421
Beveled conventional class III cavity preparation beveling and flare preparation 423
354 physical bonding 310
wet vs dry bonding 321 enhancing resistance and retention form
Beveled conventional class V preparation 364 423
Beveled conventional preparation 344, 360 amalgam bonding 322
biocompatibility 323 final cavity preparation 422
Beveling and flare preparation 423 initial cavity preparation 422
Bibeveled instrument 161 ceramic bonding 322
chemical 323 preparation of bevels and flares 423
Binary mercury-indium liquid alloy 245 proximal box preparation 422
Black’s matrices 288 disadvantages 321
glass ionomer adhesives 321 restoring occlusal plane 424
gingival extension 288 Cavity design and preparation 375, 443
mechanical 323
simple cases 288 Cavity preparation for cast restorations 394
microleakage 323
Bladed cutting 192 Cavity preparation for direct gold restorations
resin-metal bond 323
Bleaching light 463 silane coupling agents 322 370
Bleaching therapy 457 surface treatment 322 Cavity varnish 146
Bleaching tray fabrication 464 Bonding agent application 345 Cavity walls 150, 152
Bonded amalgam 246 Bur classification 185 Cement spatulas 168
Bur life 189 Cementation 419
Bonding 310
Burnishers 167 Cemented pins 380, 388
adhesion to tooth structure 311
Cementoenamel junction 135
clinical applications of adhesion 312 Cementum loss 470
enamel 312
mechanism of interfacial debonding 312 C Central fossa 75
Centric interference 112
dentin adhesive system 316 CAD/CAM restorations 431 Ceramic bonding 322
adhesives 316 Calcium hydroxide 148, 499 Ceramic inlays and onlays 430
etchants 316 Calcium hydroxide applicator 168 Ceramic posts 506
fillers 316 Calcium hydroxide-based cements 503 Ceramic whiskers 334
initiators and accelerators 316 Canines 72 Cerec system 432
other ingredients 316 Capping cusps 411 Cervical cross-section 483
primers 316 Carbamide peroxide bleaching process 461 Chemical and light curing 334
 Index 519
Chemical bonding 310 apicocclusal taper of a preparation 396 dental chart 48
Chemical degradation 338 preparation features 396 dental record 47
Chemical methods 476 preparation path 396 examination of dental pulp and periradicular
Chemically activated resin 330 proximal box margin (cavosurface margin) 397 tissue 36
Chemical-physical microabrasion 468 types and design features 397 color 36
Chemistry of setting 434 removing the casting from tooth 419 palpation 36
Chemomechanical caries removal 180 rotary cutting instruments 413 percussion 36
Chemomechanical method 475 soldering contacts 419 sinus evaluation 36
Chip syringe 168 cementation 419 examination of dentition 29
Chisel vs hoe 165 method 419 active caries 31
Chisels 163 repair 420 arrested caries 31
Circumferential filing 511 tray instrument set-up 413 caries examination 29
Circumferential slots 390 trying in mouth 417 elements of clinical examination 29
Circumferentially beveled instruments 162 types and designs 396 newer technologies 32
Class I Class III pit and fissure caries 29
cavity preparation 347 amalgam restoration 299 plaque and caries risk 29
composite restoration 347 buccal/lingual approach (class III tunnel) 438 proximal surface caries 30
fissure seal 436 cavity preparation 359 root surface caries 31
restoration 136 composite restoration 354 smooth surface caries 30
tooth preparation and restoration 371 direct filling gold restoration 374 examination of occlusion 37
Class II other carious lesions 436 abrasion 38
composite restorations 348 restorations 137, 439 assessment of additional defects 38
direct filling gold restoration 372 tooth preparation 354 attrition 38
inlay 402 Class IV restorations 137 erosion 38
inlay restoration 393 Class V esthetic evaluation 39
occlusal approach 437 composite restoration 361 evaluation of periodontium 39
pin retained restoration design feature 388 direct gold restoration 375 interarch space available 37
preparation with gingival extension 410 preparation for abrasion/erosion lesion 365 number and position of occlusal contacts 37
proximal approach 438 restorations 137 occlusal interferences 37
restorations 136 Class VI harm prevention 57
tunnel approach 438 composite restoration 354 indications for operative treatment 46
adjusting and polishing the casting 417 restorations 137 amalgam restorations 47
advantages 393 Classification: ISO grouping 506 direct tooth colored filling material 47
armamentarium for temporary restoration 416 Cleaning and lubricating handpieces 177 intracoronal cast restorations 47
cavity preparation for class II cast metal Clearance angle 188 operative preventive treatment 46
inlays 403 Clinical decisions in operative dentistry 18 replacement of existing restoration 47
facial or lingual groove extension 410 about patient 22 replacing restoration 47
final cavity preparation 404 age, gender and occupation 22 restoration of incipient lesions 46
initial cavity preparation 403 allergic manifestations 23 treatment of abrasion, attrition and
mandibular premolar 410 attitude and motivation of patient to erosion 46
maxillary premolar 410 dental treatment 25 treatment of root caries 46
mesiocclusal-distal cavity preparation 410 biographic and demographic information long case presentation 52
preparation of bevels and flares 406 22 additional tests 54
proximal box 404 chief compliant and history of present attitude towards dental treatment 53, 55
checking for occlusal high points 418 illness 22 caries lesion 53, 55
class II inlay 402 diet 25 caries risk assessment 53, 55
consideration for temporary restoration 403 family and social background 25 chief complaint 52, 54
indications and contraindications 402 habits 25 clinical examination 53, 55
indications for inlay restoration 403 medical condition of patient 22 diagnosis 54, 55
local anesthesia 403 medications 23 dietary habits 53, 55
occlusion 403 past dental history 23 evaluation of dentition 53
other indications 402 review of systems 22 evaluation of periodontium 53, 55
class II preparation 410 risk assessment 26 existing restorations 53, 55
capping cusps 411 systemic disease and cardiac extraoral examination 53, 55
maxillary molar 411 abnormalities 23 family and social background 53, 55
direct method 414 advantages 58 general examination 53
direct vs indirect technique 393 access and visibility 58 history of present illness 52, 54
disadvantages 393 dry, clean operating field 58 intraoral examination 53, 55
final impression 416 improved properties of dental materials 58 long case sheet format 52
function of occlusal and gingival bevel 397 operating efficiency 58 lymph node examination 53
improving marginal adaptation (burnishing) protection of patient and operator 58 medical history 52, 54
419 certain conditions preclude use of rubber occlusal evaluation 53, 55
indications 401 dam 58 oral habits 53, 54,
indirect method 414 clinical examination 26 past dental history 52, 54
materials used for cast restorations 394 examination of temporomandibular joint preventive management 54, 56
mechanical design features 398 27 problem list worksheet and treatment
mouth preparation prior to cast restorations extraoral examination 27 sequencing 54
394 general appearance 26 radiographic evaluation 53
occlusal portion 401 intraoral examination 28 short case sheet format 54
features in class I inlay 402 lymph node examination 27 temporomandibular jaw 53
tooth preparation 401 soft tissue examination 28 treatment planning 54, 55
principle of cavity preparation 394 vital signs 27 vital signs 53
520 Essentials of Operative Dentistry

moisture control 57 general criteria 33 final cavity preparation stage 359

operating field 57 marginal opening 34 indications for facial approach 354
patient assessment 19 occlusion and interproximal contacts 34 initial cavity preparation stage 355, 359
problem list formulation 19 restoration related periodontal health 34 insertion of composite 361
problem oriented treatment planning model secondary caries 35 lingual access 355
19 structural integrity 33 matrix application 361
professionalism 18 teeth and investing tissues 66 modified cavity preparation 360
diagnosis 18 enamel 66 modified class III cavity preparation 357
emergency visit 19 structures of teeth 66 restorative procedures 360
main decisions 18 tooth notations 50 class V composite restoration 361
patient visits 18 deciduous dentition 50 advantages over conventional
preventive treatment 18 Federation Dentaire International System preparation 364
prognosis 18 50 beveled conventional class V preparation
recall appointment 19 palmer system 50 364
revaluation appointment 19 permanent dentition 50 class V preparation for abrasion/erosion
routine initial visit 19 universal numbering system 50 lesion 365
treatment options 18 treatment sequencing 19 common pitfalls in composite restorations
purpose 58 chief complaint 21 366
radiographic examination of teeth and definitive care phase 21 conventional preparation 364
restorations 39 diagnostic procedure 21 esthetic materials 363
adjunctive special tests 42 disease control phase 21 final cavity preparation stage 364, 365
amount and form of remaining tooth maintenance care 21 initial cavity preparation 364
structure 44 medical/systemic care 21 insertion of composite 365
control phase 45 re-evaluation phase 21 modified class V preparation 364
definitive phase 46 treatment plan presentation 21 nonesthetic materials 361
diagnosis and prognosis 43 Cohesive and noncohesive gold 367 tooth preparation 364
endodontics 46 Colloidal silica 329 class VI composite restoration 354
esthetic needs of each tooth 44 Color 36 contraindications 342
evaluation of diagnostic casts 42 Common design characteristics 183 disadvantages 342
final objective of overall restorative Common infections in dentistry 196 indications 342
treatment 45 Compaction method 368 local anesthesia 343
functional needs of each tooth 44 Completion of proximal extensions 264 moisture control 343
history and examination process 42 Complex restorations 379 occlusal evaluation 343
holding phase 45 Composite restoration class I to VI 342 preoperative evaluation 343
interdisciplinary considerations 46 advantages 342 preparation of restorative site 343
limitations with radiographs 42 armamentarium 346 problem areas in composite restorations
maintenance phase 46 tray instrument set-up 346 346
oral surgery 46 basic preparation designs 343 liners and bases under composite
orthodontics 46 beveled conventional preparation design restorations 346
periodontics 46 344 marginal gap 346
phases in treatment plan 45 conventional design 343 retention in class V lesion 346
planning the restoration 44 modified preparation 344 wear 346
radiographic techniques 40 class I and II composite restoration 347 restorative technique 345
treatment plan 43 class I cavity preparation 347 bonding agent application 345
retraction and access 57 class II composite restorations 348 contouring composite 346
rubber dam holder 59 conventional class II preparation 348 etching 345
rubber dam material 58 conventional preparation 347 insertion of composites 345
rubber dam punch 60 extensive class II preparations 351 matrix band application 345
absorbents and throat shields 62 final cavity preparation 349 polishing 346
advantages 63 finishing and polishing 351 rotary cutting instruments 346
disadvantages 64 internal occlusal fossa (tunnel shade selection 343
drugs 64 preparation) 352 tooth preparation for composite restorations
ejectors 62 modified class II preparation 350 343
high volume evacuators 62 modified preparation 347 Compound supported matrix (anatomic matrix)
lubricant 60 proximal box preparation 348 287
mirror tip and evacuator tip for retraction restorative technique 350 Compressive bleaching technique 464
64 sandwich restoration (laminate Compressor 10, 177
modeling compound 60 technique) 353 Computer assisted design (CAD) 432
mouth prop 64 tooth preparations 348 Computer assisted machining (CAM) 433
recent advancements in rubber dam 60 tunnel restoration 352 Concentricity and runout 188
retraction cord 64 class III and IV composite restoration 354 Condensation 242, 369
rubber dam application 60 advantages of lingual approach 354 Condensers 166, 368
rubber dam napkin 60 beveled conventional class III cavity Conservative approach 2
rubber dam retainer forceps 60 preparation 354 Conservative cavity preparation 247
saliva ejectors 62 beveled conventional preparation 360 Conservative design 373
throat shields 64 class III tooth preparation 354 Contact and contours 272
rubber dam retainer (clamps) 59 class IV cavity preparation 359 Contact angle of wetting 311
symptoms of caries 32 contouring and finishing of composite 361 Contact area 75, 295
amalgam blues 34 contraindications 354 Contact configuration 275
anatomic form 34 conventional class III cavity preparation Contact size 275
assessment of existing restorations 32 354 Contouring and finishing 361, 375, 378
esthetics 35 facial approach 356 Contouring composite 346
 Index 521
Convenience form 263, 481 permanent maxillary canine 81 class II direct filling gold restoration 372
Conventional class II preparation 348 permanent maxillary first molar 96 conservative design 373
Conventional class III cavity preparation 354 permanent maxillary first premolars 85 conventional design 372
Conventional design 343, 372 permanent maxillary incisor 77 simple design 373
Coolant 189 permanent maxillary lateral incisor 78 class III direct filling gold restoration 374
Copper content 233, 235 permanent maxillary molar 96 contouring and finishing 375
Coronal cavity preparation principles 481 permanent maxillary second molar 100 restoration 374
Cotton holder 168 pits and grooves 88, 92, 94, 99 tooth preparation 374
coupling agents 315, 330 premolar 84 class V direct gold restoration 375
Crossing ridge 144 canines 72 cavity preparation design 375
Cross-section of wedge 285 classes of human teeth and form 71 contouring and finishing 378
Crown depressions 75 dental structures 72 restoration 378
Crown elevations 74 description of terms 72 tooth preparation 376
Crown surface form 76 incisors 71 cohesive and noncohesive gold 367
Crowns 74 molars 72 compaction method 368
Curing lamps 335, 337 premolars 72 condensers 368
Cusp-fossa pattern of occlusion 112 supporting structures 72 pressure application 368
Cusp-ridge pattern of occlusion 111 gingiva 70 energy of condensation 369
Cusps 95 pulp dentin complex 68 metallurgical consideration 369
Cutting instruments 162 teeth surfaces 72 cohesive gold foil 369
Cutting mechanisms 192 anterior teeth 72 mat gold 369
Cutting recommendations 192 crown elevations 74 powdered gold 369
line angle 73 principles of cavity preparation 370
mammelons 75
contraindications 370
D point angle 73
fundamentals of cavity preparation 370
posterior teeth 73
Dappen dish 168 proximal 73 indications 370
Deciduous dentition 50 roots 73, 74 principles of condensation 369
Definitive care phase 21, 46 thirds of teeth 74 sealability of gold restorations 370
Degree of conversion 336 tooth-to-tooth contacts 111 Direct innervation theory 470
Delayed vs immediate finishing 340 centric interference 112 Direct pulp capping 127, 498
Dental anatomy, physiology, histology and clinical identification of tooth contacts 113
occlusion 66 Direct technique vs indirect technique 393
cusp-fossa pattern of occlusion 112 Direct/indirect resin inlays and onlays
cementum 70 cusp-ridge pattern of occlusion 111
crown depressions 75 (semidirect) 428
factors influencing occlusion 112 Disease control phase 21
central fossa 75 nonworking interference 112
contact area 75 Double wedging techniques 284
occlusal interferences 112 Drugs 64
developmental (primary) groove 75 protrusive interference 113
fissures 75 Dual curing resin and extraoral curing 336
working interference 112
fossa 75 Dental burs 184
groove 75
lobe 75
Dental chair 3 E
Dental chart 48
pit 75 Dental handpieces 10 Ejectors 62
supplemental (secondary) groove 75 Dental record 47 Electric dental motors 175
triangular fossa 75 Dental school and practice environment 3 Electric motor handpieces 177
crown surface form 76 Dental simulators 228 Electrosurgical methods 476
anterior teeth 76 Dental structures 72 Embrasures (spillways) 272
components of occlusal surface 92 Dentin adhesive system 316 Emergency visit 19
components of occlusal table 87, 108 Dentin bonding 314 Enamel and dentin bonding 312
cusps 95 Dentin bonding agents 499 Enamel bonding 312
facial and lingual surfaces 76 Dentin desensitization 448 Enamel bonding agents 314
fossae 88, 94, 95 Dentinal caries 118 Enamel etchant 314
grooves 95 Dentinal hypersensitivity 470, 472 Enamel loss 470
mandibular central incisor 78 Dentinoenamel junction 135 Enamel margin strength 135
mandibular first premolar 90 Dentinogenesis imperfecta 133 Enameloplasty 132
mandibular posterior teeth 76 Dentitions 71 Endodontic imaging 480
mandibular premolars 89 Description of terms 72 Endodontics 46
mandibular second premolar 93 Desensitization 472 Environment 339
maxillary central incisor 77 blocking pulpal sensory nerves 473 Enzymes 181
maxillary posterior teeth 76 occluding dentinal tubules 472 Ergonomics in dentistry 3
maxillary premolar 84 Diamond abrasive instruments 189 Erosion or abrasion 304
maxillary second premolar 88 Diet 25 Esthetic evaluation 39
maxillary vs mandibular canine 83 Dietary habits 53, 55 Esthetic materials 363
mesial and distal surfaces 76 Differential diagnosis 471 Esthetic operative dental procedures 451
permanent canines 81 Dimensional stability 237 bleaching 456
permanent incisors 76 Direct cutting and lateral cutting instruments 160 advantage 464
permanent mandibular canine 82 Direct filling gold restoration 367 alternatives 467
permanent mandibular first molar 103 class I tooth preparation and restoration 371 at home 464
permanent mandibular incisor 78 design 371 carbamide peroxide 460
permanent mandibular lateral incisor 80 general shape 371 carbamide peroxide bleaching process 461
permanent mandibular molar 101 instrumentation 371 compressive bleaching technique 464
permanent mandibular second molar 107 restoration 371 constituents of bleaching material 460
522 Essentials of Operative Dentistry

contraindications 465 clinical features of dentinal sensitivity 471 access cavity preparation 480
disadvantages 464 desensitization by blocking pulpal advantages 501
effect on restoration 466 sensory nerves 473 anatomy of pulp cavity and root canal
extrinsic stains 456 desensitization by occluding dentinal 481
factors that affect bleaching 461 tubules 472 brief description about pulp 481
flavoring agents 460 differential diagnosis 471 calcium hydroxide-based cements 503
hydrogen peroxide bleaching 461 direct innervation theory 470 cervical cross-section 483
indications for bleaching 465 enamel loss 470 cleaning and debridement of root canal
intrinsic stains 456 etiology 470 485
laser assisted in-office bleaching 464 hydrodynamic theory 471 convenience form 481
light 463 management of dentin hypersensitivity coronal cavity preparation principles 481
McInnes solution 464 472 disadvantages 502
mechanism of bleaching action 461 mechanisms of pain transmission theories endodontic imaging 480
nonhydrogen peroxide containing 470 functions of pulp 481
materials 460 glass ionomer cements 503
prevention of dentinal hypersensitivity 472
nonvital 457 ideal requirements 500
transducer mechanism 470
over counter bleaching kits (OTC kits) 461 indications 479
management of gingival tissues 473
preservative 460 labiolingual section 482
chemical methods 476
properties of ideal bleaching agent 463 master cone radiograph 480
chemomechanical method 475
rate of color change 463 maxillary anterior teeth access cavity
electrosurgical methods 476
safety factors 466 preparation 483
indication for gingival tissue
saturation point 461 mechanism of action 503
management 473
soft tissue problem 466 mesiodistal section 482
lasers 477
surfactants 460 metal points 502
methods of gingival tissue management
systemic effects and response 466 mid-root cross-section 483
474
thickening agents 460 mineral (metal) trioxide aggregate 504
physicomechanical method 474
tooth and pulpal problems 466 obturating points 500
recent techniques for gingival retraction
tooth color 457 obturation of root canal space 480
476
tray fabrication 464 outline form 481
retraction by dilatation of gingival sulcus
tray wear time 465 polydimethyl siloxanes 503
477
types of bleaching therapy 457 postobturation radiograph 480
rotary curettage 476
types of stains 456 preliminary radiograph 480
surgical methods 476
urea 460 preparing the root canal 485
microabrasion/macroabrasion 467
vehicle 460 principles in radicular cavity preparation
clinical technique 468
vital bleaching 460 485
indications/contraindications 468, 469
vital in-office bleaching (power principles of access cavity preparation 481
macroabrasion 469
bleaching) 463 proper access cavity preparation 479
microabrasion (chemical-physical
clinical aspects of endodontic materials 504 proper diagnosis 479
microabrasion) 468
anticurvature filing 511 pulp anatomy of maxillary incisors 482
pulp capping materials 499
balanced force technique 511 radicular cavity preparation 483
dentin bonding agents 499
barbed broach and rasps 507 removal of any remaining caries 481
failure after direct pulp capping 500
biocompatibility 504 resins 503
root canal preparation 486
ceramic posts 506 root canal filling materials: ADA No. 78
armamentarium 492
circumferential filing 511 500
characteristic of ideal root canal filling 491
classification: ISO grouping 506 root canal sealer cement: ADA No. 57 502
cleaning and shaping of root canal 486
fiber-reinforced resin posts 505 root canal treatment sequence 479
common pitfalls 494
files and reamers 507 sealing of access cavity preparation 480
concepts and strategies for canal
Gates Glidden drill 512 toilet of cavity 481
preparation 488
Gates Glidden modification 513 working length 485
contraindications 495
GT profiles 509 working length determination 479
guideline for adequate shaping 488
H-file modifications 509 working length radiograph 480
ideal requirements in intracanal
K-type instruments 508 zinc oxide eugenol 503
medicament 490
K-type modifications 508 veneers 451
ideal requirements of root canal filling
lightspeed instrument 509 advantages 453
materials 490
mechanical instrumentation 511 clinical cases 453
indications 495
metal posts 505 contraindications 451
intracanal medicaments 490
nickel titanium instruments 513
irrigation 489 disadvantages 453
peesoreamer 512
lateral compaction of cold gutta-percha 92 full veneer tooth preparation 452
physical properties 505
method of irrigation 490 indications 451
post and core 505
mode of application 490 partial veneer tooth preparation 452
power driven instruments 512
objective 486 types 451
root canal instruments 506
obturation 490, 494 vital pulp capping 498
sealing properties 504
pulpotomy 495 direct pulp capping 498
sonic and ultrasonic instruments 513
root canal instruments 492 indirect pulp capping 498
standardization 507
rotary instruments 492 Etchants 316
tip modification 510
step-back technique 488 Etching 313, 345
types of post systems 505
techniques of cleaning and shaping of Excavators 162
U-file 509
root canal 488 Exploring instruments 157
watch winding and pull 511
treatment approaches to pulpotomy 495 Extensive class II preparations 351
dentinal hypersensitivity 470
various obturating techniques 491 Extracted teeth for operative dental procedures
cementum loss 470
root canal treatment 479, 500 224
clinical examination 471
 Index 523
F vale experiment 144
weak areas of tooth 144
class II occlusal approach 437
class II proximal approach 438
Facial and lingual concavities 275 zinc phosphate cement 148 class II tunnel approach 438
Facial and lingual contours 275 zinc polycarboxylate cement 148 class III and class V restorations 439
Facial and lingual flare 397 noncarious terminologies 132 class III buccal/lingual approach 438
Facial and lingual surfaces 76 abfraction 133 clinical procedures 440
Facial or lingual groove extension 410 abrasion 132 disadvantage 440
Facial surfaces 272 amelogenesis imperfecta 133 glass ionomers as liners and bases 440
Federation Dentaire International System 50 attrition 132 indications 438, 440
Fiber reinforced composites 334 dentinogenesis imperfecta 133 instrument required 437, 438, 439
Fiber-reinforced resin posts 505 erosion 132 tooth preparation 437, 438, 439
Finishing enamel walls 250, 306 objectives of cavity preparation 130 Glass slab 168
First amalgam war 233 pulpal consideration 153 Grafting to collagen 316
First generation indirect composite resin systems clinical considerations 153 Guards 170
426 determination of effective depth 153
Fissures 75 irritating agents of tooth preparation 153
Flavoring agents 460 restorative material factors 132 H
Flowable composites 334 extension for prevention 132
Fluoride containing amalgam 245 tooth preparation terminology 133 Hand cutting instruments 162, 171
Forceps 158 cementoenamel junction 135 Hand instrument techniques 169, 170
Four-handed dentistry 13 dentinoenamel junction 135 Handpieces 174
Friction grip pins 386 enamel margin strength 135 Harm prevention 57
Friction locked pins 380 intracoronal and extracoronal tooth Head design 184, 189
Full veneer tooth preparation 452 preparations 135 Heat generation 189
Fundamentals in tooth preparation 130 simple, compound and complex tooth H-file modifications 509
biologic basis 154 preparations 133 High copper alloys 235
biologic width 154 tooth preparation angles 134 High intensity curing 337
clinical considerations 154 tooth preparation walls 133 High volume evacuators 62
irritating factors to periodontium 154 Hoe chisel 165
biological form 153 Holding phase 45
Home bleaching 464
classification of tooth preparations 136 G Homogenizing annealing 234
class I restorations 136
class II restorations 136 Gallium-based alloys 245 Horizontal pins 390
class III restorations 137 Galvanism 259 Hybrid composites 333
class IV restorations 137 Gates Glidden 512 Hybridization 320
class V restorations 137 drill 512 Hydrodynamic theory 471
class VI restorations 137 modification 513 Hydrogen peroxide bleaching 461
final cavity preparation stage 138 Gingiva 70 Hydrolysis theory 338
initial cavity preparation stage 138 Gingival retention groove 301
operating site 138 Gingival tissue management 473
stages and steps in cavity preparation Glass ionomer 149 I
138 adhesives 321
cement 149, 503 Ideal bleaching agent 463
conservation of tooth structure 130
modification 436 Incipient lesion 117
enameloplasty 132
restoration 434 Incisal retention cove 301
factors affecting cavity preparation 130
initial cavity preparation stage 138 Glass ionomer restoration 434 Incisors 71
base 148 advantages 435 Indirect pulp capping 129, 498
calcium hydroxide 148 chemistry of setting 434 Indirect resin inlays and onlays 428
cavity varnish 146 classification 435 Indium containing alloy powder 245
cavity wall conditioning 150 type I luting 435
Infection control 194
convenience form 145 type II restorative 435
common infections in dentistry 196
factors 139, 143, 151 type III liners/bases 435
clinical application 435 infection control methods 199
final procedures 152
abrasion/erosion lesion 436 infection control with regard to impression
glass ionomer cement 149
class III, class V and other carious lesions making 220
ideal requirements of a base material 146
liner 147 436 exercises in plaster square block 223
marginal ridge 144 clinical performance 436 instrument audit for dental instruments 217
mechanical features 149 dispensing, mixing and insertion 436 instrument reprocessing and sterilization
Noy’s structural requirements 151 finishing and polishing 436 monitoring 209
outline form and initial depth for pit and glass ionomer modification 436 Infection control methods 199
fissure cavities 139 isolation 436 Inhibitors 330
outline form and initial depth for smooth preparation of dentinal surfaces 436 Instrument design 155
surface cavities 140 pulpal protection 436 Instrument tray set-up 169
primary resistance form 141 surface protection 436 Instruments and equipment used for diagnosis
primary retention form 144 tooth preparation 435 155
pulp protection or lining materials 146 composition 434 Instruments name or nomenclature 158
removal of any remaining infected disadvantages 435 Interdisciplinary considerations 46
dentin 145 modifications 435 Internal occlusal fossa (tunnel preparation) 352
secondary resistance and retention forms tooth preparation design 436 Interproximal spaces 272, 275
149 advantages 440 Intracanal medicaments 490
sterilization of cavity walls 152 atraumatic restorative technique 440 Intracoronal and extracoronal tooth preparations
stresses on tooth structure 143 class I/fissure seal 436 135
524 Essentials of Operative Dentistry

Intrinsic sources 447 incisal retention cove 301 esthetics 299

Intrinsic stains 456 initial cavity preparation 300 isolation of operating site 300
Introduction to operative dentistry 1 lingual dovetail 301 local anesthesia 300
conservative approach 2 outline form 300 occlusion 300
considerations 1 procedures for finishing external walls 302 size and position of carious lesion 299
development in field of operative dentistry 2 pulp protection 301 tooth movement 275
factors affecting operative treatment 1 removal of any remaining infected advantages 277
functions and purposes of operative dentistry dentin 301 disadvantage 277, 278
1 resistance and retention form 301 indications 277
history 1 features in class III preparation 302 methods 278, 279
Ionic polymer 315 features of class II preparation 294 objectives 275
Irrigation 489 contact area 295 rapid tooth movement 277
Isthumus 261 matrix retainer application 295 slow or delayed tooth movement 277, 279
Ivory matrix no. 1 286 occlusal portion 294 wooden or plastic wedges 278
proximal portion 295 Master cone radiograph 480
hazards 275 Matrix application 361
K contact configuration 275 Matrix band application 345
Kidney tray 169 contact size 275 Matrix removal 285
K-type instruments 508 contour 275 Matrix retainer application 295
K-type modifications 508 facial and lingual concavities 275 Maxillary anterior teeth access cavity
facial and lingual contours 275 preparation 483
interproximal spaces 275 Maxillary central incisor 77
L marginal ridge 275 Maxillary first molar 268, 271
intraoral procedures for creation of contacts Maxillary first premolar 268
Labiolingual section 482 and contours 275 Maxillary molar with unaffected oblique ridge
Lathe cut powder 234 matrices for two and three surface 411
Led 335 restorations 279 Maxillary posterior teeth 76
Light activated resin 330 anatomic matrix (template) 289 Maxillary premolar 84, 410
Light activation 334 automatrix systems 287 Maxillary second premolar 88
Lightspeed instrument 509 Black’s matrix for gingival extension 288 Maxillary vs mandibular canine 83
Line angle 73 compound supported matrix 287 Mcinnes solution 464
Liner 147 condensation of amalgam 290 Mechanical bonding 310
Lingual access 355 cross-section of wedge 285 Mechanical design features 398
Lingual dovetail 301 double wedging 284 Mechanical instrumentation 511
Lingual pit in maxillary incisors 253 finishing and polishing 290 Mechanical sharpeners 171
Lingual surfaces 272 Ivory matrix no. 1 286 Medical/systemic care 21
Lobe 75 Ivory no. 8 286 Medications 23
Locks 392 matrices for class II preparations 281 Mercury free direct filling silver alloys 245
Long case presentation 52 matrices for class III tooth colored Mesial and distal bevel 161
Low copper alloys 235 restorations 289 Mesial and distal surfaces 76
Low mercury amalgams 245 matrices for class IV restoration 289 Mesiocclusal-distal cavity preparation 410
Lubricant 60 matrices for class V preparations 290 Mesiodistal section 482
Luting procedure 426 matrix for class I restoration 280 Metal points 502
Lymph node examination 27, 53 matrix removal 285 Metal posts 505
objectives of matrix 280 Microabrasion/macroabrasion 467, 468
omni matrix system 287 Microfilled composites 333
M parts of retainer 282 Microfracture theory 338
Macintosh sheet 168 prewelded bands 286 Microleakage 323
Macroabrasion 469 procedure for carving occlusal portion Mid root cross-section 483
Mammelons 75 290 Miller’s chemico-parasitic theory 115
Management of gingival tissues 473 quadrant dentistry 292 Mineral (metal) trioxide aggregate 504
Mandibular canine 305 removal of matrix band 290 Minimal invasive dentistry 442
Mandibular central incisor 78 sectional matrix 286 cavity design and preparation 443
Mandibular first premolar 90, 271 S-shaped matrix 288, 290 restorative materials 443
Mandibular posterior teeth 76 Steele’s Siqveland self-adjusting matrix general principles of cavity design 442
Mandibular premolar 89, 410 retainer 286 new cavity classification 443
Mandibular second premolar 93 transparent crown form matrices 289 four sizes of carious lesions 443
T-shaped matrix 289 three sites of carious lesion 443
Marginal gap 346
types of matrices for class I restoration treatment procedure 443
Marginal leakage 337
280 preparation 444, 445
Marginal opening 34
wedge placement 284 restoration 443, 444, 445
Marginal ridges 144, 275 wedge-wedging 284 site 443
armamentarium 296, 303 wedging techniques 284 Mirrors 157
from left to right 296, 303 window matrix 290 Modeling compound 60
class III amalgam restoration 299 matrix for class III preparations 302 Modification of bur design 186
selection of restorative material 299 finishing and polishing of restoration 302
tooth location 299 Modified cavity preparation 360
procedures 302
common pitfalls 295, 303 restoration 295 Modified class II preparation 350
distal cavity preparation 300 rotary cutting instruments 298, 303 Modified class III cavity preparation 357
final cavity preparation 300 service 299 Modified class V preparation 364
final procedures 302 age of patient 299 Moisture control 57, 343
gingival retention groove 301 economics 299 Molars 72
 Index 525
Mount and Hume classification 443 Palmer system 50 tooth preparation 388
Mounting 226 Palpation 36 class II pin retained restoration design
acrylic model 226 Paper pad 168 feature 388
arch form 227 Partial veneer tooth preparation 452 final cavity preparation 388
extracted teeth 226 Particle treatments 234 finishing and polishing 388
natural teeth in typodont arch form 227 Past dental history 54 initial cavity preparation 388
plaster model 227 Patient assessment 19 inserting and carving 388
single natural tooth 227 Patient visits 18 matrices 388
Mouth prop 64 Patterns of etching 313 pin placement 388
Peesoreamer 512 types of pins 380
Percussion 36 cemented pins 380
N Periodontal probes 157 friction locked pins 380
Periodontics 46 self threading pins 380
Nano composites 333 Permanent canines 81 Pin retained restoration 383
Natural tooth exercises 225 Permanent dentition 50 Pin size 383
Neck 184 Permanent incisors 76 Pit and fissure sealant 325
Nickel titanium instruments 513 Permanent mandibular canine 82 Plaque and caries risk 29
Noble metals 233 Permanent mandibular first molar 103 Plaster model exercises 223
Noncarious cervical lesions 446 Permanent mandibular incisor 78 Plastic instruments 167
clinical features 447 Permanent mandibular lateral incisor 80 Plastic spatula 168
diagnosis 447 Permanent mandibular molar 101 Point angle 73
isolation 447 Permanent mandibular second molar 107 Polishing 346
etiology 447 Permanent maxillary canine 81 Polydimethyl siloxanes 503
treatment 448 Permanent maxillary first molar 96 Post and core 505
dentin desensitization 448 Permanent maxillary first premolars 85 Post systems 505
restorative treatment 448 Permanent maxillary incisor 77 Postcarve burnishing 251
treatment options 448 Permanent maxillary lateral incisor 78 Posterior teeth 73
types of noncarious cervical lesion and Permanent maxillary molar 96 Postobturation radiograph 480
definition 446 Permanent maxillary second molar 100 Powder particle size 233
Noncarious terminologies 132 Phantom head or patient position 8 Power bleaching 463
Noncutting instruments (restorative instruments) Phases in treatment plan 45 Power driven instruments 512
166 Photo activated-disinfection 179 Powered cutting instruments 172
Nonesthetic materials 361 Photo curing with visible blue light 334 Precarve burnishing 250
Nonhydrogen peroxide containing materials 460 Physical bonding 310 Preclinical conservative laboratory exercises 223
Nonvital bleaching 457 Pin design 386 alloy composition 232
Nonworking interference 112 Pin hole preparation 384 amalgam waste management 245
Noy’s structural requirements 151 Pin insertion 386 amalgamation and resulting microstructures
Pin placement 383 235
Pin retained amalgam restoration 379 admixed alloys 236
O advantages 379 high copper alloys 235
Obturating points 500 complex restorations 379 low copper alloys 235
Obturation materials 494 factors to be considered 379 single composition alloys 236
Obturation of root canal space 480 occlusion, esthetics and economics 379 classification of amalgam 233
Occlusal and gingival bevel in cavosurface resistance and retention form 379 alloyed metals 233
margin 396 role of teeth in overall treatment plan 379 copper content 233
Occlusal outline form (occlusal step) 263 status and prognosis of tooth 379 noble metals 233
Occlusal pits and fissures in maxillary first disadvantages 379 powder consists of unmixed or admixed
molar 254 failure of pin retained restorations 388 alloys 233
Occlusal pits of mandibular first premolar 253 indications 380 shape of powdered particle 233
Occlusal portion 294 mechanical aspects 380 zinc content 233
Occlusal surface 262 anatomical aspects 383 components of alloy powder 235
Occlusion and interproximal contacts 34 effect of pin on amalgam 382 copper 235
Occlusolingual cavity preparation and retention of pins to restorative material 382 silver 235
restoration 251 retentive capabilities of pins in dentin 382 tin 235
Office bleaching 463 strengths of pins 382 zinc 235
Offset hatchet 165 stressing capabilities of pins 380 dental simulators 228
Old restorative material 266 mishaps during pin retained restorations 388 extracted teeth for operative dental
Omni matrix system 287 other alternative to pins 390 procedures 224
Operative cutting instrument formula 158 amalgapins 391 history and controversies 232
Operative preventive treatment 46 circumferential slots 390 first amalgam war 233
Operator’s chair 5 horizontal pins 390 second amalgam war 233
Operator’s position 5 locks 392 third amalgam war 233
Optical modifiers 331 slots 391 manufacture of alloy powder 234
Oral habits 53 pin placement 383 atomized powder/spherical particles
Oral surgery 46 cemented pins 388 234
Orthodontics 46 friction grip pins 386 homogenizing annealing 234
location of pins 384 lathe cut powder 234
number of pins 384 metallurgical phases 235
P pin design 386
pin hole preparation 384
particle treatments 234
microstructure of amalgam 236
Pac lamps 335 pin insertion 386 fifth generation 237
Packable composites 334 pin size 383 sixth generation 237
526 Essentials of Operative Dentistry

mounting 226
acrylic model 226
Q light activation 334
pac lamps 335
arch form 227 Quadrant dentistry 292 photocuring with visible blue light 334
extracted teeth 226 disadvantages 327
natural teeth in typodont arch form 227 acrylic resins 327
plaster model 227 R silicate cements 327
single natural tooth 227 evolution and history of composites 327
Radicular cavity preparation 483, 485
natural tooth exercises 225 historical development 327
Radiopacity 338
advantages 225 other properties of composites 337
Rake angle 187
criteria 226 chemical degradation 338
Rapid tooth movement 277
disadvantages 226 contraindications for composites 338
Rebonding 340
plaster model exercises 223 hydrolysis theory 338
Recall appointment 19
care of plaster models 224 marginal leakage 337
Recent advancements 60
exercises in plaster tooth model 223 mechanism of wear 338
in amalgam 245
restoration with wax 224 microfracture theory 338
in rubber dam 60
properties of amalgam 237 principal modes of wear 338
Recent techniques for gingival retraction 476
advantages of amalgam 244 protection theory 338
Recommended instrument kit 166
bonded amalgam 246 radiopacity 338
Repaired amalgam restoration 244
carving and finishing 243 wear 338
Resin composite 327
clinical significance 243 rebonding 340
direct composite restoration 428
condensation 242 reduction of residual stresses (polymerization
inlays and onlays 426
dimensional stability 237 shrinkage) 336
restorative material 327
disadvantages of amalgam 244 high intensity curing 337
Resin composite restorative material 327
factors 240 incremental build-up and cavity
advantages of acrylic resins 327
fluoride containing amalgam 245 configuration 336
biocompatibility of composites 340
gallium-based alloys 245 precaution for using curing lamps 337
classification of composite resin 331
indium containing alloy powder 245 soft start, ramped curing and delayed
according to anusavice 331
low mercury amalgams 245 curing 337
according to sturdevant 331
manipulation of amalgam 240 repair of composites 340
ceramic whiskers 334
mercury free direct filling silver alloys 245 selection criteria for composites 339
clinical consideration 332, 333
properties of mercury 240 advantages (over ceramics) 339
fiber reinforced composites 334
recent advancements in amalgam 245 composites for resin veneers 339
first generation 334
repaired amalgam restoration 244 delayed vs immediate finishing 340
flowable composites 334
side effects of mercury 244 disadvantages 339
hybrid composites 333
strength 238 environment 339
Lutz and Phillips (1983) 332
tarnish and corrosion 240 finishing of composites 339
microfilled composites 333
safety in laboratory 223 indirect composites 339
nano composites 333
transport of extracted teeth 225 indirect resin inlays 339
packable composites 334
working in typodont 228 types of material 340
properties 332, 333
precautions 229 Resin matrix 328
second generation 334
Premolar 72, 84 Resin tags 313
small particle filled composites 332
Preservative 460 Resin-metal bond 323
traditional composites 332
Pressure application 368 Resins 503
Willems classification 332
Preventive resin restoration 325 Resistance form 260
components of a composite resin 328
Prewelded bands 286 Restoration of incipient lesions 46
activator-initiator system 330
Primary resistance form and retention form 266 Restoration related periodontal health 34
benefits of filler 328
Primers 316 Restoration with wax 224
chemically activated resin 330
Problem list formulation 19 Retentive capabilities of pins in dentin 382
colloidal silica 329
Problem list worksheet and treatment Retraction and access 57
composition and function of components
sequencing 54 Retraction by dilatation of gingival sulcus 477
328
Problem oriented treatment planning model 19 Retraction cord 64
coupling agents 330
Protection theory 338 Root 73, 74
disadvantages 330
Proteolysis—chelation theory 115 Root canal filling materials: ADA no. 78 500
fillers 328
Proteolytic theory 115
inhibitors 330 Root canal instruments 492, 506
Protrusive interference 113
light activated resin 330 Root canal preparation 479, 486
Proximal box margin (cavosurface margin) 397
optical modifiers 331 Root canal sealer cement: ADA no. 57 502
Proximal box preparation 348, 422
pyrogenic silica 329 Root canal treatment sequence 479
Proximal contact areas 272
resin matrix 328 Root caries 46
Proximal ditch cut 263
uses and applications 328 Rotary curettage 476
Proximal lock 267
curing of resin-based composite 334 Rotary instruments 492
Proximal outline form (proximal box) 263
Proximal surface caries 30 advantages 334 Rotary speed ranges 175
Pulp anatomy of maxillary incisors 482 argon laser lamps 335 Rotated tooth 269
Pulp capping 498 chemical and light curing 334 Routine initial visit 19
Pulp capping materials 499 chemical curing 334 Rubber dam 58
Pulp cavity and root canal 481 curing lamps 335 application 60
Pulp dentin complex 68 degree of conversion 336 holder 59
Pulp protection or lining materials 146 depth of cure and exposure time 335 material 58
Pulpal consideration 153 disadvantages 334 napkin 60
Pulpal protection 436 dual curing resin and extraoral curing punch 60
Pulpotomy 495 336 retainer (clamps) 59
Pyrogenic silica 329 led 335 retainer forceps 60
 Index 527
S Throat shields 64
Tin 235
spoon excavator 163
terminology and classification 162
Safety factors 466 Tip modification 510 triangular chisel 165
Safety in laboratory 223 Toilet of cavity 481 triple beveled instruments 161
Saliva ejectors 62 Tooth and pulpal problems 466 development of rotary cutting instrument 172
Sandwich restoration (laminate technique) 353 Tooth color 457 advantages over air turbine 175
Saturation point 461 Tooth colored inlays and onlays 425 air abrasives 179
Sealability of gold restorations 370 ceramic inlays and onlays 430 air turbine handpieces (airotor) 175
Sealing properties 504 advantages 431 characteristics of rotary instruments 178
Second amalgam war 233 CAD/CAM restorations 431 chemomechanical caries removal 180
Second generation indirect composite resin CEREC system 432 cleaning and lubricating handpieces 177
systems 427 computer assisted design (CAD) 432 cleaning and lubrications 178
Secondary caries 35 computer assisted machining (CAM) 433 compressor 177
Secondary polymerization 427 contraindication 431 disadvantages 175
Sectional matrix 286 disadvantages 431 electric dental motors 175
Self threading pins 380 fabrication of ceramic inlay/onlay 431 electric motor handpieces 177
Sensitive areas 304 indication 431 enzymes 181
Shade selection 343 tooth preparation design 431 future developments 174
Shank 183 try-in and cementation 433 handpieces 174
Sharpness test 171 general considerations 425 instrumentation 172
Short case sheet format 54 luting procedure 426 lasers 180
Silane coupling agents 322 resin composite inlays and onlays 426 other powered equipments 179
Silver 235 advantages 428 photo activated-disinfection 179
Simple box preparation 269 contraindications 428 rotary speed ranges 175
Single beveled instrument 160 direct/indirect resin inlays and onlays 428 sonic and ultrasonic caries removal 179
Single composition alloys 236 disadvantages 428 exploring instruments 157
Single ended and double ended instruments 162 first generation indirect composite resin explorers 157
Single proximal cavity preparations 268 systems 426 forceps 158
Single step 317 indications 430 instruments name or nomenclature 158
Sink 10 indirect resin inlays and onlays 428 mirrors 157
Sinus evaluation 36 laboratory process 429 periodontal probes 157
Slot preparation 269 materials for direct resin inlays/onlays 427 types 157, 158
Slow or delayed tooth movement 277, 279 materials for indirect resin inlays/onlays hand cutting instruments 155
Small particle filled composites 332 426 effects of sterilization 155
Smear layer dissolving 317 second generation indirect composite hand instruments 155
Smear layer modifying 317 resin systems 427 hardening and tempering heat
Smear layer removing 317 secondary polymerization 427 treatments 155
Smooth surface caries 30, 116, 119 tooth preparation design 426, 428 instrument design 155
Soft tissue 28 Tooth location 299 materials 155
examination 28 Tooth movement 275 hand instrument techniques 169
problem 466 Tooth notations 50 guards 170
protection 16 Tooth preparation and restoration 155 material used for sharpening stones 170
Soldering contacts 419 accessory instruments 168 mechanical sharpeners 171
Sonic and ultrasonic caries removal 179 articulating paper 169 principles of sharpening 171
Sonic and ultrasonic instruments 513 chip syringe 168 rests 170
Spoon excavator 163 cotton holder 168 sharpening of hand instruments 170
S-shaped matrix 288, 290 dappen dish 168 sharpness test 171
Stains 456 instrument tray set-up 169 stationary sharpening stones 170
Stationary sharpening stones 170 kidney tray 169 sterilization and storage 171
Steele’s Siqveland self-adjusting matrix retainer Macintosh sheet 168 noncutting instruments 166
286 surgical tray 169 amalgam carriers 166
Sterilization 211 armamentarium and instruments 159 amalgam well 166
Sturdevant 331 angle former 163 burnishers 167
Supplemental (secondary) groove 75 bibeveled instrument 161 carvers 166
Supporting structures 72 chisel vs hoe 165 condensers 166
Surface cavity preparation 263 circumferentially beveled instruments types 167
Surface energy 310 162 operative cutting instrument formula 158
Surface protection 436 cutting instruments 162 plastic instruments 167
Surface treatment 322 direct cutting and lateral cutting agate spatula or plastic spatula 168
Surfactants 460 instruments 160 calcium hydroxide applicator 168
Surgical tray 169 excavators 162 cement spatulas 168
Systemic disease and cardiac abnormalities 23 hand cutting instruments types 160, 162 glass slab 168
hoe chisel 165 paper pad 168
mesial and distal bevel 161 powered cutting instruments 172
T offset hatchet 165
other instruments according to Marzouk
rotary cutting instruments 183
abrasive cutting 192
Tarnish and corrosion 240 165 additional features in head design 189
Teeth and investing tissues 66 recommended instrument kit 166 bladed cutting 192
Teeth surfaces 72 right and left instruments 160 bur classification 185
Temporomandibular jaw 53 single beveled instrument 160 bur life 189
Thickening agents 460 single ended and double ended clearance angle 188
Third amalgam war 233 instruments 162 common design characteristics 183
528 Essentials of Operative Dentistry

composition and manufacture 185 Transducer mechanism 470 Van Meerbeek scientific classification 317
concentricity and runout 188 Transparent crown form matrices 289 Vehicle 460
coolant 189 Transport of extracted teeth 225 Veneers 451
cutting mechanisms 192 Tray instrument set-up 346, 413
cutting recommendations 192 Tray wear time 465
dental burs 184 Treatment oriented model 19
design of dental burs 186 Triangular chisel 165 W
diamond abrasive instruments 189 Triangular fossa 75 Watch winding and pull 511
evaluation of cutting 192 Triple beveled instruments 161 Wear 338, 346
hazards of cutting instruments 192 Try-in and cementation 433 Wedge placement 284
head design 184 Trying in mouth 417 Wedge-wedging 284
heat generation 189 T-shaped matrix 289 Wedging techniques 284
historical development 184 Tunnel restoration 352 Wet vs dry bonding 321
influence of load 189 Typodont 228 Wetting 311
materials 192 Willems classification 332
modification of bur design 186 Window matrix 290
neck 184 U Wooden or plastic wedges 278
number of teeth 188
rake angle 187 U-file 509
shank 183 Universal numbering system 50
Unusual outline form 270
shapes 185
Urea 460 Z
sizes 185
terminology 189 Zinc 233, 235
Zinc oxide eugenol 503
Tooth structure 44
Tooth-to-tooth contacts 111
V Zinc phosphate cement 148
Traditional composites 332 Vale experiment 144 Zinc polycarboxylate cement 148