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1
3 Chapter 1 Brief Review of Dental Caries 3

Smooth surface caries

CLASSIFICATION OF DENTAL CARIES
According to location of caries:
Caries that seen in: (Figures 1.2 a-c)
 Gingival third of buccal (or labial) and lingual (or
palatal) surfaces.
 Gingival third of proximal surfaces.

Pit and fissure caries

Caries that seen in: (Figures 1.1 a-c)
 Pit and fissures on occlusal surface of posterior
teeth.
 Buccal and lingual surfaces of molars.
 Lingual surface of maxillary anteriors.

Root caries

Caries that seen on exposed root surface. (Figure 1.3)

Figure 1.1(b) showing pit and fissure caries

According to Extent of Caries

Incipient Caries

 It is the first evidence of caries activity. It

consists of demineralized enamel which has not
extended to DEJ.
 This lesion can be remineralized by proper
preventive procedures, hence called as
reversible caries. (Figures 1.4 a-b)
4 Clinical Operative Dentistry
Figure 1.4(a) incipient carious lesions .Note
whitish appearance
Figure 1.4(b) non cavitated white spot
carious lesion.
Cavitated Caries
 Caries extend beyond enamel into the dentin.
(Figure 1.5 )
 This lesion cannot be remineralized, so also
termed as irreversible caries.
Figure 1.5 small cavitated carious lesion.
According to Speed of Caries Progression
Active Carious Lesion
 Rapidly invading caries involving several teeth.
4
 If untreated, acute caries can result in pulp
exposure.
 It is soft in consistency and light colored.
( Figure 1.6 )
Figure 1.6 active caries.
Inactive/Arrested Carious Lesion
 Slowly progressing, long-standing caries
characterized by a large open cavity which no
longer retains food and becomes self-cleansing.
( Figure 1.7 )
 Disease is managed by preventing further
disease progression and stabilizing existing
lesions before restoring teeth permanently. If
caries is not managed by preventive, non-
operative treatment the restorative treatment
will be doomed to a cycle of disease, repair, new
disease and further repair, and, before too long,
extraction.
Figure 1.7 inactive (arrested) caries.
Rampant Caries
 It is the name given to multiple active carious
lesions (Involving at least two teeth and two
surfaces) occurring in the same patient,
frequently involving surfaces of teeth that are
usually caries free. ( Figures 1.8 a-b )
 Rampant caries may also be seen in the
permanent dentition of teenagers and is usually
5 Chapter 1 Brief Review of Dental Caries 5

due to frequent cariogenic snacks and sweet Recurrent Caries

drinks between meals. Lesions developing adjacent to restorations are
 It is also seen in mouths where there is a referred to as either recurrent or secondary caries.
sudden marked reduction in salivary flow (Figure 1.10 a-b)
(xerostomia).
 The Radiation in the region of the salivary
glands used in the treatment of a malignant
growth, Sjögren’s syndrome and an
autoimmune condition which may involve the
salivary glands, are the most common causes of
severe xerostomia.

Figure 1.10 (a) failure composite due to

recurrent caries.

Figure 1.8(a) rampant caries of both anterior

and posterior teeth.

Figure 1.10 (b) failure amalgam due to

recurrent caries.

Residual Caries
 It is caries that remains in the prepared tooth
surface even after placing the restoration.
 Sometimes caries close to pulp are left
Figure 1.8(b) rampant caries in an adult man. intentionally so as to prevent pulp exposure
According to Treatment and Restoration
According to New Lesion or Recurrent
Design
Lesion
Class I:
Primary Caries
It denotes Pit and fissure caries that occur in: (Figure
It denotes lesions on unrestored surfaces. (Figure
1.11)
1.9)
 The occlusal surfaces of premolars and molars,
 The occlusal two-third of buccal and lingual
surfaces of molars.
 Palatal surface of maxillary anteriors.

Figure 1.9 primary caries of premolar

Figure 1.11 class I caries.
6 Clinical Operative Dentistry 6

Class II: Class V:

It denotes Caries on proximal surface of premolars It denotes Caries on gingival third of facial and
and molars. (Figure 1.12) lingual or palatal surfaces of all teeth. (Figure 1.15)

Figure 1.15 class v caries.

Class VI:
It denotes Caries on incisal edges of anterior and
cusp tips of posterior teeth without involving any
other surface. (Figure 1.16)

Figure 1.12 class II caries.

Class III:
It denotes Caries in the proximal surface of anterior
(incisors and canines) teeth, not involving the
incisal angles. (Figure 1.13)

Figure 1.16 Class VI caries

CONTRIBUTING FACTORS IN DENTAL

CARIES

Four factors contribute to caries process:

(Figure 1.17)
Figure 1.13 class III caries.
 Host factor:
Class IV: - Tooth morphology, position and chemical
It denotes Caries in the proximal surface of anterior nature.
teeth involving the incisal angle. (Figure 1.14) - Saliva.
 Microflora (dental plaque).
 Diet:
- Physical nature.
- Chemical nature.
 Time.

Figure 1.14 class IV caries.

7 Chapter 1 Brief Review of Dental Caries 7

Figure 1.19(b) teeth with exposed margins of

restoration are more prone to caries.
Figure 1.17 modern theory of dental caries.  In younger age groups pit and fissure caries is
more common than approximal caries and
Morphology and position of teeth: buccal & lingual caries while posterior
 Teeth with deep pits and fissures are more approximal caries is more common than anterior
prone to caries. (figure 1.18) approximal caries.
 However, in older patients root surfaces
exposed by gingival recession may be the
predominant site for caries to occur.
 Irregularities in arch form & crowding make
teeth more prone to caries. (figure 1.20)

Figure 1.18 teeth with deep pits and fissures are Figure 1.20 Irregularities in arch form &
more prone to caries. crowding make teeth more prone to caries.
 Partially impacted third molar and bucally and
 Teeth with exposed root surfaces and margins
lingually placed teeth are more prone to caries.
of restoration are more prone to caries. (figure
(figure 1.21)
1.19 a-b )

Figure 1.19(a) teeth with exposed root Figure 1.21 partially impacted third molars
surfaces are more prone to caries. are more prone to caries.
8 Clinical Operative Dentistry 8

 Most susceptible teeth to caries are mandibular  Actionomyces viscosus is the main
firs molars ‹ then maxillary first molars ‹ then microorganism in root cemental caries
mandibular and maxillary second molars
Plaque retention and susceptible sites:
The following sites particularly favor plaque
Chemical nature of teeth:
retention:
 Enamel pits and fissures on occlusal surfaces of
 Surface enamel is more resistant to caries than
molar and premolar teeth, buccal pits of molars
subsurface enamel.
and palatal pits of maxillary incisors.
 With passage of time, teeth become more
 Approximal enamel smooth surfaces just
resistant to caries due to decrease in
cervical to the contact area.
permeability and increase fluoride content.
 The enamel at the cervical margin of the tooth
 Caries progression tends to be slower in older
at the gingival margin.
adults than in the young due to generalized
 In patients with gingival recession, the area of
dentinal sclerosis with aging and caries
plaque stagnation is on the exposed root
involvement of secondary dentin is slower
surface (mostly mandibular molars).
because dentinal tubules are fewer in number
 The margins of restorations, particularly where
and more irregular in their course.
there is a wide gap between the restoration and
the tooth or those where the restoration
Saliva:
overhangs the margin of the cavity.
A decrease in the flow of saliva result in increased  Restoration with rough surface.
caries risk due to loss of cleansing effect  Around dental appliances e.g. RPD &
(accumulation of food debris and plaque) and loss of orthodontic appliances
buffering effect (acid environment result).
Diet:
Xerostomia occur due to
 Physiologic causes : Physical nature
- Salivary flow rate is decreased during sleep  More refined and less fibrous foods stick
(Physiological xerostomia occurs in all human stubbornly to the teeth and are not removed
beings during sleep thus the most important easily due to lack of roughage. They favor
time for plaque removal is before sleeping to stagnation of food on tooth surfaces thus
avoid caries). increase caries risk.
- During periods of anxiety.  Mastication of hard and fibrous food decrease
 Age-related changes in salivary gland. number of microorganisms.
 Drug induced : Medications associated with Chemical nature
xerostomia include :Atropine, Antidepressants,  Carbohydrate is one of the most important
Antihypertensives,Antihistamines,Opioids,,Diur factors in caries production (only refined
etics,Benzodiazepines carbohydrates are effective in caries
 Disease in salivary gland tissue: e.g. Sjögren’s production).
syndrome.  Frequency of sugar intake: more frequent intake
 Other causes include: of small amount of sugar is more harmful than
- Mouth breathing less frequent intake of large amount of sugar.
- Water or metabolite loss (for example during  Time of stagnation of carbohydrate to teeth: the
hemorrhage, vomiting, diarrhea, and fever). more the time, the more caries risk.
- Irradiation of the salivary glands.  Sugar given in solution form is much less
capable of producing caries than the same
amount of sugar incorporated in the form of
Micro flora and dental plaque:
Microorganisms are essential for caries to occur: sticky food.
 Steptococcus mutans is the main Time:
Increase frequency of time period to which teeth
microorganism playing a vital role in initiation of
exposed to cariogenic (acidic) environment (after
caries (enamel caries).
intake of snacks containing sugar) increase caries
 Lactobacilli is the main microorganism in deep
development.
dentinal caries.
9 Chapter 1 Brief Review of Dental Caries 9

 Before attempting an accurate visual diagnosis,

DIAGNOSIS OF CARIES clean the occlusal surface with a rotating bristle
brush in the handpiece. Unless this is done, the
The conventional caries detection methods are lesion may not be seen.(figure1.24 a-b)
visual and radiographic examinations.

Visual examination:

The first clinical sign of caries is a chalky and matte

(rough) whitish surface (hence white spot lesion)
(figure 1.23).This white spot is a porous surface that
can easily be stained into brown or black
discoloration by chromogens from foods; thus, a
carious lesion can be seen either as a white or as a
brown/black spot lesion.
Figure 1.24 (a) erupting molar that appear as
caries free but it is not.

Figure 1.22 visual examination.

Figure 1.24(b) molar seen after cleaning and

drying occlusal surface. Now we can see
white spot lesion in fissure.

Dry tooth
 The teeth should be thoroughly dried with an air-
water syringe (> 5 seconds) before all surfaces
are carefully examined.
 The presence of saliva on tooth surfaces
interferes with the detection of white spot
lesions because a white spot lesion is a porous
surface, and the pores are filled with saliva when
the lesion is wet.
Figure 1.23 white spot carious lesions in
 Furthermore, drying the tooth surface during
enamel.
examination has diagnostic as well as
The sensitivity and specificity of this method of
prognostic functions .Removing water from the
examination can be improved by certain
porous tissue enables the dentist to gauge how
prerequisites as seen in the following:
far through the enamel a lesion has progressed :
Clean tooth - A white spot lesion visible on a wet tooth surface
 Most often the tooth is covered by a film of indicates that demineralization is over halfway
bacterial plaque that can camouflage a suspect through the enamel, possibly extending into
lesion. dentin.
 It is necessary before caries detection that the - A white spot lesion that becomes visible only
plaque be removed gently with the explorer. after thorough air drying will be less than
 halfway through enamel.
10 Clinical Operative Dentistry
- Prognostically, the latter condition has a better
chance of complete reversal, while the former
condition may only be arrested.
Magnification and lighting
 It has been demonstrated that the accuracy of
visual caries detection can be improved 50%
with the use of a magnifying device.
 Good lighting aids vision.
 The dental mirror can catch and reflect the light
onto individual tooth surfaces. (figure 1.25)
Figure 1.25 The dental mirror can catch and
reflect the light onto individual tooth surfaces.
GENERAL CLINICAL CRITERIA FOR
VISUAL CARIES DETECTION
Whitish incipient caries and
developmental hypomineralization
The whitish appearance of a lesion is due to changes
in the optical properties of enamel
demineralization or hypomineralization.
carious white spots should be differentiated from
developmental hypomineralizations such
fluorosis as in the following: (figure 1.26 a-b)
Figure 1.26(a) white spot lesions that are due
enamel hypomineralization due to its location
(coronal third of tooth that is not plaque
stagnation area).
10
Figure 1.26(b) white spot lesions that are
mostly due to caries not because
developmental hypomineralization due to its
location (near gingival margin that is plaque
stagnation area).
Appearance and texture:
 After prolonged drying (> 5 seconds) with an air-
water syringe, then gentle running the tip of
probe or blunt explorer on the surface of the
lesion:
- White spot lesions from developmental
hypomineralization usually have smooth and
glossy surfaces like a sound enamel surface.
- While active caries lesions have chalky, matte
(rough) surfaces.
 Carious white spots can be discolored after a
long exposure in the oral environment, while the
surface of developmental hypomineralization is
not porous and cannot be easily discolored,
except in mottling due to severe fluorosis.
with
Location and distribution:
Hence,
 Caries occurs in plaque stagnation areas (areas
as that are difficult to reach by toothbrush), such
as gingival margins, occlusal pits and fissures,
buccal/lingual grooves and fossa, proximal
areas below contact points, and stagnant areas
created by overcrowding of teeth.
 However, developmental hypomineralization
can occur at any point on the tooth surface, a
white spot at the tip of the cusp or coronal third
of a tooth is more likely to be a developmental
anomaly because these areas are self-cleansing
and harbor hardly any plaque.
Visual caries detection specific to
different types of lesions
Pit and fissure lesions:
 These lesions are caused by plaque stagnation
at the entrance to the fissure.
 Any sign of visible cavitation in the occlusal
surface corresponds to progression of the
lesion into the dentin.(Figure 1.27)
11 Chapter 1 Brief Review of Dental Caries 11

The clinician should use the explorer in the following

appropriate ways:
 Detect and remove plaque in fissures, along
gingival margins, and in proximal spaces.
 Gently “feel” margins and defects to confirm
and assess cavitations.
 Gently “feel” the hardness of root surface
lesions.
 Gently “feel” the texture (roughness) of white
spot lesions by gentle running of the tip of a ball-
ended CPITN probe or blunt explorer on the
surface of the lesion.
Lesions involving proximal surfaces:
Figure 1.27 cavitated lesion exposing  Extensive active proximal lesions can be
dentin.
revealed by shadowing or grayish discoloration
of the undermined occlusal enamel ridge.
 The enamel lesion that is only visible on a dry
(Figure 1.29)
tooth surface is in the outer enamel. The lesion
visible on a wet surface is all the way through
the enamel and may be into the dentine.
 Shadowing or grayish discoloration of the
adjacent translucent enamel along the pits and
fissures may indicate possible undermining of
enamel by hidden caries.(Figure 1.28)

Figure 1.29 that proximal lesions can be

revealed by shadowing or grayish
discoloration of the undermined occlusal
enamel ridge.

 Fortunately, it is possible to use an elastic

Figure 1.28 Note opacity and grayish
discoloration under enamel margins. separator to create a small space between the
teeth. Now a probe may be used gently to feel for
a cavity.(Figure 1.30 a-c)
 Tactile examination of fissures with a dental
explorer has long been advocated as an
important method to detect caries lesions, but
research has shown this to be an unwise
practice. The method is inaccurate and, worse
because the explorer:
- May transmit cariogenic bacteria from one site
to another.
- May produce irreversible traumatic defects in
potentially remineralizable enamel.
- Mechanical binding in fissure may not be
because of caries .However, because of other
causes such as Shape of fissure, Sharpness of
explorer, Force of application.
12 Clinical Operative Dentistry
Figure 1.30(a) delayed separation using
orthodontic elastic band.
Figure 1.30(b) orthodontic elastic separator
has been placed between premolars
12
Figure 1.30(c) after 5 days, here elastic
separator is removed and now probe can be
used to examine proximal surface.
 Otherwise, when there is contact between
proximal surfaces, the radiograph is the most
accurate method for detecting demineralization.
 The radiograph should be examined carefully to
determine whether caries lesions are present in
the outer enamel, at the dentinoenamel junction,
in the outer half of dentin, or in the inner half of
dentin.
 Transmitted light can also be of considerable
assistance in the diagnosis of approximal
caries, particularly in anterior teeth. The
operating light is reflected through the contact
point with the dental mirror, and a carious lesion
appears as a dark shadow following the outline
of the decay.(Figure 1.31)
Figure 1.31 mirror view of palatal aspect of
incisors. There are small lesion seen on
mesial aspect of central incisor and large
lesion seen on mesial aspect of lateral
incisor.
13 Chapter 1 Brief Review of Dental Caries
 In posterior teeth a stronger light source is
required, and fibre-optic lights, with the beam
reduced to 0.5 mm diameter, have been used.
The light should be used with dry teeth. The
technique has particular advantages in patients
with posterior crowding, where bitewing
radiographs will produce overlapping images,
and in pregnant women, where unnecessary
radiation should be avoided.(figure 1.32 a-b)
Figure 1.32(a) fibrooptic transillumination.
Figure 1.32(b) Transillumination of carious
lesion.
Secondary or recurrent caries:
 Defined as caries on the tooth surface which is
in contact with the restoration. (primary lesions
at the margins of a restoration thus the clinical
criteria are identical to those for primary caries)
(Figure 1.33)
13
Figure 1.33 recurrent caries.
 It may be present at surface enamel surrounding
the restoration or extend below it along the
margins.
 The dentist can check that the restoration is
secure in the cavity by pushing it with an
explorer; a loose restoration ensures plaque
stagnation, and active caries is likely to be
present.
 It may be caused by:
- Marginal leakage (main cause).
- Rough surface of a restoration coupled with
poor oral hygiene may retain more plaque
subsequently acids that can diffuse into
microspaces adjacent to cavity walls.
- Also improper cavity preparation &
restoration: fissure still unsealed, Fracture of
the marginal tooth structure& Presence of
overhangs.
Active and arrested caries:
 Arrested carious lesion is a lesion that may have
formed earlier and then stopped.
 It usually presents as a large open cavity which
no longer retains food and becomes self-
cleansing.
 Arrested carious lesions are most commonly
seen on lingual and labial aspects of teeth and
less commonly interproximally.
 In arrested caries, superficially softened and
decalcified dentin is gradually burnished away
due to mastication until it takes on a brown,
stained, polished appearance which is hard.
This type of dentin is referred as eburnated
dentin.
 Clinical observations have demonstrated that
caries lesions can be arrested at any stage of
lesion development provided that clinically
plaque-free conditions are maintained.
14 Clinical Operative Dentistry 14

 If the lesion is active, treatment is needed to Proximal lesions:

arrest lesion progression and must include
preventive measures. It may also include The following features tend to indicate proximal
restorative dentistry. lesion activity: (Figure1.36)
 There are some features of individual lesions  A patient with proximal lesions on the
that indicate whether a lesion is active or radiograph who is at high risk for caries.
arrested as in the following :  A proximal lesion present radiographically plus
persistent gingival inflammation despite the
Occlusal lesions: patient’s attempts to remove plaque with dental
floss.
The following features indicate occlusal lesion  A lesion not present at previous examination.
activity :( Figure 1.34)
 White spot lesions that have a matte or visibly
frosted surface or are plaque covered (visible
after drying or application of a disclosing
solution).
 Cavitated lesions, including small cavities and
cavities exposing dentin.
 Lesions visible in dentin on bitewing
radiographs.

Figure 1.36 active proximal caries.

The following features indicate that the lesion may

be arrested: (figure 1.37 a-b)
 Successive, reproducible bitewing radiographs
showing no lesion progression
 A patient who is now judged to be at low risk for
caries because, following preventive behavior,
Figure 1.34 active occlusal caries. he or she presents with no new lesions.

The occlusal lesion may be arrested if white or

brown spot lesions with a shiny surface are present.
(Figure 1.35)

Figure 1.37(a) arrested caries on mesial

surface of lower molar.

Figure 1.35 arrested occlusal caries.

15 Chapter 1 Brief Review of Dental Caries 15

Figure 1.37(b) arrested caries on mesial

surface of lower second molar. Lesion
arrested after extraction of lower first
molar. Figure 1.38(b) matt, white active cervical
lesion.
Smooth, free surface (buccal & lingual)
lesions:  The following features indicate that the lesion is
arrested : (Figure 1.39 a-b)
 These are probably the most straight forward - Shiny white or brown lesions, often well
lesions for assessment because they are the exposed due to gingival recession; the lesions
most visible. are not plaque covered.
 Of all lesions, these are the ones most likely to - Cavitated lesions, often dark brown, with hard
be arrested by preventive treatment alone. dentin at their bases; the lesions are not plaque
 The following features indicate lesion activity : covered and are often remote from the gingival
(Figure 1.38 a-b) margin.
- White spot lesions close to the gingival margin
that have a matte or visibly frosted surface;
these are often plaque covered.
- Cavitated, plaque-covered lesions with or
without exposed dentin; if dentin is exposed and
soft, the dentin is heavily infected and the lesion
is active.

Figure 1.39(a) arrested cervical caries.

Figure 1.38(a) Cavitated active cervical lesion.

Figure 1.39(b) shiny, white arrested caries.

16 Clinical Operative Dentistry 16

RADIOGRAPHIC EXAMINATION OF
DENTAL CARIES

The importance of radiographs to diagnose initial

caries lesions in proximal surfaces is well
established. (Figure 1.40 a-b)

Figure 1.42 occlusal carious dentin is well

detected in lower first molar.

Figure 1.40(a) proximal caries in upper first

molar. (b) Proximal caries in premolar and molar.

However, radiographic evaluation of occlusal

surfaces has been found to be of minimal diagnostic
value for detecting enamel caries and superficial
dentinal caries because of the large amounts of
surrounding sound enamel.

In deeper occlusal lesions reaching the dentin,

radiographs show a high specificity. (Figure 1.41 to
1.43)

Figure 1.43 from a to d showing suggested

occlusal caries.
Buccal smooth surface caries also can be seen on
radiograph. (Figure1.44).

Figure 1.41 occlusal caries

Figure 1.44 appearance of caries of buccal

surface of molar on radiograph.
17 Chapter 1 Brief Review of Dental Caries 17

The radiographic extent of radiolucency is not Lesions that are obviously in dentin as seen
precisely correlated to the histologic extent of the radiographically tend to be cavitated and active.
lesion. Radiographs have been shown to
underestimate the depth of the lesion.
SYMPTOMS OF CARIES
Digital intraoral radiographs appear to be as
accurate as film radiographs for the detection of  Caries presents symptomatically at a relatively
dental caries. The sensitivity of digital systems is late stage.
relatively high for detection of occlusal lesions into  The patient may feel a ‘hole in a tooth’ with the
dentin but is also of no value for detection of early tongue, brown or black discoloration or cavities
enamel lesions. may be seen, or frank pain may be suffered.
Recurrent caries on radiograph  Caries, even in dentine, is not painful, but
cavitation may occasionally present as mild pain
The bitewing radiograph is very important in the
with sweet things or with heat or cold.
diagnosis of recurrent caries lesions because they
 Normally, the enamel and the necrotic dentine
often form cervical to an existing proximal
insulate the sensitive dentine and pulp from
restoration, in the area of plaque stagnation. (Figure
these stimuli.
1.45)
 However, a much more common cause of pain,
which may be intense, is pulpitis (the
commonest ‘toothache’) which occurs late in the
development of a carious lesion when the caries
is very close to the pulp or actually exposing it.
 A chronically inflamed pulp may be
symptomless or produce only mild symptoms.
In contrast, acute pulpitis is very painful, with
the pain often being initiated by hot and cold
stimuli. Unfortunately, the pain is not well
localized to the offending tooth, and the patient
may only be able to indicate which quadrant, or
even which side, of the mouth is involved.

CARIES RISK ASSESSMENT

Identifying the risk factors (Figure 1.46)

Figure 1.46 if pathological factors

overweight protective factors, caries
develops.
Figure 1.45 recurrent caries
18 Clinical Operative Dentistry 18

Presence of caries: Diet: Patients with high frequency of sugar intake

 The presence of Cavitated, noncavitated (initial
lesions), and/ or radiographic (mainly proximal
lesions) caries lesions is an indication that the
patient is actively developing new caries. Any of
these findings is an indication that the patient is
at risk of developing caries, and they should be
carefully assessed.
 Recent restorations (one or more within the past
3 years) is also an indication that the patient has
are at more risk to develop caries.
Saliva: A dry mouth (xerostomia) predisposes to
high caries risk, and low salivary flow rate may help
to explain multiple lesions.
Medical history:
 Medically compromised and handicapped
people may be at high risk for developing caries.

been active in developing caries which places

the patient in a high-caries-risk category.
Poor oral hygiene & excessive dental plaque:
 Patients with poor oral hygiene practice (no
toothbrushing,no flossing,no mouthwash..etc.)
have high risk to develop caries.
 It should also be remembered that placing a
dental appliance such as an orthodontic
appliance or a partial denture in the mouth can
encourage plaque retention and explain the
development of caries lesions.
 The following should be discussed with the
patient :
Fluoride concentration of toothpaste: Confirm that
the patient is using a toothpaste containing fluoride
(1,000 ppm and above).
Frequency of brushing: Fluoride-containing
toothpaste should be used twice a day, including
immediately before bedtime.
 For these patients, oral hygiene may be difficult,
and long-term use of medicines can be a
problem if the medicines are sugar based or
cause reduced salivary flow.
Social history:
 Social deprivation can predispose to caries.
 The patient or parent may possess little
knowledge of dental disease. Concern about
dental health may be low and dental visits
irregular.
Guide to identifying the overall caries risk
status of the patient (Table 1)
The dentist is now in a position to categorize the
caries risk status (low, moderate, high) of a patient:
Low caries risk: (Figure 1.47)
No white spot or cavitated primary or secondary
caries lesions during the last 3 years and no factors

Rinsing behavior: Ask whether large volumes of that may increase caries risk.

water are used to wash away excess toothpaste. The

message should be to “spit, don’t rinse” or to use
the toothpaste slurry as rinse before spitting. This
maintains the fluoride in contact with the teeth
longer.
 One of the best ways to ensure active patient
cooperation is to turn the patient into their own
personal dentist so that the patient could, in
theory, check their own mouth. The dentist
should give the patient a mirror and show the
patient their own carious lesions. The dentist
should show the patient the white spot and a red
and swollen gingival margin that bleeds on
probing.
Figure 1.47 low caries risk patient.
Use of fluoride:
Patients, that live in an area with non-fluoridated
water or use non fluoride toothpaste, are at more
risk to develop caries.
19 Chapter 1 Brief Review of Dental Caries 19

Moderate caries risk: (Figure 1.48)

 One or two white spots or cavitated primary or
secondary caries lesions in the last 3 years.
 Or No white spot or cavitated primary or
secondary caries lesions in the last 3 years but
presence of at least one factor that may increase
caries risk.

Figure 1.48 moderate caries risk patient.

High caries risk: (Figure 1.49)

 Three or more white spots or cavitated primary

or secondary caries lesions in the last 3 years.
 Presence of multiple factors that may increase
caries risk (e.g. Suboptimal fluoride exposure,
Xerostomia..etc.)

Table 1 showing caries risk assessment.

RISK-BASED CARIES MANAGEMENT

Prevention and treatment

General guidelines for caries management for
a high- caries-risk patient:

Step 1: Plaque control

 Provide prophylactic treatment followed by

fluoride application.
 See patient regularly to reinforce oral hygiene.

Figure 1.49 high caries risk patient. Step 2: Treatment of existing caries lesions
 Treat noncavitated lesions as needed.
 Restore cavitated lesions and seal surrounding
pits and fissures as needed.
20 Clinical Operative Dentistry
Step 3: Protection of surfaces at risk
 Seal all deep pits and fissures.
 Apply fluoride varnish to exposed roots.
Step 4: Maintenance care for prevention
Review oral hygiene and dietary habits and advise
patient to:
 Reduce the number of between-meal sweet
snacks.(Substitute snacks rich in protein)
 Brush at least twice daily with high fluoride
delivery toothpaste.
 Advise patient to floss once daily.
 Provide home treatment and/or other adjunctive
therapy:
 Use over-the-counter fluoride rinse daily.
 Chew or suck xylitol-containing gum or candies
three times daily.
Recall patient every 3 months to:
 Reevaluate current caries risk.
 Receive fluoride varnish treatment of all teeth.
 Obtain bitewing radiographs every 3 to 6 months
to check for lesions
General guidelines for caries management for
moderate-caries-risk patient:
Step 1: Plaque control (Same as in high
caries risk patient).
Step 2: Treatment of existing caries lesions
(Same as in high caries risk patient).
Step 3: Protection of surfaces at risk (Same
as in high caries risk patient).
Step 4: Maintenance care for prevention
Same as in high caries risk patient except
 Recall patient every 3 to 6 months to: Reevaluate
current caries risk & Receive fluoride varnish
treatment of all teeth.
 Obtain bitewing radiographs every 12 to 18
months to check for cavities.
General guidelines for caries management for
a low- caries-risk patient:
Step 1: Plaque control
Continue to reinforce oral hygiene.
20
Step 2: Maintenance care for prevention
 Review oral hygiene habits.
 Advise patient to brush twice daily with over-
the-counter fluoride toothpaste.
 Recall patient every 12 to 24 months to
reevaluate current caries risk.
 Obtain bitewing radiographs every 24 months to
check for caries.
CARIES PREVENTIVE MEASURES
Fluoride dentifrices for plaque control
Fluoride containing dentifrices:
 Tooth brushing with a fluoride dentifrice twice
daily has caries-inhibiting effect.
 In areas where the water is fluoridated to optimal
levels, twice daily careful cleaning of the teeth
with fluoride toothpaste is a safe and effective
preventive treatment and caries management
strategy.
 Dental floss could be indicated for individuals
with closed interdental spaces and
interproximal brushes for periodontal patients
or in those with open embrasures. Flossing
once daily may be recommended for caries
prevention, but twice daily flossing may be
required if gingivitis needs to be prevented as
well.
Options when plaque control by fluoride tooth
paste and flossing is insufficient to prevent
carious lesions:
Fluoride tooth paste is insufficient protection for
high-risk patients, and therefore alternative
therapies are usually needed for these patients:
 The fluoride supply should be intensified,
perhaps by adding a third daily fluoride
application in the form of additional brushing, a
fluoride mouthwash, or a fluoride tablet.
 Professionally applied preventive measures,
such as topical applications of concentrated
fluoride solutions, gels, or varnishes should be
performed.
 Salivary flow can be stimulated by daily use of
sugar-free chewing gum.
21 Chapter 1 Brief Review of Dental Caries 21

Fluoride gels, mouthrinses and Xylitol products

supplements:
 The most commonly available at-home-use
 Their noncariogenicity is based on the inability
fluoride gels for daily application come in
of the cariogenic bacteria to metabolize this
prescription-strength 1.1% NaF. These are
sugar and produce acid.
recommended for high-risk adults and children
 They have a caries-preventive effect, which is
6 years and older and are to be applied once
probably based on stimulation of salivary flow,
daily over the tooth surfaces using a finger,
recommended for saliva stimulation, especially
toothbrush, or individually fitted trays,
in moderate- and high-caries-risk individuals.
preferably immediately before bed. The gel
 Two pieces of gum should be chewed for at least
should be left in contact with the teeth surfaces
5 minutes three times daily, preferably after each
for 5 minutes, after which the individual should
meal.
spit and not rinse.
 Over-the-counter (OTC) mouthrinses are
available as 0.05% or 0.02% NaF for daily use.
Prescription-strength 0.2% NaF rinses maybe
Dietary management for caries prevention
used daily or weekly depending on the caries
risk status of the patients. It is recommended
 A frequent and prolonged eating pattern, such
that 10 mL of the fluoridated mouthrinse be
as snacking with sugary foods between meals,
swished around in the mouth for 1 minute.
increases the caries risk of an individual.
 Mouthrinses have also been formulated with
 It is often not possible to gain the compliance of
acidulated phosphate fluoride (APF), stannous
people when asking them to abstain from
fluoride, ammonium fluoride, and amine
snacking. Alternatively, patients can be advised
fluoride. Acidulation of the solutions may
to snack smartly by choosing nonsugary and/ or
increase the fluoride uptake into the tooth
low-fat snack foods, such as raw vegetables,
mineral:
fresh fruits, or whole-grain crackers or bread
- Application of an acidulated product causes
with margarine or peanut butter, low-fat (or filled
mild etching of the enamel, which creates
milk) cheese, lean meats, or skim milk.
micropores for increased fluoride diffusion and
 Thus, the following basic dietary principles may
increases the surface-reactive area for fluoride.
help to reduce the risk for dental caries:
The result is increased uptake and accumulation
- Eat a diet that is low in sucrose and retentive
of fluoride within a caries lesion or healthy
fermentable carbohydrates.
tissue.
- Reduce the frequency of eating or drinking
- Caution: Although some of these mouthrinses
fermentable carbohydrates.
tend to recharge glass-ionomer restorations, the
- Combine cooked and processed foods with non
pH of the topical fluoride used to recharge glass-
acidogenic foods.
ionomer restorations is important. Acidic topical
- Do not eat cariogenic snacks.
fluoride solutions, such as APF solutions and
- Include foods of firm or hard texture.
other acidified fluoride preparations, degrade
- Choose fats in diet wisely to reduce risk of
glass-ionomer materials, porcelain crowns, and
chronic disease while still benefiting from fat
veneers and should be avoided in these
coating on tooth surfaces, which reduces the
patients. Resin-modified glass ionomers are
adherence of plaque.
more resistant to surface degradation than
- Chew sugarless gum (preferably with xylitol) for
conventional glass ionomers but still degrade
15 to 20 minutes after eating to increase salivary
when exposed to acids and orange juice. Resin
benefits.
composites are also degraded by frequent
applications of acidic fluoride solutions,
producing filler dislodgment and destruction of
the filler-resin matrix interface.
22 Clinical Operative Dentistry 22

Fluoride containing tooth paste.

SUGAR FREE CHEWING GUM.

Pit and fissure sealants

 However, lesions can be prevented, and

Fluoride mouth wash.
active white spot lesions can be arrested by
brushing alone, Sealing is a recommended
procedure to prevent caries of the occlusal
surfaces of permanent molars, but it is only
required if occlusal surfaces are not being
cleaned.
 Sealants may be indicated for children and
adults who, because of poor oral hygiene,
may be at moderate or high risk of
developing dental caries, have active white
spot lesions (limited to enamel of pits and
fissures), or have existing pits and fissures
that are anatomically susceptible to caries.
 This is especially important during the
period of tooth eruption, although the
application of sealants in suspect fissures
is also advisable in older patients with high
caries risk.

NONINVASIVE OPTIONS FOR

TREATMENT OF EXISTING LESIONS

Noninvasive Treatment of noncavitated

lesions
Lesion arrest (remineralization therapy)

 Active noncavitated caries lesions on occlusal,

proximal, and nonproximal coronal smooth
surfaces or root surfaces can be arrested.
 Arrest of active caries lesions can be achieved
Sodium fluoride tablets. successfully with a combination of improved
23 Chapter 1 Brief Review of Dental Caries 23

oral hygiene and application of topical fluoride surface using ethanol and air drying, the low-
agents, such as varnishes, gels, or foams. viscosity infiltrant is applied on the lesion
 Application of the agent can be repeated every 3 surface in two stages. In the first application, the
months until caries activity is under control. infiltrant is allowed to infiltrate the lesion for 3
minutes and then is light cured. In the second
Occlusal sealants (figure 1.54) application, the infiltrant is allowed to infiltrate
for only 1 minute and then is light cured.
 The choice of management of an initial  However, the current infiltrant is radiolucent,
noncavitated caries lesion depends on the making it difficult to determine the depth of
caries risk status of the individual patient and infiltration or identify an already infiltrated
the location of the lesion in the dentition. lesion in a radiograph. 
 When active fissure caries has been diagnosed
or if a high risk has been established, and
fissures have susceptible morphologic
characteristics, sealants may be indicated.
 There are several advantages of fissure
sealants:
 No irreversible interventions are necessary.
 Active dentin lesions inadvertently covered by
the resin do not progress further, and the
possible development of new lesions in other
sites of the fissure is prevented.

Figure 1.53 efficacy of resin infiltrate on

treatment of white spot lesion.

Noninvasive Treatment of cavitated

lesions
Figure 1.54 pit and fissure sealant.
 Although lesions that are cavitated are treated
traditionally by preparation and restoration,
Lesion infiltration (Figure 1.55) clinical observations suggest that caries lesions
can be arrested at any stage of lesion
 Lesion infiltration technique is an emerging development (i.e., even at the cavitation stage if
alternative method of treating active plaque-free conditions are maintained).Thus, a
noncavitated lesions extending radiographically preventive treatment approach is often
into inner enamel or the outer third of dentin that successful, especially when the lesion is in a
are located on the nonproximal and proximal free, smooth surface. Before invasive
coronal smooth surfaces. procedures are initiated, noninvasive options
 In contrast to sealing of fissure caries, where the must be explored and preventive measures
protective resin layer is established on the tooth taken.
surface, caries infiltration occludes lesion pores  When a lesion is present in an occlusal or
with low-viscosity light-curing resins in order to proximal surface:
create a diffusion barrier and hence arrest caries - It will often be difficult to arrest lesion
progression. progression because of the difficulty of
 Following etching of the lesion with removing plaque.
hydrochloric acid and achievement of a dried
24 Clinical Operative Dentistry 24

- Measures directed at a thorough removal of  Sealed restorations placed directly over frankly
plaque are ineffective on the occlusal surface cavitated lesions can arrest lesion progression.
because the bristles of the toothbrush cannot  Sealing of restorations, therefore, conserves
get into the undermined cavity. sound tooth structure, protects the margins of
- Proximal cavitations are also difficult to reach restorations and prevents recurrent caries
(Dental floss will skim the surface but will not (secondary caries).
achieve access to the cavitated area).
 Although occlusal or proximal caries lesions
cannot be approached by preventive measures
alone, in the primary dentition this method can
be successful. Therefore, undermined enamel
margins should be eliminated so that when
plaque is removed, fluoride can be applied
easily to the carious dentin. Under ideal
conditions, carious dentitions can be managed
so that caries is arrested and demineralization
and remineralization are in equilibrium.
 When a lesion is present on free, smooth
surfaces, the situation is different :
- Those areas are easily reached by the
toothbrush but may be difficult to clean due to
undermining of the enamel.
- Thus, removal of the overhanging enamel
margins must be considered to aid in keeping
the whole area free of plaque.
- Cavities in these surfaces, cleaned twice daily
with a fluoride toothpaste, can be arrested and
converted into leathery or hard lesions.

MINIMALLY INVASIVE TREATMENT Sealed amalgam restoration.

OPTIONS

Restoration of cavitated lesions

 Cavitated caries lesions are candidates for

traditional restorative treatment, such as resin
composite, resin-modified glass ionomer, or a
sandwich technique combining resin-modified
glass ionomer and resin composite or amalgam.
 It is necessary to have well-defined criteria for
the decision to restore a tooth due to caries.
 The most important reason for placing a
restoration is to aid plaque control.
 Nowadays other procedures have also been
used for removal of caries like air abrasion,
chemomechanical caries removal, atraumatic
restorative therapy (ART).

Preventive resin restorations and

preventive amalgam restorations
 Restoration of the carious surface should be
accompanied with sealing of surrounding pits
and fissures.
25
27 Chapter 2 Pulpal Considerations 27

Physiologic considerations

Thickness of enamel
 Enamel is thicker on the occlusal and incisal
areas and becomes progressively thinner on the
axial surfaces toward the cement enamel
junction (CEJ), with a thickness of 0.2 mm on
cervical areas. (Figure 2.1)
 The thickness also varies from one type of tooth
to another, with an average of 2 mm on the
incisal edges, ranging from 2.3 to 2.5 mm on the
premolar’s cusp tips and 2.5–3 mm on the Figure 2.2 Transverse cut of an upper central
molar’s cusp tips. incisor crown showing the enamel and dentin
 Generally, on the occlusal surface of posterior
teeth, the thickness is reduced toward the
junction of the developmental lobes. On the Causes of pulpal inflammation
internal third of the occlusal cusp inclines, the 1. Dental caries (main cause).
thickness varies from 0.2 to 0.5 mm and 2. Tooth preparation & operative procedures.
sometimes zero when there is a fissure in the 3. Toxic effects of dental restorative materials.
junction of the lobes.
 The lingual layers of the enamel generally are
thinner than the facial ones.
Effect of dental caries on pulp
 With the aging, the enamel thickness on the  From carious lesion, the acids and other toxic
occlusal surfaces decreases due to tooth wear. substances penetrate through the dentinal
tubules to reach the pulp. (Figure 2.3 a)

Figure 2.3(a) Microorganisms from caries

resulting in pulpal irritation
Figure 2.1 varying thickness of enamel in
different areas of tooth.
 Following defense reactions take place in a
Thickness of dentin carious tooth to protect the pulp:
 Formation of reparative dentin: Rate of
 Dentin thickness is usually more on cuspal
reparative dentin formation is inversely related
height and incisal edges and less in cervical
areas of the tooth. (Figure 2.2) to rate of carious attack  Faster the caries
attack, lesser is the reparative dentin formation.
 It is nearly 3 to 3.5 mm on coronal surface.
 Dentinal sclerosis, i.e. reduction in permeability
 With advancing age, thickness of secondary and
of dentin by narrowing of dentinal tubules.
tertiary dentin increase.
(Figure 2.3 b)
 The tooth preparation on teeth of a young
patient presents a significantly greater chance
of pulpal exposure than on those of a patient
with more advance age.
28 Clinical Operative Dentistry
Figure 2.3(b) secondary and tertiary dentin
formation in response to dental caries and
attrition.
Effect of tooth preparation on pulp
 The remaining dentinal thickness (RDT), from
the depth of the cavity preparation to the pulp, is
the single most important factor in protecting
the pulp from insult.
 Dentin permeability increases with decreasing
RDT.
 As dentin thickness decreases, the pulpal
response increases. (Figure 2.4)
 It has been shown that a 0.5-mm thickness of
dentin reduces the effect of toxic substances on
the pulp by 75% and a 1.0-mm thickness reduces
the effect of toxins by 90%.
 Little or nil pulpal reaction occurs when there is
an RDT of 2 mm or more.
 The greatest impact on the pulp occurs when the
RDT is no more than 0.25 to 0.30 mm.
 Conservation of remaining tooth structure is
more important to pulpal health than is
replacement of lost tooth structure with a cavity
liner or base.
 A cavity of only 2 mm deep on a first permanent
molar of an 8-year-old child may be considered
very deep, but it may be considered shallow on
this same tooth when the patient reaches 40
years old. Thus, the clinical determination of the
cavity depth is a difficult procedure, and it must
be assisted by the radiographic examination of
the tooth structures.
 When a pink discoloration is observed on the
pulpal wall, this indicates that probably less
than 0.5 mm of dentin remaining is covering the
pulp. In this case, some small pulpal exposures
can be present, not visible to naked eyes, and
the cavity is named very deep
28
Figure 2.4 as dentin thickness decreases,
the pulpal response increases.
Pressure:
Pressure of instrumentation causes aspiration of
odontoblasts leading to their complete
degeneration.
It has shown that pressure applied during rotary
instrumentation has a greater effect on temperature
rise than does rotational speed, which is probably
why preparation using low-speed rotary
instrumentation has been shown to be more
traumatic to the pulp than high-speed preparation.
Heat Production:
The temperature rise of the pulpal tissue must not be
superior to 5.5 °C above the body temperature, due
to higher risk of irreversible tissue alterations and
pulpal necrosis.
“Heat” is a function of:
 Rotational speed: more the RPM , greater is the
heat production.
 Pressure: It is directly proportional to heat
generation.
 Surface area of contact: More is the contact
between tooth structure and revolving tool,
greater is the heat generation.
 Desiccation: excessive drying of the preparation
with a strong air stream must be avoided, being
preferably performed with small cotton pellets,
absorbent papers, or small indirect and
intermittent air stream.
The key to controlling both friction and desiccation
is water spray at the site of contact between the bur
and tooth structure. (Figure 2.5)
Light pressure with intermittent cooling can
minimize temperature increase.
29 Chapter 2 Pulpal Considerations
Figure 2.5 (a) proper use of water spray
directed towards the tip of the diamond (b)
improperly directed water spray.
Nature of Cutting Instrument:
Use of worn off and dull instruments can cause
vibration and reduced cutting efficiency: Their use
encourages the clinician to apply excessive
operating pressure, which results in increased
temperature (thermal injury to pulp).
Diamond burs tend to produce more temperature
increase than do carbide burs.
Therefore, the keys to minimizing adverse pulpal
reaction from rotary instrumentation are the
following:
 Adequate air-water coolant spray.
 Light pressure.
 Sharp rotary cutting instruments.
 Preservation of tooth structure.
Effect of chemical irritant on pulp (effect
of restorative materials)
Factors Influencing the Effect of Restorative
Materials on Pulp include:
Factors related to teeth
Dentin permeability:
It depends upon a number of factors like:
 Location: Dentin permeability varies in different
areas of the same tooth, e.g. it increases
towards the pulpal side. This is because both
the tubule diameter and the number increase
towards the pulp chamber.
 Smear Layer: Presence of smear layer reduces
permeability.
 Patency of the Dentinal Tubules: Sclerotic
dentin is less permeable than the physiologic
tubular dentin.
 Reparative Dentin: In cases where reparative
dentin has been formed previously, the
29
response of the pulp is less, probably because
it reduces the penetration of the solute.
 Remaining Dentin Thickness: As the remaining
dentin thickness increases, the concentration of
the solute reaching the pulp decreases.
Dentin Pre-treatments:
 Preconditioning of dentin by acids (etchants and
conditioners) might increase dentin
permeability by removing smear layer and
enlarging tubule orifices.
 Acid etching of dentin has long been considered
detrimental to the pulp, but the pulp can readily
tolerate the effects of low pH if bacterial invasion
is prevented and resin components are
precluded from traversing the dentinal tubules
and entering the pulp.
 In deep and very deep cavities, it is necessary to
use a protective material before the acid etching
and hybridization, avoiding that adhesive
system becomes a source of irritation of the
pulpal tissue.
Factors related to dental materials
 Acidity: The more the acidity of dental material,
the more hazard to pulp tissue.
 Absorption of water from dentin during setting:
such materials may result in dentin desiccation
thus pulp insult.
 Heat generated during setting: material that
release heat during setting reaction may cause
pulpal insult.
 Poor marginal adaptation leads to bacterial
penetration: material that that do not provide
optimal marginal adaptation can cause
microalgae of bacteria causing pulpal damage.
 Cytotoxicity of material: material shouldn’t
cause any cytotoxic effect otherwise will cause
pulpal damage.
Assessment of Pulp Condition
 The odontogenic pain may basically have three
origins: exposed dentin, pulpal inflammation,
and periapical inflammation.
 Exposed dentin pain is generally acute and
easily localized, provoked by specific stimulus,
such as mechanical (touch), physical (cold or
heat), chemical (acids), osmotic (sugar), and
dehydration and the pain disappear as soon as
the causing agent is removed.
 Reversible pulpitis: The pain is acute and
provoked, generally localized, with the duration
no longer than 1 minute, stopping after the
removal of the stimulus. Such case Need
conservative treatment i.e. direct & indirect pulp
capping.
30 Clinical Operative Dentistry
 Acute irreversible pulpits: The pain is sharp,
spontaneous, and generally intense and
throbbing, of long duration and sometimes
diffuse and not localized. Such case need root
canal treatment.
 Ulcerative chronic pulpitis: Characterized by
presenting an ulcer on the exposed surface of
the pulp; the pain is provoked, localized, and
produced by the compression of food in the
carious cavity. Such case need root canal
treatment.
 Hyperplastic chronic pulpitis: Characterized by
the proliferation of a granulomatous tissue on
the level of pulp exposure. The pain is generally
provoked, localized, and produced by the
compression of food during mastication. Such
case need root canal treatment.
 Pulp necrosis: Generally asymptomatic, it can
produce a color change of the tooth crown.
Generally, there are no response to the pulp
sensitivity testing, but on doubtful cases, the
cavity preparation test must be performed. Such
case need root canal treatment.
Restorative materials and pulp
reaction
Composites:
 There is no thermal conductivity to pulp tissue.
 Marginal leakage: if not properly placed, may
cause marginal leakage that destroy pulp tissue.
 If it is not light-cured enough, residual
monomers irritate dental pulp.
 There is little resistance to secondary caries
activity
 It has shown that levels of cariogenic bacteria in
the plaque present on surfaces of resin
composite restorations are significantly higher
than on either amalgam or glass ionomer. (for
more details see chapter 6)
Glass-Ionomer Cements:
 The material is considered biocompatible, thus
it is indicated in cavity bases and liners.
 Glass ionomer has the ability to decrease
bacterial penetration, possibly through its
fluoride release, initial low pH, or physical
exclusion of bacteria.
 It has shown that the level of cariogenic bacteria
show significantly lower levels adjacent to glass
ionomer compared to either resin composite or
amalgam. (for more details see chapter 11)
30
Dental amalgam:
 It cause thermal conductivity thus must be
insulated to protect pulp.
 Although typically not considered a material
possessing antibacterial properties, dental
amalgam has demonstrated varying levels of
antibacterial activity. This activity has been
attributed to a variety of elements released from
amalgam, including copper, mercury, zinc,
silver, and chloride compounds.
 It has shown that metallic solutions of copper,
silver, and zinc are all capable of reducing acid
production in plaque. 
 In addition to its antibacterial properties,
amalgam is the only restorative material in
which the marginal seal improves with time.
(For more details see chapter 9)
Materials used for pulp protection
Cavity sealers:
They provide a protective coating to the walls of the
prepared cavity and a barrier to leakage at the
interface of the restorative material and the walls
(minimize marginal leakage).
They are applied over all walls with the aim to seal
the dentin tubules.
They Include varnishes and adhesive systems
(Resin bonding agents).
Cavity liners:
It is coating of minimal thickness (usually less than
0.5 mm)
Purpose:
 Achieve a physical barrier to bacteria and their
products.
 And/or to provide a therapeutic effect, such as
an antibacterial or pulpal capping effect.
 Acting as a thermal and electrical isolator.
Liners are usually applied only to dentin cavity walls
that are near the pulp. (Pulpal floor and axial wall ‹
not all dentinal walls ‹ generally applied only on the
deeper areas of the preparations).
They include Zinc-oxide eugenol, calcium hydroxide
& GIC.
Cavity bases:
Materials to replace missing dentin, used for bulk
buildup and/or for blocking out undercuts.
31 Chapter 2 Pulpal Considerations
They include Zinc-oxide eugenol, zinc phosphate,
zinc polycarboxylate & GIC.
Pulp protection.
Varnishes
Varnish is an organic copal or resin gum suspended
in solutions of ether or chloroform. When applied on
the tooth surface the organic solvent evaporates
leaving behind a protective film.
Function:
 It is used as a barrier against the passage of
bacteria and their by-products into dentinal
tubules, and it reduces the penetration of oral
fluid at the restoration-tooth interface. Copal
varnishes were used for many years to fill the
gap at the amalgam-tooth interface until
corrosion products formed to reduce the gap.
 Varnishes have also been used as barriers
against the passage of irritants from cements
and bacteria into dentinal tubules. (Commonly
used before cementation of indirect restorations
with zinc phosphate cement).
 It also prevents discoloration of tooth by
checking migration of ions into the dentin.
Disadvantages:
 Provides no thermal insulation.
 Use of varnish is contraindicated under glass
ionomers as it interferes with the bonding of
tooth to these cements.
 Varnish is not used with restorative resins
because the varnish liners dissolve in the
monomer of the resin and it also interfere the
polymerization of resins.
Manipulation: (Figure 2.6)
 There is no mixing necessary with cavity
varnish.
 Remove the cap of the bottle.
 Using sterile college tweezers and a cotton
pellet, or disposable applicator brush
(preferred), dip the cotton pellet/disposable
applicator into the cavity varnish and dab off the
excess.
31
 Replace the cap immediately as cavity varnish
evaporates quickly.
 The operator will dry the surface in between
applications using a 3-in-1 syringe/air-water
syringe.
 New disposable applicator brush (es) used to
repeat application of varnish coat (Two
applications have been shown to be more
effective than a single coat, but a third
application does not significantly improve the
coating of the cavity walls).
Figure 2.6 cavity varnish.
Resin Bonding Agents
An adhesive sealer is commonly used under
composite restorations.
For application, cotton tip applicator is used to apply
sealer on all areas of exposed dentin.
Indications:
 To seal dentinal tubules.
 To treat dentin hypersensitivity.
 When applied on shallow and medium depth
cavities, they are biocompatibility and
favorable for the maintenance of the pulp
vitality. However, on deep and very deep
preparations, its components can diffuse
through the dentin tubules and reach the pulpal
tissue Causing toxicity.
Zinc oxide eugenol
Eugenol is used to alleviate pain from mild-to-
moderate inflammation of pulp.
As an insulating base, ZOE cement will protect the
pulp from thermal trauma. It also has a sedative and
soothing effect on the dental pulp; for this reason, it
is used as a temporary restoration before a
permanent one is placed.
It should not be used under composite restorations
as it inhibits polymerization of bonding agent and
composite.
They must not be used in direct contact with the
pulpal tissue, because of its irritating and cytotoxic
effect. (The zinc oxide eugenol placed in direct
32 Clinical Operative Dentistry 32

contact with the pulp tissue result in chronic

inflammation and necrosis. However, when placed
against dentin, the cytotoxic effects are nil.)

The liner and bases prepared with this material allow

a good thermal isolation. However, they have non-
satisfactory mechanical properties and can increase
the microleakage under amalgam restorations

Available in powder and liquid form, two-paste

system and capsule form. It is also available in a
non-eugenol form (does not contain eugenol), which
is suitable for use in patients having a sensitivity to
eugenol.
Powder and liquid measured for base
Manipulation: (Figure 2.7) consistency.

 Prepare and isolate the tooth appropriately.

 Dispense the material immediately prior to use.
 Fluff powder bottle with cap in place (this
provides a more consistent volume of powder in
each scoop).
 Dispense powder onto waxed paper pad (using
measuring scoop, if provided).
 Replace the lid on the powder bottle immediately
after dispensing.
 Divide the zinc oxide eugenol powder into four
equal portions using the broad-bladed spatula.
 Dispense the liquid, holding it perpendicular to
the waxed paper pad, following the
manufacturer’s instructions. A ratio of
approximately 3:1 powder to liquid should be
used.
 Replace the dropper in the bottle.
 Incorporate the first powder measure into the
Figure 2.7 zinc oxide eugenol manipulation.
dispensed liquid. Use the broad part of the
spatula to mix in the powder using a ‘stropping Zinc phosphate cement
motion’. Use firm pressure with the flat face of It reduces the thermal conductivity of metallic
the spatula when incorporating powder. The mix restorations thus Used under amalgam restorations
may initially appear thick or crumbly; keep as a base providing thermal insulation. (Its thermal
mixing with the stropping motion as this will conductivity is approximately equal to that of
bring out the oil in the mixture, bringing the mix enamel)
to the desired consistency.
 Continue mixing until the desired consistency is Disadvantages:
met, which is a putty-like mixture that can be  No adhesive properties
rolled into the shape of a rope or ball for  High solubility
placement using the spatula.  Irritating to pulp because of its low pH and the
 Leave a small amount of powder as it may be rapid penetration of its lower molecular weight
used as a separator. phosphoric acid into the dentinal tubules and
 Note that Mixing time is 30–60 seconds while pulp tissues. In deep preparations, a moderate
setting time is 7–9 minutes. to severe localized pulpal damage is produced
within the first three days probably because the
cement has an initially low pH on setting. The pH
of the set cement approximates neutrality only
at 48 hours. Resolution of inflammation occurs
by 5 to 8 weeks. When used as a thick base, it
has a low toxicity level but when used as a luting
agent in a thin state, it can be quite toxic. A
young tooth or deep preparations with wide
open tubules are more susceptible to intense
inflammatory response to zinc phosphate
33 Chapter 2 Pulpal Considerations
cement, than in an older tooth, which has
produced a considerable amount of sclerotic
and reparative dentin that blocks the dentinal
tubules and prevents acids from reaching the
pulp.
Zinc phosphate is supplied in a powder/liquid form.
(Figure 2.8)
Figure 2.8 zinc phosphate cement.
During manipulation of zinc phosphate, once the
powder and liquid are mixed together, heat is
produced, i.e. an exothermic reaction takes place.
This exothermic reaction speeds up the setting of
the material. To control the setting of zinc
phosphate, it is always mixed on a cool, dry glass
slab, and the whole surface area of the slab should
be used during the mix to minimize heat production.
The manipulation technique is very important as a
warm slab, mixing too fast or contamination by water
will speed up the setting time of the material.
Manipulation: (Figure 2.9)
Figure 2.9 zinc phosphate manipulation.
33
 Ensure that you have a clean, disinfected,
cool, dry glass mixing slab.
 Fluff the zinc phosphate powder in the
bottle (shake the bottle, ensuring the lid is
securely in place) to disperse powder
particles evenly.
 Dispense the powder on the glass slab
according to the manufacturer’s
instructions, replacing the cap immediately
after dispensing.
 Less liquid is used for mixing a base
consistency than a luting cement.
 You must take care when mixing zinc
phosphate to replace the cap on the liquid
once it has been dispensed. The material is
water based and if the cap is left off, the
water will evaporate and slow down the
setting process.
 To ensure uniform drops, hold the bottle
perpendicular to the glass slab and
immediately replace the cap.
 Mix in the powder increments at 15-second
intervals.
 Using spatula incorporate the first mound of
powder into the liquid, spatulating in a
figure-of-eight motion over the entire
surface area of the slab for 15 seconds.
(Figure 2.10)
Figure 2.10 figure of eight mixing technique.
 Ensure that all the powder has been
incorporated into the liquid and then add the
second powder increment, following the
same mixing technique for 15 seconds.
 Continue mixing until you have achieved the
desired putty-like consistency.
 Note that Mixing time is 2 minutes while
setting time is 5–7 minutes.
34 Clinical Operative Dentistry
Polycarboxylate cement
Polycarboxylate cement is a derivative of zinc
phosphate cement in which the zinc phosphate has
been replaced with a polyacrylic acid. The pH of the
cement liquid is approximately 1.7. The pH of the mix
rises rapidly as the setting reaction proceeds.
Despite the initial acidic nature of the
polycarboxylate cements (At all times, the pH of the
polycarboxylate cement is higher than the pH of the
phosphate cements), these products produce
minimal irritation to the pulp probably because the
larger size of the polyacrylic acid molecule limits its
diffusion through the dentinal tubules.
It is used as base under dental amalgam.
Advantages:
 Chemically bonds to tooth (Varnish should not
be used with polycarboxylate cement because it
would neutralize the adhesion potential of the
cement).
 Antibacterial properties.
 They have an excellent biocompatibility with the
pulp and are almost equivalent to zinc oxide
eugenol cements.
Disadvantage: Lower compressive strength when
compared to zinc phosphate.
Manipulation: (Figure 2.11)
Figure 2.11 manipulation of polycarboxylate
cement.
 Ensure you have a clean, disinfected, cool, dry
glass mixing slab or waxed paper pad.
 Fluff the polycarboxylate powder in the bottle
(shake the bottle, ensuring the lid is securely in
place).
 Dispense the powder on the glass slab or waxed
paper pad according to the manufacturer’s
instructions, replacing the cap immediately after
dispensing (use dispensing scoop, if provided)
34
 Dispense liquid as per the manufacturer’s
instructions, according to the appropriate
amount of powder dispensed (most often two
scoops to two drops of water base
consistency).To ensure uniform drops of the
liquid, hold the bottle vertically during
dispensing and immediately replace the cap.
 Spatulate the powder and liquid together quickly
using a folding motion for 15–20 seconds using
spatula.
 The material will appear glossy once mixed.
 Mix to a putty consistency.
 Working time is 2.5–3.5 minutes.
 Note that mixing time is 15–20 seconds, setting
time is 6–9 minutes.
Glass ionomer
Advantages:
 Chemical bond to tooth structure.
 Fluoride release property.
 Anticariogenic property.
 Excellent mechanical properties, modulus of
elasticity, and restoration support.
 Well tolerated by the pulp.
As a result, glass ionomers can be used as cavity
bases as well as cavity liners.
Glass ionomer has been shown to reduce
microleakage under amalgam restorations.
Glass-ionomer cements have been recommended as
liners under resin composite restorations to reduce
microleakage. The use of glass-ionomer cement as
an intermediate layer between dentin and resin
composite, particularly in Class V & II restorations,
is often referred to as the sandwich technique.
It can be used in much thicker layers than other
lining materials (e.g. calcium hydroxide).
Both visible light–activated and conventional glass-
ionomer liners exhibit good physical properties, with
the conventional version exhibiting reduced
interfacial gap formation, a higher modulus of
elasticity, and subsequently improved support for
amalgam restorations.
Disadvantages:
 The GICs should not be directly applied over the
exposed pulp tissue.
 Short working time.
 Long setting time.
35
Manipulation: (Figure 2.12)
Powder/ liquid form: (Figure 2.13 a)
Figure 2.13 a powder & liquid form.
Figure 2.12 glass ionomer manipulation.
 Fluff the powder of the glass ionomer by
shaking with the lid secured tightly
 Using the supplied powder scoop dispense the
material as per the manufacturer’s instructions.
(Figure 2.14)
Figure2.14 eliminating excess powder.
 Dispense the liquid by holding the bottle
perpendicular to the waxed paper pad or glass
slab to get an accurate drop – replace caps
securely. (Figure 2.15)
Chapter 2 Pulpal Considerations 35
Figure 2.15 holding the bottle
perpendicular to the waxed paper pad or
glass slab to get an accurate drop.
 Using spatula divide the powder into two equal
portions.
 Incorporate the first powder mound into the
liquid (following the manufacturer’s instructions
for timing).
 Spatulate the mix over a small surface area
using the flat surface of the spatula. Ensure all
of the powder is completely incorporated into
the liquid before proceeding with the second
mound of powder.
 Incorporate the second mound of powder and
mix until a homogenous mix is achieved.
 Ensure the complete removal of cement from the
instruments and glass slab (if applicable), as
any remaining cement will impede the
sterilization process.
Note that Mixing time is 30–60 seconds (follow the
manufacturer’s instructions) .Working time is 1.5–2
minutes & Initial setting in the oral cavity is 6–9
minutes from the initiation of the mixture while
Complete setting is several days.
Capsule form: (Figure 2.13 b)
Figure 2.13 b capsulated form
 Activate the glass ionomer capsule (following
the manufacturer’s instructions).
36 Clinical Operative Dentistry
 Select the time for the glass ionomer to be
titrated by the dial or the button (follow the
manufacturer’s instructions when selecting
titration time).Push the button to activate the
trituration of the glass ionomer.
 Remove the glass ionomer capsule from the
amalgamator and load it into the applicator/gun.
Guidelines for basing, lining and
sealing
Best possible base for any restoration is sound
tooth structure.
The following are guidelines for placement of bases,
liners, and sealers:
 Do not remove sound tooth structure to provide
space for a base. Maintaining sound dentin will
enhance restoration support and provide
maximum dentinal thickness for pulpal
protection.
 Bases in cavity preparations for amalgam
restorations and bonded resin lead to decreased
bulk of restorative material and increased
potential for restoration fracture.
 Use the minimum thickness of liner necessary
to achieve the desired result. For liners under
amalgam restorations, this should not exceed
0.5 mm.
 When a base is used to provide insulation to
counter thermal sensitivity in amalgam
restorations, the thickness of the material must
be minimized in areas subject to occlusal
loading. It has shown that, as the thickness of
the base increases, the fracture resistance of the
overlying amalgam decreases.
 As the modulus of elasticity of a basing material
decreases, the resistance to fracture of
overlying amalgam decreases.
 If a base is used, its thickness should be
restricted to no more than 0.75 mm.
Management of Moderate Carious
Lesions
 In a moderate carious lesion, caries penetrates
the enamel and may involve one half of the
dentin, but not to the extent of endangering the
pulp.
 In these cases, to protect the pulp, liner is
applied to cover the axial and/or pulpal wall.
Then, base is placed over the liner. After the
base material hardens, permanent restoration is
done.
 Fortunately, dentine itself is a good insulator
and thus there is no justification for removing it
to make room for an insulating layer.
36
 However, in a deep or moderately deep cavity
there may be insufficient thickness of dentine
remaining and the cavity will then require a
lining. Glass ionomer cement is a good choice
but should be sublined with calcium hydroxide
in deep cavities.
 If the restoration is to be amalgam, the glass
ionomer lining should be designed so that the
amalgam is thick enough for strength. If
composite is to be used, the glass ionomer
cement lining is usually built up to the enamel–
dentine junction (or overbuilt and cut back to
this level when set). In other words, the glass
ionomer cement replaces all the dentine and the
composite replaces the enamel.
Management of Deep Carious
Lesions
Direct and Indirect Pulp Capping
Several favorable conditions must be present before
considering direct or indirect pulp capping:
 The tooth must have a vital pulp and no history
of spontaneous pain.
 Pain elicited during pulp testing with a hot or
cold stimulus should not linger after stimulus
removal.
 A periapical radiograph should show no
evidence of a periradicular lesion of endodontic
origin.
 Bacteria must be excluded from the site by the
restoration.
If these conditions can be met, an indirect pulp
capping procedure is preferable to a direct pulp
capping procedure. Why?
Because an indirect pulp capping procedure:
 Allows a protective thickness of dentin to
remain adjacent to the pulp.
 Not only does this provide the advantages
previously described for maintaining dentin (as
RDT), but because RDT is directly related to
odontoblast survival, reparative dentin
formation is also enhanced.
 In addition, avoiding pulp exposure means that
there is less chance for infected debris to be
introduced into the pulp to cause an
inflammatory reaction.
 Avoiding pulp exposure also means that there is
no concern for hemorrhage from the pulp, a
factor that has been associated with decreased
success rates in direct pulp capping.
If the pulpal status of a tooth is uncertain, the
clinician should consider endodontic therapy before
initiating restorative treatment.
37 Chapter 2 Pulpal Considerations 37

Pulp capping materials  The appearance of so-called tunnel defects in

reparative dentin formed beneath calcium
Calcium hydroxide hydroxide pulp caps. A tunnel defect has been
It is used in direct & indirect pulp capping. (Figure described as a patency from the site of the
2.16) exposure through the reparative dentin to the
pulp, sometimes with fibroblasts and capillaries
present within the defect facilitating bacterial
microleakage.

Manipulation: (Figure 2.17)

Most often supplied in a two-paste system

(‘catalyst’ and ‘base’).Calcium hydroxide may
also be supplied in a light-cured form

Figure 2.16 calcium hydroxide liner.

The calcium hydroxide is considered the best

material for direct application over the exposed pulp,
with a large clinical and scientific evidence of its
efficacy.

Advantages:
 Calcium hydroxide has excellent antibacterial
properties. A 100% reduction in microorganisms
associated with pulpal infections after 1 hour of
contact with calcium hydroxide can occur.
 Promoting formation of mineralized tissue.

Disadvantages:
 The self-curing formulations are highly soluble
and are subject to dissolution over time, the
solubility of the calcium hydroxide cements in
acidic conditions, under restorations with the
deficient marginal sealing, produces its
softening and complete dissolution, resulting in
empty spaces in the tooth-restoration interface
that may increase microleakage and reduce the
fracture resistance of the large restoration.
Thus, placing the mixed material on walls and
margins must be avoided.
Figure 2.17 calcium hydroxide manipulation.
 It has unfavorable physical properties (poor
modulus of elasticity) that restrict calcium Two-paste system:
hydroxide use to application over the smallest  Before placement of calcium hydroxide, check
area that would suffice to aid in the formation of the dentin surface (it should be moist).
reparative dentin when a known or suspected  Dispense equal volumes of both catalyst and
pulp exposure exists. Note that Visible light– base onto a waxed paper pad according to the
activated calcium hydroxide products have manufacturer’s instructions. Do not allow the
overcome most of deficiencies associated with two pastes to touch.
chemical cured forms ‹They exhibit improved  Ensure that the correct caps are replaced on the
physical properties significantly reduced appropriate tube to prevent cross-
solubility. contamination of the base and catalyst.
 Such teeth that treated with CaoH may show  Mix pastes together in a circular motion until a
evidence of calcification or internal resorption; homogeneous (even) colour is achieved (10–15
subsequently root canal treatment may be seconds).
initiated.  With a calcium hydroxide applicator, deliver the
 Calcium hydroxide has no inherent adhesive mix to cavity. (Figure 2.18 a-c)
qualities and provides a poor seal.
38 Clinical Operative Dentistry
Figure 2.18(a) Liner Applicator (Also referred to
as a Dycal instrument ) used To place dental
liner material (such as calcium hydroxide or
glass ionomer) in cavity preparation.
Figure 2.18(c) placement
Figure 2.18(b)
completed mix of of calcium hydroxide in
cavity preparation.
calcium hydroxide.
 Check the setting of calcium hydroxide using
the tip of an explorer with minimal pressure.
There should be no indentation.
 Note that Mixing time is 10–15 seconds & setting
time is 1.5–2.5 minutes.
Light-cured system:
 Dispense material (usually supplied in syringe
form).
 Light cure material as per manufacturer’s
instructions.
Mineral trioxide aggregate (MTA)
MTA has been used in the cases of direct pulp
capping.
When the MTA powder is mixed with water, there is
a formation of calcium hydroxide, which is
responsible for the high alkalinity after the
hydration, allowing the material to be considered
bioactive and present a capacity to allow an
adequate environment for the repair of the pulpal
tissue.
It is available in white or gray colors. Due to the fact
that the gray MTA may cause tooth staining by the
presence of iron and manganese ions on its
composition, the white MTA was developed to be
used on regions that might have an esthetic
involvement.
Advantages:
 Similar to those for calcium hydroxide, it has
antibacterial and biocompatibility properties,
38
high pH and has ability to promote formation
mineralized tissue.
 Compared with calcium hydroxide, MTA
produces more dentinal bridging in a short
period of time with significantly less
inflammation.
 It resists microleakage better than calcium
hydroxide.
 Compared with calcium hydroxide, Presence of
blood has little impact on leakage of MTA.
 It seems that the greater advantage of the MTA
lies on the fact that it can set and a seal by itself
the exposed area.it is hydrophilic &Sets in a wet
environment.
Disadvantages:
 The presence of iron in the gray MTA
formulation may darken the tooth.
 A significant downside to MTA is the prolonged
setting time of approximately 2 hours, 45
minutes. This requires that pulp capping with
MTA either be done in a two- step procedure,
placing a provisional restoration to allow the
MTA to set before placing the restoration, or
using a quick-setting liner to protect the MTA
during definitive restoration placement.
 MTA is very expensive.
 MTA is a difficult material to handle. Once it
starts to dry it loses its cohesiveness and
becomes hard to handle.
Manipulation:
 MTA powder is mixed with sterile water at a ratio
of 3:1 (three parts of powder to one of water) on
a glass slab or paper pad a plastic/metal
spatula.(mixing time is 30 seconds)
 The final mixture should resemble wet sand.
 Powder sensitive to humidity: the cap must be
replaced immediately after dispensing.
 After the hydration of the MTA, the material
forms a colloidal gel that gets solid after 2–3 h.
 It is placed over exposure site using plastic/
metal spatula.
 As the setting time of the MTA is of 2 h and 45
min thus, after the protection of the pulp tissue,
it need the application of a fast setting cavity
liner or base over it, such as a GIC or a RMGIC,
making possible to restore the tooth at the same
treatment session. Another option is to perform
the procedure to protect the pulp on two
separate clinical sessions. In the first one, the
direct protection with the MTA is performed, and
a small sterile cotton pellet embedded on
distilled water or physiological solution is
applied over the MTA, to allow the setting of the
cement, followed by a temporary restoration. On
the second session, the temporary restoration is
removed, and then a final restoration is made.
39 Chapter 2 Pulpal Considerations
Direct pulp capping
It is an attempt to maintain pulpal vitality by placing
a material directly over the exposed pulp. It is hoped
that this will allow the pulp to heal normally,
regenerate reparative dentin, and prevent the need
for more extensive and expensive treatment, such as
root canal therapy. (Figure 2.19-2.20)
Figure 2.19 direct pulp capping.
Pulp capping is more likely to be successful if the
cause of the pulp exposure is mechanical rather than
due to caries. A carious exposure will cause
bacterial contamination of the pulp resulting in
inflammation and a pulp that is less able to respond
and heal. (Ideally, direct pulp capping would be
attempted only when a small mechanical exposure
of an otherwise healthy pulp occurs).
If the exposure occurs during the removal of a deep
caries lesion, and the removal of the remaining
carious tissue will result in an increase of the
exposure, it must be interrupted and the capping be
made.
If the remaining carious tissue does not coincide
with the exposure area, the capping should be
performed and the remaining carious tissue
removed, since this procedure does not lead to new
exposures.
After a pulp has been exposed, it is important to
control pulpal bleeding before placing a pulp
capping agent. Why? Because
 First, increased pulpal bleeding may be
indicative of a higher level of pulpal
inflammation and therefore a reduced capacity
for pulpal healing.
 Second, the blood contamination of dentin
adjacent to the exposure site may compromise
the seal required to exclude bacterial
contamination of the exposed pulp.
Pulpal bleeding is normally controlled with a cotton
pellet saturated in a solution applied to the exposure
39
site. A variety of solutions have been used in this
situation:
 Water or saline are the most benign to the pulp.
 Sodium hypochlorite, in concentrations ranging
from 0.12% to 5.25%, is more caustic to the pulp
but is extremely effective at controlling bleeding
and is very effective at disinfecting the area.
 However, ferric sulfate should not be used as it
results in increased postoperative pain.
After controlling bleeding, pulp capping material is
placed. (It is placed with little pressure because
displacement of capping material/dentin chips into
In the case of calcium hydroxide, the glass-
ionomer/resin-modified glass-ionomer liner is
needed to provide a protective antibacterial seal that
the calcium hydroxide alone cannot provide.
In the case of MTA, the glass-ionomer/resin-modified
glass-ionomer liner is needed to protect the MTA
during restoration placement due to the prolonged
setting time.
It must be possible to restore the tooth with a well-
sealed restoration that will prevent subsequent
bacterial contamination.
Hypersensitivity to temperature change may persist
for a day or so.
In the favorable cases, the dentin bridge closing the
exposure must be formed 30–45 days after the
procedure.
It is necessary to wait a period of 45–60 days for the
postoperative control. After this time the pulp
sensitivity testing to cold is performed, and also a
new radiographic exam is done, in order to evaluate
the periapical area looking for signals of pulpal
necrosis. The tooth must remain without symptoms.
In the case of pulp vitality, absence of symptoms and
periapical lesions, the removal of the superficial
portion of the GIC can be done, and the final
restoration is performed.
Success in direct pulp capping:
There are several keys to direct pulp capping
success:
 Restricting pulp capping to asymptomatic or
mildly symptomatic teeth consistent with
reversible pulpitis.
 Controlling bleeding.
 Providing a bacterial seal at the exposure site.
 Providing a well-sealed restoration following the
pulp capping procedure.
40 Clinical Operative Dentistry 40

An indirect pulp capping procedure should be

considered when there is a radiographically or
clinically evident deep caries lesion encroaching on
the pulp and the tooth has no history of spontaneous
pain and responds normally to vitality tests.

Procedure of indirect pulp capping: (Figure 2.21)

Figure 2.20 summary of pulp capping

steps.

Indirect pulp capping

It has shown that restored teeth with partial caries
removal have equal success compared with restored
teeth with complete caries removal.

It is known that inflammation is present when active

caries is adjacent to the pulp, but there is little to no
inflammation if caries is arrested.

Typically, partial caries removal is accomplished,

and a sealer or liner and restoration is placed for a
period of 4 to 12 months.
The type of liner is less important to success than
the placement of a well-sealed restoration. (Calcium
hydroxide or glass ionomer are the materials of
choice for indirect pulp capping).
Figure 2.21 summary of indirect pulp
capping steps.
 After the initial entry into the carious dentin, a
spoon excavator or large round bur, rotating
very slowly in a low-speed handpiece, should be
41 Chapter 2 Pulpal Considerations
used to excavate the caries-softened dentin.
(The use of a large round bur for soft caries
removal is preferred).
 Demineralized dentin not near the pulp should
be completely removed, leaving hard, sound
dentin.
 A spoon excavator may aid in tactile detection
of softened dentin. The wet (soft, amorphous)
carious dentin should be removed; as the pulp
is approached, the dry, fibrous, demineralized
dentin that offers some moderate resistance to
gentle scraping with a spoon excavator should
be allowed to remain.
 After soft caries removed, a calcium hydroxide
liner is placed over the demineralized area of
dentin. Then a layer of resin-modified glass
ionomer is placed, covering the calcium
hydroxide and extending onto sound dentin on
the periphery to provide a seal. Resin-modified
glass ionomer alone (without calcium hydroxide
as an initial layer) is also effective at providing
favorable clinical and microbiologic changes
when used as a liner on remaining caries.A
glass-ionomer liner should be placed over the
calcium hydroxide liner to improve strength
during amalgam condensation and to enhance
the seal.
 The definitive restoration should be placed to
minimize microleakage at the interface of the
restoration with the cavity-preparation walls.
 In a two-step procedure, the tooth is reentered
for the purpose of excavating the remaining
acid-affected dentin to confirm reparative dentin
formation. This procedure not preferred
because Bacterial levels in caries lesions are
reduced most significantly after the initial caries
excavation and liner placement, with little
additional benefit from the subsequent
excavation. In addition, a reentry procedure
risks creating a pulp exposure and causing
further traumatic insult to the pulp.
Affected and infected dentin
 Infected dentin: It is necrotic, soft dentin, not
painful to stimulation and grossly infected with
bacteria.it must be removed in pulp capping
procedure.
 Affected dentin: It is demineralized, discolored
but hard dentin, painful to stimulation
containing very few bacteria. It is capable of
being remineralized. However affected dentin
can be left on pulpal and axial walls and never
on dentinoenamel junction and cavity margins.
 Note that some studies have shown that even
when infected dentin remained in the
preparation walls, the restored teeth presented
a similar success rate to the ones that had the
entire softened dentin removed.
 Note that the removal of the entire carious tissue
is not necessary for the success of the
41
restorative treatment. However, it is essential to
obtain a restoration with an adequate marginal
sealing in order to eliminate the nutrition source
for the remaining bacteria.
Indirect Pulp Capping Using Step-
wise Excavation
More recently, the step-wise excavation of deep
caries has been revisited and shown to be
successfully in managing reversible pulpitis without
pulpal perforation.
Indicated in the cases of very deep acute carious
lesion, in young patients, with the absence of
spontaneous pain and with response to the tactile
and thermal stimuli, especially to the cold with a fast
relief.
This approach involves a 2-step process:
The first step:
 The removal of carious dentin along the dentino-
enamel junction (DEJ) and excavation of only
the outermost infected dentin, leaving a carious
mass over the pulp.
 Then, over the softened tissue on the internal
walls, a layer of calcium hydroxide cement liner
is applied.
 The whole preparation is then filled with a
temporary restoration made of GIC or
RMGIC.This restoration can remain in place for
a period of 30–45 days up to 1 year, so that the
carious lesion activity is reduced and allows that
dentin-pulp complex to remineralize the
demineralized dentin and forms sclerotic and/or
tertiary, significantly reducing the number of
microorganisms and the risk of pulpal exposure
during the removal of the remaining carious
tissue, on the next opening of the cavity.
The second step:
 Sensitivity and pulp vitality tests must be
repeated. The radiographic exam may show the
formation of sclerosis or tertiary dentin below
the remaining dentin.
 With a positive determination of the pulp vitality
and absence of any symptoms, the treatment
can be continued, removing the remaining
carious dentin and placement of a final
restoration.
 Critical to both steps of excavation is the
placement of a well-sealed restoration.
It has shown that when the cavity is opened again:
 The color of the lesion changes from light
brown to dark brown.
42 Clinical Operative Dentistry 42

 The consistency changes from wet and soft

to dry and hard.
 The number of viable Microorganisms is
significantly reduced or even completely
disappears.
 The radiographic image may show no
change or even decrease of the radiolucent
area, the dentin sclerosis, or the formation
of tertiary dentin.
43
45 Chapter 3 Field Isolation 45

Rubber Dam
The rubber dam has been recognized as an effective
method of obtaining field isolation, improving
visualization, protecting the patient, and improving
the quality of operative dentistry services.

Indications:
 During root canal treatment/endodontic
procedures: To prevent swallowing of foreign
bodies and contamination of root canal space.
 Excavation of deep caries: To prevent
contamination of pulp in case of pulpal
exposure.
 Subgingival restorations: To provide gingival
retraction and control gingival fluid.
 During adhesive restorations: To prevent
salivary contamination and ensure complete
dryness of operating field.
 In high-risk patients: In patients with hepatitis B
or HIV, isolation prevents spread of oral fluids. Rubber dam equipment.
 Bleaching of teeth: To prevent damage of
Rubber dam material (sheet)
adjacent soft tissues by bleaching agents.
They have the following characteristics:

Contraindications Size:
 Asthmatic patients.  5’’× 5’’ or 6’’ × 6’’ square.
 Allergy to latex.  The most common size is the 6 × 6-inch square,
 Mouth breathers. which is used for isolation of posterior teeth in
 Extremely malpositioned tooth. the permanent dentition. Another common size
 Third molar (in some cases). is the 5 × 5-inch square, which is used for
primary dentition or anterior applications.
Thickness:
Rubber Dam Equipment The heavy and extra-heavy gauges are
recommended for isolation in operative dentistry.
Why? Because:
Main components:  The heavy dams are no more difficult to apply
 Rubber dam sheet than are the thinner materials.
 Rubber dam punch  Heavier dams are less likely to tear.
 Rubber dam clamps  The heavier materials provide a better seal to
 Rubber dam forceps teeth and retract tissues more effectively than
the thinner materials. It is indicated for isolation
 Rubber dam frame
of class V lesions.
Note that Thinner dam can pass through the
Rubber Dam Accessories: contacts easier. Thus, it is indicated in teeth with
tight contacts.
 Lubricant
 Dental floss
Thin 0.0063"
 Rubber dam napkin
 Modeling compound Medium 0.008"
 Wedge
Heavy 0.010"
 Scissors
 Interproximal contact disk Extra heavy 0.012"
Special heavy 0.014"
46 Clinical Operative Dentistry
Color:
 Available in several colors, but green and blue
colors are preferred because they provide good
contrast with the surroundings. (Figure 3.1)
 Rubber dam sheet has a shiny side and a dull
side. The dull side should face the operator so
as to reduce any light reflected from it.
Figure 3.1 rubber dam sheet with different
colors.
Shelf life:
 Latex dam material that has exceeded its shelf
life becomes brittle and tears easily;
unfortunately, this is usually noticed during dam
application.
 A simple test for the resistance of rubber dam
material to tearing is to attempt to tear a sheet
grasped with thumbs and index fingers; a strong
dam will be very difficult to tear.
Rubber Dam Punch & Rubber Dam
Template (Hole-positioning guides)
Rubber Dam Punch
Rubber dam punch is used to make the holes in the
rubber sheet through which the teeth can be
isolated. (Figure 3.2)
Figure 3.2 rubber dam punch.
It is characterized by a rotating metal disc, which
bears five or six holes of different sizes, and a sharp
pointed plunger.
46
The holes are of different sizes according to the size
of different teeth. The Use of the particular hole
suggested for that particular tooth should be
performed, otherwise a tight seal will not be possible
or the dam may tear during its placement. (Figure
3.3)
Figure 3.3 recommended hole sizes
For standard latex heavy- gauge dams,
recommended hole sizes are
 Size 5 for clamped molars (anchor molars).
 Size 4 for other molars.
 Size 3 for premolars, canines, and maxillary
central incisors.
 Size 2 for maxillary lateral incisors.
 Size 1 for mandibular incisors.
Some variation from the recommended hole sizes
may be needed, depending on the size of individual
teeth, operator preference, dam material, and gauge
of the dam.
Holes must be cleanly cut; incompletely punched
holes will promote tearing of the dam during
application or will affect the ability of the dam to seal.
(Figure 3.4)
Figure 3.4 incompletely punched holes will
promote tearing of the dam during application
or will affect the ability of the dam to seal.
When a prestamped dam or a template is used:
47 Chapter 3 Field Isolation 47

 Holes should be punched away from the spots
to accommodate atypical alignment of teeth.
 When the dam is being prepared to provide
isolation for Class 5 restorations, the hole for
the tooth to receive a facial Class 5 restoration
should be punched approximately 1 mm facial to
the spot to allow retraction with the no. 212SA
clamp.
 No holes should be punched for missing teeth.
Hole-positioning guides (Rubber Dam
Template)
 If inadequate little spacing is present between
the holes, there are chances that the rubber dam
sheet will move to the mesial or the distal of the
papilla, thereby exposing and injuring the
gingiva as well as not providing proper isolation.
This also increases the chances of tear of the
dam.
 If the holes are over spaced, rubber dam will
bunch in between the teeth thus interfering with
the operative procedure.

Marking the position of the teeth directly in

the mouth. Note that the rubber shall be
stretched over the teeth and held in
position, while the center of the tooth is
marked using a permanent marker.
Rubber dam template.

Take a rubber dam sheet. Punch a hole on its upper

right corner or mark it with ‘R’ for identifying the
patient’s right side.

The sheet is then placed on a template and the

position of the holes marked on it with a pen.

However with a template, only fixed positions can be

obtained. When considerable variations are
required, the dam can be centered on the teeth to be
isolated and the positions marked. (Figure 3.5)

When the dam is in position it should reach up to a

point just below the patient’s nose, thus covering the
mouth but not the nose. To achieve this, the
following should be considered:
 When applying the rubber dam to the maxillary
teeth or mandibular third molars, the position of
the upper central incisors should be stamped Figure 3.6 when applying the rubber dam to the
about 2.5 cm (1 inch) from the top edge of the maxillary teeth or mandibular third molars, the
rubber sheet. (Figure 3.6) position of the upper central incisors should be
 For mandibular teeth the holes should be placed stamped about 2.5 cm (1 inch) from the top edge
further up the sheet so that the rubber does not of the rubber sheet.
cover the nose.

Spacing between two holes in the dam should be

adequate (approximately ¼ inch):
48 Clinical Operative Dentistry 48

RUBBER DAM Frame (holder) Clamps

Rubber dam frames support the edges of rubber
dam.
Rubber dam frames are available in either metal or
plastic: (Figure 3.7)
- Also known as retainers.
- Its components shown in (Figure 3.9a-b).
- Clamps may be:
 Metallic
 Nonmetallic: Nonmetallic are made from
polycarbonate plastic. An advantage of these
clamps over metallic is radiolucency.
Some clamps simply have a number designation;
others have a W in front of the number. The W
indicates that the clamp is wingless while those
clamps that do not bear a W have wings.

Figure 3.7 Ostby frame a) plastic b) metal

 A plastic frame is advantageous when

radiographs will be a part of the procedure
because it is radiolucent.
 The plastic frames do not, however, stand up to
heat sterilization as well as do metal frames, Figure 3.9 (a) winged clamp components.
 And they have a shorter life span while Metal
frames are less bulky and last for years.
The frame is preferably placed beneath the dam
rather than above it.

Rubber Dam Forceps

Rubber dam forceps are used to carry the clamp to
the tooth. (Figure 3.8)

Figure 3.9 (b) a&c)winged clamps b&d)wingless

Figure 3.8 rubber dam forceps.
It should be taken care that forceps do not have deep
grooves at their tips or they become very difficult to
remove once the clamp is in place.
clamps.
The number of clamps should be limited to a few that
will satisfy most needs. Clamps that will serve in
most situations and are recommended for inclusion
in operative dentistry instrument kits are the
following: (figure 3.10)
49 Chapter 3 Field Isolation 49

No. W8A clamp:

 The jaws of a no. W8A clamp, for most
applications, should be approximately
horizontal as the jaws are spread, the angle of
the jaws will change to a gingival orientation.
(figure 3.12)

Figure 3.10 clamps recommended for routine use

(top row, left to right) no. W8A, B1, 27 ;( bottom
row) no. W2A clamp and no. 212SA retractor.
- For molars:
 No. W8A, W8ASA or B1 (wingless clamps).
 No. 8A or 27 (winged clamps).
- For premolars:
 No. W2A (wingless).
 No. 2A (winged).
- For canines & incisors: no. 212SA.
Figure 3.12W8A clamp.
Supplemental clamps, to be available on the rare
occasions when the usual clamps will not suffice,
 For no. W8A clamps in which the jaws have a
should be packaged and sterilized separately.
significant gingival angulation, a modification
Supplemental clamps include: (figure 3.11)
procedure is recommended unless deep
subgingival placement of the points is needed.
 This modification may be made with a stone
used in a low-speed handpiece or a finishing bur
used in a high-speed handpiece. After the
modification is made, the points, which have
been sharpened by the modification procedure,
must be blunted to prevent damage to tooth
surfaces.
 The no. W8ASA clamp (Hu-Friedy) incorporates
most of the advantages of the modification of
the no. W8A. (figure 3.13)

Figure 3.11recommended supplemental clamps

(left to right) no. 00 ,W14A & W1A.

- For partially erupted molars:

 No. W14A (wingless).
 No. 14A (winged).
- For premolars with subgingival margins:
 No. W1A (wingless). Figure 3.13 The no. W8ASA clamp (Hu-Friedy)
 No. 1A (winged). incorporates most of the advantages of the
- For mandibular incisors and other small teeth: modification of the no. W8A.
 No. W0 (wingless).
 No. 00 (winged).
50 Clinical Operative Dentistry 50

Butterfly clamp:  The double bow of the no. 212SA clamp

precludes placement of two clamps on adjacent
The butterfly clamp, no. 212SA , is designed to serve teeth. When two Class 5 restorations are to be
as a retractor only. placed on adjacent teeth, two no. 212SA clamps
Because of its double bow and the closeness of the may be modified; one of the bows of each clamp
points of each jaw, this clamp must often be is cut off so that the remaining bow of one clamp
stabilized on the tooth, or it may rock mesiodistally extends to the right and the bow of the other
during the procedure and damage the root. extends to the left. If these clamps are stabilized
with modeling compound, adjacent Class 5
For retraction for a facial Class 5 restoration: restorations may be accomplished
 Dental impression compound (such as red or simultaneously. (figure 3.15)
green compound) should be used under the
bows of the clamp on the occlusal (or incisal)
and lingual aspects of the teeth to provide
stabilization.
 The hole for the tooth that is to receive the no.
212SA retracting clamp should be offset facially
from the line of teeth by approximately 1 mm.
This provides for a greater width of interdental
rubber dam septum so that, when the dam is
displaced apically for access to the gingival
margin of a Class 5 restoration, a water-tight
seal will be maintained. (figure 3.14)

Figure 3.15 When two Class 5 restorations

are to be placed on adjacent teeth, two no.
212SA clamps may be modified.

 Note that a no. 212SA clamp or a modified no.

212SA clamp may be used on one root of a molar
that has a long clinical crown as well as on
single-rooted teeth.

An important consideration when a clamp is

selected is that only its jaw points contact the tooth;
this gives four-point contact. (Figure 3.16)

No clamp jaw can ever be contoured to fit a tooth

precisely, nor is there any reason for a clamp to fit
precisely, because the dam, not the clamp, creates
the seal.

Clamp Present 2 prongs which means that there are

4 prongs in a clamp and each prong rests on the
mesial/distal line angle of the tooth to be clamped. A
prong should not extend beyond the angle of the
tooth otherwise it would interfere with the placement
of a wedge or matrix band, also may cause gingival
trauma& Difficulty in achieving complete seal
around anchor tooth.

Clamps should be expanded with the clamp forceps

no more than is necessary for the clamp to be
passed over the facial and lingual heights of contour
Figure3.14 butterfly clamp used for retraction of the tooth. If a clamp has been over expanded, it
for a facial Class 5 restoration
51 Chapter 3 Field Isolation 51

will grasp the tooth with less strength and is more

likely to be dislodged. It is usually best to discard a
clamp that has been overexpanded.

Figure 3.16 clamp should contact tooth

at mesial and distal extent of jaws. This 4
point contact provides stability or
resistance to rotation or dislodgment for
clamp.
Figure 3.18 strip of rubber dam placed
Other retainers between canine and premolar in both sides
to hold rubber dam in place.
Other methods are sometimes used for rubber dam
retention:

 Dental floss or tape is placed doubly through a

contact and then cut to a short length so that it
does not impede access. (figure 3.17)
 A short strip of rubber dam material is cut from
the edge of the rubber dam, stretched and
carried through the contact, and then allowed to
relax to retain the dam. (figure 3.18)
 Floss is tied to a sterilized rubber plunger from
an anesthetic cartridge or similar item and then
tied around the most distal isolated tooth.
(figure 3.19) Figure 3.19 anesthetic cartridge plunger
 Elastic cord, e.g., Wedjets (Hygenic), is placed tied around the distal tooth with floss.
interproximally to retain the dam. (figure 3.20a-
b)

Figure 3.17 dental tape placed doubly

through the contacts between the teeth.

Figure 3.20 (a) wedjets.

52 Clinical Operative Dentistry
Figure 3.20 (b) use of wedjets in isolation
of anterior teeth.
Modeling compound
Modeling compound may be used as an adjunct to
the application of any clamp as a retainer or
retractor.
It is especially useful and necessary for anchoring
and stabilizing the no. 212SA retainer (butterfly
clamp).
The clamp is positioned appropriately on the tooth
and held in position with a finger until stabilization is
completed.
First technique:
 Modeling compound is placed into a plastic
syringe, such as a large Monoject or impression
syringe, which is then placed in a water bath at
the appropriate temperature for the type of
modeling compound used.
 The diameter of the aperture of the tip should be
made larger to allow the softened compound to
be ejected easily from the syringe.
 When the clamp is positioned, the practitioner
removes the syringe with the prewarmed
modeling compound from the water bath and
flows it into the desired area to stabilize the
clamp.
Another technique involves the use of the
compound in stick form:
 A stick is held over a low alcohol flame and
rotated and moved back and forth so that the
length to be softened is heated evenly.
52
 After the surface is softened, the stick is
withdrawn from the flame to allow the heat to
diffuse to the center of the stick. When the
length is warmed to the center, there will no
longer be a core of unsoftened compound to
support the shape, and the softened length will
sag or droop.
 If the stick has been overheated, so that it
elongates in addition to drooping, it should be
cooled slightly in a container of water.
 Before the compound is taken to the mouth, the
surface should be briefly reheated to enhance
adhesion of the compound to the retracting
clamp and teeth.
 The compound should be applied to the retainer
and teeth in a location as far away from the area
to be restored as possible.
 The stick is then twisted and pulled away,
leaving softened compound in place.
 The compound should be shaped and molded
with damp, gloved fingers into embrasures and
made to contact a large area of the clamp and
the lingual surfaces of the teeth.
 It should then be cooled with the air syringe for
20 seconds or more.
 Stabilization of the retracting clamp is then
completed; the finger holding the clamp may
now be released, and the clamp is tested for
stability.
Compound should be kept away from the planned
area of operation so that it will not inhibit access; in
that regard, for a facial restoration, compound
should be confined to the occlusal (or incisal) and
lingual surfaces. When the lingual surfaces are
covered by the compound, the lingual notches for
the clamp forceps will be covered.
To remove the clamp with forceps, the operator
would have to chip away the compound to expose a
lingual notch. In a simpler method, an instrument is
used to pull the facial jaw of the clamp away from the
facial surface and then occlusally (incisally)
Dental Floss
It can be used as in the following:
 Flossing agent for rubber dam in tight contact
areas.
 Also required for testing interdental contacts.
 Bow of retainer should be tied with
approximately 12 inches long dental floss before
placing retainer in mouth. It helps in retrieval of
the retainer or its broken parts if they are
accidentally aspirated. (figure 3.21)
 Retainer instead of clamp: Dental floss or tape is
placed doubly through a contact and then cut to
a short length so that it does not impede access.
53
Figure 3.21 floss tied to the clamp to help in
retrieval of the retainer or its broken parts if
they are accidentally aspirated.
Wedge
 The wooden wedge, which is used to stabilize a
matrix and hold it against the gingival margin of
a cavity preparation involving a proximal tooth
surface, is also useful for protecting the dam
when rotary cutting instruments are used in
proximal areas.
 Placement of water-soluble rubber dam
lubricant on the wedge enhances the ease of
wedge placement.
 Care should be taken while using wooden
wedge as it can damage the interproximal tissue
if inserted forcibly.
Scissors
 It is necessary for cutting the dam for removal.
 Scissors used for cutting rubber dams must be
sharp, or they will frustrate the operator.
Rubber Dam Napkin
This is a sheet of absorbent materials usually placed
between the rubber sheet and soft tissues. (Figure
3.22)
Figure 3.22 rubber dam napkin.
Chapter 3 Field Isolation 53
Interproximal contact disk
 An interproximal contact disk (Thierman
Products or Centrix) is used to plane rough
enamel, amalgam, or resin composite contacts
so that the floss will pass through without
shredding and so that the dam can be flossed
through without tearing. (Figure 3.23)
 The plain metal disk, without abrasive, is
recommended.
 It is pushed firmly, but with control, gingivally.
 If it cannot be worked through the contact, the
teeth should be separated slightly with a plastic
instrument placed snugly into the gingival
embrasure and rotated slightly while the disk is
being pushed into the contact from the occlusal
embrasure.
 Several passes of the disk through the contact
will usually plane it smooth.
Figure 3.23 interproximal contact disc used
to plan rough contact.
Lubricant
 Aids in passing the dam over the tooth. The
lubricant makes passage of the dam through the
interproximal contacts much easier, and the
dam will often pass through the contacts in a
single layer without the use of floss.
 Lubricants may be commercially available or
ones like soap, vaseline, shaving cream, etc. can
also be employed.
 A water-based gel is supplied for this purpose
but brushless shaving cream is equally suitable.
A water-soluble lubricant is preferred.
 Petroleum-based lubricants, such as Vaseline,
should be avoided as rubber dam lubricants
because they are difficult to remove from the
dam after application and therefore can impede
54 Clinical Operative Dentistry
bonding procedures and make inversion of the
dam more difficult.
 Water-soluble lubricant is applied in a thin coat
in the area of the holes on the tissue surface of
the dam before it is taken to the mouth. If
additional lubrication is desired, lubricant may
be applied to the teeth prior to placement of the
dam.
 A lubricant for the lips will make the patient more
comfortable during the procedure. Petroleum-
based lubricants, such as Vaseline, cocoa butter
function well as lip lubricants.
Application and removal of rubber
dam
Isolation planning
When using rubber dam, isolate at least three teeth
at a time.
Single tooth isolation is usually not recommended
except in certain cases:
Single tooth isolation.
Multiple teeth isolation.
54
Single tooth isolation is done in following
cases:
 Class I and V restorations
 Endodontic treatment
 Pit and fissure sealants.
Isolation of multiple teeth is done in following
conditions:
 Class II restoration
 Quadrant dentistry
 Bleaching.
- For working on central incisors, lateral incisors
or on mesial aspect of canines, isolation is done
from first premolar to first premolar of the
opposite side. This extension of the area of
isolation to the opposite side will hold the dam
flat in the arch to give room for fingers and
instruments in the area of the teeth to be
restored. It will also expose teeth in the anterior
area for finger rests during the operation. (figure
3.24)
Figure 3.24 for anterior restorations, first
premolars are exposed to provide
adequate working area on lingual aspect of
anterior teeth.
- Isolation in the anterior area may not require the
use of retainers. The use of supplemental aids
of retention may suffice especially if there is a
tight contact.
- For working on the distal aspect of canines and
premolars, isolate two teeth posteriorly and
punch holes until the opposite lateral incisor
anteriorly.
- For working on the molars, isolate till the
posterior most tooth on the same side and till
the lateral incisor on the opposite side. (figure
3.25)
- When a posterior segment is isolated, the clamp
is usually placed on the distal most exposed
tooth.
55 Chapter 3 Field Isolation 55

Check for tightness of the proximal contacts by

passing the floss obliquely from buccal or lingual.
This way the floss is prevented from snapping
through the contact and traumatizing the gingiva.
Very tight proximal contacts would not allow the
passage of rubber dam hence one should consider
some other form of isolation in such cases.
However, minimally tight contacts that are difficult to
floss can be wedged apart to allow the passage of
rubber dam.

If a restorative procedure that involves an occlusal

surface is planned, maximum intercuspation
contacts may be marked with articulating paper or
tape prior to application of the dam. Centric
occlusion markings may be coated with a clear light-
cured resin or varnish to protect them from being
Figure 3.25 for working on the molars, rubbed off. (Figure 3.27)
isolate till the posterior most tooth on the
same side and till the lateral incisor on the
opposite side. Note that second clamp can
be placed on an unexposed molar to give an
additional access to lingual surfaces of
teeth.

Preparation of the mouth

Teeth should be cleaned, if necessary, and contacts
should be checked with floss. Any rough contact
should be smoothed with the interproximal contact
disk. (Figure 3.26)
Figure 3.27 Centric occlusion markings
coated with a clear light- cured resin or
varnish to protect them from being rubbed
off.
If the lips are to be lubricated, this should be
accomplished prior to application of the dam.
(Figure 3.28)

Figure 3.26 Verification of interproximal

contacts with dental floss to make sure it
will be possible to pass the rubber between
the teeth without tearing.

Figure 3.28 Lips are lubricated with

Check for any debris or calculus around the teeth. petroleum-based lubricant prior to placement
Remove them before proceeding for placement of of the rubber dam.
the rubber dam.

Check for any overhanging margins or sharp edges Anesthetizing of the gingiva:
with the help of a dental floss. These are first  If an inferior alveolar block has been given, the
corrected before proceeding to avoid any rubber lingual nerve will almost always have been
dam tear. anesthetized as well, so the gingival tissue
56 Clinical Operative Dentistry 56

lingual to the mandibular teeth will also have
been anesthetized.
 If infiltration anesthesia has been administered
to maxillary teeth, the facial gingival tissue will
have been anesthetized. For application of a
rubber dam clamp, the portions of the gingival
tissue that have not been anesthetized (palatal
gingiva ) along with the delivery of pulpal
anesthesia will not normally need to be
anesthetized. When the clamp is applied, as long
as the points of the clamp’s jaws are firmly on
the tooth and have not penetrated gingival
tissue, the patient may feel some discomfort for
a few seconds where the jaws are pressing
against tissue. This pressure discomfort will
usually disappear within 1 minute due to
“pressure anesthesia,” and injection anesthesia
for the gingival tissue is usually unnecessary.
 If additional gingival anesthesia is necessary,
topical anesthetic solutions or gels may suffice.
Preparation of the dam
The Use of a prestamped, dark (gray, green, or blue),
heavy (or extra heavy) gauge material is
recommended.
After the dam is punched, the tissue side of the dam
should be lubricated with a water-soluble lubricant.
The rubber dam frame can then be attached to the
top and bottom of the dam, leaving a relaxed area or
“pouch” of dam material between the top and
bottom. Attaching the dam to the frame in this way
holds the edges of the dam away from the holes for
better visualization during application.
to be an open slit; the hole is then carried over
the bow and jaws of the clamp.
 The hole at the opposite end of the row (usually
for the lateral or central incisor on the opposite
side) is then passed over the appropriate tooth,
and the septa are worked through the
interproximal contacts.
 A gloved fingernail used to slightly separate the
anterior teeth is very helpful, and floss is not
usually needed to carry the dam through
anterior interproximal contacts. To use the
“fingernail technique,” the edge of the septum is
positioned at the incisal extent of the contact
and pulled gingivally with fingers on the facial
and lingual aspects. The dam should be passed
through each contact in a single layer. This may
be accomplished by stretching a septum over
one of the teeth adjacent to the contact and
sliding the edge of the rubber to the contact so
that a leading edge of dam is touching the
contact.
 In posterior areas, the leading edge should be
touching the occlusal portion of the contact in
the occlusal embrasure. Waxed tape (ribbon
floss) or waxed floss may then be used to move
the dam progressively through the contact To
accomplish this, the tail of the floss that is on
the lingual side of the teeth is doubled back
across the occlusal embrasure of the contact so
that both ends are on the facial aspect.

Placement methods of the dam

Dam over clamp method: (figure 3.29-3.30)

 A wingless clamp is placed on the tooth.
 It is recommended that a finger be maintained
over the inserted clamp to prevent its
dislodgment until its stability on the tooth has
been confirmed. The operator checks stability
by engaging the bow of the clamp with an
instrument and firmly attempting to pull it
occlusally. If the clamp rotates on the tooth, it is
not stable and should be repositioned or
replaced. Minute instability may be overcome by
using impression compound to stabilize the
clamp. Often the prongs may require grinding to
improve stability.
 The tissue side of the dam is lubricated in the
Figure 3.29 a) Testing the clamp onto the
area of the holes.
tooth; b) verification of the clamp stability
 Then, with a finger on each side of the distal hole with the finger.
in the dam, the dentist (or assistant) stretches
the dam so that the hole is enlarged and appears
57
Figure 3.30 Placing the rubber dam and
frame set over a pre-positioned clamp. A)
Placing the clamp; b) passing the most distal
perforation over the bow of the clamp; c) the
remaining perforations are passed over their
corresponding teeth
 Never place floss wholly on the rubber dam as it
will create a double thickness of the sheet in that
area. The rubber should be ‘knifed’ through each
contact area, sawing it from side to side while
pressing its leading edge apically to carry it
through the contact point. The dental nurse
should hold the rubber in this position while the
dentist passes floss through the contact,
carrying the rubber with it. Once the floss has
passed the contact it should be removed
bucally. (figure 3.31 a-b)
 Larger holes (size 2 or 3) are required in this
technique as rubber dam has to be stretched
over the clamp.
Chapter 3 Field Isolation 57
Figure 31(a) the rubber is knifed through
contact area.
Figure 31 (b) the dentist floss rubber down
through contact area.
 When a tight contact is encountered, the dentist
should not spend too long on it but move to the
next tooth. Once most of the teeth are through
the rubber, the paper towel and the frame are
applied. This improves access to deal with any
remaining difficult contacts.
 Advantages:
 Quick and simple technique
 Good vision of clamp and tooth during dam
placement
 Minimal tissue trauma.
Winged clamp in dam method: (figure 3.32
a-d)
 Prior to lubrication of the dam, the clamp is
placed into the distal hole so that the hole is
stretched over the wings of the clamp from its
tissue side.
 The dam is then lubricated, and the frame is
attached. The forceps are inserted into the holes
of the clamp, and the clamp, dam, and frame are
carried as a unit into place.
 After the stability of the clamp is confirmed, the
dam material on the wings of the clamp is pulled
58 Clinical Operative Dentistry 58

off the wings with finger tension or with a bladed

instrument such as a plastic Instrument.
 Advantage: Indicated in third molar regions.
 Disadvantages:
 Restricted vision during clamp placement.
 Trauma to gingiva

Figure 3.32(d) the dam material on the wings

of the clamp is pulled off the wings with
finger tension or with a bladed instrument
such as a plastic Instrument.

Wingless clamp in dam method: (figure

3.33)
Figure 3.32(a) the hole is stretched over the
wings of the clamp.

Figure 3.32(b) the dam is then lubricated on

the side to be in contact with the teeth.

Figure 3.33 Sequence for placement the

Figure 3.32(c) The forceps are inserted into rubber dam over the wingless clamp,
the holes of the clamp, and the clamp, dam, without the frame. A) Testing the clamp,
and frame are carried as one unit into place. which is then removed; b) passing the
rubber dam over the bow of the clamp
outside of the mouth; c) fitting the forceps
into the round orifices of the clamp; d)
placement of the dam and clamp on the
tooth; e) assembling the dam on the frame;
f ) passing the rubber dam completely over
the clamp.
59 Chapter 3 Field Isolation 59

 The distal hole of the lubricated dam is passed rubber dam; the most apical jaw is carefully
over the bow of a wingless clamp, such as the placed to retract the gingival tissue, so the
modified no. W8A, so that the hole comes to rest margins are completely exposed.
at the junction of the bow and the jaw arms.
 The frame is not attached to the dam at this
point.
 The dam is gathered up and elevated to expose
the jaw arms of the clamp, and the forceps are
then inserted into the forceps holes. The
gathered dam is carried to the mouth with one
hand and the forceps with the other. (figure 3.34)

Figure 3.34 The dam is gathered up and

elevated to expose the jaw arms of the
clamp, and the forceps are then inserted into
the forceps holes. The gathered dam is
carried to the mouth with one hand and the
forceps with the other.
Figure 3.35 Sequence for placement of the
 After the clamp is applied to the distal tooth and clamp over the rubber dam. a Fitting the
the dam has been pulled over the jaws of the punched dam over the tooth; b fitting the
clamp, the frame is attached and the other teeth clamp no. 212, retracting the gingiva on the
are isolated as previously described. labial surface and exposing the gingival
cavosurface angle of the preparation; c
Clamp after dam method: (figure 3.35) isolation finished

 The dam is applied to the teeth and then the Completion of application
clamp is placed. This technique, occasionally
necessary, is the most difficult.
Application of the napkin:
 This technique is generally performed when the
 For longer procedures, the use of a rubber dam
rubber dam is used to restore class V cavities or
napkin is recommended.
non-carious cervical lesions using the gingival
 The napkin may be positioned before or after the
retractor clamp no. 212. This clamp is wingless
dam is in place on the teeth.
and large, and therefore the techniques
described previously do not apply.  For placement of the napkin after the dam has
been applied, the frame is removed, the napkin
 Therefore, the dam is first attached to the frame.
is placed so that its edges remain on the skin
The hole on the rubber dam is pushed towards
and not in the mouth, and the frame is replaced.
the cervical area of the selected tooth until the
preparation margins are visible. Clamp no. 212,
engaged in the forceps, is brought over the
60 Clinical Operative Dentistry 60

Adjustment of the dam in the frame:  Inverting instrument:

 The frame and dam are adjusted so that there is
a minimum of folds and wrinkles and so that the
dam does not obstruct the nostrils.
 It is important that the rubber is not stretched
too tightly when the frame is applied since this
may both restrict access and pull the rubber
away from the teeth, allowing leakage.
- Almost any instrument may be used to tuck the
edge of the dam gingivally.
- Commonly used instruments include explorer
tip, plastic filling instruments, a beavertail
burnisher or spoon excavator. (figure 3.37)

Washing of the dam:

 The dam and isolated teeth are washed with an
air-water spray to remove the lubricant. After
they are washed, the dam and teeth should be
dried with air from the air syringe.
 A high volume evacuator tip on the other hand
is placed above the rubber dam for intermittent
suctioning throughout the procedure.
Inversion of the dam:
 The dam should be inverted around the necks of
the teeth, at least in the area of the tooth or teeth
to be restored.
 The edge of the dam that is against the tooth
acts as a valve. If the edge is directed occlusally,
when a positive pressure is created by the
tongue and cheeks under the dam, the valve
opens, and saliva and other liquids under the
dam are pushed between the tooth and dam to
flood the operating field; then, when a negative
pressure is created under the dam, the valve
closes and the saliva is trapped in the field.
When the dam is inverted, a positive pressure
under the dam simply serves to push the valve
more tightly against the tooth so that no
flooding of the field occurs. (figure 3.36)

Figure 3.37 inversion of dam using a)

explorer b) plastic instrument c) a beavertail
burnisher. Note that air stream is necessary.

 A steady, high-volume stream of air should be

Figure 3.36 a) If the edge is directed
occlusally, when a positive pressure is
created by the tongue and cheeks under the
dam, the valve opens, and saliva and other
liquids under the dam are pushed between
the tooth and dam to flood the operating
field; b) then, when a negative pressure is
created under the dam, the valve closes and
the saliva is trapped in the field. When the
dam is inverted, a positive pressure under
the dam simply serves to push the valve
more tightly against the tooth so that no
flooding of the field occurs.
directed at the tip of the instrument used to
invert the dam as the dam inverts more easily
when the surfaces of the tooth and adjacent dam
are dry.
 The instrument should be moved along the
margin of the dam so that the inversion is
progressive.
 Floss may be used to invert the dam in
interproximal areas. When it is used to carry the
edge of the dam gingivally, the floss should not
then be pulled occlusally for removal because it
will frequently pull the edge of the dam with it,
eliminating the inversion. Instead, the floss can
be doubled over on itself on the lingual aspect
61 Chapter 3 Field Isolation 61

and passed again through the contact. (figure  Prior to removal of the dam, the ligature should
3.38) be cut with scissors, a sharp carver or scalpel
blade and removed.

Flat plastic instrument is used to push the

floss on palatal side of tooth apical to
Figure 3.38 floss used to invert the dam. maximum height of contour while the floss

Protection of the dam from tearing

Ligation for retraction  An example of protection would be the use of a
wedge interproximally when rotary instruments
are used in the proximity of the dam.
 Occasionally, because of the gingival location of  Another example is the use of a second clamp
a lesion or preparation, a ligature may be helpful to retract the dam below a margin that is near, or
for retracting the dam to a position cervical to below, the level of the gingival crest.
the margin.
 Dental floss or tape is passed through one
interproximal area, around the lingual aspect of
the tooth, then back through the other
interproximal area or contact. Then the floss or
tape is tied, preferably with a surgeon’s knot, on
the facial aspect of the tooth. This ligation will
usually carry the edge of the dam cervically to
expose the area of the planned margin. (figure
3.39)

The use of wooden wedge to protect the

dam.

Removal of the dam

 The interproximal septa are stretched and
clipped with scissors but leave the rubber dam
over the anterior and posterior anchor teeth.
(figure 3.40)

Figure 3.39 dental floss ligation for retraction.

62 Clinical Operative Dentistry
Figure 3.40 removal of the dam.
 The underlying soft tissue must be protected by
the dentist’s fingers, and care must be taken not
to cut the lips of the patient, which sometimes
are exposed on the perforations when the
rubber dam is stretched. (figure 3.41)
Figure 3.41 Note the dentist finger protecting
anesthetized patient's lip.
 When all septa are cut, the clamp is removed
with the forceps and the dam is snapped from
the teeth.
 After the dam is free from the mouth, the teeth
should be examined to ensure that no rubber
remains around them or in the contacts. A small
piece of dam left subgingivally can cause
inflammation, gingival abscess, or even
significant loss of periodontal support.
62
 Gently massage the gingiva surrounding the
tooth especially around the clamped tooth.
(figure 3.42)
Figure 3.42 after the dam is free from the
mouth, the teeth should be examined to
ensure that no rubber remains around them
or in the contacts.
Isolation in Special clinical
situations
Isolation of Malpositioned teeth
To manage these cases, following modifications are
done:
 Adjust the spacing of the holes.
 In tilted teeth, estimate the position of root
center at gingival margin rather than the tip of
the crown.
 Another approach is to make a customized
cardboard template.
63 Chapter 3 Field Isolation 63

Isolation of teeth with Extensive loss of

coronal tissue
When sound tooth margin is at or below the gingival
margin because of decay or fracture, the rubber dam
application becomes difficult. In such cases, to
isolate the tooth:
 Use additional retentive clamps.
 Punch a bigger hole in the rubber dam sheet so
that it can be stretched to involve more teeth,
including the tooth to be treated.
 In some cases, the modification of gingival
margin can be tried so as to provide
supragingival preparation margin.This can be
accomplished by gingivectomy or the flap
surgery.

Isolation of teeth with poor retentive

shapes
Sometimes anatomy of teeth limits the placement of
rubber dam (lack of undercuts and retentive areas in
the tooth). In such cases, following can be done: Figure 3.43 bite block is inserted in the left
 Placing clamp on another tooth. side after rubber dam is applied to isolate
 Building retentive shape on the crown with right side.
composite resin bonded to acid etched tooth
surface.  Bite blocks are available in a variety of sizes.
 A piece of floss or tape may be attached to the
Isolation of Teeth with porcelain crowns bite block to allow retrieval if necessary. (figure
 Clamp should be placed on another tooth. or 3.44)
 Clamp should engage below the crown margin.
Or
 Place a layer of rubber dam sheet between the
clamp and the porcelain crown, which acts as a
cushion and thus minimizes localized pressure
on the porcelain.

Leakage problem
Sometimes leakage is seen through the rubber dam
because of the accidental tears or holes. Such
leaking gaps can be sealed by using cavit (a
provisional restorative material) which hardens with
moisture.

Repair of a torn rubber dam

A small tear in a dam may often be patched. A piece
of dam material is cut to cover the tear, extending 1
cm or so beyond the tear on all sides. The piece is
Figure 3.44 A piece of floss or tape may be
attached over the tear with cyanoacrylate glue. attached to the bite block to allow retrieval
if necessary.
Placement of Bite block
 Patients often have difficulty in keeping their Isolation for a fixed partial denture
mouths open or are uncomfortable with wide When a fixed partial denture must be included, there
opening. are several techniques that can be used; they are all
 A rubber bite block can relieve their discomfort, somewhat time-consuming but often valuable. Two
allow them to relax the musculature, and permit methods are described as in the following:
them to keep the mouth open without effort.
(figure 3.43)
64 Clinical Operative Dentistry 64

First method ‹ Cyanoacrylate method: (figure

3.45 a-e)
 Holes for the teeth are punched in the dam. Note
that no hole is punched for the pontic.
 The holes for the abutment teeth are connected
with a cut that is in an arc to give a “tongue” of
dam material between the holes.
 The tongue of material is folded back, and a
piece of dam material is attached with
cyanoacrylate glue over the opening left when
the tongue was folded back. This piece is glued
into place so that there is a slit connecting the
abutment holes and a tongue of material that is
free to swing down over the attached piece of
dam material.
 The dam is inserted over all teeth for which
holes have been punched, and the tongue of
material is pulled under the pontic(s) and glued
into place on the added piece of dam.
 Tension on the tongue while the glue is setting
(10 to 15 seconds) will ensure that the dam is
tight around the abutments after tension is
released.

Figure 3.45(b) the tongue of material is

folded back, and a piece of dam material is
attached with cyanoacrylate glue over the
opening left when the tongue was folded
back. This piece is glued into place so that
there is a slit connecting the abutment
holes and a tongue of material that is free
to swing down over the attached piece of
dam material.

Figure 3.45(c) The dam is inserted over all

teeth for which holes have been punched.

Figure 3.45(a) the holes for the abutment teeth

are connected with a cut that is in an arc to
give a “tongue” of dam material between the
holes.
65 Chapter 3 Field Isolation 65

unit fixed partial dentures, another hole is

punched for the pontic.
 A piece of floss or suture materials used to
tie through the holes so that the septum
between adjacent holes is stretched around
the retainer-pontic connector.
 If floss is used, a “floss-feeder,” made for
carrying floss under partial denture pontics
for oral hygiene measures, may be used to
guide the floss under the pontic and pull it
through.

Figure 3.45(d) the tongue of material is

pulled under the pontic(s) and glued into
place on the added piece of dam.

Figure 3.46 Procedure for isolating a fixed

bridge. A, Apply the dam except in the area
of the fixed bridge. B, Thread the blunted
suture needle from the facial to the lingual
aspect through the anterior abutment hole,
Figure 3.45(e) Tension on the tongue while then under the anterior connector and
the glue is setting (10 to 15 seconds) will back through the same hole on the lingual
ensure that the dam is tight around the surface. C, Pass the needle facially
abutments after tension is released. through the hole for the second bridge
unit, then under the same connector and
through the hole for the second unit. D, Tie
Second method ‹ Ligation of septa around the off the first septum. E, Cut the posterior
retainer-pontic connectors: (figure 3.46) septum to initiate removal of the dam.
 This procedure is for three-unit fixed partial
dentures or splinted teeth. Holes are
punched for each abutment, and, for three-
66 Clinical Operative Dentistry 66

Placement of clamp over dam dressing are needed, and healing should
proceed uneventfully.
 When it is desirable to clamp a tooth that was
not considered when the dam was punched, the
clamp may be applied over the dam.
 The clamp jaws should be dull, so as not to cut
through the dam.
 The dam should be stretched loosely over the
tooth being clamped, as stretching it tightly will
cause the clamp jaw to perforate the rubber,
initiating a tear in the dam.

Gingival relaxation incisions (figure 3.47)

 When using a no. 212SA retractor for isolation
for a Class 5 restoration, the jaw of the retractor
should be positioned at least 0.5 mm (preferably
1.0 mm) gingival to the gingival margin of the
planned restoration. This can usually be
accomplished without laceration of tissue,
because the free gingiva is elastic enough to be
retracted.
 If, however, the free gingival margin is fibrous
and difficult to displace gingivally, forced
retraction could lacerate the tissue. In such a
case, it is preferable to make one or two small
incisions to allow the tissue to be displaced
without tearing.
 For this technique (sometimes referred to as a
miniflap procedure) to be successful, the
periodontium must be healthy.
 The incisions should be confined to the
keratinized gingival tissue and kept as short as
possible (just long enough to allow adequate
exposure for isolation).
 Incisions can often be limited to the free gingiva,
and, although reattachment to previously
unexposed cementum can be expected,
unnecessary severing of attachment should be
avoided.
 Full-thickness vertical incisions should be
initiated at the mesial and/or distal aspects of
the facial surface and should be directed
perpendicular to the root and surface of bone,
first perpendicular to the gingival margin and
slightly toward the interproximal papilla, then
apically.
 Again, the jaw should be dull, not sharp, so that
it will not damage the root surface. A finger
should be used to hold the clamp in place while
it is stabilized with compound.
 After the restorative procedure is completed:
 The no. 212SA clamp is removed, and then the
dam is removed.
 Any blood in the area is washed away.
 The reflected gingival tissue is returned to its
original location and held there with a dampened
gauze sponge and finger pressure for about 2
minutes to allow initiation of a fibrin clot.
 As long as the incisions were confined to
keratinized tissue, no sutures or periodontal Figure 3.47 miniflap procedure.
67 Chapter 3 Field Isolation 67

Unassisted Evacuation of fluid from the Sealing a root concavity

dam (figure 3.48)  The rubber dam seals well on convex tooth
surfaces.
 The molded plastic suction tip is cut off with a
 If the dam is retracted so that its edge goes
pair of crown scissors; then an additional 0.4
across a root concavity, however, saliva will leak
inch of the plastic tube is cut off without cutting
into the operating field.
the wire within the plastic. The 0.4-inch length of
plastic tubing is then pulled off the wire, leaving  A solution is to seal the gap between the edge of
the wire extending from the end of the tube. the dam and the concave root surface. This may
be accomplished with a provisional restorative
 Using forceps such as hemostats, the wire is
material, such as Cavit (3M ESPE), which
bent in its center at a 90-degree angle in the
direction of the tube to form an “L” shape. hardens with moisture.(figure 3.49)
 The wire is then carried under the jaw of the
clamp and placed into the hole in the jaw of the
clamp, usually on the lingual side of the clamped
tooth.
 This method will supply continuous fluid
evacuation during the operative procedure.

Figure 3.49 sealing a root concavity.

Isolation with Cotton Rolls

Loose cotton can either be rolled manually into a
cotton roll or prefabricated cotton rolls are also
available.

Prefabricated rolls are more compact and can

absorb a greater amount of moisture. (Figure 3.50)

Figure 3.48 Unassisted Evacuation of fluid

from the dam.

Figure 3.50 prefabricated cotton rolls.

68 Clinical Operative Dentistry 68

The removal and placement of cotton rolls is

basically carried out by the operator’s assistant. He
should continually remove drenched cotton rolls
and insert dry ones.

The use of cotton rolls combined with suction in

operative dentistry are indicated in the following
situations:
 When rubber dam isolation is impossible.
 In patients with nasal obstruction or mouth
breathing.
 In patients who are allergic to latex, if latex-free
sheets are not available.
 In teeth that are partially erupted or misaligned
and placing the clamp or other retainer is not Figure 3.52 Cotton roll isolation of the area
possible. adjacent to the mandibular anterior teeth.
 For topical fluoride application. Cotton rolls are placed beside the lower labial
 In cases of temporary restorations. frenulum. Cotton rolls placed on the lingual
 For direct veneers or large restorations on
side are stabilized by the saliva ejector.
anterior teeth. Here, the use of cotton rolls and
suction allows a better overview of the operating  The maxillary posterior teeth are isolated by
field and improved visualization of the inserting a cotton roll in the adjacent vestibule.
relationship between the teeth and the gingival (figure 3.53)
level.
 For multiple cervical lesions. Here several teeth
can be restored at once, while the rubber dam
limits restoring two teeth at a time

Technique:
 For isolation in the maxillary anterior area, small
sized rolls are placed on either side of the labial
frenum. (figure 3.51)

Figure 3.53 Cotton roll isolation of the

Figure 3.51 Cotton roll isolation of the area
of maxillary anterior teeth. Two cotton rolls
placed on each side of the upper labial
frenulum.
 For mandibular anterior area, in the lingual
sulcus along with one cotton roll on either side
of the mandibular labial frenum. (figure 3.52)
area adjacent to the maxillary posterior
teeth.
 The mandibular posterior teeth are isolated by
inserting one cotton roll in the buccal vestibule
usually the medium sized roll and the larger one
between the teeth and the tongue. In the lingual
sulcus even two cotton rolls can be used, one
inserted to the depth of the sulcus and the other
one laid above it. (figure 3.54)
 Such placements are aided by the use of saliva
ejectors to remove saliva from the lingual
sulcus.
 One should take care while removing cotton
rolls that they should be moist not dry, to
prevent inadvertent removal of the epithelium.
69 Chapter 3 Field Isolation 69

 Always protect floor of mouth beneath the

ejector using cotton rolls or gauze piece to avoid
tissue injury.

Throat shield
 It is especially important when maxillary tooth is
being treated.
 Unfolded gauze sponge is stretched over tongue
and posterior part of mouth.
 It is useful in recovering a restoration (e.g.
crown) if it is dropped in oral cavity.
 Disadvantage: Not well tolerated by some
patient as it can cause gagging.

Figure 3.54 Cotton roll isolation of the area of

mandibular posterior teeth. a Cotton rolls
positioned on the lower vestibule, under the
tongue and over the exit of the parotid duct.

Disadvantages
 Provide only short-term moisture control.
 Ineffective if high volumes of fluid are present.
 Shallow sulci and hyperactive tongue may make

placement and retention difficult.

Note that after acid etching and rinsing of the Gauze piece
surface during an adhesive technique, you need
to change the cotton rolls or absorbent pads in
order to avoid moisture reaching the operating
field. Also, if the cotton rolls are contaminated
with adhesive or resin-based materials, these
must be changed to avoid contact of
unpolymerized material with the patient’s soft
tissues.

Low-Volume Evacuator (Saliva Ejector)

Disposable plastic suction tip. Throat shield is useful in recovering a

Precautions to be Taken While Using Saliva
Ejector:
 Before using, mold the ejector so that its tip
faces backward with upward curvature. In other
words, floor of mouth should not directly
contact the tip so as to avoid trauma.
 Sides of saliva ejector should not rub against
surface of mouth to avoid injury.
 When rubber dam is used, always make a hole
so that ejector can pass through the dam
instead of placing it under the dam.
restoration (e.g. crown) if it is dropped in oral
cavity.
Gingival retraction
Indications of gingival retraction:
 Control of gingival bleeding especially when the
margins of restoration are close to gingiva, for
example, restoration of class V.
 To extend the margins subgingivally in case of
cervical Caries extending below the gingiva.
70 Clinical Operative Dentistry 70

Retraction cord
Flexible cords are inserted into the gingival crevice
to retract the gingiva, improve the visualization and
access to gingival margins during tooth preparation
and restoration, as well as control gingival fluid or
bleeding during the restorative procedure.
When applying cords impregnated with astringent,
their use shall be limited to short periods of time,
preferably up to 15 min. Since procedures in
operative dentistry generally take longer,
mechanical retraction is preferred using non-
impregnated cords.
 Cord should end where interdental col has the
maximum height.
 Remove the cord slowly and take care that it
should not be dry. A dry cord may adhere to
epithelium and on removal, it may cause its
abrasion.
 Check for any pieces of retraction cord
immediately after its removal and remove if any,
to avoid gingival irritation.
 It should not be used for the displacement of
gingival tissues when the gingival tissues are
swollen/inflamed. (Used only in healthy gingiva).

Application: (figure 3.56)

 Anesthetize the area.

 Select the appropriate size of cord which can be
placed into gingival sulcus without causing any
injury/ ischemia.
 Take the length of cord so that it extends1mm
beyond the gingival width of the preparation or
extends around the Whole circumference of the
tooth.
 Take an instrument for packing the cord. It
should be blunt hatchet or hoe shaped.

Cord tucking instrument.

 Apply slight force laterally and slightly

angulated towards the tooth surface. Avoid
application of apical pressure as it May harm the
junctional epithelium. (figure 3.55)

Figure 3.55 while tucking the cord in the sulcus,

apply slight force laterally and angulated
towards tooth surface.
 Insert one end of the cord, stabilize it with blunt
instrument and pack the rest of the cord. Avoid
putting ends of the cord interproximally for
better grip of the cord.
Figure 3.56 placement of retraction cord.
Rolled cotton twills
 Is simple and effective method which is used for
lateral displacement of the gingival tissue by
mechanically packing the cotton twills in the
sulcus.
71 Chapter 3 Field Isolation 71

 Cotton twills combined with zinc oxide eugenol

(fast-setting) can also be used for gingival
retraction.

Rotary Curettage (gingetage)

 This is troughing technique which is used to
remove minimal Amount of gingival epithelium
during placement of restorative margins
subgingivally.
 This is usually done with high speed handpiece
and chamfer diamond bur.
 Disadvantages of rotary curettage are:
 Excessive bleeding.
 Damage to gingiva.

Rotary curettage.
73
75 Chapter 4 Morphologic features of teeth 75

THE PERMANENT MAXILLARY

INCISORS

PERMANENT MAXILLARY CENTRAL

INCISOR (Figures 4.1 a-d)

 The mesiodistal dimension of maxillary central

incisor is wider than that of any other anterior
tooth.
 The tooth is longer cervicoincisally than it is
wider mesiodistally
 The mesial outline is relatively straight and
meets incisal edge at a sharp angle.
 The distal outline is more convex than the
Figure 4.1(b) Lingual aspect.
mesial outline & the distoincisal angle is more
rounded.
 Mesial contact area is at incisal third of the
crown near the mesioincisal angle.
 Distal contact area is higher towards the cervical
line, at the junction of incisal and middle third of
the crown at the center labiolingually.
 Height of labial contour of the crown is at the
cervical third.
 Incisal ridge is usually regular and straight
mesiodistally.
 Newly erupted incisors show three elevations at
incisal portion called ‘mamelons’ corresponding
to three labial lobes. The mamelons disappear
soon as the incisal surface of the tooth gets
worn by mastication.
Figure 4.1(c) Mesial aspect.
 It has lingual convergence: Lingual surface of
crown is narrower than the labial surface.

Figure 4.1(d) Distal aspect.

Figure 4.1(a) Labial aspect.
76 Clinical Operative Dentistry 76

PERMANENT MAXILLARY LATERAL

INCISOR (Figures 4.2 a-d)

 It is smaller than the central incisor in all

dimensions except root length. Labial surface is
about 2 mm narrower and 2: 3 mm shorter than
the maxillary permanent central incisor.
 It shows greater variation in morphology than
any other teeth except third molars.
 Mesioincisal angle is more rounded than that of
maxillary permanent central incisor.
 Distal outline is shorter than mesial outline. It is Figure 4.2(a) Labial aspect.
more rounded than found in maxillary
permanent central incisor with more rounded
distoincisal angle. In some maxillary permanent
lateral incisors, the distal outline may be a
semicircle extending from cervix up to center of
the incisal ridge.
 Mesial contact area is at the junction of middle
and incisal thirds.
 Distal contact area is at the center of the middle
third.
 Incisal ridge is relatively straight and distal half
is more rounded curving towards cervical line to
Figure 4.2(b) Lingual aspect.
join the distal outline.
 Labial outline of maxillary permanent lateral
incisor is less convex than labial outline of
maxillary permanent central incisor with Height
of labial contour of the crown at cervical third.
 There is lingual convergence of proximal walls
as seen in maxillary permanent central incisor.
 Lingual surface is more regular. Marginal ridges
are more prominent and stronger than found on
central incisor. Lingual fossa is deeper and well-
circumscribed. Cingulum is more prominent.
 There may be a deep developmental groove
crossing the distal side of the cingulum
extending on the root for a varying length. This Figure 4.2(c) mesial aspect.
groove is called as palatogingival groove or
palatoradicular groove.(Deep palatogingival
developmental groove may cause localized
periodontal disease)

Figure 4.2(d) Distal aspect.

77 Chapter 4 Morphologic features of teeth 77

THE PERMANENT MANDIBULAR

INCISORS

PERMANENT MANDIBULAR CENTRAL

INCISOR (Figures 4.3 a-d)
 Mandibular central incisors are the smallest
teeth in the permanent dentition.
 They are also among the first permanent teeth to
erupt into the oral cavity along with the 1st
molars around 6 to 7 years of age.
 Both mesioincisal and distoincisal angles are
sharp and at right angles.
 Mesial and distal contact areas are at incisal
third near the mesial and distal incisal angles.
This places both the contact areas at the same Figure 4.3(c) mesial aspect
level.
 Height of labial contour of the crown is at the
cervical third
 Incisal ridge is straight.

Figure 4.3(d) distal aspect

Figure 4.3(a) Labial aspect.  In a tooth with occlusal wear, there is a flat
incisal edge sloping labially. Incisal surface of
mandibular incisors have a labial slope and
occlude with lingually sloping incisal edges of
the maxillary incisors during mastication.
(Figures 4.3)

 The lingual marginal ridges are ill defined. The

lingual fossa between marginal ridges and
cingulum is a smooth shallow concavity devoid
of developmental grooves.

 The crown appears to be inclined lingually. The

lingual inclination of crown is a feature of
mandibular teeth to facilitate normal overjet.

Figure 4.3(b) Lingual aspect.

78 Clinical Operative Dentistry 78

Figure 4.5(a) Labial aspect.

Figure 4.4 Incisal surface of mandibular incisors

have a labial slope and occlude with lingually
sloping incisal edges of the maxillary incisors.

PERMANENT MANDIBULAR LATERAL

INCISORS (Figures 4.5 a-d)

 Mandibular lateral incisor is very similar to the

mandibular central in form. It is slightly larger
than the mandibular central incisor. The
mesiodistal width of crown is approximately 1
mm more than that of mandibular central
incisor. Figure 4.5(b) Lingual aspect.
 Mesioincisal angle forms a right angles but the
distoincisal angle is more rounded.
 Mesial outline is longer than the distal outline.
 Mesial contact area is at incisal third of crown.
 Distal contact area is still within incisal third but
is more cervically placed than the mesial contact
area in order to reach the mesial contact area of
mandibular canine.
 Height of labial contour is at cervical third.
 The incisal ridge is straight but has a tendency
to slope cervically in a distal direction.
 In a worn tooth, an incisal edge with a labial
slope is seen.
 Lingual surface is similar to that of mandibular
central incisor but is wider mesiodistally.

Figure 4.5(c) Mesial aspect.

79 Chapter 4 Morphologic features of teeth 79

 The mesial contact area is broader than the

distal.
 Height of labial contour is within cervical third
but is placed more incisally than that of the
maxillary permanent central incisor.
 The distal cusp ridge is longer and is slightly
rounded, whereas the mesial cusp ridge is
usually concave.
 The pointed cusp becomes flat over the time due
to wearing away.
 Position of cusp tip: The cusp tip is located
labial to the center of the crown labiolingually,
and mesial to the center mesiodistally.
 The cingulum of maxillary canine is largest of all
anteriors and sometimes it is pointed like a
Figure 4.5(d) Distal aspect. small cusp.
 The lingual fossa is more concave and may be
divided by a lingual ridge into two small
THE PERMANENT CANINES concavities called mesial and distal lingual
fossae. The lingual fossa is usually devoid of
Common Characteristics (Class Traits) OF any developmental grooves. The distal lingual
Permanent canines: marginal ridge is strongly developed than the
mesial.
1. They are wider buccolingually than
mesiodistally.
2. Their labial surfaces have a labial ridge
extending from the cusp tip to the cervical line.
3. Lingual aspect shows well-formed cingulum and
a lingual fossa, which may be divided by a
lingual ridge into two small fossae.
4. Their distal cusp slope is longer than the mesial
cusp slope.
5. The canines typically have their contact areas at
different levels cervico-occlusally. This is
because the adjacent teeth of canines, with
which they make contact, are of different
classes lateral incisor mesially and the 1st Figure 4.6(a) Labial aspect.
premolar distally.

Permanent maxillary canines (Figures 4.6

a-d)

 The crown is narrower than the maxillary central

incisor mesiodistally by 1 mm and much
narrower at cervix.
 Mesial outline is a convex arc from cervix to the
area where it joins the mesial cusp slope.
 Distal outline is convex for most of its part
except near cervix, where it is concave.
 Mesial contact area is at the junction of incisal
and middle third of the crown and is at the center
labiolingually. Figure 4.6(b) Lingual aspect.
 Distal contact area is at the center of middle
third of the crown.
80 Clinical Operative Dentistry 80

 The lingual surface is less concave and more

flattened similar to that of mandibular lateral
incisor. The lingual fossa is shallow. The
cingulum is poorly developed. The marginal
ridges are less prominent.
 The cusp tip is in the center or lingual to the
vertical root axis. It can be remembered that
cusp tip of maxillary canine is labial to the
vertical root axis.
 Cusp tip and cusp ridges are lingually inclined.
Whereas cusp ridges of maxillary canine extend
straight to bisect the mesial and distal contact
areas.

Figure 4.6(c) Mesial aspect.

Figure 4.7(a) Labial aspect.

Figure 4.6(d) Distal aspect.

Permanent mandibular canines (Figures

4.7 a-d)

 The mandibular canine closely resembles the

maxillary canine. In comparison to its maxillary
counterpart, the mandibular canine has a long
narrow crown, poorly developed cingulum and
less prominent cusp.
 The mesial contact area is near the mesioincisal
angle.
 The distal contact area is more incisally located
than that of maxillary canine.
 Cusp ridges are straight and the distal cusp
ridge is longer than the mesial as in case of
maxillary canine.
 Crown of mandibular canine appears longer, not Figure 4.7(b) Lingual aspect.
only because of its extra length of 1 mm, but also
due to its narrow mesiodistal width and more
incisally placed contact areas.
 When cusp tip is worn off, the tooth appears like
a lateral incisor from labial aspect.
81 Chapter 4 Morphologic features of teeth
Figure 4.7(c) Mesial aspect.
Figure 4.7(d) Distal aspect.
THE PERMANENT MAXILLARY
PREMOLARS
Common Characteristics (Class Traits) of
Premolars:
1. They generally have two cusps, one buccal and
one lingual except for mandibular 2nd premolars
which often carry three cusps.
2. Their buccolingually dimension is greater than
the mesiodistal dimension.
3. The contact areas are broader than that of the
anterior and are placed nearly at the same level.
Contact areas are buccal to center of the crowns
buccolingually.
4. Height of buccal and lingual contours are more
occlusal than seen on anterior teeth.
5. Marginal ridges are at a higher level (occlusally
placed) mesially than distally. Exception is in
case of mandibular 1st premolar where the distal
marginal ridge is more occlusally placed than
mesial marginal ridge.
81
MAXILLARY PERMANENT 1st premolar
(Figures 4.8 a-d)
 Tooth appears similar to maxillary canine from
buccal aspect but the crown is shorter and
narrower than that of maxillary canine.
 The maxillary permanent 1st premolar has two
cusps: buccal and lingual cusps.
 The buccal cusp is longer than the lingual cusp
by 1 mm.
 The mesial outline is slightly concave near
cervical line and becomes convex as it joins the
mesial cusp slope. Distal outline is more
straighter
 Mesial contact area is occlusal to the center of
crown cervico-occlusally and more bucally
placed buccolingually.
 Distal contact area is broader, slightly occlusally
placed than the mesial contact area and more
buccally placed buccolingually.
 Buccal Height of contour is at the junction of
cervical and middle third.
 Mesial cusp slope of buccal cusp is straight or
sometimes concave whereas distal cusp slope
is more rounded.
 Mesial slope of buccal cusp is longer than the
distal slope (It can be remembered that distal
cusp slope is generally longer in other teeth).
 Lingual cusp is pointed with its cusp slopes
meeting at right angles.
 Lingual surface is narrower than buccal surface
as the proximal walls converge towards smaller
lingual cusp.
 A marked concavity located in the center of the
mesial surface, cervical to the contact area is
called as mesial developmental depression.
This concavity extends apically crossing the
cervical line and joins the developmental
depression between the two roots.
 There is a deep developmental groove crossing
the mesial marginal ridge called mesial marginal
developmental groove. This groove runs from
occlusal surface and crosses the marginal ridge
lingual to the mesial contact area to end on the
mesial surface after running for a short distance.
82 Clinical Operative Dentistry
Figure 4.8(a) Buccal aspect. Note that Tooth
appears similar to maxillary canine from buccal
aspect but the crown is shorter and narrower than
that of maxillary canine.
Figure 4.8(b) lingual aspect
Figure 4.8(c) mesial aspect
82
Figure 4.8(d) Distal aspect.
Occlusal Aspect of maxillary first premolar
(Figure 4.9)
 The crown is wider buccally than lingually.
 The buccal cusp is placed slightly distal to the
midline.
 The lingual cusp tip is located mesial to the
midline.
 Mesiobuccal cusp ridge meets the mesial
marginal ridge at right angles whereas the angle
formed by distobuccal cusp ridge with distal
marginal ridge is acute.
 Mesial and distal marginal ridges converge
towards lingual cusp.
 Buccal and lingual cusps:
- Among the two cusps, the buccal cusp is
longer and well-formed:
 Mesiobuccal and distobuccal cusp ridges are
well-defined and make a relatively straight line.
 Buccal triangular ridge is well-defined
extending from buccal cusp tip lingually up to
the central developmental groove in the center
of the occlusal surface.
- Lingual Cusp:
 The lingual cusp is smaller and shorter than the
buccal cusp.
 Mesiolingual and distolingual cusp ridges are
more curved and form a semicircular outline
merging with the marginal ridges.
 A less prominent lingual triangular ridge
extends from lingual cusp tip to the central
groove.
83 Chapter 4 Morphologic features of teeth 83

- There are four major grooves:

1. Central groove.
2. Mesiobuccal groove.
3. Distobuccal groove.
4. Mesial marginal developmental groove.
 The central developmental groove running in a
mesiodistal direction divides the occlusal
surface evenly. This groove is at the bottom of
central sulcus.
 Two small grooves join the central groove near
mesial and distal marginal ridge buccally. These
are called mesiobuccal and distobuccal
developmental grooves.
 The mesial marginal developmental groove
extends from the central groove mesially and
crosses the mesial marginal ridge to reach the
mesial surface. This is the important identifying
feature of maxillary 1st premolar.
- There are two pits:
 Mesial pit is formed by convergence of Central
developmental groove, Mesiobuccal
developmental groove & mesial marginal
developmental groove.
 Distal pit is formed by convergence of Central
developmental groove & Distobuccal
developmental groove.

- There are two marginal ridges:

 Mesial marginal ridge is notched by mesial
marginal developmental groove.
 Distal marginal ridge is smooth. Figure 4.9 occlusal aspect

- There are two triangular fossae: MAXILLARY PERMANENT 2nd premolar

(Figure 4.10 a-d)
 Mesial triangular fossa is a small triangular
depression with mesial marginal ridge forming  Mesial outline is slightly convex from cervix to
the base and mesial pit forming the apex of the the point where it joins the mesial slope of the
triangle.Mesial marginal groove runs across buccal cusp.
mesial triangular fossa.  Distal outline is more convex than the mesial
 Distal triangular fossa is a shallower triangular outline.
depression with distal marginal ridge forming  Mesial contact area is broader than that of the
the base and distal pit forming the apex of the maxillary permanent 1st premolar though
triangle. located at the same level (occlusal to center of
crown).
 Buccal height of contour as located at cervical
third while lingual height of contour is located at
middle third.
 The tip of the buccal cusp is less pointed than
that of maxillary permanent 1st premolar.
 Distal slope of buccal cusp is longer than the
mesial slope. This feature is similar in all the
permanent canines and premolars. (One
exception is maxillary 1st premolar in which the
mesial slope is longer than the distal slope).
84 Clinical Operative Dentistry
 Its buccal ridge is not as prominent as that of
maxillary permanent 1st premolar.
 The lingual cusp is nearly as long as the buccal
cusp.
Figure 4.10(a) Buccal aspect.
Figure 4.10(b) Palatal aspect.
Figure 4.10(c) Mesial aspect.
84
Figure 4.10(d) Distal aspect.
Occlusal Aspect of maxillary second premolar
(Figure 4.11 a-b)
 The crown tapers lingually to a lesser extent
than the maxillary permanent 1st premolar,
since both buccal and lingual cusps are of
similar size.
 Lingual cusp is as large as buccal cusp and their
tips are less pointed than that of maxillary
permanent 1st premolar cusps.
 Grooves:
 The central developmental groove is shorter and
irregular
 Multiple supplementary grooves radiate from
the central developmental groove giving a
wrinkled appearance to the occlusal surface.
 Pits: The mesial and distal pits are placed less
apart as the central developmental groove is
shorter.
 Marginal Ridges and Fossae:
 Both mesial and distal marginal ridges are
strong and well-developed.
 Mesial and distal triangular fossae are shallow
and harbor supplemental grooves.
Figure 4.11(a) Compared to first premolar, the
second premolar is less angular with oval
occlusal form, two cusps of equal size.
85 Chapter 4 Morphologic features of teeth 85

groove of occlusal surface onto the lingual

surface mesially.
 The mesial marginal ridge slopes prominently in
lingual direction. Distal marginal ridge is
perpendicular to the long axis of tooth rather
than sloping lingually. It is placed at a higher
level than mesial marginal ridge from the cervix.

Figure 4.11(b) Occlusal aspect of

maxillary second premolar

THE PERMANENT MANDIBULAR

PREMOLARS

PERMENANT MANDIBULAR 1st premolar

(Figure 4.12 a-d) Figure 4.12(a) Labial aspect.

 Mesial outline is convex except near the cervical

line where it is slightly concave.
 Distal Outline is concave near the cervix and
becomes convex as it joins the occlusal outline.
 The mesial contact area is just occlusal to the
center of the crown cervico-occlusally and is in
line with the buccal cusp tip.
 The distal contact area is broader and is at the
same level as the mesial contact area.
 Height of buccal contour is at the cervical third
of the crown.
 Lingual height of contour is at the middle third
of crown, near to lingual cusp tip.
 The buccal cusp tip is sharp and the
mesiobuccal and distobuccal cusp ridges are Figure 4.12(b) Lingual aspect.
slightly concave on unworn premolar.
 Distal cusp ridge is longer than the mesial cusp
ridge. The buccal cusp tip is pointed and is
placed slightly mesial to the center of the crown.
 The lingual cusp tip is pointed.
 Lingually, the occlusal outline is notched by a
groove passing between mesial marginal ridge
and mesiolingual cusp ridge.
 There is marked lingual convergence of the
crown resulting in a much narrower lingual
surface.
 The characteristic feature of mandibular 1st
premolar is the mesiolingual developmental
groove extending from mesial developmental

Figure 4.12(c) Mesial aspect.

86 Clinical Operative Dentistry 86

Figure 4.12(d) Distal aspect.

Occlusal Aspect of mandibular first premolar Figure 4.13 Occlusal aspect.

(Figure 4.13)
 Buccal cusp is larger making the major bulk of PERMANENT MANDIBULAR 2nd premolar
the crown and the lingual cusp is much smaller. (4.15 a-d)
The crown converges sharply towards lingual
 The mandibular 2nd premolar is larger than the
surface. Buccal triangular ridge is strong and
mandibular 1st premolar and it resembles the
well developed whereas the lingual triangular
latter only from buccal aspect.
ridge is less defined.
 Fossae :  These are two common forms of mandibular 2nd
premolar: (Figure 4.14)
 Mandibular 1st premolar has two fossae: The
mesial and the distal - Three cusp form (‘Y’ groove pattern) ;
Frequently seen
 The fossae near marginal ridges are irregular
- Two cusp form (‘U’ and ‘H’ groove pattern).
rather than triangular and thus named as mesial
and distal fossae.

 Grooves :
- It has three grooves:
1. Mesial developmental groove: It is located in the
mesial fossa; is short and extends
buccolingually.
2. Distal developmental groove: It is in the distal
fossa is longer.
3. Mesiolingual developmental groove: It is
continuous from mesial groove and it extends
between mesial marginal ridge and mesiolingual
cusp ridge onto the lingual surface mesially.
This groove is the characteristic feature of
mandibular 1st premolar.
Figure 4.14 Mandibular second premolar have
 Marginal Ridges: diverse occlusal anatomy a) with 3 cusps (Y
 Mesial marginal ridge is shorter and is groove pattern) b) with 2 cusps (U groove
constricted because of mesiolingual pattern) c) with 2 cusps (H groove pattern)

developmental groove. It slopes sharply

lingually in a cervical direction.
 The distal marginal ridge is confluent with the
distolingual cusp ridge.
 Mesial outline is convex for a short distance
near the cervical line.
 The distal outline is more convex.
87 Chapter 4 Morphologic features of teeth 87

 Mesial contact area is at the middle third of the

crown and centered buccolingually.
 Distal contact area is also at the middle third but
is broader.
 Buccal the height of contour is at the middle
third of crown.
 Lingual height of contour is at the occlusal third
of the crown.
 Buccal cusp tip is blunt with the mesial and
distal buccal cusp ridges meeting at a more
obtuse angle.
 The buccal ridge extending from cervical line to
the buccal cusp tip is very prominent.
 The crown does not taper much lingual. Figure 4.15(c) Mesial aspect.
 The lingual cusp/cusps are well developed and
are of nearly same length as that of buccal cusp.
 The mesial marginal ridge is at right angles to
the long axis of the tooth.
 The distal marginal ridge is also at right angles
to the long axis but is at a lower level than the
mesial marginal ridge.

Figure 4.15(d) Distal aspect.

Occlusal Aspect of mandibular second

premolar
There are two common forms:
 Three cusps type with a ‘Y’ groove pattern.
 Two cusps type with a ‘U’ or ‘H’ groove pattern.

Three Cusps Type (More Common) (Figure 4.16 a-b)

 There are three cusps:

Figure 4.15(a) Buccal aspect.
- Buccal cusp is the largest one, followed by
mesiolingual cusp and distolingual cusp in that
order.
- Each cusp has mesial and distal cusp ridges of
its own, and a triangular ridge sloping from cusp
tip towards the center of the occlusal surface.

 Grooves :
- There are three developmental grooves
converging at a central pit and thus, forming a
‘Y’ shaped pattern.
- Few supplementary grooves radiate from
developmental grooves in the triangular fossa.

Figure 4.15(b) Lingual aspect.

88 Clinical Operative Dentistry 88

- Mesial developmental groove: It is long and runs

from the central pit mesiobuccally and ends in
the mesial triangular fossa.
- Distal developmental groove: It is a shorter
groove running from the central pit to the distal
triangular fossa.
- Lingual developmental groove:
 It runs in a lingual direction between two lingual
cusps and ends on the lingual surface of the
crown.
 The mesiolingual cusp is wider than distolingual
cusp; the lingual groove is placed slightly distal
to the center of the crown
- In three cusp type, there is no central
developmental groove.

 Pits: There are three pits:

Figure 4.16(b) Three Cusps Type (More
- Central pit is located in the center of occlusal Common)
surface buccolingually and slightly distal to the
center mesiodistally.
- Mesial pit is in the mesial triangular fossa. Two cusps type with a ‘U’ or ‘H’ groove pattern
- Distal pit is in the distal triangular fossa. (Figure 4.17)

 Marginal Ridges:  The two cusps are buccal and lingual. Buccal
- Both the marginal ridges are strongly cusp is larger and lingual cusp is also well
developed. developed though it is slightly smaller. The
- Sometimes supplementary groove can cross crown tapers slightly towards lingual aspect.
them.  The cusps have mesial and distal cusp ridges
and occlusally converging triangular ridges.
 Fossae:  Grooves :
- There are two small triangular fossae: mesial - The central developmental groove extends
and distal mesiodistally across the occlusal surface and
- Triangular fossae harbor mesial/distal ends in mesial and distal fossae.
developmental groove mesial/distal pit and - It may be straight/crescent shaped and
some supplemental grooves. separates the triangular ridges of buccal and
lingual cusps.
- There are two groove patterns:
 ‘U’ pattern: Where central groove is crescent
shaped.
 ‘H’ pattern: Where central groove is straight
connecting mesial and distal fossa.

 Pits:
- There may be mesial and distal pits located in
the mesial and distal fossae.
- In two cusps type, there is no central pit.

 Marginal Ridges and Fossae:

- Mesial and distal marginal ridges are strongly
developed.
- The fossae near marginal ridges are irregular
rather than triangular and are called as mesial
Figure 4.16(a) Occlusal aspect.
and distal occlusal fossae.
89 Chapter 4 Morphologic features of teeth
Figure 4.17 Two cusps type with a ‘U’ or ‘H’ groove
pattern
THE PERMANENT MAXILLARY
MOLARS
Common Characteristics (CLASS TRAITS) of
Molars:
1. The crowns usually taper from mesial to distal
aspect so that the buccolingual width of the
mesial half is greater than that of the distal half.
2. The mesial and distal contact areas are broader
and at the same level.
3. Usually, their distal marginal ridge is at a lower
level than the mesial marginal ridge.
4. The crest of curvature of the crowns on buccal
surface is at the cervical third, whereas that of
the lingual curvature in the middle third of the
crown.
5. The lingual cusps (especially, the mesiolingual
cusp) are longer than the buccal cusps.
Permanent Maxillary 1st molar (Figure
4.18 a-d)
 The mesial outline is straight for most its course
and becomes slightly convex as it joins the
occlusal outline. There is a concavity cervical to
the contact area.
 The distal outline is a more convex arc from
cervix up to the point where it joins the occlusal
outline except for a concave area near the
cervical line.
 Mesial contact area is at the occlusal third of the
crown is more buccally placed buccolingually.
 Distal contact area is at the middle third of the
crown. The distal contact area is at the center of
the crown both cervico-occlusally and
buccolingually.
89
 Height of contour of the buccal outline is within
the cervical third. While Height of lingual
contour is at the middle third of the crown.
 The cusp slopes of mesiobuccal cusp make an
obtuse angle, whereas the cusp slopes of
distobuccal cusp meet at right angle.
 The occlusal outline is interrupted in midway by
the buccal developmental groove. The buccal
developmental groove separating the buccal
cusp runs for half the length of buccal surface
and ends in the buccal pit.
 The mesiobuccal cusp is widest but the
distobuccal cusp is more pointed.
 The mesiolingual cusp is much larger than the
distolingual cusp which is smooth and
spheroidal.
 The lingual developmental groove interrupts the
occlusal outline. The lingual development
groove separating the two lingual cusps is
confluent with the distolingual cusp, and
extends mesiocervically to end at the center of
lingual surface.
 The slopes of mesiolingual cusp are longer and
meet at an obtuse angle.
 The characteristic feature of lingual surface of
maxillary 1st molar is the presence of some
expression of Carabelli’s trait. The fifth cusp
may be well developed into a large cusp or may
show traces of its development in the form of
grooves, depressions or pits.
 The distal marginal ridge is shorter and at a
lower level than the mesial marginal ridge.
 The distal surface is narrower than the mesial
surface as the crown tapers towards distal
aspect.
Figure 4.18(a) Buccal aspect.
90 Clinical Operative Dentistry 90

dimension buccally. In other words, the crown

does not show lingual convergence which is
generally seen in most permanent teeth.
 The maxillary 1st molar has four major cusps
and a supplemental fifth cusp (cusp of
Carabelli), which may or may not be well
developed. The cusps in the decreasing order of
size are:
1) Mesiolingual (largest cusp)
2) Mesiobuccal
3) Distobuccal
4) Distolingual
5) Fifth cusp.
- Each cusp has mesial and distal cusp ridges and
a triangular ridge of its own slopping towards
the center of the occlusal surface.
Figure 4.18(b) Palatal aspect.
- There are inclined planes on either side of each
triangular ridge.
- There is an additional ridge crossing the
occlusal surface obliquely, called the oblique
ridge. The oblique ridge is formed by the union
of the triangular ridge of the distobuccal cusp
and the distal ridge of the mesiolingual cusp. It
is at the same level as the marginal ridges and
is sometimes crossed by a developmental
groove.
 Grooves :
- The maxillary 1st molar exhibits several
developmental and supplemental grooves on its
occlusal surface. The developmental grooves
Figure 4.18(c) Mesial aspect.
are:
 The buccal developmental groove
 The central developmental groove
 The transverse groove of oblique ridge
 Distal oblique groove
 Fifth cusp groove
 Multiple supplemental grooves.
- Buccal developmental groove: It runs buccally
from the central pit located in the central fossa
and continuous onto the buccal surface of the
crown separating the two buccal cusps.
- Central developmental groove: It runs in a
mesial direction and ends at the apex of mesial
triangular fossa where it is joined by
Figure 4.18(d) Distal aspect. supplemental grooves. This groove separates
the triangular ridges of mesiobuccal and
Occlusal Aspect of maxillary first molar mesiolingual cusps.
(Figure 4.19) - Transverse groove of oblique ridge: It runs in a
 The crown tapers distally, thus it can be noted distolingual direction from the central pit and
that, the buccolingual measurement of the crosses the oblique ridge to reach the distal
crown mesially is greater than the same fossa.
measurement distally. - Distal oblique groove :

 The mesiodistal dimension of the crown  It is irregular and runs in an oblique direction;
lingually is greater than its mesiodistal parallel to the oblique ridge. This groove
91 Chapter 4 Morphologic features of teeth 91

separates the distolingual cusp from the rest of o It has distal oblique developmental groove at its
the occlusal surface. deepest position.
 The distal oblique groove joins the lingual  Mesial triangular fossa:
developmental groove which runs the lingual o Mesial triangular fossa is a triangular
surface separating the two lingual cusps. depression having mesial marginal ridge for its
- Fifth cusp groove: It separates the fifth cusp base and mesial pit for its apex.
from the mesiolingual cusp, when the fifth cusp o Supplemental grooves radiate from the mesial
is not well developed, these is some trace of fifth pit forming the side of the triangle.
cusp development in the form of a  The distal triangular fossa:
developmental groove which is also called as o The distal triangular fossa has the distal
fifth cusp groove. marginal ridge at its base and distal pit at its
- Multiple supplemental grooves: There are apex.
several supplementary grooves especially at the o Supplemental grooves radiate from the distal pit
apices of mesial and distal triangular fossae. forming the sides of triangle.
Some of these supplemental grooves may cross
the marginal ridges.  Marginal Ridges:
 Pits: Three pits can be noted on the occlusal - The mesial and distal marginal ridges are well
surface of maxillary 1st molar: developed.
- Central Pit: It is a pin point depression in the - The distal marginal ridge is shorter and is at a
central fossa. Three major developmental lower level than the mesial marginal ridge.
grooves originate from the central pit and run in
three different directions. The three grooves are
at obtuse angles to each other. They are the
buccal developmental groove radiating in a
buccal direction, the central developmental
groove running mesially &Transverse groove of
oblique ridge running distally.
- Mesial Pit: It is at the apex of mesial triangular
fossa developmental groove terminates at this
pit.
- Distal Pit: It is at the apex of the distal triangular
fossa and the distal oblique grooves ends at this
pit.
 Fossae :
- There are two major and two minor fossae.
- The two major fossae are central fossa and the
distal fossa.
- The two minor fossae are mesial and distal
triangular fossae.
 The central fossa:
o The central fossa is a large triangular
depression in the center of the occlusal surface
mesial to the oblique ridge.
o The central fossa is bounded by the distal slope
of the mesiobuccal cusp, mesial slope of the
distobuccal cusp, the crests of the oblique ridge Figure 4.19 Occlusal aspect.
and the crests of triangular ridge of mesiobuccal
and mesiolingual cusps. PERMANENT MAXILLARY 2nd molar
o It has the central pit at its center and three major (4.21a-d)
developmental grooves run across it.
 The distal fossa:  There are two forms of maxillary 2nd molar
o The distal fossa is small linear developmental depending on their occlusal anatomy : (Figure
depression distal to the oblique ridge. 4.20)
92 Clinical Operative Dentistry 92

 Four cusp type with rhomboidal occlusal

design. This type is more common and
resembles maxillary 1st molar in occlusal form.
 Three cusp type with pear/heart-shaped
occlusal aspect resembling maxillary 3rd molar.

Figure 4.21(a) Buccal aspect.

Figure 4.20 There are two forms of maxillary 2nd

molar depending on their occlusal anatomy: a) 4
cusp type b) three cusp type

 Mesial contact area is at the junction of occlusal

and middle third of crown.
 Distal contact area is at the middle third of the
crown.
 Buccal Height of buccal contour is in the
cervical third of the crown. Buccal contour of all
the molars exhibit maximum convexity at the
cervical third—due to buccal cervical ridge.
 Height of lingual contour—at the middle third.
Buccal surface is similar to that of maxillary
permanent 1st molar. But the crown is shorter
and narrower mesiodistally
 The distobuccal cusp is much smaller and Figure 4.21(b) Palatal aspect.
shorter than the mesiobuccal cusp.
 The buccal developmental groove separates the
two buccal cusps.
 There are sharper mesiolingual cusp and
rounded distolingual cusp. The outline is
interrupted by the lingual developmental
groove.
 The distolingual cusp is much smaller and
shorter than the mesiolingual cusp.
 There is no fifth cusp seen.
 The distal marginal ridge is at a lower level than
mesial marginal ridge.

Figure 4.21(c) Mesial aspect.

93 Chapter 4 Morphologic features of teeth
Figure 4.21(d) Distal aspect.
Occlusal Aspect of maxillary second molar
Four-cusp type with Rhomboidal Form: (Figure 4.22-
4.23)
 The tooth resembles maxillary permanent 1st
molar.
 Mesiolingual cusp is the largest followed by the
mesiobuccal cusp.
 The distobuccal cusp is less well developed and
its small size accentuates the rhomboid outline
of occlusal aspect.
 The distolingual cusp is small and appears to be
separated from the rest of the occlusal portion.
 The oblique ridge is less prominent.
 The crown tapers towards the distal surface.
Thus, the buccolingual dimension of the crown
is greater mesially than distally.
 Multiple supplemental grooves can be seen
along with the developmental grooves.
Figure 4.22 Occlusal aspect. (4 cusp type)
93
Three cusp type with Heart-shaped Form: (Figure
4.23)
 This type of maxillary 2nd molar resembles
maxillary 3rd molar.
 The mesiolingual cusp is as well developed as
seen in the 1st maxillary molar.
 But the distolingual cusp is very minute or
absent making the crown appear heart shaped.
Figure 4.23 Occlusal aspect.
THE PERMANENT MANDIBULAR
MOLARS
PERMANENT MANDIBULAR 1st molar
(Figure 4.24 a-d)
 The mesial outline is convex except near the
cervical line where it is concave.
 Mesial contact area is at the junction of occlusal
and middle thirds and in the center of the crown
buccolingually below the mesial marginal ridge.
 The distal outline begins as a straight line near
cervix and soon becomes convex forming the
distal contact area at the middle third of crown
that placed more buccally.
 The height of buccal contour is in the cervical
third of the crown.
 The height of lingual contour is at the middle
third.
 The outline is interrupted by two developmental
grooves separating the three cusps (two buccal
cusps and a small distal cusp).
 The mesiobuccal cusp is wider than the
distobuccal cusp, which is relatively sharper of
the two.
94 Clinical Operative Dentistry 94

 The mesial and distal cusp ridges of the two

buccal cusps are relatively flat and meet at more
obtuse angles.
 The two buccal cusps are separated by the
mesiobuccal developmental groove which runs
for half the distance of buccal surface to end in
the buccal pit.
 The distobuccal and distal cusps are separated
by the distobuccal developmental groove which
approaches the distobuccal line angle of the
crown. Occasionally, this groove may be absent.
 The crown tapers lingually making the lingual
surface narrower than the buccal surface.
 The two lingual cusps are almost of same width
and are sharper and longer than the buccal Figure 4.24(b) Lingual aspect.
cusps.
 The mesiolingual cusp tip is at a higher level
than the distolingual cusp. The distal cusp tip is
at a much lower level.
 The lingual developmental groove separating
the two lingual cusps runs for a shorter distance
on the lingual Surface.
 The distal marginal ridge is shorter and is at a
lower level than the mesial marginal ridge.
 The distal surface is shorter and narrower than
the mesial surface.

Figure 4.24(c) Mesial aspect.

Figure 4.24(d) Distal aspect.

Occlusal Aspect of mandibular first molar

Figure 4.24(a) Buccal aspect.
(Figure 4.25)
 The crown is bulkier mesially than distally as the
crown tapers in a distal direction towards the
small distal cusp.
 Lingual Convergence: the mesial and distal
surfaces converge lingually making the lingual
surface of the crown narrower than the buccal
surface.
95 Chapter 4 Morphologic features of teeth 95

 Among the five cusps of mandibular 1st molars, - The mesiobuccal developmental groove joins
the mesiobuccal cusp is the largest followed by the central developmental groove just mesial to
the mesiolingual and distolingual cusps which the central pit and runs buccally separating the
are nearly equal in size. The distobuccal is the mesiobuccal and distobuccal cusps and ends
next cusp to follow and the distal cusp is the on the buccal surface in the buccal pit.
smallest one. The size of the distal cusp can - The distobuccal developmental groove joins the
vary. central groove, distal to the central pit and runs
 The cusp ridges of the buccal cusps and distal distobuccally between the distobuccal and
cusp are usually flattened by occlusal wear. The distal cusps to end on the buccal surface.
lingual cusps are sharp with well-defined cusp - The lingual developmental groove takes a
ridges. lingual course from the central pit and extends
 Fossae : onto the lingual surface separating the two
- There is one major fossa namely central fossa lingual cusps.
and two minor fossae mesial and distal - Several supplemental grooves can be seen
triangular fossae. originating from the developmental grooves.
- The central fossa is a circular large depression
in the center of the occlusal surface. It is
bounded buccally by the distal slope of
mesiobuccal cusp, the mesial and distal slopes
of the distobuccal cusp and the mesial slope of
distal cusp. Lingually, it is limited by the distal
slope of mesiolingual and the mesial slope of
distolingual cusp.
- The mesial triangular fossa has the mesial
marginal ridge as base, the mesial pit as apex
and the mesial slopes of mesiobuccal and
mesiolingual cusps as the sides of the triangle.
- The distal triangular fossa is smaller than the
mesial triangular fossa. It has the distal marginal
ridge as the base, distal pit as the apex and the
distal slopes of the distolingual and the distal
cusps as the sides of the triangle.

 Marginal Ridges: The distal marginal ridge is

shorter and at a lower level than the well-
developed mesial marginal ridge.

 Grooves and Pits:

- There are four developmental grooves and some
supplemental grooves are seen on the occlusal
surface.
- There are three pits. The central pit is at the
center of the central fossa. The mesial and distal
pits are in the mesial and distal triangular fossae
respectively. Figure 4.25 Occlusal aspect.
- The central developmental groove originates at
the central pit and runs in the opposite PERMENANT MANDIBULAR 2nd MOLAR
directions. Its mesial course from the central pit (Figure 4.26 a-d)
is relatively smooth and terminates in the mesial
triangular fossa. Again from the central pit, the  The crown appears shorter and narrower than
central groove takes a rather irregular course in that of mandibular 1st molar.
a distal direction and ends in the distal  The mesial and distal outlines are usually
triangular fossa. convex with their maximum convexity at the
center of middle third of the crown. Mesial
96 Clinical Operative Dentistry 96

contact area: It is at the center of the mesial

surface both cervico-occlusally and
buccolingually.
 The distal contact area: It is at the center of the
distal surface both cervico-occlusally and
buccolingually. Generally, the contact area both
mesially and distally are at the same level in
case of molars.
 The occlusal outline is formed by the flattened
cusp ridges of two buccal cusps. Occlusal
outline is divided by the buccal developmental
groove.
 The mesiobuccal and distobuccal cusps are
equal in their width and are separated by a short
buccal developmental groove which ends within
the occlusal third of the crown. The buccal Figure 4.26(b) Lingual aspect.
aspect has only one developmental groove as
there is no distal cusp.
 The buccal cervical ridge may not be as
pronounced as in the mandibular 1st molar.
 The height of buccal contour is in the cervical
third of the crown.
 The height of lingual contour is in the middle
third of the crown.
 Two lingual cusps separated by the lingual
developmental groove.
 The mesiolingual and distolingual cusps are of
equal width and are sharper than the buccal
cusps.
 The lingual developmental groove separating
the two lingual cusps runs for a short distance
onto the lingual surface.
Figure 4.26(c) mesial aspect
 The lingual surface is nearly as wide as the
buccal surface since the tooth does not
converge much towards the lingual aspect.
 The distal marginal ridge is at a lower level than
the mesial marginal ridge.

Figure 4.26(d) Distal aspect.

Figure 4.26(a) Buccal aspect.

97 Chapter 4 Morphologic features of teeth 97

Occlusal Aspect of mandibular second molar

(Figure 4.27)

 From occlusal view, it can be appreciated that

the tooth is as wide lingually as it is buccally.
This is because the tooth does not taper much
lingually.
 It can also be noted that the distal outline of the
crown is more rounded than the mesial outline.
The crown is squarish and broader mesially and
is more rounded distally.
 Cusps :
- The mandibular 2nd molar has only four cusps.
There is no distal cusp.
- The mesiobuccal and distobuccal cusps are
almost equal in size, although the cervical
portion of the tooth near mesiobuccal cusp may
be more bulky.
- The mesiolingual and distolingual cusps are
equally well developed. In general, the lingual
cusp ridges are well defined than the more
flattened buccal cusp ridges.
- The triangular ridges of all the cusps converge
towards the center of the occlusal surface.

Figure 4.27 Occlusal aspect.

 Fossae and Marginal Ridges:
- There are two fossae; mesial and distal
triangular fossae: ESTHETIC CONSIDERATIONS OF
- The mesial and distal triangular fossae are ANTERIOR TEETH
nearly equal in size and may have supplemental
grooves. Incisal edge placement of maxillary
- The mesial and distal marginal ridges are well central incisors (Figure 4.28)
developed and form the base of respective
triangular fossa. The following guidelines are used to determine the
 Grooves and Pits: correct incisal edge position:
- There are three pits; central, mesial and distal 1) In full smile, the incisal edges of the maxillary
pits. anterior teeth should be cradled by the lower lip.
- The groove pattern forms a typical plus mark ‘+’ 2) In gentle repose (have the patient say “M” or
or a cross in the center of occlusal aspect, “Emma” and ask them to let their lips lightly fall
dividing the occlusal portion into four nearly apart), approximately 3 to 4 mm of the incisal
equal parts. edges of the maxillary central incisors should be
- The central developmental groove runs across displayed in the young adult female. In the
the occlusal surface from mesial pit to the distal young adult male, approximately 1 to 2 mm of
pit. the incisal edges should be displayed. After age
- The buccal and lingual grooves meet the central 40 years, the amount of incisal edge display
groove at right angles at the central pit and they decreases approximately 1 mm per decade.
run onto the buccal and lingual surfaces of the 3) The average length of the maxillary central
crown respectively. incisor is 10 to 11 mm.
- There is no distobuccal groove. 4) When the patient says “F” or “V,” the incisal
edges of the maxillary central incisors should
lightly touch the wet-dry border of the lower lip.
98 Clinical Operative Dentistry
Figure 4.28 ideal position of maxillary incisal edge.
Gingival contour (Figure 4.29 a-b)
 To evaluate the gingival line, a straight line is
drawn from the tooth-gingiva interface of the
right maxillary canine to the tooth-gingiva
interface of the left maxillary canine.
 The tooth-gingiva interface of both central
incisors should be on this line. The tooth-
gingiva interface of the lateral incisors may
either fall on the gingival line or be up to 1.5 mm
below it.
Figure 4.29(a) gingival contour.
98
Figure 4.29(b) Gingival line from canine to canine.
Note that the tooth-gingiva interface of the lateral
incisors may either fall on the gingival line or be up
to 1.5 mm below it.
Facial contour of maxillary incisors
(Figure 4.30)
 Divide the facial surface of the maxillary central
incisor into two planes:
- The gingival half of the tooth should be parallel
to and continuous in contour with the surface of
the gingival tissue overlying the alveolus.
- The incisal half is tapered back for ease in
speaking and swallowing.
 Facial overcontouring of a restoration in the
gingival half can result in chronic gingival
inflammation.
 Facial overcontouring in the incisal half may
result in lip pressure, causing linguoversion of
the overcontoured teeth or interference with the
path of lip closure.
Figure 4.30 Facial contour of maxillary incisors.
99 Chapter 4 Morphologic features of teeth
Figure 4.30 Facial contour of maxillary incisors.
Lingual contour of maxillary incisors
 Incorrect spacing between maxillary
mandibular anterior teeth may cause a lisp. A
lisp can occur with too much or too little space,
although it occurs most commonly with too little
space.
 If a patient develops a lisp after placement of
provisional or definitive restorations,
position of the incisal edges of the mandibular
incisors in relation to the maxillary central
incisors when the patient makes an “S” sound
must be determined:
- If the mandibular incisor approximates the
cingulum or lingual concavity of the maxillary
incisor, the lisp is corrected most commonly by
increasing the lingual concavity of the maxillary
incisors.
- If, however, the mandibular incisor
approximates the incisal edge of the maxillary
central incisor during the “S” sound, the lisp can
be corrected most commonly by changing the
length of the maxillary central incisors.
Gingival zenith (Figure 4.31)
The long axes of the maxillary anterior teeth are
distally inclined. Therefore, the gingival contour
adjacent to the maxillary incisors is not a symmetric,
rounded arch form. Rather, the marginal gingiva has
a parabolic shape with the highest point (gingival
zenith) slightly distal to the midline of the tooth.
99
and
the
Figure 4.31 the highest point of marginal gingiva
(gingival zenith) slightly distal to the midline of the
tooth.
Interproximal contact areas (Figure 4.32)
 Maxillary interproximal contact areas become
progressively more gingival from central incisor
to canine. The interproximal contact between
the maxillary central incisors is in the incisal
third of the teeth. However, the interproximal
contact between the central and lateral incisors
is at the junction of the incisal and middle thirds;
it is slightly more gingival between the lateral
incisors and the canines.
 If the interproximal contact extends too far
incisally, a closed and unnatural- appearing
incisal embrasure results.
 If the interproximal contact does not extend far
enough gingivally, an open gingival embrasure,
or black triangle, results.
100 Clinical Operative Dentistry 100

lingual facet before dropping off to the concave

lingual surface.
 Rounded maxillary incisal edges give the
restoration an unnatural appearance due to the
light reflection off a curved surface.

Figure 4.32 Maxillary interproximal contact areas

become progressively more gingival from central
incisor to canine.
Incisal embrasures (Figure 4.33)

 The incisal embrasures increase from maxillary

central incisor to canine.
Figure 4.34 Natural maxillary incisal edges, in a
 While the incisal embrasure between the buccolingual direction, are not rounded but rather
maxillary central incisors is minimal, the incisal are sharp.
embrasure between the maxillary central and Mandibular incisal edge shape (Figure
lateral incisors is more pronounced and 4.35)
between the lateral incisors and canines is the
most pronounced.  The incisal edge of the mandibular incisor
 Uniform incisal embrasures from maxillary should have a narrow, but defined, flat incisal
canine to canine are esthetically unnatural. table. This incisal table should be slightly canted
facially. This is referred to as the pitch of the
incisal table. The facial incisal line angle should
be slightly beveled.
 This incisal edge configuration not only
enhances esthetics but also improves function.
As the mandible moves forward, the
disocclusion occurs efficiently on the leading
incisofacial line angle of the mandibular incisor,
rather than dragging on the broader facial
surface.

Figure 4.33 the incisal embrasures increase from

maxillary central incisor to canine.

Maxillary incisal edge shape

(buccolingual) (Figure 4.34)

 Natural maxillary incisal edges, in a

buccolingual direction, are not rounded but
rather are sharp.
 Because of wear, the incisofacial line angle in
adults is relatively sharp and blends into a 1-mm
Figure 4.35 This incisal table should be slightly
canted facially. This is referred to as the pitch of the
incisal table.
101 Chapter 4 Morphologic features of teeth
Outline symmetry
 The distal surfaces of the maxillary central and
lateral incisors should be similar in outline form,
as should the distoincisal line angles of these
teeth.
 The outline symmetry of the maxillary central
and lateral incisors should be similar. A large
outline discrepancy (e.g., a peg-shaped lateral
incisor) negatively affects the beauty of the
smile.
Facial contour of the maxillary incisors
(Figure 4.36)
 The facial surfaces of the maxillary incisors
should not be rounded mesiodistally but rather
should be flat, with resulting bold mesial and
distal line angles and deep facial embrasures.
 Restorations with rounded facial surfaces look
unnatural; facial embrasures are not well
defined, resulting in a lack of visual distinction
of the maxillary anterior teeth.
Figure 4.36 The facial surfaces of the maxillary
incisors should not be rounded mesiodistally but
rather should be flat, with resulting bold mesial and
distal line angles and deep facial embrasures.
Outline form of maxillary canines
 The distal half of the maxillary canine should not
be visible when viewed from the front.
 As the eye moves laterally from the midline,
each tooth should appear proportionately
narrower than its mesial neighbor. This is
termed the principle of gradation. (Figure 4.37)
101
Figure 4.37 Note the principle of gradation.
Color
 Natural teeth are polychromatic:
- They generally have higher chroma in the
gingival third
- Transitioning to a lower chroma and higher
value in the middle third.
- The incisal third is characterized by the
transition to incisal translucency, which is
commonly framed by the halo effect
 The chroma and value of the maxillary lateral
incisor is commonly the same as that of the
central incisor.
 In the maxillary canine, the chroma is generally
higher, especially in the gingival third, and the
value is lower. Incisal translucency is usually
minimal in the maxillary canine, and seldom
does the halo effect occur.
Color modifiers
 It has been stated that hair color, skin color, and
lipstick color all significantly affect shade
selection when restorations are being placed in
the esthetic zone.
 Of these modifiers, skin color is by far the most
important. A given tooth shade will look lighter
and higher in value in a patient with darker skin.
Conversely, the same tooth shade will appear
yellower and lower in value in a patient with very
light skin.
Age characteristics of teeth (Figure 4.38 a-b)
Both tooth color and surface texture relate
information about the age of the patient:
Chroma and value:
 Surface texture is higher in the young patient
and decreases as the patient ages. The surface
luster is a function of the amount of surface
texture.
102 Clinical Operative Dentistry
 Therefore, the young tooth with greater surface
texture has a lower luster. As the surface texture
is worn away with age, the surface luster
increases
Surface texture:
 Surface texture is higher in the young patient
and decreases as the patient ages. The surface
luster is a function of the amount of surface
texture.
 Therefore, the young tooth with greater surface
texture has a lower luster. As the surface texture
is worn away with age, the surface luster
increases.
Figure 4.38(a) Young teeth demonstrate higher
value, lower chroma, higher surface texture &
lower luster.
Figure 4.38(b) Young teeth demonstrate lower
value, higher chroma , lower surface texture &
higher luster.
Individual tooth length and proportion
 The average length of the maxillary central
incisor is 10 to 11 mm.
 The ratio of height to width in the maxillary
central incisor should be approximately 1.2 to
1.0. In other words, the width of the central
102
incisor should be approximately 75% to 80% of
its height.
 To make an anterior tooth appear wider, the
transitional facial line angles are moved into the
interproximal facial embrasures. Conversely, to
make an anterior tooth appear narrower, the
transitional line angles are moved closer to the
tooth midline.
Tooth-to-tooth proportions
 The principle of gradation states that as the eye
moves laterally from the midline, each tooth
should appear proportionately narrower than its
mesial neighbor.
 The golden proportion (1.618:1.0) has been
proposed that when teeth viewed from the front,
the maxillary central incisor would be 1.618
times wider than the lateral incisor, the lateral
incisor would be 1.618 times wider than the
visual width of the canine, and so on as the eye
moves distally. For example, for maxillary
central incisor the apparent width is 1.618, for
lateral incisor, it is one and for canine, it is 0.618.
(Figure 4.39)
 But many studies have shown that golden
proportion is not always present in natural
dentition, yet an esthetically pleasing smile can
be there.
 In a patient with a very square maxillary arch
form, the golden proportion would result in
unesthetically wide central incisors.
 Because dental esthetics is a matter of taste, the
ultimate decision on widths and proportions
must be developed in provisional restorations
with the patient.
Figure 4.39 the golden proportion
103 Chapter 4 Morphologic features of teeth 103

Principle of illumination

 Visually, light objects are perceived to approach

the viewer and dark objects to recede from the
viewer.
 This principle must be considered when high-
value porcelain or resin composite restorations
are placed only on maxillary anterior teeth,
because the result may be an unaesthetic visual
separation of the anterior and posterior teeth.
(Figure 4.40)
 A visual coupling of the front and back of the
mouth may require placement of restorations on
one or more maxillary premolars.

Figure 4.40 (a and b) Porcelain veneers were

placed only on the maxillary anterior teeth. Note
that the maxillary first premolars are virtually
invisible when viewed from the. Front. This results
in a loss of visual coupling of the front and the
back of the mouth. Note also the lower lip
asymmetry.
105
107
TOOTH (ENAMEL & DENTIN) AS A
SUBSTRATE FOR BONDING:
 Enamel and dentin may become
hypomineralized, either through caries attack or
as a direct result of a developmental anomaly,
such as amelogenesis imperfecta, or through
erosion. These surfaces may be more difficult to
bond to because of the weakened nature of the
substrate.
 In contrast, exposure to mineralizing solutions,
such as fluoride, via intraoral application or via
the water supply in certain regions, may
produce hypomineralized enamel. This latter
material may be more resistant
demineralization and potentially requires
longer etching time to produce an adequate
surface for bonding. Fluoridated enamel has a
low surface energy and is more difficult to bond
compared to the nonfluoridated enamel.
 Over time, dentin may become more sclerotic
(i.e. calcified), bonding to sclerotic dentin may
be reduced as compared with normal dentin but
that extending etching time may enhance the
bond for certain adhesives using strong acids.
The bond to sclerotic dentin is also lower than
that for normal dentin when using adhesives
containing milder organic acids (such as those
used in the self-etching adhesives described
later in this chapter).
 Within the same tissue, nature of the substrate
presented for bonding may vary with the
location:
- Enamel etched on its rod ends provide better
area for bonding compared to enamel etched on
the side of the prisms. Thus, bevel is indicated
in various cavity preparations.
- Dentin in its superficial portion allows greater
bond strengths than in the deeper portions. This
might be because the superficial layer has more
of solid dentin and less moisture contamination
as compared to deeper portions. The presence
of moisture in dentin is the major hurdle in
achieving bonding.
Problems Encountered during Dentin
Bonding:
Bonding to dentin has been proven more difficult
and less reliable and predictable than enamel. This
is because of difference in morphologic, histologic
and compositional differences between the two:
 In enamel, it is 95 percent inorganic
hydroxyapatite by volume, in dentin it is 50
Chapter 5 Bonding in Dentistry 107
percent. Dentin contains more water than does
enamel.
 Hydroxyapatite crystals have a regular pattern in
enamel whereas in dentin, hydroxyapatite
crystals are randomly arranged in an organic
matrix.
 Presence of smear layer makes wetting of the
dentin by the adhesive more difficult.
 Dentin contains dentinal tubules which contain
vital processes of the pulp, odontoblasts. This
makes the dentin a sensitive structure.
 Dentin is a dynamic tissue which shows
changes due to aging, caries or operative
procedures.
 Fluid present in dentinal tubules constantly
to flows outwards which reduces the adhesion of
a the composite resin.
Smear layer:
 When a tooth surface is altered using hand or
rotary instruments, cutting debris are gathered
on enamel and dentin surface, forming a smear
layer.
 Smear layer is defined as mineralized debris
produced by reduction or instrumentation of
enamel, dentin or cementum.
 Smear layer is thickest when tooth is cut by
means of coarse diamond point without coolant.
 Smear layer from enamel gets easily washed
away but remains adherent to dentin.
 An important factor that influences the bonding
to tooth surface is the presence of smear layer
on cut dentin. The smear unit (smear layer +
smear plugs) may serve as a contaminant and
prevent adequate penetration of the adhesive
into the underlying substrate.
 On the contrary, some believe that it acts as a
protective barrier to the pulp by minimizing
leakage of bacterial and other substances &
lowering dentin permeability.
Smear layer & smear plug.
108 Clinical Operative Dentistry 108

MATERIALS resin of the composite but has a lower viscosity

 Dental adhesives consist of three main to permit easy flow and penetration.
components: (1) etchant, (2) primer, and (3)
bonding resin( often referred to as the adhesive
resin), but the entire system also is typically
called an adhesive :
- The etchant is composed of acidic molecules
that alter or remove the smear layer and
demineralize the enamel and dentin and prepare
it for bonding.
- The primer serves as a type of molecule that
helps make the dentin surface, which is very
hydrophilic, become more hydrophobic in order
to accept the very hydrophobic bonding resin.
- The bonding resin then becomes incorporated
into the primed dentin and, once cured, forms
the structural support of the bonded interface
between the tooth and the subsequently placed
restorative material.
 When the adhesive resin is applied, a part of it
penetrates into the microporous collagen
Figure 5.1 Schematic representation of a three-step
scaffold of the intertubular dentin known as the dentinal bonding system. A) Prepared dentin is
intertubular penetration. Here it polymerizes and covered by a smear layer. B) When the enamel and
co-polymerizes with the primer to form an dentin are etched, the smear layer is removed, the
surface of the dentin is decalcified, and the dentinal
intermingled layer of collagen and resin and is
tubules are opened. C) Primer flows into the open
termed as the ‘hybrid layer’. The rest of the tubules and the decalcified dentin. D) Adhesive
adhesive resin enters into the dentinal tubules covers the primer and the hybrid layer.
to a limited depth forming resin tags known as
the intratubular penetration (Figure5.1). Within ADHESION SYSTEMS
the dentinal tubules, these tags are attached
only at this point to the peritubular dentin and
any further extension of resin tags into the The ability of dental adhesive systems to bond to
dentinal tubules is passive. Tags do not appear tooth structures is currently recognized to depend
to contribute to the attachment mechanism and on two main factors:
it should be noted that prolonged conditioning
is actually not needed. At times the resin may  Substrate (enamel and dentin) demineralization,
not completely infiltrate into the collagen which partially removes the mineral phase and
meshwork and such microspaces are then open increases tooth receptivity.
to microleakage referred to as ‘Nanoleakage’.  Subsequent passive infiltration of monomers
 During polymerization, an oxygen inhibited layer into the demineralized layer.
of 15 µm is formed on the top of the adhesive
resin. The unpolymerized methacrylate double ADHESIVE SYSTEM CLASSIFICATION
bonds present in this layer offer co-
polymerization with the subsequently placed According to Generation (EVOLUTION OF
restorative resin. DENTIN BONDING AGENTS)
 Manufacturers often incorporate fillers in their
adhesives. The goal is to decrease Adhesives are grouped by product characteristics
polymerization shrinkage and increase strength, and order of market introduction, with each
while taking care not to add so much filler as to generation (first through eighth) reflecting
detrimentally increase the viscosity of the significant changes in product characteristics.
mixture, inhibiting its ability to flow and (Figure5.2)
penetrate the surface. Bonding resin is an
unfilled or semi filled resin, which matches the
109 Chapter 5 Bonding in Dentistry 109

Self-etching or etch-and-dry adhesives

 These systems use a non-rinsing solution of

acidic monomers to dissolve the smear layer on
enamel and dentin surfaces.
 Because the self-etching or primer agent is
simply air dried, they are also called etch-and-
dry adhesives.
 These adhesives render the smear layer
permeable to monomers rather than removing it
completely.
 Note that the formation of resin tags in dentin
tubules can be assured only with the use of
strong self-etching adhesives.

According to Number of clinical steps

(Figure5.3)

In the most commonly used classification method,

Figure 5.2 dental adhesive generation.
adhesives are grouped according to the number of
clinical steps involved in the adhesion procedure:
According to Solvent

The solvent contained in a given adhesive system

 Three-step systems 
has important
during air drying:
clinical implications, particularly
 Two-step systems
One-step systems
 Many etch-and-rinse systems contain volatile
solvents (e.g., ethanol or acetone) that decrease 
viscosity and increase wetting and molecular
mobility.  Etch-and-rinse adhesives may be three- or two-
step systems:
 Self-etching adhesives often contain water,
which achieves the same effects and allows the
dissociation of weak acids for enamel/dentin  In three-step systems, separate etchant,

demineralization. primer, and bonding resin are applied

consecutively.

According to Mechanism of smear layer

 In two-step (self-priming) systems, etching is
removal
followed by the application of a combined
This layer must be removed or made permeable to primer and bonding resin.
allow interaction between the monomers and the
dentinal surface. Thus, based on the approach to  Self-etching adhesives may be two- or one-step
smear layer removal, dental adhesives can be systems:
grouped into two major types:
 In two-step self-etching adhesive systems, a
Etch-and-rinse adhesives (formerly were combined etching and primer agent is applied
on enamel and dentin and air dried, followed by
known as total-etch adhesives)
the application and polymerization of a
These adhesives use a strong acid (usually 37%
bonding resin.
phosphoric acid at a pH of approximately 0.9) to
 While one-step self-etching adhesives combine
completely etch enamel and dentin (completely
etching, primer, and bonding resin in a single
remove smear layer), followed by a water rinse to
application.
remove the acid from the tooth surface.
110 Clinical Operative Dentistry
Figure 5.3 adhesive systems.
THREE-STEP ETCH-AND-RINSE
ADHESIVES
 Three-step etch-and-rinse adhesives are fourth-
generation products that require the sequential
application of the three agents.
 These agents are generally considered the gold
standard against which other systems are
compared.
Three-Step Etch-and-Rinse Adhesives.
110
Step 1: Etching
Conditioning
 It is the process of cleaning the surface (pellicle,
plaque and smear layer are considered as
surface contaminants) and activating the
calcium ions, so as to make them more reactive.
 A thorough dental prophylaxis for removing
materia Alba, plaque and other accretions is an
important component of the conditioning
etching regime. It has been observed that
prophylaxis alone can double the bond strength.
 The prophylaxis pastes devoid of oils, flavoring
agents and fluorides are recommended for this
purpose. Rubber cups are preferred as they are
less likely to damage gingival tissue or abrade
enamel.
Etching
It is the process of increasing the surface reactivity
by demineralizing the superficial calcium layer and
thus creating the enamel tags. These tags are
responsible for micromechanical bonding between
tooth and restorative resin.
Etching of enamel:
 Etching creates enamel microporosities within
which the resin tag extensions of monomers
interlock micromechanically.
 After cleaning, the enamel is thoroughly washed
with water, the treatment site dried and carefully
isolated from oral fluids like saliva and gingival
crevicular fluid.
 Enamel etching is affected by the content and
concentration of the acid-etching solution and
by the application technique and timing.
 Most of the adhesive systems use phosphoric
acid (usually 37% phosphoric acid at a pH of
approximately 0.9).
 The physical state of the solution also affects
etching; gels can be applied to the enamel
surface in a more controlled manner than liquids
and achieve wider and deeper enamel
penetration.
 Etching agent application methods have also
been investigated to improve clinical success;
gels may be applied using a continuous
brushing technique to obtain more etched
enamel substrate and thereby improve the
marginal adaptation of resin composite
restorations.
 In case gels are used, the washing time is
doubled so as to flush away its cellulose vehicle
which otherwise might serve as a contaminant.
Since the etched surface at this stage has a very
111 Chapter 5 Bonding in Dentistry
high surface energy, a contaminant can readily
adhere to the surface.
 Even a minor exposure to saliva, blood or oil can
ruin the potential for resin tag formation and
bonding. All measures should therefore be
taken to prevent any contamination. If accidental
contamination occurs, the procedure should be
repeated.
 Extending etching times to 60 seconds has been
shown to produce rougher enamel surfaces but
no enhancement of bond strength.
 Enamel should not be etched for more than 15
to 20 seconds. If enamel is etched for more than
required time, it results in deeper etch. Since a
bonding agent has a high viscosity, surface
tension effect of agent does not allow its full
penetration into etched enamel. This results in
‘dead space’ beyond the bonded area. When
enamel bends, or weak resin based bond breaks
off, the dead space gets exposed to oral fluids.
These oral fluids have lower surface tension and
thus penetrate into the dead space. This may
result in secondary caries or discoloration of the
margins.
 If concentration is greater than 50%, then
monocalcium phosphate monohydrate get
precipitated. If concentration is lower than 30%,
dicalcium phosphate mono hydrate is
precipitated which interferes with adhesion.
 Enamel etching is also affected by the chemical
composition of the enamel (e.g., high fluoride
concentration makes enamel more resistant to
etching).
 Moreover, aprismatic enamel is also more
resistant to etching. Deciduous teeth require
longer time for etching than permanent teeth
because of the presence of aprismatic enamel in
deciduous Teeth.
 It is established that when enamel prisms are
exposed perpendicularly, the bond strength is
reduced to 50% compared with the parallel
exposure of the prisms. Thus, beveling enamel
margins should be considered.
Acid etch gel.
111
Etching of dentin:
 Acid etching could be safely used on dentin
more than 0.5 mm thick, provided the dentin was
sealed with the restoration after the etching.
 The use of phosphoric acid to etch dentin
removes the smear layer, demineralizes the first
3 to 5 µm of dentinal tissue, and creates funnel-
shaped dentinal tubules.
 Sound dentin should be etched for no longer
than 15 seconds. For this reason, etchant is
initially applied to the enamel followed by
application to the dentin to ensure adequate
etching of enamel without over etching dentin.
 Although extended etching times have been
found to increase substrate porosity, they do
not necessarily increase bond strength.
 Etching should be limited to superficial dentin
because the viscosity of primers and bonding
agents allows only a few micrometers of
impregnation. Excessive acid conditioning
caused deeper demineralization of intertubular
and peritubular dentin, rendering them more
susceptible to incomplete infiltration by resin
monomers. The reduced infiltration decreased
bond strength by creating a weak zone where
failure was likely initiated.
 However, in some cases, such as in the
presence of aged or sclerotic dentin with a high
mineral content, etching times of up to 30
seconds may be appropriate.
 After etching, the tooth should be rinsed with an
intense air or water spray to remove the acid
completely and stop the etching process. The
rinsing time should be similar to the etching
time.
 After rinsing, the wetness of the dentin is an
important clinical consideration:
- In dry bonding, the cavity walls were dried after
etching until the enamel margins were “frosty”
to confirm the success of enamel etching.
However, this technique has been found to
cause the interfibrillar spaces between exposed
dentinal collagen fibrils to collapse, preventing
proper monomer infiltration. Although this
technique achieved high resin-enamel bond
strengths, resin-dentin bond strengths were
insufficient to resist polymerization shrinkage
forces. The low resin-dentin bond strengths
associated with dry bonding resulted in dentin
sensitivity, microleakage, secondary caries, and
loss of bonded restorations.
- The wet bonding technique, introduced which
used residual water on the dentin surface as a
112 Clinical Operative Dentistry 112

rewetting agent. This technique increased resin- Step 2: Priming

dentin bond strength (that were equal or
superior in strength to resin-enamel bonds), Enamel priming:
which provided a good dentin seal and reduced  The application of a hydrophobic enamel
postoperative pain. Wet bonding can be bonding agent to air-dried enamel avoids the
performed using several different methods: need for a separate primer application while still
achieving effective bonding .Sealants can also
 After the removal of pooled moisture by blotting be applied to acid-etched enamel without
or wiping with a slightly damp cotton pellet, additional treatment.
properly moist dentin should exhibit a shiny,  However, the enamel bonding process is not
hydrated surface. An ideal dentin surface for compromised by the application of primers to
bonding is visibly moist, without any excessive acid-etched enamel, and it may even be
water (Figure5.4). This can be achieved clinically enhanced in situations where isolation is
by blot drying with a damp cotton pledget. difficult.
 The rewetting of excessively dried dentin with Dentin priming:
water or a rewetting agent can raise collapsed  Primers are mixtures of monomers which have
collagen to a level comparable with that varying degrees of hydrophilic and hydrophobic
achieved with wet bonding. Recently, the use of properties. Hydrophilic functionality facilitates
chlorhexidine has been proposed as a rewetting monomer permeation into the collagen matrix to
agent because of its capability to disinfect and form hybrid layer, and hydrophobic functionality
stabilize the bond over time. facilitates restoration bonding to the resin
matrix.
 Solvents are added to reduce the inherent
viscosity of the primer material, allowing it to
infiltrate wet demineralized dentine.
 Primers should be actively applied and agitated
for at least 30 seconds on the dentin surface to
improve penetration and enhance adhesion.
 Primers should be gently air dried after
application to volatilize any remaining solvent
before the adhesive resin is applied. Failure to
adequately evaporate primer solvent will
significantly adversely affect the bond to dentin
and can have a more adverse effect on adhesion
Figure 5.4 Clinical aspect of moist dentin. than just about any other application mistake.
Drying times of at least 10 seconds or longer are
Summary of Clinical application steps for recommended.
etching  It was suggested that primers with ethanol/water
1) Perform oral prophylaxis procedure using solvents show reduced technique sensitivity

nonfluoridated and oil less prophylaxis pastes. compared with those with acetone solvents.
2) Clean and wash the teeth. Isolate to prevent  Additional layers of primer should be added if
any contamination from saliva or gingival the surface does not appear uniformly glossy.
crevicular fluid. To improve the surface coverage and diffusion
3) Apply 35% to 37% phosphoric acid to enamel of the primer it can be applied in multiple coats.
for 15 to 30 s and to dentin for 15 s. When a second coat of Primer was applied, it
4) Rinse the etched surface for 15 s with an air- was found that the shear bond strength
water spray. improved significantly, but there was no further
5) Gently air dry to remove excess moisture. increase up to five additional applications.
6) Apply 0.2% to 2% aqueous chlorhexidine Summary of Clinical application steps for
solution. priming:
7) Remove excess chlorhexidine solution with a 1) Perform active application of primer for at least
moist cotton pellet. 30 s (gently agitated or rubbed onto the dentin
8) If any sort of contamination occurs, repeat the surface with a small brush).
procedure.
113 Chapter 5 Bonding in Dentistry 113

2) Apply primers generously in multiple layers.  Phosphoric acid etch provides the best bond to
3) Primers must be adequately air dried to enamel.
evaporate all of the solvent; usually 30 to 40 s  The highest dentin bond strengths among all
are needed for proper solvent evaporation. dentin adhesives.
4) The primed surface should appear glossy after  Can be used with chlorhexidine rewetting for
air drying; if it appears chalky, the primer must bond preservation.
be reapplied.
Disadvantages:
Step 3: Bonding
 Multiple bottles make their use more
 These agents should be applied to the primed
cumbersome. Possibility of running out of one
surface with a brush and thinned to an optimal
component before another. Because primer and
thickness of about 60 to 120 µm, depending on
adhesive resin are dispensed into separate wells
the viscosity of the adhesive. Because no
in the same plastic container, their sequential
solvent is present, using an air syringe to thin
application may be reversed.
the adhesive resin layer should be used with
 Thick adhesives may pool easily around
care to avoid formation of a less homogenous
preparation line angles and margins.
surface, with some areas so thin that they do not
cure.
Common clinical errors and their solutions:
 Significant reductions in bond strength were
observed when air thinning was compared with
aggressive air thinning or brush thinning,
 Overetching dentin: sound dentin should be
suggesting that brush thinning may provide a
etched for no longer than 15 seconds. However,
better way to obtain a homogenous layer
in some cases, such as in the presence of aged
without over air thinning. This is done by active
or sclerotic dentin with a high mineral content,
application of the adhesive using a microbrush,
etching times of up to 30 seconds may be
then using a bristle brush to ensure an even
appropriate.
coating of the resin. Excess resin will be
 Suboptimal rinsing of the etching gel: The
absorbed into the bristle brush. If the bristles
rinsing time should be similar to the etching
become saturated, the brush can be squeezed in
time.
a gauze pad to remove the excess resin.
 Overwet/overdry dentin surface: An ideal dentin
 The adhesive resin should be properly cured
surface for bonding is visibly moist, without any
before the restorative material is applied.
excessive water. This can be achieved clinically
 Adequate light intensity is an important factor in
by blot drying with a damp cotton pledget.
curing the resin layer; prolonged curing times
 Insufficient primer application/penetration:
that slightly exceed the manufacturer
Perform active application of primer for at least
recommendations have been shown to improve
30 s (gently agitated or rubbed onto the dentin
polymerization and adhesive properties.
surface with a small brush).
 Insufficient primer solvent evaporation: Primers
Summary of Clinical application steps for
must be adequately air dried to evaporate all of
bonding: the solvent; usually 30 to 40 s are needed for
1) Generously apply the adhesive resin with a proper solvent evaporation.
microbrush.  Overthinning bonding component: brush
2) Use a bristle brush to thin and create a thinning may provide a better way to obtain a
homogenous layer. homogenous layer without over air thinning.
3) Cure for manufacturer recommended time,  Suboptimal polymerization of the bonding
which is typically about 10 to 20s. component: prolonged curing times that slightly
exceed the manufacturer recommendations
Advantages, disadvantages, and common
have been shown to improve polymerization and
errors for three-step etch-and-rinse
adhesive properties.
adhesives

Advantages:
114 Clinical Operative Dentistry 114

TWO-STEP ETCH-AND-RINSE 1) Apply 35% to 37% phosphoric acid to enamel for

15 to 30 s and to dentin for 15 s.
ADHESIVES
2) Rinse the etched surface for 15 s with an air-
water spray.
 It is also known as “one bottle” or “one
component” bonding agents. 3) Gently air dry to remove excess moisture.
4) Apply 0.2% to 2% aqueous chlorhexidine
 It is considered as fifth generation.
solution for rewetting.
 These systems employ an etching procedure
5) Remove excess chlorhexidine solution with a
similar to that for three-step systems, followed
moist cotton pellet.
by the application of a combined primer and
bonding resin. Step 2: Priming and bonding
 These simplified adhesives have been
Resin monomers have a limited capacity to diffuse
commercially successful because of their ease
into wet demineralized dentin, producing a gradient
of use and reduced application steps.
of resin penetration with the highest concentration
 Two-step etch-and-rinse adhesives combine
at the adhesive surface, lower concentrations within
hydrophilic components of primer with the more
the hybrid layer, and little resin presence in the
hydrophobic monomers of bonding agents
deepest portion of the demineralized zone.
causing them to behave as semipermeable
membranes. Numerous clinical parameters have been found to
 The polymerization achieved with these affect the proper impregnation of the demineralized
adhesives is frequently suboptimal, resulting in dentine:
increased potential for water absorption from  Application time: Prolonged primer/bonding-
the underlying dentin. These characteristics agent application times increase monomer
negatively impact long-term bond stability. penetration into decalcified dentin and increase
 The combined primer and bonding resins also solvent/ water evaporation before light curing.
contain high concentrations (up to 50%) of Extended application times, even as little as 20
solvents that may interfere with adhesive seconds, significantly increase the immediate
polymerization. and long-term bonding performance of the
adhesives.

 Mode of application:
- The use of a rubbing action is essential to
achieve a high immediate bond strength to
dentin.
- This action likely increases molecular kinetics
and inward monomer diffusion in reaction to
outward solvent diffusion, while also reducing
Two-Step Etch-and-Rinse Adhesives dentinal wetness.
- Vigorous rubbing of demineralized dentin
Step 1: Etching during the application of adhesive also
improves the long-term stability of the dentin
 The dentinal tissue moisture level is even more
bond by increasing the biomechanical
critical than with three-step etch-and-rinse
characteristics of the hybrid layer.
adhesives because two-step etch-and-rinse
- Such vigorous application techniques can also
adhesives do not have the rewetting ability of
improve the retention of restorations placed in
primers used in three-step adhesives.
noncarious cervical lesions, which typically
 If the dentin is overdried, it should be rewetted pose a clinical challenge.
prior to the next step.

 Solvent evaporation:
Summary of Clinical application steps for - Before polymerization is performed, solvents
etching: should be completely evaporated. Adhesive
solutions with higher solvent contents before
light curing have lower degrees of conversion;
115 Chapter 5 Bonding in Dentistry 115

the higher solvent content also reduces the Advantages, disadvantages, and common
mechanical properties of adhesive polymers. errors for two-step etch-and-rinse
- The adhesive layer must be carefully thinned, adhesives
and application should be repeated to ensure
adequate solvent evaporation.
Advantages:
- The use of a warm, dry airstream to evaporate  Phosphoric acid etch provides the best bond to
the solvent after the application of the enamel.
primer/bonding agent may improve bond  High immediate bond strength.
strength and hybrid layer quality by reducing the  The combined primer/bond bottle concept
number of pores within the adhesive layer. makes them extremely user friendly.
- Another issue is loss of solvent because of  Can be used with chlorhexidine for bond
storage and handling. If the bottle is left preservation.
uncapped, a significant amount of the volatile
material can be lost rapidly. This results in
alteration of the ratios from the manufacturer’s
Disadvantages:
intended formulation, which can then affect  Most two-step adhesives showed lower bond
bonding. To avoid this, the bottle should be strengths than their three-step counterparts
shaken and the material dispensed immediately (produced by the same manufacturer).
prior to application.  Acetone-based adhesives may lose their
 Curing time: efficacy with constant utilization due to rapid
- Adhesive curing should be performed carefully evaporation of volatile components.
to avoid compromised polymerization because  More coats than those recommended by the
of insufficient solvent removal, which results in manufacturer often needed to maximize bond
the presence of high concentrations of strength.
hydrophilic monomers and water.  Thick adhesives may pool easily around
- Manufacturer recommendations should be preparation line angles and margins.
followed.  Some adhesives are not compatible with self-
Summary of Clinical application steps for curing or dual-curing composites (core buildup
composites and resin luting cements).
Priming and bonding:
 Inclusion of hydrophilic components in bonding
1) Apply primer/bonding solution generously,
resin can cause increased hydrolytic
producing a shiny appearance, then vigorously
degradation.
rub at least 30 s.
2) Air dry to evaporate solvent for 30 to 40 s.
3) Actively reapply the primer/bonding solution Common clinical errors and their solutions:
and air dry.  Over etching dentin: sound dentin should be
4) Cure for manufacturer recommended time, etched for no longer than 15 seconds. However,
which is typically about 10 to 20 s. in some cases, such as in the presence of aged
or sclerotic dentin with a high mineral content,
etching times of up to 30 seconds may be
appropriate.
 Suboptimal rinsing of etching gel: The rinsing
time should be similar to the etching time.
 Over wet / over dry dentin surface: An ideal
dentin surface for bonding is visibly moist,
without any excessive water. This can be
achieved clinically by blot drying with a damp
cotton pledget.
 Reduced impregnation of primer/adhesive
agent: Perform active application of the agent
for at least 20 sec.
Bonding of resin to dentin using an etch-and-rinse
technique.  Inadequate solvent evaporation: Before
polymerization is performed, solvents should be
completely evaporated.
116 Clinical Operative Dentistry
 Overthinning adhesive when air drying to
remove solvent: use multiple coats.
 Suboptimal primer / bonding polymerization:
prolonged curing times that slightly exceed the
manufacturer recommendations have been
shown to improve polymerization and adhesive
properties.
TWO-STEP SELF-ETCHING OR ETCH-
AND-DRY ADHESIVES
 Two-step self-etching adhesives employ a self-
etching primer followed by a hydrophobic and
relatively solvent-free adhesive resin similar to
that used in three- step etch-and-rinse
adhesives.
 Because self-etching (etch-and-dry) adhesives
contain acidic monomers that simultaneously
condition and prime the dental substrate, they
do not require a separate etching procedure.
 Self-etching adhesives require only air drying,
avoiding the need for rinsing after application.
 Consequently, these adhesives do not remove
the smear layer. While their use has been
associated with lower postoperative sensitivity
than that of etch-and-rinse adhesives, mainly
when evaluated in deeper cavities and likely
because the dentinal tubules remain partially
obliterated by smear plugs,
 Such systems have thus been described as
more user friendly (shorter application time,
fewer steps) and less technique sensitive (no
wet bonding, simple drying) than etch-and-rinse
systems.
 These systems have demonstrated excellent
performance.
Two-Step Self-Etching or Etch-and-Dry
Adhesives.
116
Step 1: Self-etching and priming
Self-etching and priming of enamel:
 Clinically, the application of weak acids to
enamel cannot produce the same extent of
demineralization and typical frosty appearance
obtained with the use of phosphoric acid. Self-
etching primers produce a shallower and less
retentive enamel-etching pattern because of
insufficient penetration into the enamel surface.
 The insufficient creation of enamel irregularities
for penetration by self-etching adhesives results
in low bond strength and poor marginal
adaptation; thus, phosphoric acid should be
preferred for enamel etching.
 The clinical use of self-etching adhesives on
sound enamel is particularly problematic,
especially in unbeveled preparations.
 Most studies have confirmed that a preliminary
separate etching procedure of enamel with
phosphoric acid (> 15 seconds) should be
included in the bonding procedure to achieve
optimal enamel bonding results.
Self-etching and priming of dentin:
 Although strong self-etching adhesives with
improved enamel-etching performance are
currently available, their ability to bond to dentin
remains severely compromised. Their high
intrinsic acidity does not allow complete
buffering from the dissolved hydroxyapatite,
leading to continuous etching and incomplete
polymerization.
 Mild self-etching adhesives are thus preferred
for dentin bonding. Such adhesives partially
demineralize dentin, leaving residual
hydroxyapatite crystals that protect the collagen
fibrils.
 Mild two-step self-etching adhesives have been
found to exhibit excellent adhesion to smear
layer–covered dentin, resulting in immediate
bond effectiveness and longevity comparable
with those achieved with three-step etch-and-
rinse systems that are sometimes considered
the gold standard.
 A major advantage of two-step self-etching
systems is that they are relatively technique
insensitive.
 A concern with the bonding process for self-
etching adhesives is how to best maximize the
bond to enamel without compromising the bond
to dentin. As noted previously, a separate
application of phosphoric acid to enamel prior
117 Chapter 5 Bonding in Dentistry 117

to self-etching adhesive application will Advantages, disadvantages, and common

significantly improve the bond to enamel. errors for two-step self-etching or etch-
 Because it is often difficult to apply phosphoric and-dry adhesives
acid etchant to enamel without involving dentin,
Advantages:
this procedure must be approached with
caution.  No rinsing; quick application. No risk of overwet
or overdry dentin.
 Bonds well to enamel etched with phosphoric
Summary of Clinical application steps for acid.
Etching and priming:
1) Selectively etch enamel with 35% to
Disadvantages:
37%phosphoric acid for 15 s.
 If phosphoric acid etch not done first, enamel
2) Air-water rinse for 15 s, trying to minimize
microleakage may result due to deficient enamel
rinsing over the dentin. Dry gently.
etch.
3) Actively apply the self-etching primer agent on
etched enamel and unetched smear layer–  Prior etching of dentin surface with phosphoric
acid may compromise bond to dentin.
covered dentin for the time recommended by the
manufacturer (typically 20 s).  Thick adhesives may pool easily around
4) Air dry to remove any excess solution and preparation line angles and margins.

solvent and terminate the etching reaction.

Common errors:
Step 2: Bonding  Insufficient etching on the enamel if selective
 The bonding agents of two-step adhesives preliminary enamel etch is not performed.
contain hydrophobic monomer blends.  Inadvertent application of separate enamel
 Brush thinning to optimize adhesive thickness, etching agent to dentin.
the use of a layered application to achieve a fully
saturated surface, and the use of optimal curing
ONE-STEP SELF-ETCHING OR ETCH-
times.
AND-DRY ADHESIVES
Summary of Clinical application steps for
Bonding:  One-step self-etching adhesives are the
1) Generously apply the adhesive resin with a simplest and most recently developed adhesive
microbrush. systems.
2) Use a bristle brush to thin and create a  These systems are classified as seventh- or
homogenous layer. eighth-generation adhesives because they may
3) Cure for manufacturer recommended time, be multibottle (mixed just prior to use) or single-
which is typically about 10 to 20 s. bottle (all-in- one) systems, respectively.
 One-step self-etching adhesives combine the
three steps of the adhesion process into the
application of a single solution containing
complex mixtures of hydrophilic and
hydrophobic resin blends, acid, and water to
activate etching. This chemical complexity has
caused shelf-life problems.
 Although these adhesives simplify clinical
application, they result in lower immediate bond
strengths than that produced with more
complex adhesive systems.
 One-step self-etching adhesives have also
shown lower degrees of conversion than have
multi step systems. The high concentration of
hydrophilic domains and the presence of water
result in suboptimal polymerization and reduced
Bonding to dentin using a self-etch primer. bond longevity because of the elution of
118 Clinical Operative Dentistry 118

unreacted monomers. This process creates a hydrophobic resin layer has been shown to
porous structure with reduced sealing ability improve immediate resin-dentin bond strength
along the adhesive interface. and reduce long-term adhesive interface
degradation.

Application mode:
The use of an active brushing technique increases
the immediate bond strength produced by one-step
adhesives and improves long-term stability.

Application times and multilayering:

The use of multilayering techniques or prolonged
application times during dentin bonding has been
suggested to enhance the uniformity of adhesive
infiltration and increase water and solvent
One-step dentinal bonding systems. evaporation.

Application to enamel:
 Like two-step self-etching adhesives, one-step
systems have demonstrated a reduced ability to
bond to unabraded enamel. This clinically
relevant problem is particularly pronounced for
unbeveled preparations.
 For this reason, preliminary phosphoric acid
etching of enamel (especially non-instrumented
enamel) is recommended before the application
of one-step adhesives.
 As mentioned for the two-step self-etching
systems, it can be clinically difficult to prevent
the extension of phosphoric acid from enamel to
dentin during etching, especially in small Class
2 preparations. Thus, preliminary phosphoric
acid etching of dentin before the application of a
self-etching adhesive has not been
recommended.
Application to dentin:
Preliminary etching:
To reduce operator sensitivity, the pre-etching of
dentin before the application of one-step adhesives
should be avoided.
Appropriate polymerization:
The use of extended curing times that exceed the
manufacturer recommendations has been found to
improve polymerization and reduce permeability,
potentially improving the performance of one-step
adhesives.
Summary of Clinical application steps for
Etching, priming, and bonding:
1) Selectively etch enamel with 35% to
37%phosphoric acid for 15 s.
2) Air-water rinse for 15 s, trying to minimize
rinsing over the dentin. Dry gently.
3) Actively apply the one- step adhesive on
etched enamel and unetched smear layer–
covered dentin for the time recommended by
the manufacturer.
4) Air dry to remove any excess solution and
solvent and terminate the etching reaction.
5) Reapply the adhesive in multiple layers using
an active rubbing motion.
6) Air dry to remove any excess solution and
solvent and terminate the etching reaction.
7) Cure for manufacturer recommended time,
which is typically about 10 to 20 s.

Hydrophobic coating: Advantage, disadvantages, and common

 One-step self-etching adhesives may be treated errors for one-step self-etching or etch-
as primers that are subsequently covered with a and-dry adhesives
hydrophobic coating, such as those employed
in conventional three- step etch-and-rinse Advantage: Extremely simplified application
systems. procedure.
 This approach may improve adhesive
performance; the application of an additional
119 Chapter 5 Bonding in Dentistry 119

Disadvantages: Substrate:
 Requires multiple layers.
 Need for preliminary etching on enamel.  Within the same tissue, nature of the substrate
 Lower bond strength than unsimplified presented for bonding may vary with the

counterparts (two-step systems&three-step location:

system).
 Most of the adhesives are not compatible with
self-curing or dual-curing composites (core
buildup composites and resin luting cements).
 Inclusion of hydrophilic components in
bonding resin can cause increased hydrolytic
degradation.
Common errors:
 Suboptimal polymerization.
 Inadequate solvent evaporation.
 Overthinning adhesive when air drying to
remove solvent.
- Enamel etched on its rod ends provide better
area for bonding compared to enamel etched on
the side of the prisms. Thus, bevel is indicated
in various cavity preparations.
- Dentin in its superficial portion allows greater
bond strengths than in the deeper portions. This
might be because the superficial layer has more
of solid dentin and less moisture contamination
as compared to deeper portions. The presence
of moisture in dentin is the major hurdle in
achieving bonding.
 Bonding to dentin has been proven more
difficult and less reliable and predictable than
enamel.

Multimode or Universal Adhesive Systems Size and shape of lesion:

 Dental manufacturers have recently made slight  Less adhesion is seen in small sized cervical
modifications of dentin adhesive formulations to lesions.
produce a new class of universal adhesives.  Deep wedge shaped lesions have also shown to
 These materials are called multimode or better retain adhesive restorations than shallow
universal because they can be used as self-etch, saucer shaped lesions.
etch-and-rinse, or selective-etch systems.
 These adhesives have the ability to bond
Maxillary versus mandibular arch:
methacrylate- based restoratives, cement, and
sealant materials to dentin, enamel, glass Better adhesion results are expected in the maxillary
ionomer, and several indirect restorative arch because of lesser chances of moisture
substrates, including metals, alumina, zirconia, contamination and lower tooth flexure effects in the
and other ceramics. upper jaws.
 The primary use of these adhesives is with light-
activated resin composites in direct
Tooth flexure:
restorations.
 Nevertheless, because of the limited thickness  More recently, tooth flexure is a probable factor
of the adhesive layer, they can also be used to in influencing the retention of adhesive
lute indirect restorations with self- or dual-cured restorations especially the cervical restorations.
composites and cements in combination with a  Heavy centric occlusal and eccentric forces are
self-curing activator. responsible for generating compressive and
tensile forces in the cervical area, which may
gradually dislodge and debond the resin
SUCCESS/FAILURE OF ADHESIVES
restoration.
 The composites with adequate elastic capacity
Material factors:
like microfilled composites are preferred in such
The manufacturer’s instructions should be carefully lesions.
followed regarding washing off the conditioner and
mode of applying the primer and bonding. Elastic bonding concept:
 Composite resins shrink during polymerization.
 In order to protect the tooth composite interface
from debonding during polymerization, the
120 Clinical Operative Dentistry 120

intervening adhesive resin should be glass-ionomer improves its bond to composite

sufficiently elastic to absorb the polymerization by producing a rough surface in which glass
stresses. particles stand out above the matrix. A thin
 This can be achieved by using a relatively thick liquid resin, which is then applied is able to
layer of separately polymerized, unfilled or penetrate into the micropores between the
semifilled bonding resins. particles thereby providing mechanical
 Alternatively, the additional use of intermediate interlocking.
glass-ionomer liners under composites are  The cement should be allowed to fully set before
known to reduce the total stiffness of the it is etched otherwise the unreacted particles
restoration. may dissolve and weaken the cement. A
minimum delay of 20 minutes is therefore
recommended prior to etching.
Patient’s age:
With age, the dentin becomes sclerosed and the  15-20 seconds etching period is sufficient.
sclerosis is associated with a decrease in clinical Above 30 seconds of etching, the cement is
adhesiveness and hence a higher failure rate. excessively prone to degradation by the acid.
 Grinding of the set cement should be avoided as
it might decrease the bond strength values.
Dentin wetness:
 Overwet/overdry dentin surface will result in  The type of glass-ionomer cement has shown to
adhesive failure. influence the bond at the dentin surface and the
 An ideal dentin surface for bonding is visibly glass-ionomer/composite interface. Higher the
moist, without any excessive water. This can be strength of the cement, better are the clinical
achieved clinically by blot drying with a damp results. Use of light cure glass-ionomer lining
cotton pledget. materials have greatly reduced the chances of
debonding. These achieve high early strength
on photo-polymerization and also chemically
Method of fluid control: bond to the resin composite without the need for
Adequate isolation is mandatory. It should be done
etching.
using rubber dam.
 Glass ionomer cements should be used in
adequate bulk under composite resin to avoid
Placing composite resin: stresses from the shrinking composite.
Place composite restoration in increments to
minimize polymerization shrinkage stresses to avoid
bond failure.

Improper handling:
Bond failure may occur due to
 Thickening of bonding agent because of
evaporation of solvent. This reduces the
penetration of the bonding agent.
 Contamination of tooth surface by lubricants
used in handpieces.

BONDING OF COMPOSITE TO GLASS-

IONOMER

 Glass-ionomer invariably is used as a substitute

for dentin under composite resins. Sandwich technique.
 This technique is commonly known as bilayered
technique (Sandwich technique) in which the
enamel and cement are etched prior to
placement of the restorative resin.
 Generally, 37% phosphoric acid is used to etch
glass-ionomer and the enamel. Acid treatment of
123 Chapter 6 Material Considerations of Resin Composite 123

COMPOSITION OF RESIN COMPOSITE Coupling Agents

Functions:
1. Organic matrix or organic phase  Bonding of filler and resin matrix.
2. Filler or dispersed phase  Transfer forces from flexible resin matrix to
3. An organosilane or coupling agent stiffer filler Particles.
4. Activator-initiator system  Prevent penetration of water along filler resin
5. Inhibitors interface, thus provide hydrolytic stability.
6. Coloring agents
7. Ultraviolet absorbers.
Organic Matrix

 Like Bis-GMA or UDMA.

 It represents the backbone of composite resin
system.
 The BiSGMA/UDMA was viscous and blending
of filler particles was difficult, so other matrix
were tried having lower viscosity, such as:
TEGDMA (Triethylene glycol dimethacrylate)
The mixture of two of these three resins
provides appropriate viscosity needed for
binding of filler particles.
Inorganic filler material Composition of resin composite.
Initiator Agents

Filler particles are silanated so that the hydrophilic  These agents activate the polymerization of
filler can bond to the hydrophobic resin matrix composites.
 Most common photoinitiator used is
The size of the filler particles vary from composite camphorquinone.
to composite depending upon the requirements and  Currently most recent composites are
needs. polymerized by exposure to visible light in the
range of 410 to 500 nm.
The size of filler particles incorporated in the resin
Inhibitors
matrix of commercial dental composites has
continuously decreased over the years from the These agents inhibit the free radical generated by
traditional to nano-composite materials. spontaneous polymerization of the monomers.
Coloring Agents
Function:
 Improve physical properties: Coloring agents are used in very small percentage to
 Reduces the coefficient of thermal expansion. produce different shades of composites.
 Reduces polymerization shrinkage. Ultraviolet Absorbers
 Decreases water sorption.
 Increases translucency. They are added to prevent discoloration, in other
 Improve mechanical properties: words they act like a “sunscreen” to composites.
 Increases abrasion resistance. CLASSIFICATION ACCORDING TO
 Increases tensile and compressive strengths. FILLER PARTICLE SIZE (TYPES OF
 Increases fracture toughness.
RESIN COMPOSITE)
 Increases flexure modulus.
 Provides radiopacity.
 Improves handling properties.  Macrofilled composites
 Microfilled composites
 Hybrid composites
 Nanofilled resin composites
124 Clinical Operative Dentistry
Macrofilled Composite Resin
 The first type of dental composite developed in
the 1960s.
 The filler is a quartz material with particle sizes
of 10 to 25 µm. Filler content is 70% to 80% by
weight. (Note that there is a difference between
filler content as measured by weight and by
volume. The volume percentage is typically 10%
to 15% lower than the weight percentage).
 The large size of the filler particles in macrofilled
composites results in a restoration that feels
rough to the dental explorer and can appear
rough to the eye.
 The likelihood of plaque accumulation and
staining is greater with macrofilled than with
other types of composites.
 The typical macrofilled composite will turn
slightly gray when rubbed with an instrument.
The hard filler abrades the metal instrument.
This aids in the location of macrofilled
composite restorations.
 Macrofilled composite have little clinical
importance at this time except that some
orthodontists still use them. The rough feel and
easy detection give them an advantage during
the removal of bonded orthodontic brackets or
appliances and the accompanying bonding
material.
 The strength and other physical properties,
except wear resistance and surface roughness,
of macrofilled composites are adequate for
Class III, IV, and V restorations. Excessive wear
when used for Class I and II restorations limited
their posterior use.
Macrofilled Composite Resin.
Microfilled Composites Resins
 The particle size of microfilled composites is far
smaller than in macrofilled composites which is
124
(0.03–0.5 µm) (contain silica fillers of submicron
size only). Thus, Microfilled composites polish
very smooth (which is resistant to plaque, debris
and stains) and lustrous, and the surface
appearance is very similar to enamel.
 The problem with microfilled composites is the
low percentage filler (40–50%) by weight. This
high resin content results in an increased
coefficient of thermal expansion and lower
strength.
 To enhance the properties of these materials,
manufacturers incorporate what are called
prepolymerized resin fillers (PPRF) in addition to
the submicron-sized fillers. The resin of these
“composite filler particles” has already been
polymerized. Therefore, this resin cannot
polymerize and does not increase
polymerization shrinkage. In this way, filler
content is maximized, polymerization shrinkage
is minimized, and the resin composite remains
highly polishable. Even with this process, the
microfilled composites have smaller filler
loading in relation to the other ones, resulting in
lower mechanical strength and wear resistance.
 They are indicated for the restoration of anterior
teeth and cervical abfraction lesions.
 They were also used in Class V restorations at
the cemento–enamel junction. Microfilled
composite have a lower modulus of elasticity
and flex with the tooth better than the strongest
composite materials. Clinical research has
shown Class V microfill composite restorations
are more likely to be retained than other
composite materials.
 When a highly polished Class 4 restoration is
needed, a hybrid material may be used as a
substructure to maximize strength and wear
resistance, then veneered with a microfilled
resin composite for a smooth surface.
 They are not recommended for stress-bearing
restorations (class I&II) due to their Poor
mechanical properties due to more matrix
content.
125 Chapter 6 Material Considerations of Resin Composite 125

average particle size of less than 1 µm. Because

of the submicron size (0.4 to 0.8 µm), these
materials are called microhybrids.
 Incorporation of smaller particles make them
better to polish and handle than their hybrid
counterparts.
 Because of presence of large filler content,
microhybrid composites have improved
physical properties and wear resistance than
microfilled composites.

Universal microhybrid composite suitable for all

applications from Class I through Class VI.
Microfilled Composites Resins.
Nanohybrid composites
Hybrid Composite Resins
 Nanofill and nanohybrid composites have
 Hybrid composites contain a blend of average particle size less than that of microfilled
submicron (0.03-0.5 µm) and small-particle (1- composites.
4.0-µm) fillers. Filler content in these  Many nanohybrids also contain PPRF to reduce
composites is 75 to 80% by weight. overall curing shrinkage.
 This mixture of fillers is responsible for their  Advantages:
physical properties similar to those of  Highly polishable.
conventional composites with the advantage of  Tooth-like translucency with excellent esthetic.
smooth surface texture. They can be polished to  Good color stability.
a fairly high luster, but not to the extent of a  Stain resistance.
microfilled material.  Optimal mechanical properties.
 Hybrid resin composites are a combination of  High wear resistance.
conventional and microfilled technology and  Can be used for both anterior and posterior
can be used for anterior and posterior restorations and for splinting teeth with fiber
restorations. ribbons.
 Their strength and abrasion resistance are  Good handling characteristics.
acceptable for small to medium Class I and II
restorations.
 Their surface finish is nearly as good as that of
microfilled composite; thus, they are also used
for Class III and IV restorations.
 Two new generations of hybrid composite
resins are:
- Microhybrids.
- Nanohybrids

Microhybrid composites
Nano Hybrid Composite.
 In the last decade, dental manufacturers have
fabricated hybrid resin composites with an
126 Clinical Operative Dentistry 126

3M ESPE Filtek Z250 XT Dental Nano Hybrid

Composite.

 The research and development of these
materials were designed with the objective of
successfully integrating a high concentration of Universal Nanofilled resin composite.
nanoparticles into resin composites to enhance
mechanical properties, handling, and ease of SPECIAL USE COMPOSITE
polishing. MATERIALS
 Nanofillers are extremely small filler particles,
have dimensions below the wavelength of Two special use composite materials are available.
visible light (0.4– 0.8 µm), they are unable to Most manufacturers market flowable composites,
scatter or absorb visible light. Thus, nanofillers and some are marketing condensable composites.
are usually invisible and offer the advantage of Because composite materials are more difficult to
optical property improvement. place in the cavity preparation than amalgam, both
 Additionally, nanofillers are capable of types are designed to make the placement of
increasing the overall filler level due to their composite materials easier.
small particle sizes. Flowable composites
 Unfortunately, the term nano has been mistaken
as only referring to particle size. Actually, nano  It flows into the cavity preparation because of
refers to the technology and manipulation of their lower viscosity.
nanosized particles with the purpose of  Manufacturers have decreased the filler content
improving the final performance of the product. of the material to reduce the viscosity and
 Few materials with a true nano-fill technology increase the flow of these materials.
exist in the market at the moment (e.g., Filtek  A weaker, less abrasion-resistant material
Supreme Ultra, 3M ESPE). results.
 In general, these nanofilled composites are non-  They also generally present a larger volumetric
sticky and non-slumping. shrinkage.
 Changes in their composition have led to  Even though they are easy to use and have good
improved materials that are more esthetic, very wettability and handling properties, its clinical
easy to polish, and better maintain their luster indications are limited.
over time.  They are indicated for:
 The most notable improvement is the smooth  Class V restorations, because this region
surface of modern well-polished composite undergoes compressive and tensile stress but
materials. These materials have largely replaced has no direct contact with the opposing tooth
microfilled compositions.  As the first layer under composite restorations
on posterior teeth, because it promotes a better
adaptation to the internal angles of the
preparation
 On restorations of small preparations in the
occlusal surface of posterior teeth
 As pits and fissure sealants
 For repair the defective margins of pre-existing
restorations.
127 Chapter 6 Material Considerations of Resin Composite 127

Flowable Composite Resin.

Types of composites according to the viscosity. a

Condensable composites (or, packable
Low; b medium; c high
composite)
GENERAL PROPERTIES OF DENTAL
 Another attempt to make placement of the RESIN COMPOSITE
material into the cavity preparation easier.
 Introduced to help the restoration of the contact Coefficient of Thermal Expansion
points with the adjacent tooth. Its viscosity
helps to press the matrix during the application,  Coefficient of thermal expansion of composites
although they were more difficult to handle. is approximately three times higher than normal
However, some techniques can allow the proper tooth structure.
restoration of the proximal contacts without the  This results in more contraction and expansion
need of such a high viscous materials. For this than enamel and dentin when there are
reason, those are currently seldom used on the temperature changes resulting in loosening of
daily dental practice. the restoration.
 Clinical research has shown these materials  It can be reduced by adding more filler content.
with a different “feel” are not an improvement  Microfill composites show more coefficient of
over hybrid composite materials; most thermal expansion because of presence of more
performed poorly and few are still on the market. matrix content.

Water Absorption

 Composites have tendency to absorb water

which can lead to the swelling of resin matrix,
filler debonding and thus restoration failure.
 Water Absorption of Composites can be affected
by some factors:
- More is the filler content, lesser will be water
sorption.
- Lesser degree of polymerization causes more
water sorption.

Wear Resistance

 Composites are prone to wear under

Condensable (Packable) Composite.
masticatory forces, toothbrushing and abrasive
food.
128 Clinical Operative Dentistry 128

 Wear resistance is a property of filler particles  The use of low-shrinkage Materials.

depending on their size and quantity.  The use of flexible resin liners, slow-setting
 Factors Affecting Degradation/Wear of resin-modified glass-ionomer liners.
Composites:  Polymerization rate: “Soft-start” polymerization
- The More is the filler content, grater will be wear reduces polymerization shrinkage.
Resistance.
- Lesser is the polymerization, more is the
degradation.
Microhybrid & nanohybrid composites show
less of degradation
Surface Texture

 Size and composition of filler particles

determine the smoothness of surface of a
restoration.
 Microfill composites offer the smoothest
restorative surface.
 This property is more significant if the Polymerization shrinkage can result in a gap
(microleakage) between tooth and restoration.
restoration is in close approximation to gingival
tissues.
Radiopacity

Presence of radiopaque fillers like barium glass,

strontium and zirconium makes the composite
restoration radiopaque.
Modulus of Elasticity

 Modulus of elasticity of a material determines its

rigidity or stiffness.
 Microfill composites have greater flexibility than
hybrid composite since they have lower Polymerization shrinkage can
pull opposing two cusps
modulus of elasticity thus may be indicated to resulting in crack of fracture of
be used in non-carious cervical lesions. tooth.
Polymerization Shrinkage

 Composite materials shrink while curing which

can result in formation of a gap between resin-
based composite and the preparation wall.
 In light cured composites, about 60 %
polymerization occurs within 60 seconds,
further 10 percent in next 48 hours; remaining
resin does not polymerize.
 Note that Shrinkage in light cured composites
occurs in the direction of light.
 High-stiffness materials will typically generate
higher shrinkage stress.
 Polymerization Shrinkage can Result in:
 Postoperative sensitivity.
 Recurrent caries. Note that Shrinkage in light cured composites
 Failure of interfacial bonding. occurs in the direction of light. a)incremental
placement technique b)bulk placement
 Fracture of restoration and tooth. technique.
 Polymerization Shrinkage can be Reduced by:
 The use of incremental placement techniques.
 The use of long enamel bevels.
129 Chapter 6 Material Considerations of Resin Composite 129

Incremental placement technique result in decrease in

polymerization shrinkage.

Cavity Configuration or C-factor

 C-factor is the ratio of bonded surface of restoration to unbonded surfaces.

 The Higher the value of ‘C’-factor, the greater is the polymerization shrinkage because more of the composite
is constrained and not free to flow or deform to relax stresses.
 Three-dimensional tooth preparations (Class I and V) have the highest (most unfavorable) C-factor and thus
are at more risk to the effects of polymerization shrinkage.
 C-factor plays a significant role when tooth preparation extends up to the root surface causing a ‘V’ shaped
gap formation between the composite and root surface due to polymerization shrinkage.
 C-factor value of different tooth preparations:
- class I&V (five-walled preparation) = 5
- class II ( four-walled preparation) = 2
- class III ( three-walled preparation ) = 1
- class IV ( two-walled preparation ) = 0.5

Microleakage

 It is passage of fluid and bacteria in micro-gaps between restoration and tooth.

 Microleakage can occur due to:
 Stresses from Polymerization shrinkage of composites.
 Stresses due to difference in coefficient of thermal expansion.
 Poor adhesion.
 Mechanical loading.
 Microleakage results in:
 Bacterial leakage.
 Recurrent caries.
 Pulpal irritation and damage.
 Tooth discoloration.
130 Clinical Operative Dentistry 130

Clinical problems created by the shrinkage stress during composite polymerization.

Degree of conversion  Curing light should be kept perpendicular to

resin. If angle of light diverges from 90°,
 Complete polymerization of the composite is intensity decreases.
determined by degree of conversion of  Note that avoiding premature polymerization of
monomers into polymers. the composite during the placement and
 Factors Affecting Degree of Conversion: modeling should be considered. Thus, the
- Curing Time: Curing time depends on different central focus of the overhead chair light should
factors like shade of the composite, intensity of be moved away from the operating field, using a
the light used, temperature, depth of the minimum illumination that comes from borders
preparation, thickness of the resin, curing the light beam.
through tooth structure. - Temperature: Composite should be kept at room
- Shade of Composite: Darker shades of temperature at least 1 hour before use because
composite polymerize slower as compared to curing would be less if it is taken out
lighter shades. immediately from refrigerator.
- Distance and Angle between Light Source and - Resin Thickness: Resin thickness should be
Resin: ideally 0.5 to 1.0 mm for optimum polymerization
 Recommended distance between light source (not exceed 2.0 mm).
and resin is 1 mm. - Type of Filler: Microfilled composites are more
 Intensity of light decreases as the distance is difficult to cure than heavily loaded composites.
increased.
 Polymerization can also be achieved in tooth
preparation with deep proximal box by curing
from proximal surface.
131 Chapter 6 Material Considerations of Resin Composite 131

 For that, non-stick filling instruments made of

anodized aluminum or highly polished stainless
steel, or coated with titanium nitride or PTFE, as
well as silicone or thermoplastic elastomer tips,
should be used.
 In addition, the instrument should be kept clean
during the procedure and the composite
residues constantly removed using damp
alcohol gauze.
 If the composite is still sticking too much to the
instrument, it can be wet with a very small
amount of adhesive. The ideal are adhesives
without solvents, such as on the systems where
Polymerization can also be achieved in tooth the primer is in a separated bottle. There are
preparation with deep proximal box by curing from specific products for this purpose, such as the
proximal surface. Composite Wetting Resin (Ultradent) and
Signum Liquid (Kulzer). Some studies have
Handling characteristics shown that this procedure does not affect the
bonding between the increments. The primers or
 Ideally, resin composite materials should be soft
self-etching adhesives should be avoided,
and easily manipulated, should not stick to
because they contain water and other solvents
placement instruments and brushes, should
that adversely affect the bonding of new
adapt well to the cavity walls, and should not
increments.
slump during placement.
 Composite Placement Instrument is Used to
 Handling is greatly influenced by the viscosity
- Carry composite material to the cavity
of the resin composite. According to their
preparation.
viscosity, resin composites can be classified as
- Place, condense, and carve composite material
conventional, packable, or flowable.
in cavity preparation.
 Low-viscosity materials adapt well to cavity
 Composite Burnisher is Used to
walls, but they tend to be sticky and are prone to
- To form occlusal anatomy in composite
slump. When the viscosity is extremely low, as
restorations.
is the case with flowable resin composites, the
- To achieve final contouring of anatomy, pits,
risk of porosities inside the restoration
fissures, and grooves.
increases if the material is not handled
appropriately.
 On the contrary, high-viscosity materials do not
adapt to the tooth as easily and require careful
attention during placement. Their use is
advantageous because they are not sticky and
maintain their shape during placement.
 A gauze pad lightly moistened with alcohol may
be used to clean the active part of the instrument
during resin composite placement to prevent the
material from sticking to the instrument.
 After applying some increments into the cavity
preparation, the composite can start to stick on
the filling instrument. When the instrument is
taken away from the preparation, it can pull the
Composite gun with composite compules.
composite back, and a gap is formed between
the material and the wall. After curing, it will
generate a permanent interfacial defect.
Therefore, it is extremely important to avoid the
composite sticking to the instrument.
132 Clinical Operative Dentistry 132

6. Tension rings—Different sizes to accommodate

restoration

Composite Burnisher.

Sectional Matrix System.

Optical characteristics

 Composites have shown good esthetics

because of their property of translucency.
 Composites are available in different opacities
and shades so they can be used in different
places according to esthetic requirements. But
due to oxidation, moisture and exposure to
ultraviolet light, etc. some chemical changes
Composite Burnisher. can occur in the resin matrix which result in
discoloration of composite with time. But
improvements in composites like increase in
filler content, decrease in tertiary amines and
improvement in light curing techniques have
shown more stability in composite shade.
 Based on their optical properties, resin
composite kits usually contain three types of
materials:
- A dentin like material, designed to imitate the
dentin’s optical properties (may also be called
opaque, dentin composites).
Composite Placement plastic Instrument. - An enamel-like material, designed to simulate
the enamel’s optical properties (may be called
universal or body shade composites).
 Sectional Matrix System:
- A translucent-like material, designed to mimic
- Used To replace missing proximal wall of cavity
translucent areas of teeth. (May be called incisal
preparation for placement of composite material
shade).
or other restorative materials for class II
 When a single shade is used for a restoration, an
restorations.
- Characteristics :Variety of sizes and shapes to intermediate opacity should be selected. Usually
the manufacturer has designated the enamel-
accommodate restoration as seen in the
like material as intermediate opacity for this
following figure:
purpose.
1. Pediatric band—Primary molar
2. Small band—Premolar, small molar  When multiple shades of resin composite are

3. Extended small band—Premolar, molar, with layered, the principle of replacing dentin with

deep cervical restoration dentinlike materials and enamel with enamel-like

materials should be observed.
4. Standard band—Molar restoration
5. Large band—Deep cervical restoration
133
135 Chapter 7 Direct Anterior Composite Restorations 135

 The operator should avoid staring at the tooth

STEPS OF CLINICAL PROCEDURING and shade guide for long periods of time.
FOR COMPOSITE RESTORATION Staring at these objects during shade selection
will cause the colors to blend, resulting in a loss
of color acuity. The shade guide should be
1. Local anesthesia placed adjacent to the tooth to be restored and
2. Oral prophylaxis& Preparation of operating site then viewed briefly to determine which shade or
3. Composite selection shades match the color of the tooth; then the
4. Shade selection eyes should be moved away. Ideally, the eyes
5. Isolation should be “rested” by viewing the horizon
6. Tooth preparation through a window or by looking at an object that
7. Bonding is a muted blue, violet, or gray color.
8. Composite placement and polymerization  If patients have whitened their teeth, it is
9. Final contouring, finishing and polishing of necessary to wait 2 weeks after bleaching for
composite restoration shade selection and optimal bonding results.
Composite Selection  The tooth should be made clean and free of
contaminants by using a prophylaxis cup with a

Composite selection depends on Position of tooth slurry of pumice to remove plaque or debris
from the tooth surface and to eliminate any
preparation:
stains.
 For restoration requiring high mechanical
 The patient should be positioned in such a way
performance, like class IV preparations, large
that the teeth receive enough light from the
class I, II and class VI, choice of composite is
illuminant or light fixtures.
that with the highest filler load.
 The shade guide should be hold at least one
 For restorations of anterior teeth, esthetics is
arm’s length far from the patient’s mouth.
the main concern. So, microhybrid or
nanohybrid composites are preferred in these  The color of the room walls and of the patient
cases. and staff clothing should be neutral to avoid
imparting a negative color cast. Additionally, the
 Composites which are highly polishable are
patient should be asked to remove lipstick prior
preferred for cervical lesions both in the
to shade selection.
posterior and in anterior areas to avoid plaque
accumulation on them. Isolation
Shade Selection
 Contamination of etched enamel or dentin by
For posterior composite restorations, shade
saliva results in a decreased bond strength and
selection is not as critical as for anterior
contamination of the composite material during
restorations.
insertion results in degradation of its physical
properties.
General Guidelines for Initial Shade Selection:
 Isolation is best done by using rubber dam,
 Teeth and shade guide should be wet to
although it can be done using cotton rolls, saliva
simulate oral environment because dehydration
ejector and retraction cord.
causes
 Significant lightening of the color.
 An increase in the opacity of enamel and dentin. CAVITATED INTERPROXIMAL
 Shade matching should be carried in natural LESIONS: CLASS III
daylight. It is wise to use multiple light sources
to choose the best shade.
 Dentin shade is selected from cervical third of Interproximal caries lesions are smooth-surface
tooth, and enamel shade is selected from its lesions found slightly gingival to the proximal
incisal third. contact, without involving the incisal angle of the
 To confirm final shade, a small increment of tooth. (Figure7.1)
selected composite is placed adjacent to the
area to be restored and then light cured for
matching.
136 Clinical Operative Dentistry 136

Figure 7.2(c) removal of the carious dentin tissue

with round bur in low-speed handpiece
Figure 7.1 showing class III caries.

Cavity Preparation (Figures 7.2 a-f)

Figure 7.2(d) opening of adjacent lesion through

the access of the larger lesion

Figure 7.2(a) Initial aspect of class III lesion.

Figure 7.2(e) removal of the carious dentin tissue

 Outline form for resin composite restorations is

defect specific and determined solely by the
extent of the caries lesion(s) and access for
Figure 7.2(b) opening of the larger cavity with a
round diamond point removal of carious tooth structure.
 There is no need for further extension of the
preparation. The removal of sound tooth
structure to gain mechanical undercut retention
is contraindicated.
137 Chapter 7 Direct Anterior Composite Restorations 137

 The incisal portion of the contact point is not

necessarily removed.
 When a lesion is limited to enamel, a round
carbide or diamond bur is used in a high-speed
handpiece for cavity preparation. The finished
preparation resembles a saucer and has no
retentive undercuts.
 The lingual approach is preferred for larger
Class 3 restorations, but it is not always
possible depending on the location of the caries
lesion. (Figure7.3)

Figure 7.4(a) bevel in class III.

Figure 7.3 the lingual approach is preferred for

larger Class 3 restorations.
Figure 7.4(b) bevel placement a) proximal view. b)
 A no. 2 round bur or a pear-shaped carbide bur Facial view.
or diamond in a high-speed handpiece can be
used for initial access to the lesion. Initial
penetration should be made through the
marginal ridge, near the adjacent tooth but
avoiding damage to it.
 The outline form of the preparation is then
extended to provide access to the carious
dentin.
 A spoon excavator and a large round bur may be
used in the low-speed handpiece to excavate
demineralized dentin.
 Unsupported facial enamel may be left for
internal etching and bonding to resin composite.
The appearance of true enamel is more natural Figure 7.4(c) Completed Class III tooth preparation
(facial approach), with the bevel marked.
and esthetic than the most esthetic restorative
material.
Matrix application
 The facial approach for access to carious dentin
is indicated only when the caries lesion already  The etching and bonding steps can be done
involves the facial surface or when the adjacent either before or after the matrix and wedge
tooth overlaps the tooth being restored, have been placed. The placement of matrix
preventing a lingual approach.(Figure7.4 c) after the etching and bonding steps is
preferred. In case the matrix is placed before
these steps, the application and removal of
etchant become difficult. However, authors
who favor matrix placement before these
steps are of the opinion that while doing so the
matrix aids in isolation thereby increasing the
accessibility especially at the gingival areas.
138 Clinical Operative Dentistry
 Also some authors favor matrix placement
before etching and bonding steps because
sometimes, the wedge insertion may cause
fracture of some undermined enamel on the
cavosurface angle, which will be permanently
lost. In this case, the composite is applied
over non-etched and bonded enamel,
resulting on marginal microleakage on this
area. One possibility to overcome this
problem is to apply the matrix and wedge
before the acid etching.
 The clear plastic strip is the most commonly
used matrix with Class 3 restorations :
- The clear plastic matrix, when properly wedged,
will reduce flash (excess material) at the gingival
margin.
- It is placed between the teeth and adjacent to
the cavity preparation. (Figure7.5)
Figure 7.5 insertion of matrix and wedge.
- The resin composite may be shaped with an
instrument, or the matrix strip may be pulled
snugly around the tooth and held in place
manually to provide shape to the restoration and
intimately adapt the resin composite.
- Due to the fact that the proximal tooth surface is
convex inciso-gingivally and the polyester strip
is flat, it may be necessary to shape it to adapt
to the desired tooth contour. A way to do this is
to draw it across a hard and rounded object,
such as the round end of a clinical tweezer.
Several pull movements with strong pressure
may be required to obtain enough Convexity.
(Figure7.6)
- It must be extended at least 1 mm further than
the gingival and incisal preparation margins.
138
Figure 7.6 Contouring of the polyester strip with
the round end of a clinical tweezer.
Wedging (Figure7.7)
 Wooden wedges are inserted between the teeth
and against the matrix to
- Seal the gingival margin.
- Separate the teeth.
- Protect interproximal gingiva.
- Ensure adequate proximal contact.
- Push the rubber dam and proximal tissue
gingivally to open the gingival embrasure.
 The wedge is inserted into the interproximal
space using a mosquito forceps with a curved
end, preferably on the opposite side of the
preparation entry. In other words, it is facially
inserted when lingual access was performed
and vice versa, always apically to the gingival
cavosurface angle.
 It must be kept as short as possible to avoid
conflicts with the access area, not hindering the
placement of the restorative material.
 With proper rubber dam isolation, it is usually
possible to have direct access to the gingival
margin to be able to place and seal composite
without the need for a wedge. Floss ligatures
can greatly help in gaining access to the gingival
margins by pushing the rubber dam and gingival
tissues apically.
 When rubber dam cannot be used, care should
be taken when inserting wedges because of the
susceptibility of the gingiva to bleed upon
removal.
 If the wedge will cause deformation of the matrix
or poor cervical contours, it should not be used,
or its use may be delayed until after a freehand
increment of resin composite has been placed
and sculpted in the cervical portion of the
preparation and polymerized.
139 Chapter 7 Direct Anterior Composite Restorations 139

Incremental placement technique:

 The entire preparation and a 2 to 3 mm area
beyond the margins should be etched&bonded
for retention and to ensure proper marginal seal.
 Small Class 3 preparations of less than 2 mm
can be filled in a single increment. (Figure7.9)

 Larger Class 3 restorations should be

incrementally filled. Placement of multiple
increments is recommended to
- Optimize the degree of conversion of the resin
composite in deep areas.
- Minimize the effects of polymerization
shrinkage stress.
- Create polychromatic restorations.

Figure 7.7 using a triangular wood wedge to expose

gingival margin of large proximal preparation. A, The
dam is stretched facially and gingivally with the Figure 7.9 a) Small Class 3 preparations of less
fingertip. B, Insertion of wedge (the dam is released than 2 mm can be filled in a single increment. B)
during wedge insertion). C, Wedge in place. Larger Class 3 restorations need multiple
increments.
 Each increment of material should be light cured
for approximately 20 seconds.
Incremental placement and curing
 It should also be avoided to connect more than
(Figures 7.8 a-I)
Note that when margins of preparation extend onto two preparation walls at the same time on each
the root surface(In areas where there is little or no increment, due to the C-factor.
enamel for bonding), an open sandwich technique  If the preparation has a facial access, the pad of
using a resin-modified glass-ionomer restorative the index finger of the left hand, for the right
material may be preferred to seal the cervical portion handed people can be positioned over the
of the restoration in high caries risk patients. The lingual aspect of the strip, pressing it toward the
remaining cavity is then filled with resin composite remaining tooth structure. The labial portion is
for improved esthetics. The open sandwich reflected away from the access with the thumb.
technique reduces postoperative sensitivity and The convex shape of the finger pad will allow the
provides protection of dentin margins from ideal contour of the lingual surface, which is
demineralization. concave. Then, the composite is placed inside
140 Clinical Operative Dentistry 140

the preparation using a stratified layering facilitate application and adaptation of the final
technique. lingual enamel-like increment.
 After composite insertion, the resin composite - The final increment is then placed over the
is adapted to the cavity walls and margins. A lingual portion to complete the layering effect. If
thin, bladed instrument is used for adaptation the clear matrix is used, it is pulled slightly
and contouring, or the matrix strip may be pulled toward the facial wall to carry the material and
tightly around the tooth to achieve close improve adaptation.
adaptation. - Note that When there are two adjacent lesions to
 When the material has been light cured, the be treated on contiguous teeth:
wedge and matrix strip are removed and the o The preparation of the larger one is performed
restoration is inspected for voids. If external first, which allows the second preparation to
voids are present, they may be filled with be more conservative due to the improved
additional resin composite material, which is access. The opposite sequence should be
then light cured. followed when the material is applied during
 Large “through and through” (I.e., no facial or the restorative procedure.
lingual tooth structure is left) Class 3 o If there was any excess or over-contour at the
restorations often do not blend with the color end of the restorative procedure, the finishing
and translucency of the surrounding tooth with an abrasive strip, abrasive disc, or
structure, and sometimes a show-through of the diamond point must be performed before
darkness of the mouth can be seen: starting the next restoration.
- In order to predictably achieve an imperceptible o If the adhesive system was applied to both
restoration, the layering or stratified technique preparations simultaneously and the second
should be employed. preparation was contaminated with residues
- The cavity preparation is filled from the internal generated by the finishing, it has to be rinsed
aspect toward the external aspect. and etched and receive the adhesive
- The anatomical dentin is replaced with a application again, before any composite is
dentinlike material, which is one or two shades placed.
darker than the basic shade.
- A 2-mm layer of dentinlike material is placed
against the axial wall and carefully adapted. One
to two increments of dentinlike material may be
necessary to replace the anatomical dentin. The
final dentin increment should overlap part of the
bevel (if present) to facilitate blending and
masking.
(The following shows step by step composite
- An enamel-like material, of the same shade as
placement for class III cavity)
the basic shade, is then placed facially over the
dentin increment to replace the anatomical
enamel. This increment extends beyond the
bevel and feathers over the natural tooth
surface. This facial enamel increment should be
placed in one application and built to establish
the final facial contour of the restoration. When
the external layer is placed on more than one
increment, it is common that air can be trapped
on the junction between those increments.
Therefore, a single final increment could cover
the entire surface. As it is very difficult to place
the exact amount of composite, it is preferable
to apply a slight excess that can be removed
Figure 7.8a) finished preparation
during the sculpture or the finishing procedure.
- After polymerization of the facial increment, a
clear matrix can be placed interproximally to
141 Chapter 7 Direct Anterior Composite Restorations 141

Figure 7.8(d) matrix closed over the lingual

surface before light-curing of the last
increment.

Figure 7.8(e) insertion of matrix and wedge to

Figure 7.8(b) acid etching & bonding procedures. restore the larger preparation.
Note that application of the matrix strip between
the teeth to avoid undesirable bonding during
the light-curing of the adhesive coat.

Figure 7.8(c) insertion of matrix and wedge for Figure 7.8(f) placement of composite.
restoration on the smaller preparation.
142 Clinical Operative Dentistry 142

CLASS 4 (INTERPROXIMAL
ANTERIOR LESIONS INVOLVING THE
INCISAL ANGLE)

Interproximal lesions involving the incisal angle are

usually the result of undermining and
compromising the integrity of the incisal enamel.
This undermining can occur as a result of untreated
large interproximal caries or when replacing a large
Class 3 restoration. (Figure7.10)

Figure 7.8(g) adaptation of increments with

round-shaped nib filling instrument.

Figure 7.10 showing class IV caries.

Cavity preparation
 Cavity preparation for class 4 lesions follows the
conventional form of the Class 3 preparation
and includes a portion of the incisal edge.
 Carious tooth structure and weak enamel are
removed, and all enamel margins are beveled.
Figure 7.8(h) placement of final increment
 When a fracture has caused a need for
restoration, if there is no carious or pulpal
involvement, tooth preparation consists of just
rounding any sharp angles and placing a bevel
on all enamel margins (Figure7.11). An enamel
bevel of at least 1 mm should be placed around
the periphery of the cavity. Increasing the width
of the bevel beyond 1 mm has been shown to
provide no additional strength but a wider bevel
may provide a more harmonious esthetic blend
between the resin composite and enamel.

Figure 7.11 preparation of bevel on the labial

cavosurface angle.
143 Chapter 7 Direct Anterior Composite Restorations 143

Matrix application
 When replacing resin composite restorations, a
preparation similar to that of a fractured tooth
should be performed. Different forms of matrices can be used to form the
 On the facial surface, a longer bevel is needed lingual and proximal aspects of a Class 4
for better esthetics. This bevel has a 60-degree restoration.
angulation and is 2 to 3 mm in length. The bevel
presents a scalloped or irregular out-line, has a The transparent plastic crown forms or the palatal
variable thickness, starts inside the silicone index techniques can be applied.
dentinoenamel junction (DEJ), and feathers and
disappears onto the enamel surface. The The transparent crown form
purpose of this long bevel is to make the
The transparent crown form technique consists in
composite restoration blend onto the natural
selecting a crown with a size compatible to the
tooth structure and to make the transition
tooth to be restored. It must be cut to fit correctly to
between the two structures imperceptible.
the remaining tooth structure.
 This functional-esthetic facial bevel is created
first with a fine flame-shaped diamond bur and
It can be used in two different ways.
then blended on the surface with a medium-grit
On the first way:
polishing disk. The facial bevel is often
 The composite is applied inside the crown form,
described as infinite because its margins are
placed in position, the material excess that
difficult to detect after they have been blended
flowed through the margins is removed, and the
with the disk and they appear to be disappearing
light-curing is performed.
onto the surface.
 It is important that, before filling the form, a
 On the lingual surface, where functional
small hole is made in the incisal edge, which will
requirements are more important than esthetic
help the flowing of composite excess.
requirements, the bevel should remain shorter
 This technique presents several disadvantages
than on the facial surface, limited to about 1 mm
including that:
in length. The outline of the bevel can be straight
- The composite is placed on a single increment,
and well defined. The bevel starts at the DEJ and
making difficult to obtain a polychromatic
has a 45-degree angulation.
restoration simulating the natural tooth.
 In areas of strong occlusal stresses, cavity
- It is also hard to control the marginal overhangs.
preparation must be designed to allow for
- There is a larger risk to have air bubbles
sufficient thickness of resin composite so it is
entrapped inside the restoration.
fracture resistant. Thus, a deeper bevel or a
- As they have some standard shapes, they may
chamfer is prepared in areas exposed to
not adapt to all teeth.
occlusal loads in order to provide adequate
- Being harder and thicker than the polyester
marginal strength to the restoration.
strips, which adversely affects the passage
 Note that if the original tooth fragment is
through the proximal contact region.
available after traumatic fracture, in some
instances the fragment may be reattached to the
tooth by etching and bonding the fractured The second way to use the crown forms is:
surfaces. Clinical trials have shown these (Figure7.12)
reattachments to be successful in terms of  Select a crown that better adapts to the tooth
retention, in some cases for more than 7 years. and then cut off the labial side maintaining the
Fragment reattachment can also often provide a lingual, proximal, and incisal areas intact.
more esthetic result than can a resin composite  The crown is placed in position and wedged.
restoration, as long as the transition between  The composite is then incrementally applied,
the bonded fragment and the tooth is masked by creating a polychromatic restoration.
preparing an enamel bevel and placing
composite and blending it over the enamel
surfaces. In such cases, the bevels should not
extend into the dentin to allow the fragment to
be repositioned correctly.
144 Clinical Operative Dentistry 144

Figure 7.13(b) wax-up of the restoration over a

plaster model.

Figure 7.12 Transparent crowns forms with the labial

side removed placed on a fractured tooth.

Palatal silicone index (Figure7.13 a-e)

The technique of the palatal silicone index, which is

a custom-made matrix, is performed using a plaster
model of the defected tooth with the wax-up of the
restoration or directly in the mouth when a defective
restoration is present:

 An alginate impression of the dental arch must

be taken previously to the restorative procedure,
obtaining a plaster model.
 Over this model, the wax-up of the future
restoration is performed, sculpting the ideal
anatomy on every surface.
 A putty silicone impression material is applied
directly with the fingers to the model (trayless
impression), over the waxed tooth to be restored Figure 7.13(c) silicone modeling over the plaster
model.
and some adjacent ones.
 After the setting, the impression is removed.
 Then, with a scalpel blade, the labial part of the
mold is removed, remaining only the lingual and
proximal areas and the incisal edge.
 The adaptation of the silicone index is tested
intraorally placing it in position.
(The following shows step by step fabrication of
palatal silicone index)

Figure 7.13(d) cutting of the labial side with a

scalpel blade.

Figure 7.13(a) fractured teeth.

145 Chapter 7 Direct Anterior Composite Restorations
Figure 7.13(e) test of the silicone index intraorally.
Incremental composite placement and
curing (Figure7.14 a-h)
 Class 4 restorations are often complicated
because of the difficulty in duplicating the
natural tooth anatomical contours , surface
texture , shade gradation , and opacities
 In most cases, resin composite is layered in 2-
mm increments to achieve desired coloring and
complete polymerization. The incremental
placement technique allows the clinician to
shape the restoration to the desired form and
contour.
 An overlay technique also may be used for Class
4 restorations to obtain a combination of
strength and a very smooth surface. The bulk of
the restoration is built with a hybrid resin
composite to provide strength. The final layer is
a veneer of microfilled resin composite to
provide a smooth, glossy surface. However,
several modern hybrid and nanofilled resin
composites present adequate strength and final
gloss; thus, they can be used alone for the entire
restoration.
 To achieve imperceptible polychromatic
restorations, a layering technique employing
both enamel- and dentin like materials is
recommended. Selection of dentin and enamel
shades is based on the principle of the basic
shade, in which the dentinlike material is one to
two shades darker or more chromatic than the
basic shade and the enamel-like material is the
same shade as the basic shade.
 After proper etching and adhesive procedures
are completed, the first layer is built up.:
- A thin (0.2- to 0.3-mm) layer of enamel-shade
composite resin is placed over the custom
145
matrix outside the mouth and is limited to the
size of the missing anatomical enamel.
- The material should extend to the facioincisal
line angle over the matrix & should slightly
further than the cavosurface angle.
- It is always better to apply a thin layer because
it is easier to add composite than to remove.
- The custom matrix with the resin composite is
carried to place in the mouth and positioned on
the palatal aspect of the teeth.
- The resin composite is further adapted to the
lingual bevel, if necessary, with an ovoid-shaped
burnisher or a brush.
- The increment is light cured for the
recommended time (usually 20 sec) and the
custom matrix removed.
 The second increment, the proper dentinlike
material, should be placed to fill the angle
produced by the surface of the first increment
and the wall of tooth structure.
 The third increment, also a dentinlike material,
reproduces the dentinal lobes. An interproximal
carver or an ovoid-shaped burnisher is useful
for forming these lobes, and a brush can be used
to smooth the surface.
 When it is necessary to accentuate or make the
lobes visible from the labial aspect or to create
a high translucent incisal edge, a small
increment of a translucent material is placed
between the lobes, feathered over the incisal
edge and over the bevel, smoothed, and light
cured.
 A view from the incisal edge with an intraoral
mirror should be used to evaluate the facial
contour of each increment and to ensure that
there is enough space for the following layer.
 A final enamel-like material increment is then
placed to complete the facial contour of the
restoration. This final layer should be placed in
146 Clinical Operative Dentistry 146

one increment to avoid voids and contoured and

shaped before polymerization until it closely
resembles the desired shape. A matrix strip or
an interproximal carver instrument is used to
remove any excess and provide final proximal
contours. Brushes are used to smooth and
contour this final increment.
 After polymerization, the restoration is
contoured, finished, and polished.

The following shows step by step composite

restoration of class IV cavity

Figure 7.14(b) application of the adhesive

system &Light-curing of the adhesive.

Figure 7.14(a) acid-etching, rinsing& blot

Figure 7.14(c) application of the enamel shade

composite in the index, index with composite
taken in position &l lingual surface completed.
147 Chapter 7 Direct Anterior Composite Restorations
Figure 7.14(d) Application of a small filament of
the opaque dentin shade composite on the
incisal edge to simulate the effect of the
opaque halo.
Figure 7.14(e) restoration of dentin lobes with
dentin shade composite.
Figure 7.14(f) application of high-translucency
composite between the lobes.
147
Figure 7.14(g) application of enamel shade
composite.
Figure 7.14(h) final result after finishing and
polishing.
DIRECT RESIN COMPOSITE VENEERS
 Indirectly fabricated ceramic veneers are the
gold standard for esthetics and longevity;
however, direct resin composite veneers offer
several advantages.
 Advantages: it ,unlike ceramic materials,
- Provide a more conservative approach.
Commonly, little or no enamel removal is
required so that it is an almost entirely
reversible procedure.
- Can be placed in one visit without laboratory
involvement or laboratory fees thus economic.
- Will not cause premature wear of the opposing
dentition.
- Can be easily repaired and modified.
- Single visit treatment.
- It is atraumatic and there is no need for a local
anesthetic or for the enamel to be cut; therefore
it can be undertaken on very young or very
nervous patients without great difficulty.
 Disadvantages :
- It does not maintain their appearance as well as
ceramic restorations over time. Thus it needs
148 Clinical Operative Dentistry 148

multiple replacements in lifetime due to color  A custom matrix made from the wax-up, similar
instability. to the one described for a Class 4 restoration,
- Given in patients with excellent oral hygiene can be fabricated from the wax-up to aid with
status only. placement of the veneers.
- More chair side time.
 Tooth preparation for direct resin veneers varies
The clinical steps for a direct resin composite veneer
greatly, mainly according to tooth position and
are the following: (Figure7.15 a-h)
coloration. Thus preparation may or may not be
1. Select composite shades prior to dehydration of
required:
the tooth.
- Teeth positioned lingually or those that are short
2. Place a rubber dam and no. 212 (retractor)
cervicoincisally rarely require any preparation
clamp, if desired. If rubber dam is not used,
and can be brought into correct alignment and
place gingival retraction cord to control sulcular
length by simply adding resin composite.
fluid and retract the gingival tissue. It is often
- Facially positioned teeth with or without rotation
better to place these restorations without a
require some degree of preparation to allow
rubber dam. The gingival condition should be
space for the thickness of the material and to
healthy before these restorations are placed,
bring the tooth in alignment with the arch.
and there is no tooth preparation so that there is
- Discolored teeth require preparation only if
no risk of gingival bleeding or exudate. Placing
there is not enough space, about 1 mm, over the
the restorations without a rubber dam enables
facial aspect to place a masking agent and resin
the optimum appearance to be achieved and the
composite.
restoration can be contoured to finish just
 Direct resin composite veneers can be produced
supragingivally so that it can be cleaned.
by using single opacity shades or by layering
3. In most cases, the composite material is bonded
various shades and opacities to obtain
directly to the tooth surface. If it is necessary to
polychromatic esthetic restorations according
remove tooth structure to establish proper tooth
to adjacent teeth, desired results, and patient
alignment or to create space to mask dark tooth
expectations.
structure, a blunt ended diamond is
 If a tooth shows a dark discoloration, an opaque
recommended. Remove the smallest amount of
layer or masking agent is placed over the
tooth structure necessary to achieve the desired
adhesive and polymerized. These color
objective. At the proximal side, preparation
modifications will influence the surface shade
should be facial to the contact point. If the tooth
unless the thickness of the resin composite
is not discoloured at the gingival margin, the
exceeds 2.5 mm.
composite can be tapered down to a knife-edge
 Translucency, the appearance of lobes or
finish cervically, leaving a margin that is easy to
mamelons, and/or white or bluish
clean. The enamel may be less than 0.5 mm thick
characterization of the incisal edge may be
in the cervical region so that particular care is
added in the incisal third of the composite
needed to avoid over-cutting and exposing
veneer.
dentine. Avoiding penetration of the enamel will
 An attempt should be made to sculpt the resin
give a more reliable bond than that achieved
composite to desired contours. If the restoration
with dentine.
is slightly overcontoured, it may be finished and
4. Etch the tooth surface with an appropriate
polished to proper contours. If it is slightly
etchant, such as 37% phosphoric acid. Protect
undercontoured in any area, additional resin
adjacent teeth from the etchant with clear plastic
composite material may be added.
strips.
 Creating a diagnostic wax-up is recommended
5. Rinse the tooth thoroughly and dry the etched
to reduce clinic time and increase the
tooth surface with a stream of air.
predictability of the final veneers. The wax-up
6. Place a clear plastic strip or other matrix and
will provide information on the final contours
wedge interproximally; apply adhesive resin and
and the amount of material necessary to
light cure for the appropriate time (material-
complete the veneers. The diagnostic wax-up
specific instructions).
can be shown to the patients for their
7. Apply opaque resin, if indicated, and light cure.
acceptance, or an impression can be made by
PVS and an intraoral mock-up performed.
149 Chapter 7 Direct Anterior Composite Restorations 149

8. Add the selected resin composite, adapt and

contour the material, and light cure for the
appropriate length of time.
9. Add additional resin composite as necessary to
achieve the proper shape, color, and
translucency. Light cure each increment for the
appropriate length of time.
10. Finishing and polishing.
11. Repeat the above process on adjacent teeth, if
indicated.
12. Apply low-viscosity rebonding resin (surface Figure 7.15(c) protection of neighbor teeth with a
Mylar strip and acid etching.
sealer) to the restoration surface and margins.
(The following shows step by step direct composite
veneer restoration)

Figure 7.15(a) Tooth-shade evaluation.

Figure 7.15(d) application of the adhesive

system & light-curing.

Figure 7.15(b) application of gingival retraction

cord size No. 000.
150 Clinical Operative Dentistry 150

Continuing Figure 7.15(g) application of

enamel opacity composite.

Figure 7.15(e) 1 application of opaque light-

curing color modifier shade A1.

Figure 7.15(f) application of dentin shade

Figure 7.15(h) final result.

Repair of direct composite veneers:

 It is done with the same material with which it

has been prepared.
 After cleaning, preparation of retentive grooves
and roughening the surface, composite is
applied in usual manner, i.e. etching, bonding
and composite placement.

Figure 7.15(g) application of enamel opacity

composite.
151 Chapter 7 Direct Anterior Composite Restorations 151

DIASTEMA CLOSURE general, the apparent width of upper anterior

teeth should not be higher than 80% of its
length.
 The diastemas should not be closed before to  When diastema closure is performed, occlusal
diagnose and treat its causes: relationships and esthetic proportions as well as
- The median diastema, located between the the overall facial esthetics must be considered.
central incisors, is the most frequent one. Its When anterior teeth are widened, it may also be
etiology was generally related to the presence necessary to lengthen them to preserve natural
of enlarged labial frenum. anatomical proportions. If occlusal
- Other causes include anodontia, very small or relationships and facial appearance will allow,
badly formed teeth, and tooth size discrepancy, the proper tooth length can be established by
supernumerary teeth, and hereditary factors. adding to the incisal edge. It is also possible to
- The diastemas may also result from other improve the length-to-width ratio by surgical
problems such as tongue thrusting, crown lengthening in some patients. A study
periodontal disease, or posterior bite collapse. evaluating the length and width of anterior teeth
 The technique for diastema closure is similar to revealed that, on average, central incisors and
that for placement of direct veneers and Class 4 canines are approximately equal in length and
restorations. are 20% longer than lateral incisors. A
 In most cases, no tooth structure has to be periodontal probe or caliper may be used as a
removed, and the resin composite is retained measuring device to evenly divide the space to
solely by adhesive bonding. be closed.
 According to the size, the diastemas can be  The desired lengths and widths of teeth should
classified into three types, which are small be determined using a diagnostic wax-up before
(space smaller than 1 mm), medium (space from treatment is begun (Figure7.16). A trial
1 to 2.5 mm), and large (space larger than 2.5 application or direct mock-up, assessing the
mm). esthetic alteration of the shape and color of the
 For a small diastema (1 mm or less), an enamel- proposed restoration, may be accomplished
like resin composite is added to the proximal with expired resin composite applied to
surfaces of the two adjacent teeth producing unetched teeth. This will give the patient an idea
little interfering on the width-to-length ratio. about how the future restoration will look like,
 For a moderate-sized to large diastema, an and if that result is pleasant to him.
opaque or dentin like material should be placed
to block the show-through effect caused by the
darkness of the mouth. A slight blending of the
material onto the facial surface will help achieve
a natural transition of shades and improve the
esthetic outcome. The facial and incisal
contours can then be established with an
enamel-like resin composite.
 Besides adding composite to the both adjacent
teeth, it may be convenient to make
enameloplasty on the distal surface these teeth,
slightly increasing the mesial surface of the
other adjacent teeth, obtaining a better
distribution of the space. Figure 7.16 the desired lengths and widths of teeth
should be determined using a diagnostic wax-up
 If the diastema exceeds 2.5 mm, it may be before treatment is begun.
necessary to use a combination of direct
veneering and orthodontic movement to  Diastema closures frequently require
position the teeth into a more easily managed augmenting two to six teeth with resin
and esthetically pleasing location. If this case composite to achieve optimal esthetic
treated only with composite buildups, the relationships. (Figure7.17)
restored teeth will be larger than the natural
teeth can be. This will break the correct width-
to-length ratio, creating a non-esthetic result. In
152 Clinical Operative Dentistry 152

restored teeth. If one tooth is larger than the

other, this discrepancy can be compensated
with the restoration.
 The restoration must start below the gingival
margin to create a natural contour and ensure
adequate gingival embrasure and emergence
profile.
 The polyester matrix strip must be inserted into
the gingival sulcus between the interdental
papilla and the tooth. It is kept in position with a
Figure 7.17 Diastema closures frequently require pad of the index finger, pressing the lingual
augmenting two to six teeth with resin composite to aspect of the strip toward the remaining tooth
achieve optimal esthetic relationships. structure, while the labial portion is reflected
away.
 Wedges are, generally, not recommended
 Most diastema closures can be accomplished
because they could create an inadequate
without the use of a matrix or a wedge, thus
emergence profile.
providing better control of proximal contours in
 The composite is applied with a hand composite
the gingival embrasure areas.
filling instrument, pressing it toward the lingual
 Sculptable microfilled or nanofilled resin
side to ensure that it will reach the lingual
composites are the preferred materials.
surface. The matrix is gently closed on the labial
 When both teeth adjacent to the diastema will be
side, pulling more the gingival edge of the strip
restored, the first restoration must be finished
to prevent overhangs. Pulling the strip too much
before starting the second one.
should be avoided otherwise undercontoured
restoration will result.
The first restoration for diastema closure  Most of the small diastemas may, in many cases,
(first half): (Figures 7.18 a-i) be successfully closed only using enamel shade
 The acid etching of the enamel is performed for composites, which are more translucent.
15 s and the surface is rinsed. The acid etching  However, larger diastemas require the use of an
must be extended to the middle of the labial and opaque dentin shade, to block the dark
lingual surfaces, from the gingival to the incisal background of the mouth. On those situations,
third of the crown. The restoration will cover the first increment of dentin shade composite
about one-third of the labial and lingual may be placed until it fills approximately half of
surfaces. It is important to be sure of not the labiolingual distance. The composite is light-
covering with composite any non-etched cured, and a new layer is applied, using enamel
enamel. Any etched enamel areas that remain shade material. The matrix is closed over the
uncovered by adhesive and composite will labial tooth surface, and the light-curing is
remineralize after the contact with the saliva. performed through the strip.
 The enamel may be dried with an airstream,  The first restoration is finished and shaped until
because there is no exposed dentin, observing obtaining the correct anatomical size and shape.
the white-opaque appearance, showing it was  The polishing is only performed after the second
correctly etched. restoration is finished.
 If an adhesive with separated primer and bond The second restoration for diastema
bottles is selected, there is no need to apply the closure (second half):
primer. However, if the enamel is left wet, the  When placing the adjacent restoration, care
primer application is important, since the should be taken to confine both the etchant and
bonding resin is hydrophobic. the bonding resin to prevent inadvertent
 Before applying the composite, a polyester strip splinting.
may be contoured drawing it over the round  A tight, properly contoured contact can be
back end of a clinical tweezer and placed in achieved using a “pull-through” matrix
position. technique.
 The caliper is used to measure the mesiodistal  After the adhesive resin is polymerized, a clear
dimensions, to guarantee the symmetry of the celluloid strip is placed in the contact area and
153 Chapter 7 Direct Anterior Composite Restorations 153

the resin composite applied to the facial surface

of the second tooth.
 After the material is blended to contour and
shaped against the strip, the strip is slowly
pulled to the lingual, drawing the material with it.
 When the material is midway through the
contact, the strip should be removed with a tug,
leaving the material in the contact area. Wiping
the strip with alcohol-dampened gauze prior to
placement may help to release the material from
the strip.
Figure 7.18(b) shade selection
 A brush or placement instrument can be used to
gently push the facial resin increment into
contact with the already completed restoration
on the adjacent tooth, and then the embrasures
are shaped and refined and the composite
polymerized.
 Although the polymerized resin will stick to the
adjacent tooth, it can easily be separated by
lightly rotating (torqueing) an instrument
between the teeth.
 Following separation, a clear celluloid strip is
reinserted and contoured against the lingual
contour of the tooth.
 A small amount of resin composite is placed
against the strip to fill any deficiencies on the
lingual surface, and the lingual portion of the
strip is drawn tightly against the cingulum with
a thumb or a finger. The strip is then pulled out
to the facial, drawing the material into the lingual
deficiencies.
 After polymerization, the teeth are again
separated and finishing procedures are initiated.
 Note that on the case of medium and large
diastemas, the palatal silicone index technique,
as already described, may simplify the
procedure to be performed.
(The following shows step by step median diastema
closure by composite)

Figure 7.18(c) protection of the adjacent tooth

with PTFE strip and acid etching, rinsing&
drying with airstream.

Figure 7.18(a) initial aspect of minimal minor

median diastema.
154 Clinical Operative Dentistry 154

Figure 7.18(d) application of the adhesive system

&light-curing
Figure 7.18(g) measurement of the tooth
dimensions& analysis the space left for the
restoration of the adjacent tooth.

Figure 7.18(e) application of enamel shade

composite with the matrix in position, stabilized
with the index finger.

Figure 7.18(h) restoration of the second half.

Acid-etching, application of adhesive

Figure 7.18(f) matrix closed over the labial surface

for light-curing the increment.
155 Chapter 7 Direct Anterior Composite Restorations 155

application of the last composite increment,

closing the matrix over the labial surface. Wax up on the plaster model.

Figure 7.18(i) final result.

(The following shows step by step multiple anterior

diastemas closure by composite)

Acid-etching & etched enamel with white-opaque

appearance after the drying with air steam.

Multiple anterior diastemas.

Application of the adhesive system.
156 Clinical Operative Dentistry
Silicone index fitting test & index in position with
enamel shade composite to restore the lingual
surface.
Application of the opaque dentin shade composite.
156
Application of enamel shade composite.
Final result after polishing.
Note that the oxygen on the atmosphere inhibits the
polymerization of about 1–5 µm of the superficial
layer of each composite increment. When a new
increment is applied over it, the air is eliminated, and
the layer of uncured monomers polymerizes
together with the new material, providing bonding
between them. However, the surface of the last
composite layer of a restoration will not be
completely cured, compromising its mechanical
properties, especially if the surface does not receive
a proper polishing. To overcome this problem, after
the polymerization of the last increment, the surface
can be covered by a transparent glycerin-based
oxygen blocking gel and light-cured through it,
eliminating the oxygen and allowing a complete
polymerization, leaving a glazed aspect. The gel is
then removed with an air/water spray.
157 Chapter 7 Direct Anterior Composite Restorations 157

FINISHING AND POLISHING they should always be used with light pressure
to avoid overheating and possibly damaging the
 Finishing includes the shaping, contouring, and resin composite surface.
smoothing of the restoration, while polishing  The rotary instruments must be used with care
imparts the shine or luster to the surface. in the cervical region, especially on the root
 Even when a good shade match has been surface, to prevent the incorrect and undesired
obtained, if the finishing process does not removal of the tooth structure, usually
simulate the adjacent tooth contours, the cementum and dentin. (Figure7.19)
restoration will not appropriately blend with its
surroundings.
 The smoothest possible surface is obtained
when the resin composite polymerizes against a
clear plastic strip without subsequent finishing
or polishing. However, such a surface typically
has a higher resin content, because the
monomers tend to work their way through the
fillers like a sieve when the composite is pushed
against a surface. This may yield a very smooth
superficial layer but one that is less resistant to
wear due to its reduced amount of reinforcing
fillers.

Instruments
Diamond and carbide burs

Figure 7.19 a, b finishing of cervical restoration

with gingival cavosurface angle covered by the
marginal gingiva may result on wrong grinding of
the root surface, creating a step.

Rotary instruments for finishing procedure.

 Ideally, a minimum of finishing should be
imparted to a resin composite because the
Decreased need of contouring of the cured
composite ensures that margins and surface of
composite restoration remain sealed and free of
microcracks that can be formed
contouring.
 Fine finishing diamonds are also available for
finishing resin composite restorations and have
been found to impart less surface damage to
microfilled resin composites than
finishing burs.
 These finishing burs and diamonds may be used
to develop the proper macro- and microanatomy
for the restoration.
 The transition from resin to enamel should be
slowly smoothed until it is undetectable.
 These burs can be used dry to better visualize
the margins and anatomy being developed, and
 For safely finishing of the gingival margins on
that situation, 0.5 mm of the diamond coat can
be removed from the tip of the conical-shaped
diamond point. For that, the abrasive point is
rotated over an abrasive stone until the diamond
particles are lost in this area. The safe end tip
while instrument can be used to contour the cervical
areas of the restorations. Touching the safe end
on the root surface inside the gingival sulcus, it
can easily reshape the cervical region without
harming the root surface. (Figure7.20)
carbide
158 Clinical Operative Dentistry
Figure 7.20 a safe end tip can be created rotating
the tip of a diamond point over a mounted stone,
until complete removal of the diamond layer.
Scalpel blades and resin carving instruments
 Blades and carving instruments are effective at
refining gingival margins and interproximal
areas.
 Burs and disks can cause damage to the soft
tissue and cementum in the gingival area.
 A no. 12 or 12B scalpel blade is often used to
safely remove excess material at the gingival
margin.
no. 12B scalpel blade.
Disks
 Sequential use of disks with progressively finer
grits produces a smooth, durable finish.
 Unfortunately, disks have the tendency to leave
flat surfaces, unlike the normal rounded shapes
found in natural teeth.
 Dry finishing with disks used in sequence is
reported to be superior or equal to wet finishing
for smoothness, hardness, and color stability.
However, dry finishing tends to clog disks with
abrasive particles and makes the disks work
less efficiently.
158
Composite Finishing Polishing Discs.
Impregnated rubber points and cups
 A wide variety of rubber finishing and polishing
points and cups impregnated with abrasive
materials are available.
 Like disks, rubber cups and points are used
sequentially from coarse to fine grit.
 The coarse grits may be effective for gross
reduction and finishing, while the fine grits
create a smooth, shiny surface.
 The primary advantage of rubber points and
cups over disks is that they provide access to
grooves, desirable surface irregularities, and
the concave lingual surfaces of anterior teeth.
The surfaces obtained with these cups tends to
better resemble the natural anatomy of teeth.
Impregnated rubber points and cups.
Finishing strips
 There is almost no need to finish or polish the
proximal surface of the restoration, because the
composite is capable to copy the roughness of
the matrix strip. However, if there are cervical
159 Chapter 7 Direct Anterior Composite Restorations 159

overhangs, they must be removed without  The first step in contouring is the evaluation of
damaging the proximal contact. the length of the restoration in relation with the
 For that, the abrasive strip should be used with adjacent teeth and the establishment of the
a back-and-forth movement. facioincisal line angle. A medium-grit disk is
 Finishing strips are used to contour and polish used to reduce and contour the incisal edge
the proximal surfaces and margins gingival to (Figure7.21). Young patients will have round
the interproximal contact. incisal line angles in a mesiodistal direction
 They are available with metal or plastic because of the lack of wear; however, with age
backings. the teeth become flatter as a result of wear. A
 Most metal-backed strips are used for gross palatal inclination of the incisal edge is
reduction, but care must be taken not to over observed with age in the maxillary anterior teeth.
reduce the restoration; these metal-backed In contrast, a labial inclination is observed for
strips will also remove enamel, cementum, and the mandibular anterior teeth.
dentin.
 Plastic strips come in various widths and grits
and can be used for both finishing and
polishing.
 Like the flexible disks, finishing strips come in a
series of grits, which should be used in series
from coarsest to finest.

Figure 7.21 A medium-grit disk is used to reduce

and contour the incisal edge.

 The second step is to check the occlusion in

maximum intercuspation and in excursive
movements and adjust accordingly.
Finishing strips.
 The third step is to locate and contour the
mesiofacial and distofacial transitional line
angles. This is accomplished by using fine
carbide or diamond burs or impregnated rubber
cups. The transitional line angles are easily
identified from an incisal view with an intraoral
mirror. (Figure7.22)

Plastic strips come in various widths.

Procedures
Contouring
 Contouring has the purpose of shaping the
restoration to simulate the natural contours and
anatomy of a tooth.
160 Clinical Operative Dentistry 160

Finishing and characterization

 Finishing should be done carefully to avoid
damaging the surface or margins of the resin
composite restoration.
 Medium-and fine-grit impregnated cups are
sequentially used to progressively smooth the
facial and lingual surfaces of the restoration.
 Similarly, a sequence of finishing strips is used
on the proximal surfaces and margins
(Figure7.24). The dental floss should pass over
the proximal resin surface smoothly and snap
through the contact without shredding.

Figure 7.24 a sequence of finishing strips is used

on the proximal surfaces and margins.

 In class III restoration, to avoid any damage to

contact point, the finishing strip should be used
Figure 7.22 locate and contour the mesiofacial
in S-shaped pattern. If strip is pulled on same
and distofacial transitional line angles.
side, it can lead to open contact points.
(Figure7.25)

 The fourth step is to contour tooth embrasures.

The incisal embrasures can be easily contoured
with medium-grit disks and the gingival
embrasures with a no. 12 or 12B scalpel blade
(Figure7.23). Additionally, a perforated diamond
strip (eg, Visionflex, Brasseler) is very effective
in smoothing and contouring the gingival
embrasures.

Figure 7.25 In class III restoration, to avoid

any damage to contact point,

 Surface characterization is obtained by

Figure 7.23 The incisal embrasures can be easily
contoured with medium-grit disks.
observing and copying details of the adjacent
dentition onto the restoration. A fine diamond at
low speed is useful to reproduce imbrication
lines found in young teeth.
161 Chapter 7 Direct Anterior Composite Restorations 161

Surface characterization. Impregnated cups are sequentially used to

progressively smooth the facial and lingual
surfaces of the restoration.
Polishing
 A final surface polish can be obtained by using
Rebonding
a diamond or silicon carbide– impregnated disk
or cup.  Rebonding (also called surface sealing or
 Aluminum oxide or diamond polishing pastes glazing) is performed after the restoration is
are also used to obtain a high polish.it has been finished and polished.
showed that additional polishing with a diamond  The margins are re-etched, and a coat of unfilled
polishing paste after initial polishing with or lightly filled low-viscosity resin is placed over
abrasive discs reduces the surface staining of the restoration surface and polymerized.
the composites.
 Rebonding has been reported to improve
marginal integrity, aid color stability, improve
 Many operators have observed the development early wear resistance, and help reduce staining
of a “white line” at the margins of resin of the restoration.
composite restorations during finishing. The
 The long-term effect of rebonding is
exact cause of this phenomenon is not known, questionable because this surface layer of low-
but several investigators and clinicians have put
viscosity resin is likely to wear quickly. It may be
forward possible explanations: repeated at each patient return to the dental
- Traumatic finishing leading to microfractures in
office, every 6 months or 1 year.
the resin composite or tooth structure at the
 Rebonding is rarely needed for anterior
interface.
restorations when a proper placement and
- Improperly rotating abrasive disks (the disks
finishing protocol has been followed.
should rotate from resin composite to tooth).
- Inadequate polymerization of the resin
composite material and polymerization Techniques for Repair or Correction of
shrinkage causing microfracture of Intraoral Restorations
unsupported or fragile enamel at the margins.
 Despite the best material and restorative
 When the white line presents an esthetic technique used by the dentist, the durability of a
problem and more conservative procedures dental restorations will mainly depend on the
such as rebonding do not resolve it, the white patient’s oral care:
area must be removed with a bur and additional - People with high consumption of acidic food
composite must be bonded and finished. and beverage, as well as high level of
chromogens, or heavy smokers may present
faster degradation of the composite organic
matrix, as well as very fast staining. The
parafunctional habits may also lead to the
premature degradation of the restoration due to
the great stress they are subjected.
- Thus, the patients must be motivated to practice
preventive measurements, including dietary
162 Clinical Operative Dentistry 162

changes, good oral hygiene practices, and

periodic visits to a dental clinic.

 Resin composites are effective for the repair or

correction of intraoral restorations for many
kinds of materials.
 By combining chemical bonding techniques as
well as macro- and micromechanical retention,
attachment of the resin composite to the old
restoration can be obtained.
 In many cases, repair or correction requires less
preparation and will reduce the risk of damage
to the tooth when compared with complete
replacement of defective or unaesthetic
restorations.
 Macromechanical retention can be created by
the preparation of undercuts in the old
restoration, which can also improve the
resistance form. While micromechanical
retention can be obtained by preparation with a
coarse diamond bur or air abrasion.
163
165 Chapter 8 Direct Posterior Composite Restorations 165

ADVANTAGES OF RESIN COMPOSITE Elimination of galvanic currents

Resin composite does not contain metal and so will
AS A POSTERIOR RESTORATIVE
not initiate or conduct electrical currents.
MATERIAL COMPARED TO DENTAL
AMALGAM
Longevity

Esthetics  When it is used properly, resin composite has

 It is tooth colored restoration. demonstrated the ability to perform as well as
 Microfilled resin composites have the amalgam in posterior restorations for up to 10
smoothest surface finish of all the systems, and years.
they better maintain their esthetics than other  Long-term success of resin composite posterior
types through enhanced resistance to surface restorations depends on cavity size, restoration
staining. type, functional/occlusal stresses on the
restoration, patient caries risk status, and tooth
type.
Conservation of tooth structure
The adhesive preparation for posterior resin
composite restorations differs from Black’s
DISADVANTAGES OF RESIN
traditional amalgam design in several ways:
COMPOSITE AS A POSTERIOR
 The preparation tends to be shallower. Because
RESTORATIVE MATERIAL
retention is provided through bonding to tooth
structure rather than mechanical undercuts,
there is no need to penetrate to dentin if the Polymerization shrinkage
caries lesion does not. Contraction forces on cusps can result in cuspal
 The preparation tends to have a narrower outline deformation, enamel cracks and craze lines, and,
form, which allows less occlusal contact on the ultimately, decreased fracture resistance of the
restoration and reduces wear. cusps.
 The preparation has rounded internal line
angles; this conserves tooth structure, Secondary caries lesions
decreases stress concentration associated with  The risk for secondary caries was 3.5 times
sharp line angles, and enhances resin greater for composite restorations versus
adaptation during placement. amalgam.
 There is no “extension for prevention” :  Secondary caries is a significant cause of failure
- Extending the Class 2 preparation through of posterior resin composite restorations.
occlusal fissures does not make the restoration  It is believed that the marginal gap formed at the
more resistant to fracture than the more gingival margin as a result of polymerization
conservative proximal slot restoration. shrinkage allows the ingress of cariogenic
- Adjacent pits and fissures can be treated with bacteria.
sealants to enhance caries prevention.  Studies have shown that levels of
Streptococcus mutans are significantly higher
in the plaque adjacent to proximal surfaces of
Adhesion to tooth structure
posterior resin composite restorations than in
The bond between resin composite and tooth
plaque adjacent to either amalgam or glass-
structure achieved with bonding systems offers the
ionomer restorations.
potential to seal the margins of the restoration and
reinforce remaining tooth structure against fracture.  In addition, the organic acids of plaque have
been found to soften bis-GMA polymers, and
this in turn could have an adverse effect on wear
Low thermal conductivity
Because resin composites do not readily transmit and surface staining.
temperature changes, there is an insulating effect
that may help to reduce postoperative temperature Postoperative sensitivity
sensitivity.  Postoperative sensitivity rates as high as 29%
following placement of the restorations.
166 Clinical Operative Dentistry 166

 A number of reasons have been postulated for Decreased Fracture resistance

the occurrence of postoperative sensitivity, but  Resin composite materials have low fracture
the most commonly accepted theories relate to toughness and a low modulus of elasticity in
polymerization shrinkage. As previously comparison with metallic restorative materials.
discussed, polymerization shrinkage results in  Failures of resin composite restorations
formation of a gap, which allows bacterial associated with the high elastic deformation of
penetration and fluid flow within it. The bacteria the material have included bulk fracture,
or their noxious by-products may enter the microcrack formation and relatively low
dentinal tubules and cause pulpal inflammation resistance to occlusal loading.
and tooth sensitivity.
 Gap formation also allows a slow, continuous
Water sorption
outflow of dentinal fluid from the pulp through  Because of the swelling of the resin matrix from
the tubules to the gap. Cold or other stimuli may water sorption, the filler particle bond to resin is
cause a contraction of fluid in the gap, leading weakened. If the stress is greater than the bond
to a sudden, rapid outflow of tubular fluid that strength, the resulting debonding is referred to
stimulates the nerve surrounding the as hydrolytic breakdown.
odontoblastic processes and results in the  Incompletely cured resin composite will exhibit
perception of pain. more water sorption and greater hydrolytic
 Contraction forces of polymerization shrinkage degradation.
may also result in cuspal deformation, with
resultant cracking and crazing of remaining
tooth structure, which can cause tooth Technique sensitivity
 Composite placement technique need optimum
sensitivity.
field isolation otherwise failure occur.
 Another possible cause of tooth sensitivity is
 Application technique has been shown to
that Flexure of resin composite under an
significantly affect adhesive bond strength e.g.
occlusal load may cause hydraulic pressure in
bulk placement of composite ‹ high
the tubular fluid to be transmitted to the
polymerization shrinkage ‹ bond failure.
odontoblastic processes.
 Note that the risk of Postoperative sensitivity
increases as the size of the restoration INDICATIONS FOR RESIN COMPOSITE
increases. AS A POSTERIOR RESTORATIVE
MATERIAL
The coefficient of thermal expansion
 Because the coefficient of thermal expansion of It can be used in any situation except the following
resin composite is higher than that of tooth relative contraindications:
structure, composite tends to expand and  Restoration needed to replace supporting
contract more than enamel and dentin when cusps: Extensive resin composite restorations
subjected to variations in temperature. including the supporting cusps of posterior
 This can increase marginal gap formation and teeth do not perform as well as other restorative
exacerbate the effects of polymerization materials.
shrinkage on cuspal deformation, and it may  Large restorations required in the teeth of a
result in the fracture of composite or enamel at patient with significant parafunction, bruxism,
the margins. or heavy occlusal stress, where most or all
function will be on the restoration and not on
Decreased wear resistance tooth structure.
Some research reports that resin composites have  Patient with a high caries risk and is non-
significantly higher wear rates than amalgam but compliant with oral hygiene instructions.
other studies have indicated that posterior resin Secondary caries is a significant cause of
composite restorations resist wear as well as posterior composite failure.
amalgam restorations.  The clinician is unable to obtain adequate field
isolation.
167 Chapter 8 Direct Posterior Composite Restorations 167

PROCEDURE OF DIRECT POSTERIOR TREATMENT OF PIT AND FISSURE

RESIN COMPOSITE RESTORATIONS CARIES

Preoperative evaluation: FISSURE SEALING

 The factors noted as contraindications in the Compared to teeth with unsealed fissures, teeth with
previous list should be considered in the resin- sealed fissures have demonstrated a 35%
preoperative evaluation. reduction in fissure caries lesions during a 5-year
 The occlusion should be marked with period.
articulating paper as a guide to preparation
design.
 The best type of resin composite for the
Indications
 Sealing of susceptible pits and fissures is
restoration should be chosen. Micro-hybrids/
carried out as soon after eruption as possible.
nano-hybrids or nanofilled composites are
First, second, and third permanent molars are
considered best suited for posterior use.
obvious candidates, but all molars are not
 A shade is chosen from the shade guide that
automatically fissure sealed.
accompanies the composite.
 In high caries risk patients.
 If the dentist is going to use a warm composite
 Patient have missing teeth which have been
placement technique, an appropriate amount of
extracted because of caries in a child’s mouth.
resin composite may be transferred to a syringe
 If a young adult requires restoration of one
tip (Centrix) that is amber-colored or opaque to
second molar, fissure sealing the remaining
prevent premature polymerization. The Centrix
second molars seems to be a logical preventive
syringe tip is then placed in a composite
measure.
warming tray (Calset, AdDent) at 60°C to 68°C
 Deep fissure pattern is more susceptible so
(140°F to 155°F). This will reduce the resin
need fissure sealing since it is difficult to clean.
composite’s viscosity and aid in subsequent
 Where the dentist believes that the patient’s diet
placement.
contains frequent sugar intakes or when poor
oral hygiene cannot be improved – for example
where patients are mentally or physically
disabled – fissures should be sealed.

The Centrix syringe tip is placed in a composite

warming tray at 60°C to 68°C (140°F to 155°F). This
will reduce the resin composite’s viscosity and aid
in subsequent placement.

Isolation

 Isolation is mandatory.
 Rubber dam is preferred. a) Posterior teeth with a smooth occlusal
morphology and with shallow grooves; b) molars
 Blood contamination will adversely affect
presenting irregular morphology, with deep
adhesion in all bonding systems. grooves favoring the biofilm deposition.
168 Clinical Operative Dentistry
Clinical technique for resin sealant:
(Figures 8.1 a-f)
Anesthesia and isolation
If necessary, a little local anesthetic is infiltrated or
topical anesthetic is applied to avoid discomfort
from the rubber dam clamp.
Cleaning
 The tooth surface to be etched and sealed may
be cleaned with a bristle brush in a handpiece
and a pumice and water slurry.
 Oil-based polishing pastes or those containing
fluoride should not be used, as these may
interfere with etching.
 The pumice is washed away using the three-in-
one syringe.
Etching
 The tooth is now etched with phosphoric acid
(37%).
 The etchant is applied over the whole occlusal
surface extending onto the lingual or buccal
surface where grooves require sealing. Etching
the entire occlusal surface avoids the danger of
covering an unetched surface with sealant and
thus inviting leakage.
 The acid can be applied with a brush, or
alternatively the gel can be placed accurately
with a disposable syringe and blunt needle.
 The enamel is etched for 15–20 seconds.
Washing
 After 20 seconds the acid is washed away.
Initially a water jet from the three-in-one syringe
is used to remove most of the acid.
 After approximately 5 seconds of water, the air
button is also pressed, forming a strong water–
air spray which should be played over the
etched surface for 20–30 seconds.
Drying
 Many fissure sealants are still based on
hydrophobic resins and so a careful drying
regime is required.
 It is good practice to check that the airline is not
contaminated by water or oil by blowing it at a
clean glass or paper surface.
 The tooth surface is now thoroughly dried with
air from the three-in-one syringe. This drying is
most important since any moisture on the
168
etched surface will stop penetration of the
hydrophobic resin into the enamel.
 A minimum of 15 seconds drying is
recommended. At this stage the etched area
should appear matt, white, and frosty.
Applying the sealant
 Fissure sealants are supplied both as light-
curing and chemically-curing materials. A light-
cured resin does not require mixing but a
chemically-cured resin has two components
which are gently mixed together with a brush.
 A sealant is applied to the etched surface using
a small disposable brush or applicator supplied
by the manufacturer
 The sealant is applied to the etched pits and
fissures and up the etched cuspal slopes.
 If a light-cured material has been chosen, the
light should be placed directly over the sealant
but should not touch it.
 Most chemically-cured sealants polymerize in 1–
3 minutes and the manufacturer’s instructions
should be followed.
 The outer surface layer of any sealant will not
polymerize due to the inhibiting effect of oxygen
in the atmosphere. The sealant will therefore
always appear to have a greasy film after
polymerization.
 Finally, a fluoride-containing varnish may be
applied to the etched enamel at the periphery of
the restoration where it has not been covered
with sealant.
Checking the occlusion
 The rubber dam is now removed and the
occlusion checked with articulating paper.
 With the lightly-filled materials it is wiser to
reduce high spots by grinding with a small
round diamond stone in a low-speed handpiece.
(The following shows step by step resin sealant
application)
Figure 8.1(a) Teeth after rubber dam isolation.
169 Chapter 8 Direct Posterior Composite Restorations 169

Figure 8.1(d) light-curing

Figure 8.1(b) prophylaxis with pumice and water.

Figure 8.1(e) evaluating the sealed surface using

the probe tip.

Figure 8.1(c) phosphoric acid etching,

rinsing & opaque aspect of the etched
enamel

Figure 8.1(f) final aspect before evaluating the

occlusal contacts.

Clinical technique for glass ionomer

cement sealers (Figures 8.2 a-d)

 It is possible that the fluoride in the material may

exert a cariostatic effect. Thus, they are the
material of choice on an erupting tooth, where
oral hygiene is poor, caries risk is high, and
good moisture control is difficult.
 They should be considered a temporary
Figure 8.1(d) application of the sealant using the
tip of an exploratory probe& light-curing measure in these circumstances.
170 Clinical Operative Dentistry 170

 The tooth to be sealed is isolated and the fissure

is cleaned with 10 % polyacrylic acid-
conditioning agent for 20 seconds. It is then
washed and dried, and the glass ionomer
material, mixed to a flowable consistency, is
applied along the fissure and firmly burnished
into position. Excess material is easily removed
with the burnisher.
 Almost certainly be less well retained than a
resin-based system, the material may have a
protective effect for high-risk fissures whilst the
tooth is at its most vulnerable.

Figure 8.2(c) application of the GIC with the tip of

an exploratory probe

Figure 8.2(d) case after 6 months, showing the

retention of the GIC on the pit and fissures. The
first molar also received the same treatment.

Figure 8.2(a) initial case – maxillary second molar

erupting in the mouth of a caries high risk patient The key to resin sealant success in
preventing caries lesions:

The key is total retention of the sealant. Enhancing

complete resin sealant retention will therefore
enhance the caries-reduction benefit. Some factors
that affect sealant retention and effectiveness
include the following:
 Mandibular teeth show higher retention rates
than maxillary teeth; premolars show higher
retention rates than molars.
 The tooth to be fissure sealed must be capable
of being isolated from salivary contamination
since contamination while placing the sealant is
the most common cause of failure. Therefore
good isolation from saliva is an essential part of
the clinical technique, with a rubber dam being
the preferred method.
Figure 8.2(b) application of polyacrylic acid after
 Annual recall of patients and repair of partially
the prophylaxis.
or totally lost sealants improves effectiveness.
 Use of bonding agents following phosphoric
acid etching and prior to sealant placement
helps to wet fissures, improve sealant
171 Chapter 8 Direct Posterior Composite Restorations 171

penetration into fissures, increase bond  A local anesthetic is given. A rubber dam is
strength, improve sealant adhesion to saliva- applied and the tooth is thoroughly cleaned as
contaminated enamel, and improve clinical before.
retention of sealants.  A small, pear-shaped tungsten carbide burs
 Individual studies have demonstrated that light used to widen slightly and deepen the fissure
mechanical preparation of fissures with a very and to gain access to caries in dentine.
small bur (0.3- to 0.4-mm diameter, rounded tip)  The PRR limits preparation to pits and fissures
or air abrasion can provide clinical advantages, that are carious. Once the lesion is eliminated,
including exposing sound, unstained enamel no further preparation is performed.
prior to etchant placement; enhanced sealant  The PRR eliminates demineralized dentin,
penetration and attachment; decreased bubble overlying unsupported enamel, and associated
formation; improved marginal adaptation; demineralized enamel.
decreased marginal leakage; improved  No bevels should be placed on the occlusal
microbial elimination; and increased clinical margins of the preparation.
retention compared with unprepared fissures.  If the resultant preparation is restricted to a
 Clinical studies of RMGI sealants show good narrow and shallow opening of the fissure, a
caries prevention but very poor mechanical resin sealant (or flowable resin composite
retention compared with resin sealants. material or warmed resin composite) is placed.
However, the caries- prevention benefits of  If additional tooth structure is removed, a
RMGI sealants are comparable with those of posterior resin composite is placed in that area,
resin sealants and should be considered when and the remaining fissures and the surface of
moisture control may compromise resin sealant the resin composite restoration(s) are sealed
retention. with resin sealant material or flowable
 Flowable resin composite materials have been composite.
shown to perform as well as fissure sealants.  A number of advantages have been associated
PREVENTIVE RESIN RESTORATIONS with this technique, including the following:
- Conservation of tooth structure.
 A restoration that maximizes the benefits of - Enhanced esthetics.
conservative adhesive dentistry is the - Improved seal of restorative material to tooth
preventive resin restoration (PRR). structure.
 The technique restores the carious area and - Minimal wear.
seals the rest of the fissures. - No progression of sealed caries lesions: If a
 It is indicated where a cavity is present (either a caries lesion is inadvertently allowed to remain
microcavity in the enamel, or a cavity with in or at the base of a sealed fissure, it will not
dentine at its base). progress, because the sealant prevents
 It is indicated when some areas of the fissure nutrients from supplying cariogenic bacteria.
system of a tooth are associated with carious - Good longevity: Clinical studies have
dentin and others are not. demonstrated that PRRs are successful for
periods of up to 10 years and can equal or
Clinical technique (Figures 8.3 a-i) & exceed the performance of amalgam
(Figure 8.4) restorations.
 Occlusal contacts should be marked with (The following shows step by step preventive resin
restoration)
articulating paper prior to preparation so that
the dentist can remember where these contacts
are. Whenever possible, the tooth-to tooth
contacts occurring during centric occlusion
should not be included in the preparation
outline, remaining over the intact tooth
structure. In case it is not possible, care must be
taken so that it will not be located over the tooth-
restoration interface.
Figure 8.3(a) Ultraconservative diamond point (on
the bottom) and round diamond point (on the top)
172 Clinical Operative Dentistry 172

Figure 8.3(b) minimum tissue removal to access

the carious lesion Figure 8.3(e) prophylaxis with pumice and brush.

Figure 8.3(c) removal of the caries-infected

dentin. Figure 8.3(f) acid etching& adhesive system
application on enamel and dentin

Figure 8.3(d) conservative preparation completed

Figure 8.3(g) composite resin application into the

preparation
173 Chapter 8 Direct Posterior Composite Restorations 173

Figure 8.3(h) occlusal surface with composite

restoration and sealant on the adjacent grooves

Figure 8.4 Conservative composite restoration. A,

Occlusal view of the maxillary first and second molars.
The first molar has caries on the distal occlusal pit and
the second molar has suspicious pit on the disto
occlusal aspect. B, Caries was excavated from the first
molar, and the second molar was minimally prepared. C,
The first molar was restored with composite and the
second molar received a conservative composite
restoration with flowable composite.

OTHER CLASS I RESIN COMPOSITE

RESTORATIONS
Figure 8.3(i) evaluation of the occlusal contacts&  When a Class 1 restoration is being placed
final aspect of the conservative composite because of initial caries lesion(s), the PRR is
restoration usually the technique of choice.
 Basically, the tooth preparation for composite
restoration on posterior teeth is restricted to the
removal of carious tissue, with maximum
preservation of the healthy remaining tooth
structure.
 If there was a previous restoration, the outline
form and depth of the preparation will be
174 Clinical Operative Dentistry 174

determined by the previous restoration and any

new pathosis.
 Note that The preparation of posterior teeth for
composite with a box shape, as used for the
amalgam, increases the negative effects of the
C-factor and is not recommended
 Margins of occlusal preparations for resin
composite should not be beveled.
 Lining and bonding techniques should be used
as described for Class 2 restorations.
 Step by step class I composite restoration seen
in (Figure 8.5 a-l)
(The following shows step by step class I
composite restoration)

Figure 8.5(c) acid etching.

Figure 8.5(a) Class I caries.

Figure 8.5(d) blot drying & visibly moist dentin

surface

Figure 8.5(b) Opening of the cavitated caries lesion &

removal of the carious dentin tissue
175 Chapter 8 Direct Posterior Composite Restorations 175

Figure 8.5(e) application of adhesive system

Figure 8.5(g) filling the undermined enamel on

the lingual cusps and light-curing.

Figure 8.5(f) filling the undermined areas; l

lightcuring through the tooth structure. Figure 8.5(h) placement of oblique increments using
dentin shade composite.
176 Clinical Operative Dentistry 176

Figure 8.5(i) application of enamel shade composite using nonstick instruments of conical- and probe
shaped nibs.

Figure 8.5(k) finishing and polishing.

Figure 8.5(j) clear oxygen-blocking gel & gel
application and light-curing through it
177 Chapter 8 Direct Posterior Composite Restorations 177

 The stamp is removed and works as an index,

replicating the original anatomy of the tooth
structure.
 After the operating field isolation, bonding
procedure and placement of the dentin shade
composite, the stamp receives a separating
agent, such as a hydrosoluble glycerin-based
gel or liquid soap and a single increment of
enamel shade composite is placed into the
preparation but not light-cured.
 Then, the stamp is taken in the original position
and pressed.
 The composite overflow is removed, and the
initial lightcuring is performed through the
stamp.
 Then, it is removed, and the light-curing is
complemented for more 20 s. This way the ideal
original occlusal anatomy is quickly restored.
(The following shows step by step direct custom
made occlusal stamp technique)

Figure 8.5(l) surface sealing.

OCCLUSAL STAMP TECHNIQUE

Direct custom-made occlusal stamp

(Figures 8.6 a-k)
 On the cases of hidden caries lesions, when the Figure 8.6(a) Copy of the occlusal morphology
with acrylic resin.
occlusal surface is intact, a direct custom-made
occlusal stamp can be prepared to help the
restoration of the tooth anatomy.
 First, the occlusal surface is isolated with a thin
coat of petroleum jelly, and then the acrylic resin
is applied. That can be done using a brush
soaked with the liquid resin monomer, which is
put in contact with the polymer powder to carry
it to the tooth surface.
 Other possibilities are to use light-curing
transparent flexible temporary filling material
(e.g., Fermit -Ivoclar Vivadent or Clip F -Voco) or
a flowable composite (Clip flow - Voco).
 A small handle can be prepared for the stamp
with the same material or using a disposable
adhesive applicator. Figure 8.6(b) cavity preparation and caries
removal.
178 Clinical Operative Dentistry 178

Figure 8.6(e) enamel shade composite applied.

Figure 8.6(f) application of a separating agent

on the stamp.

Figure 8.6(c) acid etching and adhesive application.

Figure 8.6(g) stamp fitting and removal of

excess.
Figure 8.6(d) restoration of lost dentin area.
179 Chapter 8 Direct Posterior Composite Restorations 179

Figure 8.6(h) light-curing through the stamp.

Figure 8.6(k) final result.

Indirectly made occlusal stamp (Figures

8.7 a-i)

 In cases of replacement of several defective

restorations, to simplify the restorative
procedure and save clinical time during the
shaping of the occlusal surface, indirectly made
occlusal stamps can be prepared.
 For that a plaster model of the teeth to be
restored is previously obtained, through an
impression with alginate.
 On the plaster model, the area corresponding to
the old restorations is cut with a bur to create
space for waxing. The shape of the new
Figure 8.6(i) application of oxygen blocking
restoration can be created on wax by the dentist
gel& final light-curing through the gel.
or a laboratory technician.
 An occlusal stamp can be made the same way
as already described, but now outside the
mouth.
 When a flowable composite is used (e.g., Clip
flow – Voco), the handle can be prepared by
applying composite and light-curing at the same
time.
 All the stamps are previously prepared and then
available for the dentist, which can schedule the
patient for a next appointment to perform the
restorations, the same way that has already
been described for the stamp made directly in
the mouth.

Figure 8.6(j) finishing and polishing.

180 Clinical Operative Dentistry 180

(The following shows step by step indirectly made

occlusal stamp technique)

Figure 8.7(a) defective restoration.

Figure 8.7(b) grinding of the plaster model and

waxing.

Figure 8.7(d) careful sectioning of the old

amalgam restoration, separating it in small pieces,
avoiding to touch the bur on the walls; removal of
amalgam pieces with an exploratory probe and
removal of remaining carious dentin.

Figure 8.7(c) stamp preparation using high

translucency temporary flowable material.
181 Chapter 8 Direct Posterior Composite Restorations 181

Figure 8.7(e) acidic etching and application of the

adhesive system.

Figure 8.7(h) application of a separating agent on

the stamp, fitting and light curing

Figure 8.7(f) dentin shade placed and light cured.

Figure 8.7(i) final result.

CLASS 2 RESIN COMPOSITE

RESTORATIONS (FIGURES 8.17 A-I)

Prewedging
 Placement of an interproximal wedge at the start
of the procedure is recommended to open the
contact with the adjacent tooth and to
compensate for the thickness of the matrix
Figure 8.7(g) enamel shade placed but not light band.
cured.  It has been demonstrated that multiple wedging
(I.e., inserting a wedge initially and then
reapplying seating pressure several times
182 Clinical Operative Dentistry
during the course of the procedure) is more
effective in opening the contact than is a single
placement of a wedge.
 In addition, the wedge can protect the rubber
dam from damage and the gingival tissues from
laceration, thereby reducing leakage into the
operative site.
 Tooth separation obtained from prewedging
promotes more conservative preparation and
helps protect adjacent teeth from damage
during preparation.
 Failure to take measures to protect adjacent
teeth during proximal surface preparation with
rotary instruments will usually result in damage
to the adjacent teeth. Furthermore, this damage
makes it significantly more likely that the
damaged surface will require subsequent
restoration.
Prewedging.
Protection methods of the adjacent teeth from
damage during preparation.
Preparation
 As with PRRs, Class 2 restorations should be
limited to obtaining access to the carious dentin
and removing it and any overlying fragile or
demineralized enamel.
182
 Prepare occlusal part similar to class I but the
proximal box preparation depends upon extent
of caries, contour of proximal surface and
masticatory stresses.
 For small carious lesion, proximal walls can be
left in the contact.
 When caries are present only on proximal
surface, box only preparation is indicated. In
this, proximal box is prepared without the need
of secondary retention features.
 If there are one or more areas of fissure caries
lesions in the tooth, in addition to the proximal
surface lesion(s), they should be treated
separately, if possible, as described in the
section on preventive resin restorations.
Bevel placement
Bevel placement is a point of controversy with this
preparation. When used in conjunction with
adhesive agents and resin composites, bevels in
enamel provide more area for acid etching and
bonding. In addition, the bevel is designed to expose
enamel rods transversely (cross-cut or “end-on”) to
achieve a more effective etching pattern. Research
has indicated that etching of transversely exposed
enamel rods (ends of rods) results in a bond that is
significantly stronger than that attained with etching
of longitudinally cut enamel rods (sides of rods).
The Following are recommendations regarding bevel
placement in Class 2 preparations for resin
composite restorations:
Proximal Facial and lingual margins:
 Because enamel rods exit the tooth at
approximately right angles to the external tooth
surface, it is necessary for the cavity
preparation to form an obtuse angle (greater
than 90 degrees) with the external tooth surface
to expose the ends of the enamel rods. If the
preparation exits the tooth at an obtuse angle,
no further beveling of the proximal walls is
necessary.
 If the external cavosurface margin forms a right
angle with the tooth surface, conservative
bevels (0.5 mm) should be placed at an
approximately 45-degree angle to the surface,
on the facial and lingual cavosurface margins of
the proximal box preparation.
 This will achieve the benefits of beveling as well
as aid in placing the margins in a more
accessible location for finishing and polishing.
183 Chapter 8 Direct Posterior Composite Restorations
 Additionally, Research has demonstrated that
bevels on these margins significantly reduce
marginal leakage.
Proximal Gingival margins:
 The gingival margin should be beveled only if
the margin is in enamel well away from the
cementoenamel junction and an adequate band
of enamel remains.
 Because of the presence of prismless enamel in
this region, acid etching is often less effective.
Thus beveling enhance adhesion.
 As the preparation nears the cementoenamel
junction, the enamel layer is thinner than in
other regions of the crown, and beveling the
preparation increases the potential for removing
the little enamel that remains.
 When a cavity preparation approaches within
approximately 1 mm of the cementoenamel
junction, adhesion is essentially no better than
bonding to dentin.
 Use of an inverse or internal bevel, leaving
enamel that is not supported by dentin at the
gingival cavosurface margin, has been shown to
significantly reduce microleakage as compared
to a butt margin and would be preferable to
placing the gingival margin on or near the
cementoenamel junction. This type of marginal
configuration should not be created
intentionally with a bur, but if a lip
unsupported enamel remains after removal of
demineralized dentin, it should be configured to
an inverse bevel rather than planning the
unsupported enamel off to form a butt margin in
cementum or dentin.
(a-c) inverse or internal bevel. Note that
b) show butt margin that not preferred.
Occlusal margins:
 The use of occlusal cavosurface margin bevels
is not indicated because it has been noted that a
normal preparation in the occlusal surface will
183
result in end-cut enamel rods because of the
orientation of the enamel rods in cuspal inclines.
 Avoidance of bevels on the occlusal surface
prevents the loss of sound tooth structure,
decreases the surface area of the definitive
restoration, lessens the chance of occlusal
contact in the restoration, eliminates a thin area
of resin composite that would be more
susceptible to fracture and wear, and presents a
well-demarcated marginal periphery to which
resin composite can be finished more precisely.
 Therefore, occlusal cavosurface margin bevels
should be avoided.
 It should be noted that occlusal enamel should
not be left unsupported by dentin, particularly in
an area of occlusal stress. Research has shown
that unsupported occlusal enamel, even if the
lost dentin has been replaced with glass
ionomer, RMGI, or bonded composite, is
significantly weaker than enamel supported by
dentin.
of
The use of occlusal cavosurface margin bevels is
not indicated because it has been noted that a
normal preparation in the occlusal surface will
result in end-cut enamel rods because of the
orientation of the enamel rods in cuspal inclines.
Finished class 2 preparation for composite
restoration. The tooth prepared only in areas where
carious dentin present. Proximal facial, lingual &
gingival cavosurface margins beveled while
occlusal cavosurface margins not beveled.
184 Clinical Operative Dentistry
Use of cavity liners &Pulp Protection
 In case of shallow cavities, application of
bonding agent is sufficient for pulp protection.
 In case of deep preparations, pulp protection is
done using a light cured calcium hydroxide base
followed by resin modified GIC.
hydroxide liners should be limited to those
areas of the preparation that are believed to be
very close to the pulp, where there is the
possibility of a minute pulpal exposure.
Placement of a calcium hydroxide liner over an
extensive area of dentin provides no benefit to
the pulp and decreases the surface area of
dentin available for adhesion.
 Zinc oxide eugenol should not be used as a
subbase because it inhibits the polymerization
of resins.
 In deeper preparations and those in which the
gingival margin approaches or extends beyond
the cementoenamel junction, a glass-ionomer
liner may be beneficial. Glass-ionomer liners are
reported to offer a number of
advantages when used under posterior resin
composite restorations:
- Glass-ionomer materials bond to both tooth
structure and overlying resin composite.
- They introduce less polymerization stress into
tooth structure than does resin composite.
- Glass ionomer releases fluoride into adjacent
tooth structure which may be advantageous
because of the tendency for secondary caries
lesions to occur adjacent to posterior resin
composite restorations.
- Improve marginal integrity and decrease
marginal leakage.
- Less bulk of resin composite material is
required to fill the preparation, reducing the
amount of polymerization shrinkage
improving marginal adaptation.
- Can reinforce the preparation walls by adhering
to dentin and minimizing cuspal deformation
under load.
- Reduce the rise in pulpal temperature
associated with application of the curing light
during incremental insertion procedures.
- Significantly reduce postoperative sensitivity
compared to use of a dentin adhesive alone.
Bonded-base technique (or open sandwich
technique)
 If the gingival margin of a Class 2 preparation is
in enamel but within 1 mm
cementoenamel junction, or if it is in dentin, and
an alternative restorative material is not
184
appropriate (e.g., amalgam), an RMGI restorative
material should be placed as the initial
increment in the proximal box.
 This technique, known as the bonded-base or
open sandwich technique, has demonstrated a
number of advantages when compared with use
Calcium of an adhesive agent alone:
- Improved marginal adaptation and a reduction in
marginal leakage.
- Reduced postoperative sensitivity.
- Additionally, glass ionomers have
demonstrated good antibacterial activity against
microorganisms associated with dental caries,
as well as reduced demineralization adjacent to
dentin margins.
 The first evaluation of the bonded-base
technique used a conventional restorative glass
ionomer as the initial increment in the proximal
box. Unfortunately, this technique showed poor
clinical longevity. However, the use of an RMGI
restorative material for the initial increment in
the proximal box has proven to be a viable
potential technique.
 After completion of the preparation:
 The matrix is applied, and a wedge is placed.
 The gingival portion of the proximal box is
treated with the RMGI conditioner.
 The RMGI is mixed, transferred to a light-
protected Centrix syringe tip, and injected into
the gingival aspect of the proximal box.
 Because glass ionomer does not have the same
level of wear resistance as composite, this
increment of RMGI should remain apical to the
proximal contact.
 The surface of the RMGI increment is smoothed
and light cured.
 The entire cavity preparation, including the
RMGI in the gingival portion of the proximal box,
and is etched, and the adhesive system is applied
according to the manufacturer’s instructions.
The use of flowable composite as liner under
composite restoration:
 Some studies recommend the application of a
thin layer of flowable composite on the internal
walls of the preparation, as a low-elastic
modulus liner, which works as a stress
absorbing layer, before the application of a more
viscous material.
 This layer would reduce the stress on the tooth
restoration interface, preserving its integrity.
of the
185 Chapter 8 Direct Posterior Composite Restorations 185

 The flowable composite also fills more easily the
undercuts and irregularities on the walls and
internal angles of the preparation.
 This is even more relevant when replacing
amalgam restorations, which preparations have
more acute angles. The more viscous is the
restorative composite to be applied, the higher
are the chances of a bad adaptation of the
composite to the preparation walls, and more
advantageous is to use the flowable composite
liner.
Adhesive system application
 If the preparation is etched and the bonding
resin is placed before application of the matrix,
visualization and access to all areas of the
preparation are better, and it is easier to brush-
thin the adhesive and avoid pooling.
only, to ensure adequate polymerization of each
increment.
 In the past, because it was considered that with
clear plastic bands the composite shrinkage
occurs toward the light source, and this
procedure would improve the marginal
adaptation of the restoration. However, several
studies proved that this does not happen and
that the shrinkage occurs toward the bonded
walls, despite the position of the light source.
 Also, the clear matrix is thicker than the thinnest
metal matrices, and its lack of rigidity makes
placement through tight interproximal contacts
difficult.
 In addition, the rigidity and smoothness of the
plastic, light-reflecting wedge makes it less
effective than a wooden wedge in gaining the
slight tooth separation needed to ensure

 Placement of a matrix after adhesive application adequate interproximal contact. Because of

these drawbacks, most clinicians prefer metal
sometimes results in contamination of the
matrices and wooden wedges.
preparation with blood or saliva, so the operator
may prefer to place the matrix and wedge prior Sectional Matrix with a Separation Ring (Figure
to etching and application of the adhesive. If so, 8.8 a-d) & (Figure 8.9)
special care must be taken to ensure the  It is especially advantageous when only one
absence of pooling of the resin adjacent to the proximal surface will be restored, because the
matrix which would create a radiolucent area on intact contact on the other proximal surface
the interface between the composite and the does not need to receive the band, reducing the
wall that may be misdiagnosed as secondary amount of teeth separation necessary to
caries. compensate the thickness of the matrix.
 The application of the matrix before the  It has shown that separation rings and sectional
adhesive can be even more beneficial when the matrices create tighter contacts than the
gingival wall of the proximal box is very deep. circumferential matrix (Tofflemire metal
Matrix application matrices).
 To avoid flat proximal-surface contours,
precontoured matrices should be used or the
 One of the most important steps for proximal
metal matrices should be shaped or contoured
restorations of the posterior teeth is the correct
by burnishing before or after they are placed.
choice and placement of the matrix band. The
The marginal ridge strength obtained with a
composite restoration is almost completely
contoured sectional matrix is significantly
dependent on the contour and position of the
greater than that obtained with a straight,
matrix band to create the proper proximal
circumferential band.
contacts. The matrix strip must be firmly
 The preoperative wedging used during the
touching the contact area of the adjacent tooth.
preparation is removed, the matrix band is
 Several useful matrices are available, including
placed, and a new wedge is inserted.
the clear plastic matrix, the ultrathin (0.001-inch)
 The convex matrix edge is placed cervically,
Tofflemire metal matrix & the thin (0.0015-inch)
while the convex side must face the adjacent
sectional matrix.
tooth.
The clear matrix can be used in conjunction
 A matrix with occlusogingival width compatible
with a light-reflecting wedge:
with the dimensions of the preparation must be
 It offers the advantage of allowing penetration of
chosen. Its height must be enough to place the
the curing light from multiple directions. This
gingival edge of the band 1 mm below the
allows the clinician to cure the increments of
cavosurface angle of the gingival wall and the
resin composite from the proximal and gingival
directions, rather than from the occlusal aspect
186 Clinical Operative Dentistry 186

occlusal edge 1 mm beyond the marginal ridge wooden wedge and the proximal surface of the
of the adjacent tooth. adjacent tooth. The ring will have enough
 After the sectional matrix and wooden wedge tension to separate the teeth adequately and to
are placed, the ring is placed using a rubber dam cause the wedge to wrap slightly around the
clamp or similar forceps so that the vertical tooth, providing a tight gingival seal and
points of the ring are positioned in the facial and wrapping of the sectional matrix around the
lingual embrasures adjacent to the box tooth to form the proper proximal contour.
preparation. The ring holds the ends of the  On cases where both mesial and distal surfaces
sectional matrix tightly against the tooth and were prepared, after placement of the matrix
exerts a continuous separating force between band, it is recommended to use of the wedge
the teeth. alternation technique:
 The matrix should be burnished gently against - A single wedge is inserted, starting in one of the
the adjacent proximal contact. The sectional interproximal spaces, followed by restoration of
matrices in these systems are typically made of this corresponding proximal surface and the
“dead soft” metal. Heavy burnishing will cause contact.
grooves to be formed in the matrix that will be - Then, the wedge is removed and inserted into
replicated in the restoration. This makes for a the other interproximal space, and the second
rough, irregular contact that can tear and shred proximal surface is restored. This procedure can
floss when the patient performs oral hygiene allow the maximum dental separation by the
measures, so only light burnishing should be wedge at the moment to restore each proximal
used. box. This promotes a greater dental separation
 These “ring” sectional matrix systems have a than if both wedges were inserted
number of advantages: simultaneously. If both wedges are placed at the
- They provide tooth separation to ensure good same time, they will work one against the other,
interproximal contact. reducing the total teeth separation.
- They provide better proximal contours for
posterior resin composite restorations than
traditional matrices.
- They simplify matrix placement for single
proximal-surface restorations as compared to a
circumferential band.
- These systems provide a tighter, longer- lasting
contact in resin composite than does a standard
matrix in a Tofflemire retainer. It should be
recognized that the ring provides progressive
tooth separation, so if it is left in place for a long
period of time, excess separation can occur,
resulting in a very tight contact. Figure 8.8(a) placement of matrix and wedge.
 Proper placement of the ring depends on facial
and lingual extensions of the proximal box and
the size and shape of the tines of the particular
ring being used:
- If the facial and lingual proximal extensions of
the proximal box do not extend significantly
onto the facial or lingual surfaces of the tooth, it
is possible to place the ring with the tines
occlusal to the wedge or between the wedge and
enamel adjacent to the proximal surface being
restored.
- However, if one or both of the proximal walls
reach the facial or lingual surfaces of the tooth, Figure 8.8(b) better adaptation on the
placement of the tines of the ring in these embrasures using a ring with narrow tines and
locations may cause the matrix to be deformed. round cross section.
In this case, the tines may be placed between the
187 Chapter 8 Direct Posterior Composite Restorations 187

Ultrathin Tofflemire metal matrices

Figure 8.8(c) acid etching and application of the
adhesive system.
(Circumferential Matrix):
 The ultrathin metal matrices versus the clear
matrices: (Figure 8.10)
- Tight interproximal contacts are more easily
developed with the ultrathin metal matrices than
with the clear matrices because they are easier
to place, maintain their shape better, and can be
burnished against the adjacent tooth.
- One disadvantage of a metal matrix that wraps
around the facial and lingual surfaces of the
tooth is that increments must be initially cured
only from the occlusal aspect. After removal of
the matrix, the proximal resin composite may be
further polymerized from the facial and lingual
aspects.
 In general, the circumferential matrices are not
the first choice to restore posterior teeth with
composite, even on MOD preparations
 When restoring a single proximal surface, on
MO or OD preparations, the double thickness of
band, due to the presence of the strip on the
intact contact, reduces the teeth separation and
makes contact harder to achieve.

Figure 8.8(d) matrix removal after restoring

proximal surface.

Figure 8.10 clear and metal matrix bands with

Tofflemire matrix.

 Because the flat straight strip is not pre-

Figure 8.9 Different sectional matrix sizes and
separation rings.
 The wedges must be firmly applied using a
contoured, after the assembling on the retainer,
the area corresponding to position of the
proximal surface has to be burnished over a
paper mixing pad, using an egg shape
burnisher, creating a convex contour on the
opposite side, similar to the proximal tooth
surface. Then, it is taken in position and the
wedged is inserted. (Figure 8.11)
careful technique, because the separation
188 Clinical Operative Dentistry 188

provided must compensate the thickness of the Resin composite placement: Incremental
band on the mesial and distal proximal surfaces. technique
 When there are two proximal boxes to be
restored, the wedge alternation technique With incremental placement and curing of resin
should be used. composite, the C-factor of each increment is
reduced compared with bulk placement and curing.
As the C-factor decreases, bond strength increases.
The end result is that the incrementally placed and
cured restoration is bonded better to the cavity walls
than if the preparation had been filled and the resin
composite material cured in bulk.

First increment

Techniques must be used to enhance the bond and

reduce the adverse effects of polymerization
shrinkage and microleakage at gingival margin
because of the tendency for microleakage to occur
in that area:
Figure 8.11 burnishing of the matrix over the paper
mixing pad.  First, an increment no thicker than 1 mm is
placed against the gingival wall. A thin first layer
 After each wedge placement, the gingival seal of
will ensure proper light irradiation throughout
the matrix is evaluated with an exploratory
the increment.
probe, followed by the band burnishing toward
 In case of plastic wedge, exposure time should
the adjacent tooth using the backside of a spoon
be increased by 50% to ensure adequate
excavator blade. (Figure 8.12)
polymerization due to the possible attenuation
of light through the plastic wedge.
 If a metal matrix that surrounds the tooth has
been chosen, all increments must be cured from
the occlusal aspect. The tip of the light should
be positioned as close as possible to the resin
being cured. The output of curing lights
diminishes considerably with distance, with 50%
of light lost just 3 to 6 mm from the light tip. After
the metal matrix is removed, all proximal areas
of the restoration should receive additional
curing with the light to maximize restoration
cure.
 Adaptation of resin composite to cavity walls
can have a dramatic effect on the bond strength;
Figure 8.12 burnishing of the matrix toward
as adaptation worsens and voids increase, the
the adjacent tooth.
bond decreases significantly. To enhance
 Some accessory techniques can help to obtain adaptation of composite number of techniques
a good proximal contact when making proposed as in the following :
composite restoration. They are based on the Warming the composite: (Figure 8.13 a-c)
use of some contact forming instrument, to keep
the matrix pressed toward the adjacent tooth, at  Thicker-consistency resin composites have
the same time that a small increment of significantly increased cavity-wall voids
composite is light-cured, stabilizing the band in compared with medium- or thinner- viscosity
contact with the adjacent tooth. These materials. Resin composites that are supplied in
accessory techniques include Contact Forming preloaded resin composite tips or ampules tend
Instruments and Light Conducting Tips & to have a higher viscosity than do composites
Prepolymerized Ball Technique. that are supplied in syringes.
189 Chapter 8 Direct Posterior Composite Restorations 189

 Use of Centrix placement tips for resin

composite decreases the viscosity of the
material and significantly decreases voids
adjacent to the preparation walls compared with
either smearing the material into place with a
plastic instrument or “condensing” it.
 This technique that will further enhance the flow
of the resin composite into a cavity preparation.
 Involve use resin composite that has been
warmed prior to injection.
 The required amount of resin composite from
either a syringe or a premanufactured compule Figure 8.13(b) The rubber plug is placed into the
tip is transferred into a Centrix syringe tip. Centrix syringe tip.
 The tip and composite can be warmed in a water
bath; however, the tip should be sealed in a
small plastic bag prior to immersion to protect
the resin composite material from moisture.
 A more convenient means for warming
composite is to use a commercial composite
warmer (Calset, AdDent) to reduce the viscosity
and improve flow. The temperature to which the
composite is warmed is based somewhat on
individual preference but typically will be in a
range of 140°F to 155°F (60°C to 68°C).
Figure 8.13(c) The Centrix syringe tip is placed
 This material can then be syringed into place
into the placement syringe and transferred to
more easily, and the lowered viscosity enhances the composite warmer.
resin composite adaptation to the cavity walls. Use of Flowable resin composites:
 Use of warmed resin composite leads to
reduced marginal leakage in Class 2 resin  Another method that has been suggested is the
composite restorations compared with using use of low-viscosity, or flowable, resin
either room-temperature resin composite or composites for the first increment of a proximal
flowable composite. box or pulpal floor.
 Resin composite does not polymerize in the  Also, because of their lower filler content and
warming unit, even if kept at 130°F (55°C) for 4 reduced elastic modulus, it is theorized that
hours or 158°F (70°C) for 15 minutes. these materials could act as “stress relievers” to
 Finally, prewarming of the resin composite does absorb forces of polymerization shrinkage or
not adversely affect the material’s strength. cyclic loading.
 However, the efficacy of this method has not
been demonstrated.
 There are a number of problems associated with
these materials.
 Because of their higher resin content, flowable
resin composites demonstrate up to three times
greater polymerization shrinkage than do
standard hybrid resin composite
formulations.This generates significantly
greater polymerization shrinkage forces that
surpass any benefit that might be derived from
Figure 8.13(a) The appropriate resin composite the lower elastic modulus.This adversely
shade is selected and transferred to a light- impacts the adhesion of the resin composite to
protected Centrix syringe tip. the cavity preparation.To address this issue,
newer flowable dental composites with relatively
high filler content have been developed that
190 Clinical Operative Dentistry 190

have lower shrinkage stress–generating and may not produce a proper contour to the
characteristics. restoration.
 The use of a flowable resin liner in conjunction Additional increments
with a high-viscosity (packable) resin composite  Subsequent increments should be placed in
has been shown to reduce the strength of the thicknesses no greater than 2 mm.
polymerized packable material.  An oblique layering technique should be used
 The use of a flowable composite may led to whenever access allows. An oblique layering
increased incidence of gingival margin technique is preferred because it leads to higher
overhangs in beveled Class II cavity bond strength compared with either the use of
preparations. horizontal increments or bulk placement. In
Snowplow technique: addition, incremental techniques in which the
facial and lingual walls are linked by the
 In this technique, an initial thin increment of composite increment during curing tend to
flowable composite is placed over the gingival show greater cuspal deformation, particularly
and/or pulpal floors of the cavity preparation. when the final, occlusal composite increment
 This layer is not cured at this stage, but rather engages both the facial and lingual cavity walls.
an initial increment of heavily filled restorative  With the exception of the initial increment in the
resin composite is syringed or pushed into the gingival aspect of the proximal box, subsequent
unset flowable resin composite. resin composite increments should not contact
 Most of the flowable resin composite is both the facial and lingual preparation walls
displaced by the restorative composite and is simultaneously; this is to minimize
subsequently removed from the cavity polymerization shrinkage stress and cuspal
preparation with a hand instrument, microbrush, deformation.
or bristle brush.  Some accessory techniques can help to obtain
 As a result, most of the flowable composite, and a good proximal contact when making
therefore its potentially disadvantageous composite restoration. They are based on the
characteristics, is not present in the cavity use of some contact forming instrument, to keep
preparation. Instead, there is only a small the matrix pressed toward the adjacent tooth, at
amount of flowable resin composite remaining the same time that a small increment of
in those areas of the cavity in which the higher- composite is light-cured, stabilizing the band in
viscosity resin composite did not completely contact with the adjacent tooth.
adapt to the preparation and that otherwise may  These accessory techniques include the
have been void of restorative material. following :
 The combined increment of flowable resin Light Conducting Tips (Figures 8.14 a-c)
composite and restorative resin composite is
then cured.  The light conducting tips are clear plastic tips
 This technique has demonstrated significantly that are attached to the end of the light guide,
reduced void formation compared with allowing the matrix to be pressed and light cured
placement of restorative composite alone. at the same time.
 It has also shown significantly decreased  Some examples are the Light-Tip (Denbur) and
gingival margin leakage in Class 2 resin Focu Tip (Hager).
composite restorations when compared with  The proximal box is filled with composite to just
use of a restorative resin composite alone or gingival to the contact area, and the conical tip
with placement of a cured increment of flowable is wedged into the resin composite.
resin composite prior to restorative resin  Light conducting tip must be inserted inside this
composite placement. uncured composite and pushed toward the
 Note that On MOD preparations, the restoration direction of the contact with the adjacent tooth,
should preferably be started in the distal box, creating a separating force through the matrix at
reconstructing the distal surface in contact with the exact place of the desired contact.
the adjacent tooth. After that, the wedge and  This layer is light cured, creating a composite
matrix should be removed and a new band and bridge that stabilized the matrix in contact with
wedge placed on the mesial box. A band should the adjacent tooth.
not be reused because it is already deformed
191 Chapter 8 Direct Posterior Composite Restorations
 Subsequent increments restore the cone-
shaped gap formed by the tip.
 If there are two proximal boxes, wedge
alternation technique should be used, restoring
one proximal surface at each time.
 This technique is designed to ensure adequate
interproximal contact and to minimize the
thickness of resin composite that the light must
penetrate.
Figure 8.14(a) the proximal box is filled with
composite to just gingival to the contact area, and
the conical tip is wedged into the resin composite.
Figure 8.14(b) light-curing of the composite holding
the flat area (white arrow) parallel to the occlusal
plane and pushing it against the matrix band
toward the proximal contact (red arrow). The
marginal ridge guide is lined up with the tooth’s
marginal ridge (yellow
191
Figure 8.14(c) a small impression in the composite
is left on the gingival wall by the instrument.
Prepolymerized Ball Technique (Figures 8.15 a-d)
 The prepolymerized ball or plunging ball
technique is based on the use of a small ball of
the cured composite to press the band, creating
teeth separating force through the matrix,
helping to obtain an appropriate proximal
contact.
 For that, the tooth to be restored must receive a
previously burnished matrix and wedge, as it
has already been described.
 After the application of the adhesive system, it
is necessary to produce a small composite ball,
with a diameter a little bigger than the distance
between the axial wall and the proximal surface
of the adjacent tooth. It can be prepared using
powder-free gloves and then completely light-
cured outside the mouth.
 The normal incremental technique is used until
the proximal box is filled to just gingival to the
proximal contact. An additional increment of
uncured resin composite is placed into the
proximal box.
 The ball is then placed over this layer and
pressed toward the gingival wall, using a hand
instrument with a flat nib, such as an amalgam
plugger. It is important to be sure that the ball
entered tightly into the preparation, pressing the
band toward the adjacent tooth, creating the
desired teeth separation. The excess of
composite over the ball is removed, and then a
light-curing is performed.
 Then, the proximal surface is restored with
oblique increments, until it reaches the height of
the marginal ridge
 On MOD preparations, each proximal box is
restored separately, and the wedge alternation
technique is used.
192 Clinical Operative Dentistry 192

Figure 8.15(a) preparation and curing of a composite

ball. Figure 8.15(d) ball in position pushing the matrix
toward the adjacent tooth

Incremental layering technique in proximal box.

Figure 8.15(b) Placement of a composite increment

on the gingival wall.

Figure 8.15(c) prepolymerized ball applied into the

uncured composite layer, being pressed toward the
gingival wall.

After the metal matrix is removed, all proximal

areas of the restoration should receive additional
curing with the light to maximize restoration
cure.
193 Chapter 8 Direct Posterior Composite Restorations 193

Final increment polymerization throughout the entire

restoration.
 The matrix is allowed to remain in place to
 Careful control of the final increment will provide protection of the adjacent tooth during
minimize the amount of finishing. proximal-surface finishing and re-etching prior
 A number of techniques are helpful in to sealing.
accomplishing this goal.
 A rounded, cone- shaped instrument (e.g.,
PKT3), slightly moistened with resin adhesive or
a low- viscosity resin specifically designed to
prevent sticking of resin composite to the
instrument, may be used to shape and form the
occlusal surface before curing .
 A fine-bristled brush can be very helpful in
smoothing the composite surface and achieving
intimate adaptation of the resin composite to the
cavosurface margins.
 A method for replacing occlusal anatomy and
reducing finishing is called the successive cusp
build-up technique. With this procedure, Small condenser or burnisher lightly moistened
incremental resin composite placement is with adhesive used to establish occlusal contours.
accomplished as described in the preceding
sections. However, the clinician stops the
oblique layer placement and curing at a point
judged to be the base of the pit and fissure
anatomy for the definitive restoration. The final
increments of resin composite are positioned
and adapted to replace the missing portions of
the inner inclines of the cusps, one cusp at a
time. Because of their stiffer viscosity, packable
resin composites work well in this situation. The
packable resin composite can be adapted and
shaped without slumping prior to curing. As
each cusp is replaced with resin composite, it is
briefly cured (5 seconds) to set the material in A fine-bristled brush can be very helpful in
place. It is not necessary to fully cure each smoothing the composite surface and achieving
intimate adaptation of the resin composite to the
increment at this point, because the entire
cavosurface margins.
occlusal surface, and therefore all preceding
increments, will be irradiated after the final Finishing
cuspal incline is replaced with resin composite
and is irradiated for the full curing time.  Finishing and polishing procedures are
 To prevent the presence of an oxygen inhibition inherently destructive to the restoration surface
layer, the last composite increment can be and may result in the formation of microcracks
covered with transparent glycerin-based at and below the surface.
blocking gel, followed by an additional light-  Because cracks may also be produced or
curing through it, creating a fully polymerized exacerbated during mastication, the fracture
surface. toughness of the resin composite may be
 As a final step in resin composite placement and significantly reduced by destructive finishing
curing for Class 2 restorations, the wedge is techniques.
removed and the matrix is wrapped against the  A no. 12 or 12B scalpel blade is useful for
adjacent tooth. This allows access for the resin removing flash from the proximal and gingival
composite to be cured from the facial and margins and for shaping proximal surfaces of
lingual aspects to help ensure adequate resin composite
194 Clinical Operative Dentistry 194

 The composite material can then be finished and

blended to the tooth with successively finer grits
of polishing points, cups, or disks. While the use
of these rotary instruments will impact the
surface contours and smoothness, the long-
term surface finish is more dependent on the
resin composite particle size than the particular
polishing system used.
 Aluminum oxide disks, used in series from
coarse to very fine, tend to render some of the
smoothest finishes to resin composite. These
work well for restoration contours that are
relatively flat or convex, such as those in the
facial and lingual proximal embrasure areas.
 Abrasive disks are not practical for finishing
occlusal surfaces. Shaping of these surfaces
may be accomplished with multifluted carbide
finishing burs or fine diamonds.
 These burs should not be the final rotary
instruments used in the finishing process.
Rubber or silicone disks, points, cups, and
brushes impregnated with aluminum oxide, As a final step in resin composite placement and
silicon dioxide, or diamond particles have been curing for Class 2 restorations, the wedge is removed
and the matrix is wrapped against the adjacent tooth.
found to provide very acceptable results and This allows access for the resin composite to be cured
can be used to smooth the resin composite from the facial and lingual aspects to help ensure
surface after initial finishing. adequate polymerization throughout the entire
restoration. The matrix is allowed to remain in place to
 Finishing strips coated with aluminum oxide provide protection of the adjacent tooth during
particles can be used to finish proximal proximal-surface finishing and re-etching prior to
surfaces. As with the disks, these strips should sealing.
be used in series, from coarse to very fine grit.
 A final high polish may be accomplished using
a rubber prophylaxis cup with aluminum oxide
or diamond polishing pastes.
 A study showed that to finish and polish a
restoration on a later appointment also
improves the wear resistance of the composite.
This is related to the fact that, immediately after
curing, the composite has not yet reached its
maximum degree of conversion and physical
properties, important to bear the stress
generated by the rotary instruments. The called
“dark-curing” phase following application of
light-curing continues up to 24 h.

Finishing posterior composite restoration.

195 Chapter 8 Direct Posterior Composite Restorations 195

additional polymerization of the resin

composite.
 To prevent the rebonding resin from joining the
restored tooth to the adjacent tooth:
- A piece of matrix or other thin material may be
placed interproximally prior to performing the
rebonding procedure.
- Alternatively, floss is passed through the
interproximal contact after the rebonding resin
has been applied and before it is cured.
 After curing, any ledges of excess rebonding
resin should be removed with a sharp-bladed
instrument. The proximal contact and contours
are verified with dental floss.
 The rubber dam is removed, and the occlusion
is checked. If further occlusal adjustment is
required, rebonding resin should be reapplied in
the areas that were adjusted.

Continuing finishing posterior composite

restoration.
Rebonding and final cure (Figure 8.16)
 As previously mentioned, finishing procedures
are destructive to the resin composite
restoration and have been shown to adversely
affect wear.
 Finishing procedures can also exacerbate the
marginal gaps formed during polymerization.
 For these reasons, the practitioner should
consider rebonding the occlusal surface and all
accessible restoration margins with an unfilled
or lightly filled VLC resin.(not a regular adhesive
or pit and fissure sealant)
 The lower the viscosity of the rebonding resin,
the more effective it will be in penetrating
interfacial gaps and microcracks.
 Rebonding has been shown to
8.16 a) etching restoration margins prior to
- Improve the marginal integrity of resin rebonding. Note that thin plastic shim placed
composite restorations. interproximally to protect the adjacent tooth b)
- Significantly reduce microleakage and reduce rebonding resin is brushed into restoration surface
and margins.
marginal staining.
- Significantly reduce wear and prolong marginal
integrity.
 Although the need for etching before rebonding
is somewhat controversial, phosphoric acid is
usually applied to the marginal areas (1–2 mm
beyond the margins) for 15 seconds and then
rinsed off and the area thoroughly dried. The
rebonding resin is placed, thinned with a blotted
brush or applicator, and light cured for 20 to 40
seconds. This not only will polymerize the Floss is passed through the interproximal
rebonding resin, but it may also provide contact after the rebonding resin has been
applied and before it is cured.
196 Clinical Operative Dentistry 196

(The following shows step by step class II

composite restoration)

Figure 8.17(a) initial aspect of class II caries.

Figure 8.17(c) placement of matrix and wedge &

ring.

Figure 8.17(d) acid etching and adhesive

application.

Figure 8.17(b) tooth preparation

197 Chapter 8 Direct Posterior Composite Restorations 197

Figure 8.17(e) placement of first proximal

increment.

Figure 8.17(g) proximal box filled incrementally.

Figure 8.17(f) proximal surface completed and

matrix removed.
198 Clinical Operative Dentistry 198

COMPOSITE REPAIR

 Whenever possible, small defects on composite

restorations can be repaired by adding new
material, since the remaining restoration is in
good conditions.
 However, before performing a repair, the factor
that caused the defect should be determined
and controlled.
 The fractured area must be roughened by
abrasion, with a coarse grit diamond point
creating micromechanical retention.
 The surface is etched with phosphoric acid for
cleaning and the adhesive system applied,
followed by the composite placement.
 If any dentin is exposed on the fractured area,
the proper bonding technique to this substrate
must be used.

Figure 8.17(h) finishing and polishing.

Figure 8.17(i) final result.

199
201 Chapter 9 Amalgam Restorations 201

MATERIAL CONSIDERATION
ADVANTAGES
Composition
 Ease of manipulation: Amalgam is easier to Amalgam consists of amalgam alloy and mercury.
manipulate and less technique sensitive. It can Amalgam alloy is composed of silver-tin alloy with
be completed in one dental visit. varying amounts of copper, zinc, indium and
 Self-sealing ability: Corrosion products formed palladium.
at interface of amalgam restoration and tooth
seal the amalgam against microleakage. Dental amalgam alloys are mainly of two types, low
Amalgam also shows satisfactory marginal copper and high copper alloys:
adaptation.  Low copper alloys: more mercury required for
 High compressive strength: Physical amalgamation/slow setting reaction/more creep,
characteristics of amalgam are comparable to more dimensional changes and low
enamel and dentin. compressive strength.
 Good wear resistance: Because of good wear  High copper alloys: less mercury required for
resistance amalgam can be used in patients with amalgamation/fast setting reaction/less creep,
moderate to heavy occlusal loads. less dimensional changes and high
 Economical: Cost of amalgam is much less than compressive strength.
composites, ceramics and cast restorations.
 Favorable long-term clinical results.
 Subgingival amalgam margins did not
significantly alter the bacterial biofilm unlike
dental composite.
 When replacing restorations, it is much easier to
avoid enlarging the cavity preparation during
removal of amalgam than it is when removing
resin composite because of the contrast
between the color of tooth structure and
amalgam and because amalgam is not typically
bonded to the walls of the preparation.
Commercial preparation of low copper (DPI alloy)
& high copper silver alloy (fusion alloy)
DISADVANTAGES
Physical properties
 Bad esthetic.
Dimensional Change
 Need extensive tooth preparation: non
conservative.  Small amount of contraction occurs in first half

 Non-insulating: Being metallic restoration, it an hour after trituration, after this, expansion
occurs.
transmits thermal sensation to the pulp making
it non-insulating.  Factors Affecting Dimensional Changes of
Amalgam:
 Lack of reinforcement of weakened tooth
- Type of alloy being used, for example, single
structure: Amalgam is not strong enough to
reinforce the weakened tooth structure. composition spherical alloys contract more than
single composition lathe cut or admixed alloys.
 Brittle material: Poor tensile strength making
- Condensation technique, i.e. more mercury
amalgam a brittle material (easily fracture in thin
removed from alloy, more it will contract.
thickness).
- Trituration time: Overtrituration causes
 Galvanism: Results in galvanic current in
contraction.
association with gold restoration, other
- Presence of zinc: If zinc containing amalgam
amalgam restoration or even in same restoration
comes in contact with moisture or saliva during
with nonuniform condensation.
condensation or trituration, it can result in
delayed expansion after 3 to 5 days of
restoration. This expansion can result in
202 Clinical Operative Dentistry 202

extrusion of restoration beyond preparation  Zinc-free amalgam do not exhibit the

margins and pulpal pain. phenomenon of delayed expansion, but
 Difference between primary and secondary isolation to prevent any moisture contamination
expansion: is important for both zinc-containing and zinc-
- Expansion that occurs due to reaction of Hg with free amalgam restorations. Contamination of
alloy components is termed primary expansion dental amalgam with moisture will create
or mercuroscopic expansion. porosity in the restoration, which will decrease
- Expansion that occurs after 1 to 7 days due to strength and increase both corrosion and creep.
moisture contamination during trituration or
condensation before the amalgam mass is set, Biocompatibility
is termed secondary expansion or delayed  Though there has been a great debate related to
expansion.( only in zinc containing amalgam) mercury toxicity, if careful handling of mercury
is taken, amalgam has proved to be a
Strength biocompatible material.
 Strength of amalgam develops slowly. It takes  Dental amalgam restorations contain
24 hours to reach maximum. In the first hour, approximately 50% mercury, and some people
only 40 to 60% of its maximum compressive have concerns that mercury, which is known to
strength is achieved. be toxic when present in certain forms and in
 Being a brittle material, it is weak in thin high doses, is present in the mouth. Mercury in
sections, thus unsupported edges of restoration amalgam is bound in the matrix phase. The
fracture frequently. To avoid this, a 90° butt joint metallic bonds in amalgam are very difficult to
angle of amalgam is required at the margins. break, and only very heavy pressure or high heat
 Increase in mercury content decreases the can potentially cause the bonds in the
strength. restoration to degrade. During mastication,
 Spherical alloys are harder and stronger when pressures of 200 MPa or higher are common,
compared to lathe-cut alloys because they and this force, with friction, can generate heat in
require less mercury for trituration. small areas.
 There is considerable evidence of the safety of
Plastic Deformation (Creep) dental amalgam. To date, there is no confirmed
 Creep is undesirable because it causes evidence to indicate that the mercury in dental
amalgam to flow out over the margins resulting amalgam is related to any disease. Research
in marginal deterioration and fracture. reveals that no toxic effect has been linked to the
 Factors Affecting Creep: level of mercury released from amalgam, even
- Low copper alloys have higher creep than high when amalgam restorations are removed.
copper alloys.
- Increased condensation pressure reduces creep Thermal Conductivity
because it reduces residual mercury level. Because of good thermal conductivity, amalgam can
- Marginal areas show more creep because they transmit temperature changes readily to the pulp.
have higher levels of residual mercury. Hence, its closeness to pulp should be avoided
- Delay between trituration and condensation without adequate pulp protection.
increases creep.
Coefficient of Thermal Expansion
Corrosion Coefficient of thermal expansion of amalgam is three
times more than that of dentin. This large difference
 Amalgam restoration shows tarnish and is responsible for microleakage.
corrosion over a period of time.
 Corrosion causes decrease in strength of Microleakage
restoration by 50%. Following factors are responsible for microleakage
 Advantage of corrosion is that its by-products in amalgam:
seal the preparation margin, resulting in self-  Poor condensation techniques that cause
sealing of amalgam. marginal voids.
 High copper alloys corrode slower.  High coefficient of thermal expansion of
amalgam.
203 Chapter 9 Amalgam Restorations
 Use of single composition spherical alloys
which show more leakage than lathe-cut or
admixed alloys.
 Microleakage can lead to Pulpal inflammation,
Tooth discoloration & Postoperative sensitivity.
INDICATIONS OF DENTAL AMALGAM
RESTORATIONS
Class I Preparations
Moderate to large class I preparations especially in
patients with heavy occlusion loads.
May be either:
 Occlusal caries: The indication for an initial
Class 1 amalgam restoration is carious tooth
structure in the occlusal fissures (or in facial or
lingual pits in posterior teeth) detected clinically
and confirmed with bitewing radiographs.
 Defective restorations and recurrent caries:
another indication for a Class 1 restoration is the
replacement of a restoration that is defective
beyond repair or associated with a recurrent
caries lesion.
Class II Preparations
In large preparations especially in patients with:
 Heavy occlusion.
 Extension on the root surface.
 Problem of isolation. (Minor contamination
during the amalgam placement has less adverse
effects as compared to composite restorations).
It is indicated in heavy occlusion because amalgam
has greater wear resistance than composites.
Proximal caries lesions can sometimes be detected
visually during a clinical examination, but they are
usually detected with bitewing radiographs. In most
cases, a restorative procedure should not be
undertaken to treat a proximal caries lesion unless
there is radiographic evidence of at least slight
penetration of the lesion into dentin toward the pulp.
Class V Preparations: Amalgam can be used in areas
where esthetic is not a problem.
Class VI Preparations: Amalgam is used to restore
cusp tips.
Core material in endodontically treated teeth.
Tooth Having Fractured Cusp.
203
CONTRAINDICATIONS
Esthetics: Use of amalgam is avoided in esthetic
areas of oral cavity. So, preparations class III, IV, V
usually are not indicated except in certain cases.
Small Class I and Class II Preparations: These cases
should be restored with composite rather than
amalgam as former results in more conservative
tooth preparation.
Grossly Decayed Teeth: In grossly decayed teeth,
amalgam is not indicated because it does not
reinforce the remaining tooth structure. These teeth
should be restored using cast restorations.
CAVITY PREPARATION
Simple Class I Tooth Preparation: (figures
9.1 a-g)
Outline Form:
 When an occlusal restoration must be placed
because of initial caries lesions, two guidelines
should be applied in establishing the outline
form:
- Carious tooth structure should be eliminated.
- Margins should be placed on sound tooth
structure.
 A small round bur is used to enter the deepest
or most carious pit, moving the bur parallel to
the long axis of the tooth crown. When the bur
touches the dentino-enamel junction or slightly
into the dentin, the straight fissure bur/diamond
point is utilized for further preparation.
 Maintain the initial depth of 1.5 mm. Depth
should be at least 0.2 to 0.5 mm in dentin to
provide adequate strength to resist fracture due
to occlusal forces. While maintaining the same
depth and bur orientation, move the bur to
extend the outline to include the central fissure.
 Any enamel that has been undermined by the
removal of carious dentin should be removed.
The preparation should be widened only enough
to obtain enamel walls supported by sound
dentin.
 Buccolingual cavity width should not be wider
than one fourth of intercuspal distance.
 Avoid ending preparation margins in high stress
areas like cusp tip and crest of the ridges.
 Extend the margin mesially and distally but do
not involve marginal ridges. These walls should
204 Clinical Operative Dentistry 204

have dovetail shape to provide retention to the

restoration.
 Ensure that there is slight divergence of mesial
and distal walls which helps to provide dentinal
support for marginal ridges.
 Deep pit and fissure defects less than 0.5 mm
apart should be included in outline form.
 External outline form should have smooth
curves, straight lines and rounded angles to
facilitate the uncovering of the margins during
carving of amalgam. If, after the amalgam is
carved, the margins of the preparation are
jagged or rough, it is difficult for the dentist to
know if this is because the enamel margin is
rough or because amalgam is extending past the
margins onto the surface of the tooth
(overextended amalgam or amalgam flash).

Figure 9.1(a) Class I tooth caries on a mandibular

molar. Note marking the contacts with articulating
paper

Figure 9.1(c) the straight fissure bur/diamond

point is utilized for further preparation.

Figure 9.1(b) opening of the cavity with the round

diamond point perpendicular to the occlusal
surface.
Figure 9.1(d) slight divergence of mesial and
distal walls which helps to provide dentinal
support for marginal ridges.
205 Chapter 9 Amalgam Restorations 205

Figure 9.1(e) analysis of the preparation walls to Class I cavity preparation of (a lower first molar
evaluate for the presence of remaining carious b) upper first premolar.
tissue (arrows)

 Many a time, caries extends at one or more

points below the otherwise flat pulpal floor.
Such carious lesions are either excavated with
fine excavators or removed with small round
burs. These depressions in the pulpal floor are
filled with sedative cement like zinc oxide
eugenol or calcium hydroxide. All other features
remain the same. (figure 9.2)

Figure 9.1(f) modification of the outline to remove

the affected areas

Figure 9.2 Many a time, caries extends at one

or more points below the otherwise flat pulpal
Figure 9.1(g) final aspect floor. Such carious lesions are either
excavated with fine excavators or removed
with small round burs. These depressions in
the pulpal floor are filled with sedative cement
like zinc oxide eugenol or calcium hydroxide.
All other features remain the same.

 There is strong evidence that carious dentin

inadvertently left at the base of a sealed fissure
does not progress and that the sealing of
fissures associated with occlusal amalgam
restorations is an extremely effective treatment.
Therefore, the routine extension of cavity
206 Clinical Operative Dentistry
preparations through fissures not known to be
carious cannot be justified. (figure 9.3)
Figure 9.3 there is strong evidence that carious
dentin inadvertently left at the base of a sealed
fissure does not progress and that the sealing of
fissures associated with occlusal amalgam
restorations is an extremely effective treatment.
206
Resistance Form of tooth structure
It is the features included in cavity preparation to
allow tooth to resist fracture after insertion of
restoration.
Primary resistance form should have the following
features:
 Shape of the preparation should be like a box
with flat floor. This helps the tooth to resist
occlusal masticatory forces without any
displacement (figure 9.4). Though floor should
be flat, but it should also follow the contour of
occlusal surface
Figure 9.4 box shaped preparation to provide
resistance form.
 Restrict the extension of external walls so as to
have strong marginal ridge areas with sufficient
dentin support. The distance from margins of an
occlusal extension to the proximal surface must
not be less than 1.5 mm in premolars and 2.0 mm
in molars. In case the distance is slightly less,
the divergence of the walls can be avoided
(figure 9.5) However, if the said distance is
approximately 1.0 mm, the inclusion of proximal
Surfaces can be considered (converted to class
II).
Figure 9.5 the distance from margins of an
occlusal extension to the proximal surface
must not be less than 1.5 mm in premolars
and 2.0 mm in molars. In case the distance
is slightly less, the divergence of the walls
can be avoided.
207 Chapter 9 Amalgam Restorations
One should avoid excessive removal of
cuspal inclines.
 The crossing ridges should be preserved as far
as possible (transverse ridge and oblique ridge).
If the caries involves more than half the planes
of these ridges, the total ridge can be involved.
Remember loss of crossing ridges is more
detrimental for tooth than crossing the marginal
ridges.
 All unsupported enamel should be removed.
 To enhance their ability to resist fracture,
enamel margins should be prepared at a right
angle or slightly obtuse angle (90 degrees or
greater), as enamel margins of less than 90
degrees are more subject to fracture, especially
in Function. (figure 9.6)
Figure 9.6 to enhance their ability to resist
fracture, enamel margins should be
prepared at a right angle or slightly obtuse
angle (90 degrees or greater).
 The buccolingual width of the cavity should be
approximately 1.0-1.5 mm or 1/4th of the
intercuspal distance: (figure 9.7 a-c)
- In case, the caries so dictates, the width can be
more, but in no case more than half the cuspal
inclines should be involved.
207
- In case where more than half or 2/3rd cuspal
inclines are involved, the covering of cusps
become mandatory.
- If a cusp is too weak to withstand function, it
should be reduced for coverage with amalgam
or attached in some way to the amalgam to
provide cuspal reinforcement (described in the
section on complex amalgam restorations).
- Alternatively, in spite of covering cusps in such
circumstances, the undermined carious lesions
are excavated from below the cusps and this
undermined area is filled with glass-ionomer
cement or composite resin. The rest of the cavity
is restored with silver amalgam. It has been
shown that these teeth exhibit same fracture
resistance as the teeth without any undermined
cuspal caries.
 Even in narrower preparations, cusps should be
evaluated for cracks that could lead to fracture,
and the functional loading to which they will be
exposed should be assessed.
Figure 9.7(a) buccolingual width of cavity in the
premolar is greater than one third the
intercuspal distance therefore the cusps ideally
should be protected by reduction and coverage.
Figure 9.7(b) the lingual cusp not covered or
protected thus fractured.
208 Clinical Operative Dentistry
Figure 9.7(c) the lingual cusps are too weak to
withstand function, they should be reduced for
coverage with amalgam
Resistance Form of amalgam restoration
It is the features included in cavity preparation to
allow amalgam restoration to resist fracture in oral
cavity.
Primary resistance form should have the following
features:
 To provide adequate thickness of amalgam,
keep the minimum occlusal depth of 1.5 mm
(When carious dentin and the overlying enamel
are removed, the preparation will be at least that
depth and usually deeper).
 Provide cavosurface angle of 90°. Although
many amalgam restorations will have amalgam
margins that are significantly less than 90
degrees on the occlusal surface, very acute
amalgam margins are much more subject to
fracture. Marginal fracture will usually cause
marginal gaps, or ditches, between the amalgam
and the enamel.
 Round off all the internal line and point angles.
(figure 9.8)
Figure 9.8 Round off all the internal line and
point angles.
208
Retention form of amalgam restoration
Primary retention form prevents the restoration
from being displaced.
Retention can be increased by the following:
 Opposing walls of Class 1 occlusal (buccal and
lingual walls) restorations should be parallel to
each other or should converge slightly
occlusally. (figure 9.9)
Figure 9.9 opposing walls of Class 1 occlusal
(buccal and lingual walls) restorations
should be parallel to each other or should
converge slightly occlusally.
 In cases where the caries or the anatomic
contours demand the divergent walls other than
mesial and distal marginal ridges, the cavity
walls up to dentinoenamel junction is kept
parallel and the rest can be divergent. The
parallelism in the dentinal walls will provide the
requisite resistance and retention form to the
restoration.
 Giving slight undercut in dentin near the pulpal
wall. (figure 9.10)
Figure 9.10 Giving slight undercut in dentin near
the pulpal wall to provide retention.
209 Chapter 9 Amalgam Restorations 209

 Occlusal dovetail. distribution of the occlusal loads because they

 The depth of the cavity is placed 0.5 mm below
the dentino-enamel junction. This much depth
provides bulk of silver amalgam as well as
retention because of elasticity of dentin. When
the amalgam is condensed, the dentin expands
and later contract to make a grip of the
restoration.
are perpendicular to the direction of the Load.
 Retention locks are given. These locks are
placed in dentin in both mesio-axial and disto-
axial line angles. These locks terminate at the
level of pulpal floor.

Tooth Preparation on Occlusal Surface

with Buccal or Lingual Extension
(compound class I preparation): (figures
9.11 a-j)

 For removal of caries from buccal or lingual pits

and fissures, slight modification in preparation
is needed.
 After preparing the occlusal cavity, keep the
straight fissure bur perpendicular to the pulpal
floor and move towards the buccal/lingual
Class I cavity with buccal extension.
direction as the caries dictates. Make a box type
preparation with mesial and distal walls parallel.
Then with the side of tapering fissure bur, the
step is prepared, keeping the bur parallel to the
buccal/lingual surface of the corresponding
grooves.
 Remove all the unsupported enamel by using
slow speed bur. The following shows step by step compound class I
cavity preparation for amalgam.
 The axial wall so produced will be placed in
dentin, 0.5 mm inside the dentino-enamel
junction. The gingival wall is made 1.5 mm wide
and is extended till termination of the
buccal/lingual grooves.
 The axial and gingival walls of the buccal/lingual
box are flattened keeping mesial and distal walls
parallel.
 These two walls, mesial and distal can be kept
convergent occlusally in case caries dictates
wider gingival walls.
 In case where the apical ends of the buccal and
lingual grooves are at the same level as the
pulpal floor, the buccal/lingual extension will
have no steps.
 Many a times, the pulpal floor can be deeper as
Figure 9.11(a) For removal of caries from buccal or
compared to the apical end of these grooves, a lingual pits and fissures, slight modification in
condition that is called the reverse step in the preparation is needed.
occlusal direction. In these cases, the axial wall
is made by the help of base materials as zinc
phosphate cement, zinc oxide eugenol and, etc.
 The gingival wall in all cases meets the tooth
surface at 90o angle. The axial wall makes an
obtuse angle with the pulpal floor.
 The gingival wall must be parallel to the pulpal
wall and the occlusal plane, allowing the
210 Clinical Operative Dentistry 210

Figure 9.11(d) with the side of tapering fissure

bur, the step is prepared, keeping the bur parallel
to the buccal/lingual surface of the
corresponding grooves.

Figure 9.11(b) preparation of the occlusal part of

the groove

Figure 9.11(e) analysis the preparation to verify

the presence of remaining carious tissue

Figure 9.11(c) after preparing the occlusal cavity,

keep the straight fissure bur perpendicular to the
pulpal floor and move towards the buccal/lingual
direction as the caries dictates. Make a box type
preparation with mesial and distal walls parallel.

Figure 9.11(f) removal of the remaining

carious tissue.
211
Figure 9.11 (g) filling the defect with GIC.
Figure 9.11(h) preparation of the mesioaxial and
the distoaxial line angle
Figure 9.11(i) rounding of the axiopulpal angle
with the tip of the diamond point or with a
gingival margin trimmer.
Chapter 9 Amalgam Restorations 211
Figure 9.11(j) final aspect of the tooth
preparation
Class II Tooth Preparation for Amalgam
Restoration (figures 9.16 a-n)
Outline Form
Outline form for occlusal portion follows the same
principles as given for pit and fissure lesions except
that external outline is extended proximally toward
defective proximal surface.
Tooth preparation necessitated by a caries lesion on
a proximal surface should, when possible, avoid
extension of the occlusal outline more than is
necessary to allow access to the proximal lesion, to
remove demineralized enamel and dentin, and to
remove enamel not supported by sound dentin. If an
occlusal caries lesion is present, it should be treated
with a separate occlusal restoration. If the
preparation necessitated by the occlusal caries
lesion is in close proximity to the occlusal outline of
the proximal preparation so that there is minimal or
no sound tooth structure separating the two
preparations, they should be joined.
Fissures that contact the outline of a Class 1 or Class
2 preparation should not be included in cavity
preparation but sealed instead after placement of the
restoration.
Establishing the occlusal step:
 Using high-speed bur, make a punch cut in the
pit closest to the involved proximal surface.
212 Clinical Operative Dentistry 212

Keep long axis of the bur parallel to the long axis  Fracture the slice of enamel in the region of the
of the tooth and maintain the initial depth of 1.5 contact area with a small chisel or enamel
to 2.0 mm. hatchet.
 Extend the outline to include the central fissure  Widen the preparation faciolingually to just clear
while maintaining uniformity in depth of pulpal the contact areas. Ideal clearance of facial and
floor. lingual margins of the proximal box should be
 Make isthmus width as narrow as possible as, 0.2 to 0.5 mm from the adjacent tooth. (figure
not wider than one fourth of the intercuspal 9.13)
distance.
 Give slight occlusal convergence to facial &
lingual walls to provide retention for amalgam.
 A dovetail is provided in the non-involved
proximal area. It prevents mesial displacement
of the restoration.

Extending occlusal step proximally:

 Outline form in proximal area is primarily
determined by faciolingual position of the
contact area and the extent of carious lesion.
 While maintaining established pulpal depth,
extend the preparation towards proximal
Figure 9.13 widen the preparation faciolingually
surface of tooth, ending 0.8 mm short of cutting
to just clear the contact areas. Ideal clearance
through marginal ridge. of facial and lingual margins of the proximal
 Proximal cutting is sufficiently deep into the box should be 0.2 to 0.5 mm from the adjacent
dentin (0.5-0.6 mm) so that retentive locks are tooth.

prepared into axiolingual and axiofacial line

angles. (Figure 9.12).  Proximal cut is diverged gingivally. It results in
greater faciolingual dimension at gingival
surface than occlusal surface. It provides good
retention and conservation of marginal ridge.
(figure 9.14)

Figure 9.12 Proximal cutting is sufficiently deep

into the dentin (0.5-0.6 mm) so that retentive
locks are prepared into axiolingual and
axiofacial line angles.
Figure 9.14 the walls of the proximal box
Preparation of proximal box: should converge occlusally.
 Keep a small slice of enamel at the contact area
to prevent accidental damage to adjacent tooth.
If there is any doubt that accidental damage to  Proximal buccal and lingual margins should
the adjacent tooth can occur, use a metal matrix have a cavosurface angle of 90° and when
band interdentally. completed, the walls of the proximal box should
converge occlusally. (figure 9.15)
213 Chapter 9 Amalgam Restorations 213

small round bur is utilized for this purpose. The

particular area is filled with calcium hydroxide or
zinc oxide eugenol cement.

Figure 9.15 Proximal buccal and lingual

margins should have a cavosurface angle of
90° and when completed, the walls of the
Base applied on pulpal and axial walls in
proximal box should converge occlusally.
class II preparation.

(The following shows step by step cavity

preparation for class II amalgam)

Convergent proximal walls conserve marginal

ridge and also retain dental restoration. Figure 9.16(a) Figure 534 Clinical &
radiographic aspect of the proximal lesions

 Similarly, caries in the axial wall does not dictate

cutting the entire axial wall towards the pulp. A
214 Clinical Operative Dentistry 214

Figure 9.16(b) opening of the occlusal cavity with

diamond. On this example, performed on
extracted teeth, there is only a pigmented groove
on the occlusal surface, without the presence of
the caries on the dentin. On a real situation, this
groove should not be prepared, and two
separated vertical slot preparation could be
performed. On this example, the occlusal surface
was prepared only for didactic purposes to
exemplify a MOD preparation.
Figure 9.16(e) preparation of the buccal and
lingual walls of the mesial box

Figure 9.16(c) marginal ridges undermined by

caries. Figure 9.16(f) Outline of mesial proximal box

Figure 9.16(d) fracture of the mesial marginal ridge Figure 9.16(g) fracture of the distal marginal
with a hand instrument. ridge.
215 Chapter 9 Amalgam Restorations 215

Figure 9.16(h) preparation of the lingual wall of

the distal box. Figure 9.16(j) evaluating the complete removal
of the remaining carious tissue

Figure 9.16(k) GIC-based material application.

Figure 9.16(i) buccal wall of the distal box being

prepared

Figure 9.16(l) preparation of the mechanical

retentions in the proximal boxes
216 Clinical Operative Dentistry
Figure 9.16(m) trimming of the gingival
cavosurface angles.
Figure 9.16(n) final aspect of the preparation
The outline form of the proximal box is
dictated by various factors:
 Extent of caries: Mostly the caries are around
contact areas and the buccal and lingual walls
of the proximal box are kept in self-cleansing
areas.
 Convexity of the proximal surfaces: In cases of
convex proximal surfaces, the contact area is
comparatively smaller and the extension of the
cavity preparation will be minimal towards the
embrasures.
 Caries and plaque indices: The more the caries
and plaque indices, the more is the need to
extend the proximal walls into self-cleansing
areas.
216
 Masticatory loads: In cases where the
masticatory loads are great, the bucco-lingual
width of the total preparation is kept minimum
possible. The isthmus width should be as
narrow as possible and should not be more than
1/4th of intercuspal distance or 1.0-1.5 mm wide.
Hollenback’s Reverse curve (S-shaped curve)
placement: (figures 9.17 a-b)
 In class II preparations, extension of proximal
area is important for elimination of caries and
breaking proximal contacts. But in teeth with
broader contacts, reverse-S shape curve is
given to both widen the box yet remove less
tooth structure. This curve is made only enough
to create an amalgam margin at 90° in relation to
the external proximal surface. If excessive flare
is given in these teeth, proximal walls will end
past the axial angle of tooth through the cusps
resulting in weakening of tooth structure and
fracture of restoration.
 Reverse curve is given to the proximal walls by
curving them inwards towards the contact area.
(It is performed in a way that the buccal wall of
the proximal box to have a concave contour
toward the buccal surface of the tooth).
 In case of maxillary teeth, mostly the molars, the
contact area is more buccally placed, i.e. the
lingual embrasures are larger than the buccal
embrasures. In such cases, extending the
bucco-proximal wall into the embrasure may
lead to excessive cutting of the buccal cusps. To
avoid this, a reverse curve is made in the buccal
proximal wall so as to have sufficient amount of
dentin in that area and also to achieve butt joint
with the cavosurface margins. This curve is
towards the axial wall side and the rest is kept
straight. The total wall is not curved, since by
doing so the amalgam restoration will not be at
right angle to the cavosurface margins, thereby
weakening the restoration.
 Such a curve, though mostly given in maxillary
molars, can be given in any tooth where the
contact area is deviated or more pronounced on
one side.
217 Chapter 9 Amalgam Restorations 217

Primary Resistance Form of tooth

The same features as in class 1 plus the following:
 The preparation should not be extended further
into a sound occlusal surface to provide
retention of the proximal restoration, because
this will weaken the tooth’s resistance to
fracture. Retention form for the proximal
restoration should be attained within the
proximal preparation.

Primary Resistance Form of amalgam

restoration
The same features as in class 1 plus the following:
 Shape of the preparation like a box with flat
pulpal and gingival floor.
 The junction of the proximal portion and the
occlusal extension of the Class 2 amalgam
preparation must have adequate depth (1.5 to
2.0 mm). The occlusal outline form at the
junction of the proximal and occlusal
Figure 9.17(a) divergent walls toward the proximal
components (axio-pulpal line Angle) should not
surface resulting in thin margins for restoration in
the buccal wall. If excessive flare is given in these be sharp or jagged but should be slightly
teeth, proximal walls will end past the axial angle rounded in order to reduce the concentration of
of tooth through the cusps resulting in weakening stresses in that portion of the restoration. (figure
of tooth
9.18)
 All unsupported enamel must be removed. Thus,
Bevel should be given at gingival seat (figure
9.18).Gingival cavosurface bevel is not indicated
if gingival margin is placed gingival to cemento-
enamel junction (CEJ).
 The proximal preparation should have a
mesiodistal dimension of about 1.5 mm or more.
 The gingival wall, like the facial and lingual walls
of the proximal preparation, should form an
angle of approximately 90 degrees with the axial
wall of the tooth. This provides strength to both
the amalgam and the enamel and prevents
enamel not supported by sound dentin from
being left at the margins of the restoration.
 Care is taken to place the gingival wall in enamel
involving both enamel and dentin. The
approximate width of the gingival wall is 1.0 mm
or 1.5 mm, out of which 70% should be in dentin
and the rest may be in enamel. The proximal box
walls should have sufficient dentin (not less
than 0.6 mm) so as to enable the operator to
Figure 9.17(b) change of the contour of the
make retentive grooves or locks, if need arises.
buccal wall to increase the thickness of the
amalgam in the restoration margin (reverse In case where the extension of gingival wall is in
curve).reverse-S shape curve is given to both the cementum, the width of the gingival wall
widen the box yet remove less tooth structure. should always be less than 1.0 mm
Primary Resistance Form of tooth
(approximately 0.7-0.8 mm).
218 Clinical Operative Dentistry 218

Figure 9.18 roundation of axiopulpal line angle &

Figure 9.19 if all demineralized and undermined
beveling the unsupported enamel at gingival seat. enamel has been removed and a margin remains
in contact with the adjacent tooth, consideration
Primary Retention Form of amalgam should be given to allowing contact to remain.
restoration
Placement of Locks or Partial Vertical Grooves
(retention grooves or points): (figures 9.20 a-b)
The same features as in class I plus the following:
 Retention can be increased by occlusal  If the extension into the occlusal surface is
convergence (about 2 to 5%) of buccal and narrower, if there is no extension into the
lingual proximal walls of proximal box. occlusal surface, as with the proximal slot
restoration, or if no amalgam bonding system is
to be used, retention grooves must be cut into
Means for Secondary retention and resistance
the dentin of the facial and lingual walls of the
form
proximal box (The locks are generally prepared
 Place retention grooves and locks in the in proximal box only, If there is a bulky extension
proximal box
of amalgam into the occlusal surface of the
 Pins. tooth, retentive undercuts should not be
 Bonding agents. necessary).
Simple Box Preparation (no occlusal  Locks can be prepared with round bur, inverted
involvement) (vertical slot Preparation) cone bur or tapering fissure burs.
(9.22 a-l)  The selection of the diameter of the bur depends
upon the required depth of the lock. The greater
Indication of simple box preparation:
the width of the proximal box, greater would be
the width of the lock.
Small proximal caries, not involving the occlusal
surface.  The bur is moved in axio-lingual & axio-buccal
line angles 0.2-0.5 mm inside the dentino enamel
Design features: junction and keeping the pressure both on the
proximal and axial side. Remember the pressure
Prepare proximal box with minimum facial and should be on both the walls. The pressure only
lingual extensions. For retention, converge facial on axial wall can lead to exposure and such a
and lingual walls. cutting might not aid in retention.

After the removal of carious tooth structure and

fragile enamel, the proximal surface margins of a
Class 2 amalgam preparation will not usually be in
contact with the adjacent tooth. However, if all
demineralized and undermined enamel has been
removed and a margin remains in contact with the
adjacent tooth, consideration should be given to
allowing contact to remain. (Figure 9.19)
219 Chapter 9 Amalgam Restorations 219

 In the preparation with a deep proximal box, the

retention grooves should be in the proximal
walls just inside the DEJ and not in the corners
of the box; this is to reduce the risk of pulp
exposure. This type of deepening usually
finishes at axio-pulpal line angle. (Should be
completely in dentin and not at the proximal
DEJ). (figure 9.21)

Figure 9.20(a) Simple Box Preparation. Note retention

grooves.

Figure 9.21 in the preparation with a deep proximal

box, the retention grooves should be in the
proximal walls just inside the DEJ and not in the
corners of the box; this is to reduce the risk of pulp
exposure.

 If a proximal box is so wide that retentive

grooves will not oppose each other, another
Figure 9.20(b) Preparation of retention
grooves. type of retention and resistance method, such
as amalgam bonding should be used.
220 Clinical Operative Dentistry 220

(The following shows step by step simple

proximal box preparation for amalgam)

Figure 9.22(a) access to the lesion through an

opening in the marginal ridge using a round
diamond point

Figure 9.22(b) the dentist feels a sensation to fall on Figure 9.22(d) penetration of the straight fissure
an empty space when reaching the lesion bur, which is moved in the buccolingual direction
and toward the marginal ridge.

Figure 9.22(c) cavity opened allowing access to the

lesion.

Figure 9.22(e) fracture of the ridge with an

excavator spoon
221 Chapter 9 Amalgam Restorations 221

Figure 9.22(f) occlusal aspect after the opening the Figure 9.22(i) application of the glass ionomer
cavity cement

Figure 9.22(g) outline of the walls with the Figure 9.22(j) preparation of the mechanical
pendulum motion on the buccolingual direction. retentions.

Figure 9.22(h) evaluating the presence of the

residual carious tissue with an exploratory probe& Figure 9.22(k) trimming of the gingival
removal of the carious tissue with the round bur. cavosurface angle
222 Clinical Operative Dentistry 222

Figure 9.23(a) conventional class I

tooth preparation of upper first molar
involving oblique ridge.

Figure 9.22(L) final aspect of the preparation

SPECIAL CONSIDERATIONS IN
CAVITY PREPARATION
Figure 9.23(b) conservative class I
tooth preparation not involving
Conservative Preparation for Mandibular oblique ridge.
First Premolar and Maxillary Molar

Conservative design in these teeth helps in the

preservation of oblique ridge or the transverse
ridge which protects the cuspal strength.

If fissures are separated by 0.5 mm or more, restore

the tooth with individual amalgam restorations.

Design features:

 For maxillary first molar, mesio-occlusal and

disto-occlusal preparations are made
Figure 9.23(c) conservative class II
independently without involving oblique ridge.
preparation in upper molar
(Figures 9.23 a-d)
223 Chapter 9 Amalgam Restorations 223

Figure 9.25 Because of high facial pulp

Figure 9.23(d) conservative class II horn in mandibular first premolar, pulpal
preparation in lower premolar floor should have facial inclination to
preserving transverse ridge. avoid pulp exposure.

 For mandibular first premolar, transverse ridge Adjoining Restoration

is not involved in proximal preparation. (Figure
9.24)  If proximo-occlusal restoration is already
present and a new restoration is required
adjoining it, then care should be taken while
preparing the tooth for second restoration
without weakening the margins of previous
restoration.
 The intersecting margins of two restoration
should be perpendicular to each other.

Modification for Abutment Teeth

 For abutment tooth, additional extension is

required if rest seat is planned for partial
denture.
 For abutment teeth, facial and lingual walls are
extended more for providing space rest seat.
 Also pulpal floor is deepened 0.5 mm more in the
area of rest seat so as to provide sufficient
thickness for the amalgam.

Figure 9.24 conservative class I preparation

b) conventional class I preparation involving
transverse ridge.

 Because of high facial pulp horn in mandibular Pulpal floor is deepened 0.5 mm more in
the area of rest seat so as to provide
first premolar, pulpal floor should have facial sufficient thickness for the amalgam.
inclination. (Figure 9.25)
224 Clinical Operative Dentistry 224

For abutment teeth, facial and lingual walls are extended more for
providing space rest seat

Class VI Tooth Preparation for Amalgam Restoration

Indications of restoration of class VI lesions with amalgam:

 In teeth where, because of too much wear, enamel is gone and the underlying dentin has become carious,
commonly seen in geriatric patients.
 Hypoplastic cusp tips as these are more prone to caries.

Steps of Tooth Preparation:

 Penetrate enamel with a small tapered fissure bur extending to the depth of 1.5 mm.
 Prepare a 90° cavosurface margin on enamel.
 Make small undercuts along the internal line angles to provide retention.

Class VI Tooth Preparation for Amalgam Restoration.

APPLICATION OF TOFFLEMIRE MATRIX BAND

This step is done in case one or more walls of tooth are missing. For example class II, class I with extension and
complex amalgam restorations.

Tofflemire Matrix.
Because these bands are flat, they should be contoured so that they will impart physiologic contours to the
restorations (Contact with the adjacent tooth should be more than a pinpoint touch):
225 Chapter 9 Amalgam Restorations 225

 A flat band may be contoured before it is placed

in the retainer. The band is laid on a paper pad
or other compressible surface, and the area to
be contoured is heavily rubbed with an ovoid
burnisher, a beavertail burnisher, the convex
back of the blade of a spoon excavator, or a
convex side of the cotton forceps. (Figure 9.26)
 A band may also be contoured after it has been
applied to the tooth. The area to be contoured is
rubbed with the back of the blade of the spoon
excavator or with some other thin, convex
instrument.

Figure 9.26 burnishing of the matrix at the region

of contact over the paper mixing pad

Assembly: (Figure 9.27)

 The straight assembly is for restorations near

the front of the mouth where the rubber dam–
covered cheek will not get in the way if the
retainer protrudes perpendicularly from the line
of teeth.
 The right and left assemblies allow the retainer
to be aligned parallel or tangent to the line of
teeth in more posterior areas.
Figure 9.27 (h) the loop of the band may
extend from the head of the retainer in
one of three directions: straight (1), left
(2), right (3). (i) The matrix must be
assembled with the slots in the head
directed gingivally. (j) The slots in the
head of the matrix should not be directed
occlusally.

Application (Figure 9.28)

 When the matrix is around the tooth, it should be
tightened snugly, but not too tightly, because a
very tight matrix will deform the tooth because
this will flex the cusps, resulting in post
restoration sensitivity, and failure of the
restoration.
 The matrix band must extend gingival to the
gingival margin of the proximal box of a Class 2
restoration.
226 Clinical Operative Dentistry 226

to allow the wedge to be positioned apical to the

gingival margin.

Figure 9.30 the wedge must be positioned so

that its base is also gingival to the gingival
margin. If the wedge cannot be placed so that
its base is gingival to the preparation margin.

 Another option is to use a rigid bladed

instrument to hold the matrix against the
gingival margin during condensation. (Figure
Figure 9.28 Application of matrix and band 9.31)

WEDGING

 The Premier wedges, with seven color-coded

sizes, are recommended for amalgam
restorations. (Figure 9.29)

Figure 9.31 The blade of a plastic filling instrument

has been placed into the gingival embrasure and is
being slightly rotated (torqued) to provide enough
separation to allow the matrix band to slip through
the contact.
 When there is a MOD preparation to be restored,
Figure 9.29 Wooden interproximal wedges. the wedges are placed simultaneously on the
Premier Sycamore wedges are shaped to impart mesial and distal surfaces of the tooth.
a more physiologic contour to the matrix. There
is a larger selection of sizes, and they are color
coded for easy selection.
 The wedge must be positioned so that its base
is also gingival to the gingival margin (Figure
9.30). If the wedge cannot be placed so that its
base is gingival to the preparation margin, a
concavity will be created in the matrix just
occlusal to the gingival margin, and this
concavity will be transferred to the amalgam.
Occasionally, the gingival papilla will need to be
surgically reflected from the interproximal area

Wedging.
227 Chapter 9 Amalgam Restorations 227

 Occasionally, a single unsupported area of a

 There are various ways of applying compound
- Probably the simplest is to employ a stick of
- An alternative way is to break up a stick of
Continue wedging.
REINFORCING MATRICES WITH
MODELING COMPOUND
 After the compound is pressed into place, it is
(FIGURE 9.32)
 The matrix may be recontoured after compound
 When a Class 2 preparation has only proximal
boxes that are adjacent to other teeth, and when
the preparation does not to any significant
degree extend to facial and lingual surfaces, the
stainless steel matrix is usually well supported
by the adjacent tooth or teeth. In these cases, no
reinforcement is necessary.
 In larger restorations that involve surfaces not
supported by adjacent teeth, it is often desirable
 If modeling compound extends occlusal to the
to reinforce or support the matrix in some way
in these areas to maintain the rigidity and shape
of the matrix.
matrix may be reinforced during condensation
by the operator, who places a finger or holds an
instrument against the matrix in a facial or
lingual area. For large unsupported areas,
however, modeling compound may be used.
to support a metal matrix:
compound. Approximately 1 inch of one end of
the compound stick is heated over an alcohol
burner. The stick is moved back and forth, while
being rotated, over the tip of the flame. After 5 to
10 seconds, the stick is removed from the flame
and held for a few seconds until the heat has
diffused through the radius of the stick to its
center, as indicated by its starting to droop or
sag. At that point, the 1-inch end is soft enough
to carry to the matrix and press into place with a
dampened, gloved finger. If adhesion of the
compound to the matrix and adjacent teeth is
desired, the softened end of the stick should be
passed through the flame again just before it is
carried to the mouth; this will provide a tacky
surface that will impart some adhesion.
compound into smaller pieces and insert them
into a plastic syringe. This syringe can then be
placed into warm water so that the compound
softens. Once softened, it is then possible to
extrude the warmed composite from the syringe;
it may be necessary to cut off a portion of the
syringe tip to ensure an adequate lumen size to
allow the compound to flow easily. This makes
it straight forward to inject compound into the
areas needed to stabilize the matrix or rubber
dam clamp. The compound can be adapted with
a dampened, gloved finger as described earlier.
cooled and hardened with air from a three-way
syringe.
application. A warmed instrument may be used
inside the matrix to soften the compound and
exert pressure on the matrix to give it the shape
that will allow the restoration contours and
shape to be similar to the original shape of the
tooth. Again, the compound should be cooled
with air after reshaping with a warmed
instrument.
occlusal edge of the matrix band, it should be
trimmed back with a sharp instrument;
otherwise pieces of compound could chip of
228 Clinical Operative Dentistry 228

during amalgam condensation and contaminate the amalgam.

 If condensation forces dislodge the compound, matrix reinforcement will be lost, therefore, to ensure that the
compound does not dislodge. While it is soft, a portion of it may be pushed onto the cusps of an adjacent
tooth to provide retention.
 After completion of the procedure, the compound can usually be pried away from the adjacent teeth and
matrix with an instrument such as a Hollenback carver or enamel hatchet. After the compound is removed,
the matrix may be removed as previously described.

Figure 9.32 Modeling compound can be used to support a matrix. (a and b) The compound stick is heated over
an alcohol flame, then removed from the flame to allow warmth to diffuse to the core of the stick. (c) When the
warmed tip of the compound stick begins to droop, softness is uniform throughout, and the compound is
ready for use. (d) A finger is dampened in water to prevent the glove from sticking to the softened compound.
(e) The compound has been pressed into place. It will be cooled with air to reharden it. (f) Compound has been
broken into smaller pieces and inserted into a plastic syringe, which in turn is placed into a warm water bath.
(g ) Once the compound has softened, it can be easily ejected. Note that the tip has been shortened to provide
a wider lumen so that the compound extrudes easily. (h ) The matrix may be recontoured after application of
the compound. A warmed instrument is used to soften the compound and reshape the matrix. (i) Any
compound extending past the edge of the matrix should be trimmed to prevent chipping during amalgam
condensation.

compressive strengths for spherical alloys.

MANIPULATION OF AMALGAM
 Excessive trituration should be avoided,
because it generates heat that will cause the
amalgam to set prematurely after trituration, and
Trituration
 Purpose of trituration is a homogeneous mass this will prevent adequate condensation and
for condensation. adaptation to the walls of the preparation,

 It is done with the help of automatic resulting in a weakened product.

amalgamator.  The time of trituration varies from 6 to 20

seconds and even it can be 40
 Overtrituration causes increase in contraction,
creep, tensile and compressive strength values seconds.(according to manufacturer

for lathe-cut alloys, decrease in tensile and instructions)

229 Chapter 9 Amalgam Restorations 229

Automatic amalgamator Figure 9.33 Aspects of amalgam with various

degrees of trituration. A) under triturated; b)
Tests for optimum trituration: (Figure 9.33) ideal trituration; c) over triturated

Normal trituration Amalgam insertion

 Good shiny mix.
 Convenient to handle.
 Mix is plastic in consistency.
 Homogeneous mass which adheres together.
 When a small amount of a recently triturated
amalgam is dropped onto a hard surface, from
25 to 30 cm high, it will slightly flatten but
 Done with Amalgam carrier that used to pick up
amalgam from amalgam well and carry, place it
in prepared cavity.
 The application and condensation of amalgam
must start in the proximal boxes, pressing the
material toward the line and point angles,
retentions, and gingival wall.

remains cohesive.
Over-trituration
 Mix is ‘warm’, wet and soft.
 Mix sticks to the capsule which is difficult to
remove.
 Very shiny but with low plasticity.
 Increasing the creep and shrinkage and
reducing the setting expansion.
 When the dropping test is performed, the
material does not change its shape.
Under-trituration
 Dry and crumbly mix without plasticity and with
an opaque appearance that is very weak.
 Low final strength values.
 Increase in creep, expansion and porosity,
predisposing it to fractures, marginal
degradation, and corrosion of the surface.
 When the dropping test is performed, the
material will spread.
Amalgam carrier & amalgam well.
230 Clinical Operative Dentistry 230

Amalgam condensation (Figures 9.34 a-d) displace the spherical particles rather than
condensing them.
Rules:  Should condensers be smooth or serrated,
 Amalgam must be condensed into the remained controversial:
preparation as soon as trituration is completed. - Authors favoring serrated condensers are of the
One increment of amalgam should not be view that serrations make the surface of
allowed to set significantly before the next increment rough so that when next increment is
increment is added. If the time lapse between added, mechanical bonding would take place.
trituration and condensation is more than 3 to 4 - Authors favoring smooth condensers are of the
minutes, then the mix should be discarded. view that mechanical retention is of least
Within this time the setting reaction partially importance in packing various increments of
hardens the mass and it will not be condensed amalgam mix because bonding occurs due to
properly. residual mercury which occurs at the surface of
 Condense continuously. each increment.
 Amalgam should be condensed both vertically  Higher condensation pressure leads to close
and horizontally or laterally (toward the walls of packing of the mass, so the residual mercury
the preparation). This will promote a close rises on the surface, which can be removed
adaptation of the amalgam to the walls as well during burnishing and carving. After proper
as to the floor of the preparation. Lateral condensation the surface of restoration
condensation can be achieved in more than one becomes shiny. This is due to accumulation of
way. One is to alter the direction of the face (end) residual mercury at the surface of restoration.
of the condenser so that it is pushed toward the To reduce the amount of mercury left in the
walls. Another method is to place the condenser restoration (residual mercury), the preparation
into the preparation vertically, then to move it is overfilled, and the mercury-rich excess is
laterally toward the walls so that the side of the carved off. The lower the residual mercury in the
condenser condenses the amalgam against the carved restoration, the greater its strength and
walls. the better the expected longevity of the
 Apply adequate force for condensation. restoration.
 The condensation should preferably start from
center to periphery.
 The increments should be small at one time.
Large bulk of increments leads to air entrapment
and leads to a porous and a weak restoration. A
larger mass results in incomplete condensation.
Each portion of amalgam carried to the
preparation should result in an increment
thickness of 1 mm or less to ensure maximum
condensation effectiveness.
 The cavity is overfilled slightly, which help in
burnishing and carving.
 The size of the condenser nib (end) determines
the amount of pressure actually transferred from
the operator’s hand to the amalgam mass; the
larger the nib, the less force per unit area
Amalgam condenser in use.
(pressure) is applied to the mass for a given
force from the operator’s hand. In other words,
when a larger-faced condenser is used, the
operator must exert more force on the
condenser to deliver adequate condensation
pressure. A large condenser should be used for
the overfilling of the preparation.
 Use larger condensers when condensing
spherical alloys because smaller condenser will
231 Chapter 9 Amalgam Restorations 231

Amalgam condensers (plugger) with Various sizes and shapes of working end: round, oval, diamond,
rectangular.

Interproximal Condenser used to pack and condense amalgam into interproximal areas of cavity
preparation

Figure 9.34(a) application of amalgam; &condensation toward the internal angles of the proximal box
232 Clinical Operative Dentistry 232

Precarve Burnishing

 The amalgam may be further condensed and

shaping of occlusal anatomy begun with a large
burnisher, such as an ovoid (football) burnisher.
 It should take place immediately after the
completion of condensation. The burnisher
should be used with heavy strokes, made in the
mesiodistal and faciolingual directions, that
pinch much of the amalgam off as the burnisher
contacts the cusp inclines and, in some places,
Figure 9.34(b) filled proximal boxes. the margins of the preparation.
 The pressure applied is similar to the one used
during the condensation.
 Objectives of Precarve Burnishing:
 Precarve burnishing is the first step in shaping
the occlusal surface of the restoration.
 Helps in reducing the mercuric content of
amalgam.
 Produces denser amalgam at the margins of
restorations.

Figure 9.34(c) filling and condensation on the

pre-carve burnishing
rest of the preparation

Precarve Burnishing.: always move ball burnisher

from central groove to the margin using firm
pressure.

Figure 9.34(d) condensations toward the buccal&

the lingual restoration margin
233 Chapter 9 Amalgam Restorations 233

Ball burnisher.

Football(Egg ball) burnisher.

Pointed ball burnisher (Also known as “Anatomical Carver” or acorn burnisher).

Football (Egg ball) burnisher in use.

T-ball burnisher.

Beavertail burnisher.
234 Clinical Operative Dentistry
Carving (Figure 9.35 a-l)
 The objective is to remove mercury rich layer on
the surface and reestablish the contact with the
opposing dentition.
 Amalgam should not be carved until it is
sufficiently firm. If the mass is not set properly
or is still plastic, then initiation of carving leads
to pulling out of amalgam from the margins.
When scraping silver amalgam with carver, a
“ringing sound” appears or heard that is taken
as a guide for appropriate time of carving. Most
material can be carved up to 7–8 min after the
trituration although the same may vary from 4 to
13 min.
 For adequate carving, it is preferable
overpack the preparation and then carve it to the
margins.
 Amalgam can be carved with any bladed dental
instrument that has a sharp edge. Numerous
carvers are available, and each has its own
merit. Recommended amalgam carvers that
satisfy most amalgam carving needs include a
small cleoid- discoid carver, a Walls no. 3 (or
Tanner no. 5) carver, a Hollenback no. ½ carver,
an interproximal carver, and a no. 14L sickle-
shaped carver. In addition, some
instruments, such as a small spoon excavator
and hoe, make excellent amalgam carvers,
especially for carving occlusal anatomy in large
restorations.
 Larger instrument is used first, followed by
smaller instruments.
 In proximal tooth preparation, carving of the
cervical margins should begin following the
removal of matrix band.
 Trim the axial margins towards the gingiva in
downward direction with a sharp carver.
 Do not over carve amalgam as it can lead to
acute angles and stress concentration within
amalgam which can fracture
restoration .Amalgam should not be overcarved
such that groove anatomy is deep, leaving thin
fins of amalgam adjacent to the preparation
margins. The operator should try to develop
margins that will leave a 75- to 90-degree angle
at the margin of occlusal amalgam. Acute angles
(fins) of amalgam at the margins on an occlusal
surface are subject to fracture during function.
(Figure 9.36)
234
Figure 9.36 over carving of amalgam can lead to
acute angles and stress concentration within
amalgam which can fracture the restoration.
to
 Carve the occlusal surface with a sharp carver
like Hollenback. Hold the carver in such a way
that its blade lies across the margin of
restoration, half on tooth and half on restoration.
During carving, movement of instrument should
be parallel to the margin and edge of blade
should be perpendicular to the margins. It is
done to avoid ditching of the metal and to
minimize the overlay.
 Most occlusal carving is performed with pulling
cutting strokes, but the pushing stroke can also be
advantageous in developing occlusal anatomy.
The carver should be pulled from enamel to
amalgam. If it is pulled from amalgam to enamel,
it will be more likely to carve the surface of the
amalgam to a level that is below the surface of
the enamel.
 Amalgam preparations should have enamel
margins that are not jagged or rough; if the
margins of a carved restoration appear ragged,
it will be because of thin amalgam flash that
extends outside of the preparation onto the
adjacent enamel surface. This flash is more
difficult to remove when amalgam bonding
the resins are used. A sharp carver is even more
necessary for effective removal of this flash.
 For Class 2 restorations, while the matrix is in
place, the marginal ridge should be carved very
nearly to the height of the adjacent marginal
ridge. Development of the occlusal embrasure of
the marginal ridge is begun with the tip of an
explorer angled at approximately a 45-degree
angle to the long axis of the tooth and touching
the matrix band. The explorer tip should be
moved from the facial enamel, past the margin
of the box, to the center of the marginal ridge
and then from the lingual enamel, past the
margin of the box, to the center. The explorer
235 Chapter 9 Amalgam Restorations 235

should not be moved from the amalgam toward the margin, because this movement could easily result in
overcarving, leaving the marginal ridge with a deficient contour.
 Removal of band and wedge:
- A finger or thumb is placed on the loop of the matrix band to keep it in place on the tooth, and the retainer is
pulled occlusally to remove it.
- The matrix band can be grasped with fingers, cotton forceps, or a hemostat.
- The distal end of the matrix band is grasped and pulled occlusally and lingually (if the free ends are on the
facial aspect) and out of the distal contact of the tooth.
- The mesial end is then grasped and pulled facially and occlusally until the band is out of the contact.
- There are a few techniques that may help the dentist remove the Tofflemire matrix without breaking the
marginal ridge:
 As the matrix edge is coming out of the contact, the matrix can be tipped so that the edge will not “flip” the
newly carved marginal ridge and break it.
 A condenser can be held against the marginal ridge to support it and prevent it from breaking as the matrix
is removed.
 The movement of the band should be primarily to the facial or lingual aspect as the band slips occlusally out
of the contact.
 The matrix band should be used only once and then discarded.
 For Class 2 restorations, after the matrix is removed, amalgam flash on proximal surfaces should be removed
and the proximal contours should be refined. A thin carver, such as the interproximal carver, is useful for
both removing flash and refining proximal contours.

Discoid-cleoid carver has Two ends shaped differently: Discoid end—Disc shaped & Cleoid end—
Pointed.

Hollenback carver two sizes: smaller version is called a Half Hollenback

236 Clinical Operative Dentistry 236

Hollenback carver in use.

Gold Carving Knife used to trim interproximal amalgam restoration, recreating contour of
proximal wall(s)

Trim the axial margins towards the gingiva in

downward direction with a sharp carver.
237 Chapter 9 Amalgam Restorations 237

Amalgam carvers. a, b No. 3S and No. 3 Hollenback; c–e No. 6, No. 2, and No. 10 Frahn; f cleoid; g IPC 1

Figure 9.35(a) carving of the occlusal embrasure

in the marginal ridge Figure 9.35(c) removal of the matrix retainer &
wedge

Figure 9.35(b) carving of the cusps incline

Figure 9.35(d) removal of matrix band

238 Clinical Operative Dentistry 238

Figure 9.35(e) removal of the cervical excess

Figure 9.35(h) Use of Frahm carver

Figure 9.35(f) adjustments of the height of the

marginal ridge

Figure 9.35(i) post-carve burnishing with the exploratory

probe and No. 6, No. 33, and No. 29 burnishers,
respectively

Figure 9.35(g) use of the No. 3S Hollenback, cleoid, Figure 9.35(j) superficial smoothing with a small
discoid respectively cotton ball
239 Chapter 9 Amalgam Restorations 239

Figure 9.35(k) visualization of the proximal

Improper carving
contour and the contact point

Adjusting the occlusion

 When the carving appears to be correct, the

occlusion is checked.
 This is accomplished with articulating ribbon
which marks the points of contact when the
mandibular and maxillary teeth are brought
together. It is wise not to ask the patient to close,
because, if the amalgam has not been carved
adequately, it will be “high” in the occlusion so
that it contacts first, prior to any other tooth
contact. Thus, the amalgam will usually be
fractured, and the operator will have to remove
amalgam and begin again.
 It is therefore best for the operator to perform
Figure 9.35(l) final aspect of the burnished
restoration the tapping of the teeth by grasping the patient’s
chin, having the patient close to very near
contact, and then, by hand, manipulating the
mandible so that mandibular and maxillary teeth
are tapped together in maximum intercuspation
position (MIP).
 An alternative to this tapping by the dentist is to
instruct the patient to “very, very gently, tap the
back teeth together.” The amalgam must be
carved until occlusion is adjusted.

Postcarve Burnishing

 It is done after completion of carving with the

help of small sized burnishers using light
strokes (light rubbing) to improve the
smoothness with shiny appearance.
Results of poor carving. A. Overextension or
 Heavy forces should not be used, and postcarve
flash. B. Submarginal area. C. Open margin.
burnishing should be avoided near the margins
of restorations of fast-setting amalgam.
 The purpose of postcarve burnishing is to
smooth the surface of the restoration.(helps in
reducing the surface roughness produced by
carving).
240 Clinical Operative Dentistry 240

 At this stage, the mass is hard/set enough to

prevent any disturbance of anatomy formed by
carving.
 Final smoothening can be done by rubbing the
surface with moist cotton pellet.

RESTORATION OF COMPOUND
CLASS I PREPARATIONS (FIGURE 9.37
A-N)

Due to the leaning of the buccal surfaces of the

mandibular molars and lingual surfaces of the
maxillary molars, the use of a universal matrix will
Figure 9.37(a) Application of the universal matrix
not result in the correct adaptation of these surfaces,
making the restorative procedure more difficult.

On those cases, the matrix proposed by Barton can

be applied:
 First, the tooth is surrounded by a universal
matrix with a matrix retainer. When a universal
matrix is applied, the matrix retainer should be
positioned on the opposite surface to the one
that will be restored.
 A small piece of the metallic band must be cut,
in a way that it beyond the gingival cavosurface
angle.
 It is applied between the universal matrix and
the tooth surface. Then, a No. 6 Hollenback
burnisher is used to correctly adapt it to the
Figure 9.37(b) cutting the Barton matrix
surface.
 A wooden wedge with small dimensions or a
piece of 1.3 cm of round toothpick is selected,
which must be covered with melted low fusion
compound.
 The Barton matrix is displaced with an
exploratory probe, and the wedge is inserted
into the position, stabilizing the set.
 If the wedge is higher than the matrix, it must be
cut, so it will not adversely affect the next step.
 The adaptation of the matrix on the cavosurface
angle is checked with the exploratory probe.
 Then the amalgam is condensed with excess.
Then, the pre-carve burnishing is performed,
and the carving of the region near the matrix
starts with an exploratory probe and the
occlusal surface with a carver.
 The matrix is completely removed, and the
carving is finished. After that the post-carving
burnishing is performed.

Figure 9.37(c) placing of band

241 Chapter 9 Amalgam Restorations 241

Figure 9.37(d) displacement with the exploratory

probe

Figure 9.37(g) checking the adaptation with an

exploratory probe

Figure 9.37(e) adaptation with the No. 6 Hollenback

burnisher

Figure 9.37(h) condensation of the amalgam

Figure 9.37(f) insertion of a wedge with melted

compound & adaptation over the lingual surface

Figure 9.37(i) precarve burnishing of occlusal

surface
242 Clinical Operative Dentistry 242

Figure 9.37(j) carving of occlusal surface

Figure 9.37(m). Burnishing

Figure 9.37(k) removal of matrix and band

Figure 9.37(n) result after the polishing

Figure 9.37(l) carving of the lingual surface

243 Chapter 9 Amalgam Restorations 243

Finishing and Polishing Amalgam

Restorations
 Final polishing is delayed until 24 hours so that
the setting reaction has completed.
 Polishing is defined as smoothing the surface to
a point of high gloss or luster. It has been
demonstrated that polishing a high-copper
amalgam restoration does not enhance its
clinical performance (because they have a
Abrasive disks, manufactured for polishing
tendency of self-polishing.), but finishing is an resin composite restorations, are also useful
important part of restoration placement. for polishing amalgam.
 Finishing is usually accomplished at the
placement appointment, but it may be refined at
succeeding appointments.
 When an amalgam restoration is polished, a
high luster is often more comfortable to the
patient’s tongue than an unpolished surface, so
polishing is sometimes desirable.
 Care must be taken not to create excessive heat
during the polishing procedure. Excessive heat
generation may be injurious to the pulp of a vital
tooth. Abrasive-impregnated cups and points for
polishing amalgam restorations: (left to right)
 Steps for Finishing and Polishing of Amalgam:
coarsest (black), prepolish (brown), high shine
- Using an explorer, evaluate the cavosurface (green), and super high shine (green with yellow
margins for marginal integrity. band).
- Identify the high spots which appear burnished
shiny area on the surface of restoration.
Establish proper occlusion by grinding.
- Use a large round finishing bur to eliminate
scratches and graininess from the amalgam.
- Use a finishing strip for smoothening and
polishing of the gingival cavosurface margins
and interproximal space.
- Smoothen the facial and lingual surfaces with
finishing disks.
- Polish the surface by using progressively finer
abrasive agents. Use rubber cup with pumice
slurry to polish the surface.
- Rinse and clean out all debris completely. Multibladed bur set (12 blades) for finishing.

Finishing burs.
244 Clinical Operative Dentistry 244

Finishing procedure

Abrasive of rubber rotary instruments set for polishing with points and cups with
decreasing grit and different colors

Polishing
245 Chapter 9 Amalgam Restorations 245

Checking the margins Placing the first increment of amalgam into the
preparation with an amalgam carrier.

Finished & polished restoration

(The following showing summery of

amalgam manipulation in class II)

A. Condensing the first increment. B. Condensing

subsequent increments.

Properly wedged matrix band tightened with a

matrix retainer.

Burnishing the condensed amalgam.

246 Clinical Operative Dentistry 246

CUSPAL-COVERAGE PREPARATIONS
(FIGURE 9.38 A-G)

The tooth preparation will usually include

 Removal of any existing restoration.
 Removal of any carious tooth structure and
fragile enamel and/or dentin.
 Preparation of margins to provide a cavosurface
angle of approximately 90 degrees in all areas.
 In addition, weak cusps that have not fractured
should be reduced for coverage and protection
with amalgam.

The thickness of amalgam needed for cuspal

protection will vary depending on the functional load
to which the cusp will be exposed:
 A good guideline for amalgam thickness in
centric holding cusps (stamp or functional
cusps) of molars and premolars is 2.5 mm.

 In a facial cusp of a maxillary premolar, on those

occasions when there is little or no function on
the facial cusp, a reduced thickness of amalgam
is acceptable to allow a maximum amount of
facial enamel to remain for esthetics.
Carving the marginal ridge.
When cusps are reduced for coverage, the occlusal
tooth structure should be reduced anatomically to
provide for an adequate and consistent occlusal
amalgam thickness. To facilitate consistent
reduction, depth cuts are recommended. The length
of the head of the bur that is used for depth cuts
must be known. A periodontal probe or caliper
should be available for measuring the length of bur
heads.

Consistent reduction of cusps provides anatomical

reduction rather than flat reduction. Anatomical
Carving the cavosurface margin. reduction imparts adequate strength to the amalgam
while preserving and protecting as much natural
tooth structure as possible.

A timesaver in practice is to take note of cuspal

height and cusp tip location or even to make a
drawing or photograph prior to cuspal reduction so
that cusps may be built and carved back to their
original height prior to removal of the rubber dam.

Accentuating the occlusal anatomy.

247 Chapter 9 Amalgam Restorations 247

Depth cuts are used to provide for even reduction of occlusal tooth structure of a
mandibular molar and consistent thickness of amalgam. (a) Depth cuts 2.5 mm
deep; (b) cuspal reduction viewed from the facial aspect; (c) cuspal reduction
viewed from the proximal aspect.

Preoperative registration of the height of cusps to be reduced and restored with amalgam. (a) The midfacial
and distofacial cusps are to be reduced for coverage. A periodontal probe is placed along the facial cusp
tips of the tooth to be restored and the adjacent teeth, and the relationships of the cusp tips to the probe are
remembered or drawn. (b) The amalgam cusp tips of the carved restoration are seen to have a similar
relationship to the probe. (c) If there are no adjacent teeth or cusp tips to guide the height of amalgam cusp
tips, the distance from a landmark (such as the cervical line) may be measured with a periodontal probe.
248 Clinical Operative Dentistry 248

Reduction of weak cusps of a mandibular molar for coverage. (a) An instrument is placed so that it touches cusp
tips of the adjacent teeth. A note can be made of the position of the cusps to be reduced so that they can be
rebuilt in amalgam and carved to approximately the correct height before the rubber dam is removed. (b) Half the
5.5-mm length of a no. 169L bur head is used to make depth cuts approximately 2.5 mm deep in the cusps. (c) The
depth cuts are completed. (d) The head of the handpiece is rotated so that the no. 169L bur can be used to reduce
the cuspal structure between the depth cuts. (e) Facial cusps are reduced. (f) All cusps are reduced, and
resistance features are placed. (g) Amalgam is placed, carved, and smoothed. The instrument is placed as it was
prior to cusp reduction to ensure that cuspal height is similar to preoperative cuspal height. (h) Completed
restoration. (i) Polished restoration.
249 Chapter 9 Amalgam Restorations 249

(The following show step by step cavity

preparation for cuspal coverage
restoration)

Figure 9.38(d) evaluation of the height of the

Figure 9.38(a) Tooth with defective restorations

and recurrent caries

Figure 9.38(b) removal of the caries tissue

Figure 9.38(e) Determination of the amount of the

reduction; f evaluating the depth determined; g
reduction of the marked depth
Figure 9.38(c) filling with GIC. It can be observed
that the mesiobuccal cusp is fragile
250 Clinical Operative Dentistry 250

 They can be continuous or segmented,

Figure 9.38(f) finished preparation involving the
buccal surface
depending on the amount of lost tooth structure.
Some operators have called these segmental
slots “cleats.”
 It must be approximately 0.5 mm wide in the
entrance, according to the rotary instruments
used, and 0.6 mm wide on the base, with a depth
between 0.5 and 1 mm.
 Generally they are between 2 and 4 mm long,
depending on the distance between the vertical
surrounding walls, especially when the gingival
wall is long.
 It must always be made in dentin, at least 1 mm
away the DEJ.
 As the retention will be produced by a projection
of the amalgam restoration inside the dentin, its
resistance is related to the setting of the
restorative material, which is completed at least
only 24 h later. Therefore, extreme care must be
taken at the moment of removing the matrix
band, because an abrupt movement may lead to
a fracture of the amalgam on the entrance of the
slot.

Figure 9.38(g) finished restoration

RESISTANCE AND RETENTION

METHODS IN CUSPAL-COVERAGE
PREPARATIONS

When a large amount of cuspal tooth structure is lost

or removed, the walls, or portions of them, which
provide resistance and retention for the amalgam,
are lost. For this reason, it is necessary to add
features or adhesives to the preparation that will
provide adequate resistance and retention for the
restoration. Several methods of obtaining resistance
and retention for complex amalgam restorations
include:

Pins: Rarely used nowadays.

Non pin mechanical resistance and

retention features:

These include the circumferential slot and the

amalgapin, as well as adhesive bonding.

Circumferential slots
 It can be made on the gingival walls of the
preparations using short inverted cone rotary A circumferential slot is prepared with a small,
instruments, such as the No.33½ or No.34 burs inverted cone bur, such as a no. 33½.
or the 1031 diamond point.
251 Chapter 9 Amalgam Restorations 251

Amalgapins

 Circular chambers that they cut vertically into

dentin to provide resistance and retention form
for the restoration; they called these features
amalgam inserts.
 They should be preferably made with a long
inverted cone bur No. 329 or No. 330 or with a
No. 1031 diamond point.
 A channel of 1.5–2 mm depth and 0.8–1 mm
diameter must be prepared.
 The same way as the slots, the channels are
made in dentin at least 1 mm away from the DEJ.
 One channel per lost cusp can be prepared,
preferably on the region near the axial angles to
avoid perforation on the furcation region.
 They also require careful removal of the matrix
band to avoid amalgapin fracture.
 To avoid the pulpal or periodontal perforation
during the channel preparation, it is important
that the long axis of the rotary instrument is
placed parallel to the nearest external surface of
the tooth on that area.
 To finish the preparation, a bevel is performed at
the entrance of the channel, increasing the
thickness of the material at this area, reducing
the stress concentration on the base of the pin.
 On those channels, the amalgam condensation
must be performed with a thin amalgam
condenser.

Preparation of amalgapin channel

Amalgapin channels are prepared with a diameter

of 0.8 to 1.0 mm, such as that of a no. 330 bur, to
a depth of approximately 1.5 mm.

Channels for the amalgapin

252 Clinical Operative Dentistry 252

Retentive Locks and Coves

 Another possibility to obtain retention is the preparation of undercuts in the walls, such as locks and coves.
 Locks are prepared in a vertical plane and coves are prepared in the horizontal plane.
 The locks are prepared using rotary cone shaped instruments in the line angle between the vertical
surrounding wall and the axial wall.
 The coves are prepared in the line angle between the vertical surrounding walls and the pulpal wall, at the
region under the cusps because this area has a larger volume of dentin.
Rotary short inverted cone or round instruments can be used

Preparation of the retentive lock on the mesiofacial line angle& on the buccoaxial line angle

Preparation of coves under cusps

FAILURES OF DENTAL AMALGAM  If ditching is shallow, it is not a sign of failure

because sealing property of amalgam can
improve the marginal seal. But if ditching is
Signs of Failures
deep, it can result in secondary caries.
Marginal Ditching (Figure 9.39)
 Marginal ditching is breakdown of amalgam at
the margins due to fracture, wearing improper
cavity margins.
253 Chapter 9 Amalgam Restorations
Figure 9.39 amalgam failure due to marginal
ditching.
Proximal overhang (Figure 9.40)
 Proximal overhangs can be detected
radiographically and clinically. Overhang is
confirmed by tearing of a floss when passed
through it.
 Overhangs lead to gingival and periodontal
problems because of food impaction.
Figure 9.40 amalgam failure due to Proximal
Overhang.
Improper Marginal Ridges
 Marginal ridge of a restoration should be at the
same level as that adjacent tooth.
 If there is incompatible marginal ridge, it leads
to improper embrasure form, food impaction
and periodontal disease.
Fracture of Restoration or Tooth (Figure 9.41)
Fracture of tooth or restoration can occur because
of lack of resistance and retention form.
253
Figure 9.41 fracture of amalgam causing failure of
restoration.
Poor Occlusal Contacts
Poor occlusal anatomy can result in improper
functioning.
Improper Proximal Contacts (Figure 9.42)
Improper contact in form of open contact leads to
food impaction and further periodontal problem.
Figure 9.42 improperly restored proximal
contacts resulting in periodontal problems.
Such restorations need to be replaced.
Secondary or Recurrent Caries
 Secondary caries can occur where gaps or
fracture are present in amalgam restorations.
 These can be confirmed by clinical or
radiographical examination.
254 Clinical Operative Dentistry 254

Amalgam Blues Under Extension of the Proximal Box

 To prevent occurrence of secondary caries,
 It is display of bluish hue through a thin layer of walls of proximal box of class II preparation
enamel. must be extended to self-cleansing areas.
 Amalgam blues occur due to leaching products  If the proximal margins of the filling are not
into dentinal tubules or due to color of adequately extended into the embrasures, they
underlying amalgam shown through thin layer are not open to cleaning by mastication and
enamel. brushing resulting in secondary caries.

Overextended Tooth Preparation

Width of isthmus should be less than one fourth of
intercuspal distance. If the faciolingual width of the
preparation is more than half of the intercuspal
distance, cusp capping should be considered. Cusp
capping becomes necessary if the tooth preparation
involves more than two-third of the intercuspal
distance.

Insufficient Depth of Preparation

Minimum depth of preparation should be 1.5 to 2 mm
so as to provide bulk which can prevent its fracture
under masticatory load.

Curved Pulpal Floor

Failure of amalgam restoration due to recurrent
caries and fracture.  There should be flat pulpal floor of the
preparation to avoid Fracture of amalgam and
REASONS OF FAILURE the tooth.
 Curved floor for restoration acts as a wedge,
Reasons for failure of amalgam restorations can be which can result in tooth fracture.
divided under the following headings:
 Improper case selection. Lack of Butt Joint at Cavosurface Angle
 Defective tooth preparation.  Cavosurface angle should be a butt joint.
 Defective amalgam manipulation.  If cavosurface angle is acute, enamel margins
 Defective matrix adaptation. may fracture under load. But if cavosurface
 Post-restorative failures. angle is obtuse, marginal amalgam may fracture
Earlier studies evaluating defective amalgam under masticatory stresses.
restorations have reported that 56% of the failures
were because of improper cavity preparation and Sharp Line Angles
42% of the failures were because of faulty Fracture of amalgam restoration may occur because
manipulation of amalgam. of sharp axiopulpal line angle because of
concentration of stresses in that area. So these
Defective Tooth Preparation angles should be rounded to avoid stress
concentration and also provides bulk of the
Following defects occur during tooth preparation:
amalgam which is required for its strength.

Inadequate Occlusal Extension

Unsupported Enamel Rods
 One should involve all carious pits and fissures
 Presence of unsupported enamel rods can
in the preparation margins.
result in fracture and thus secondary caries
 Insufficient extension to include adjacent
because of gap formation.
carious pits and fissures increases chances for
 They should be removed properly.
secondary/recurrent caries. This is specially
seen in patients with high caries index.
255
Incomplete Removal of the Defective Enamel
Incomplete removal of defective enamel can result in
fracture of the restoration under masticatory load.
Improper Proximal Preparation
In proximal preparations, fracture of amalgam can
occur because of inadequate width and depth of
isthmus or insufficient proximal retention form.
Undermined marginal ridge enamel
 Failure to diverge the mesial and distal walls of
the occlusal class I cavity preparation.
 When the mesiodistal extension of the cavity is
extensive it can cause fracture because of the
undermining of the mesial and distal marginal
ridge enamel.
Improper retentive devices
Retentive devices should be prepared entirely in
dentin without undermining the enamel.
Use of low speed for cutting
Post-operative pain can also be a routine failure. The
dentist should use high speed rotary instruments,
with intermittent cutting and adequate cooling of
tooth structure thereby minimizing the
operative pain.
Defective Amalgam Manipulation
Defective amalgam manipulation may occur in the
following forms:
Inappropriate Condensation
Following points should be kept in mind while
condensing amalgam:
 Small increments of amalgam should be used to
make sure proper condensation.
 Use of adequate condensation pressure.
 Avoid delay between trituration
condensation. The effectiveness of removing
residual mercury from the restoration
possible only if the amalgam is used within four
minutes of trituration. Delayed use of triturated
amalgam does not allow proper condensation of
the material and also does not remove mercury
from the restoration. If a larger cavity demands
that the working time of the amalgam exceeds 3-
4 minutes, the use of multiple mixes will allow
the operator to handle plastic amalgam
throughout the condensation procedure and
ensure building a homogenous restoration.
Chapter 9 Amalgam Restorations 255
Overcarving
Overcarving of deep pits and fissures results in
reduced thickness of amalgam, this can cause
fracture of the restoration.
Contamination during Manipulation
Contamination with moisture causes delayed
expansion (in zinc-containing amalgam) resulting in
pain, weakness at the margins, tarnish, and
corrosion.
Faulty Finishing and Polishing
 Excessive heat production during polishing may
result in pulpal trauma.
 Heavy pressure applied during polishing results
in spur like overhangs, which fracture under
mastication causing leaky margins and prone to
secondary caries.
 Excessive heat production can be minimized by
use of adequate coolant and polishing should be
done with very light pressure.
Defective Matrix Adaptation
 If wedge is not used, excess material can go into
gingiva and thus irritate the periodontium.
post-  Before condensation of amalgam, matrix should
be properly made stable to avoid distortion of
the restoration.
 If matrix band is removed prematurely before the
restoration is set, it may fracture the restoration.
Post-restorative Failures
Post-restorative Pain
It can occur because of the following reasons:
 High points in amalgam restoration can result in
apical periodontitis or fracture of the filling or
tooth and pain.
 In zinc containing alloys, delayed expansion can
and cause fracture of filling or tooth and pain.
 If the patient has restoration placed adjacent or
is opposite to gold restoration, in presence of
saliva, there is production of galvanic currents.
This can also result in pain after amalgam
restoration.
 Extreme changes in temperature in oral cavity
may cause pulpal hyperemia resulting in pain.
Because of good thermal conductivity,
insufficient pulp protection may give rise to
pain. Thus it is advisable to use pulp protective
materials beneath amalgam restoration.
256 Clinical Operative Dentistry 256

 Cracks in tooth: such cracks cause pain during
chewing because of expansion/contraction of
tooth structure with every bite.
Premature Fracture of Restoration
If patient bites the restoration soon after its
placement and before final setting of amalgam takes
place, restoration may fracture. Therefore,
postoperative instructions must be clearly explained
to the patient.
BONDED AMALGAM RESTORATIONS
 One of major disadvantages of the amalgam is
that it does not adhere to the preparation walls.
To conquer this problem, bonded amalgam is
developed
 The use of adhesive resins to increase the
retention, resistance, and marginal seal of
amalgam restorations has gained a strong
foothold in restorative dentistry. There is now
more than adequate evidence that properly
bonded amalgam restorations will
successful as pin-retained
restorations.
 The amalgam is condensed into the filled resin
while the resin is in a viscous liquid form.
Microscopic “fingers” of resin are incorporated
into the amalgam at the interface.
hardened, these provide the attachment of
amalgam to resin. Because light
penetrate to the resin underlying amalgam
restorations, it is important to use a self-curing
or chemically activated bonding resin. The
bonding resin of an amalgam bonding system is
supplied in two parts that are to be mixed. The
attachment of resin to tooth structure when
Manipulation (Figure 9.43 a-d)
The procedure for a bonded amalgam restoration is
illustrated using All Bond 2 (Bisco) resin:
 The unsupported enamel is removed and
finished.
 Enamel and dentin are etched with a 10%
phosphoric acid gel for 15 seconds after which
the acid gel is removed with an air water spray.
 The dentin and enamel are dried with absorbent
paper or gently with air through chip syringe.
Properly etched enamel will have a dull white
frosted appearance.
 Adhesive primer (Primer A + Primer B, All Bond
2 System) is applied thoroughly throughout the
cavity surface. The enamel dentin bonding agent
(All Bond Liner F) is applied with a disposable
brush.
 Freshly initiated amalgam which has been
triturated by an assistant is condensed
immediately into the cavity while the resin is still
wet, i.e. has not polymerized.
 The restoration is carved, finished and polished.
be as
amalgam
Matrices for bonded amalgam restorations
 Care should be taken to prevent or minimize
resin application to the matrix. If resin is applied
to the matrix, it may cause the matrix to stick to
When
the amalgam. This sticking can lead to fracture
of the amalgam during removal of the matrix.
cannot
 Because amalgam must be inserted immediately
after placement of the adhesive, the bonding
material cannot be placed before matrix
application.
 A very small applicator should be used to apply
the resin to the preparation walls so that it may

amalgam bonding systems are used is be kept away from the matrix. It is advisable to

accomplished as with other dental bonding try to stop the resin application approximately 1

systems. mm short of the cavosurface margins that are

adjacent to the matrix. Unless the set of the
 Amalgam is hydrophobic, and tooth is
material is too advanced by the time the
hydrophilic, to achieve optimal wetting, bonding
amalgam is placed, it will be pushed to the
systems must have dual properties. For this,
margin in a thin coat as the amalgam is
monomer molecule having hydrophilic and
condensed.
hydrophobic ends are used, for example,(4-
META).  Matrices that resist adhesion to the bonding
materials are available, but if a band that is
 Various agents that have been tried are
specifically designed to prevent adhesion to the
amalgam bond, amalgam bond with HPA
matrix is not used, the application of a very thin
(Parkell), All Bond 2 (Bisco), Optibond 2 (Kerr),
coat of wax with a wax pencil or crayon or with
Panavia 21 (Kuraray), Clearfil Linerbond 2
a piece of inlay wax or boxing wax may be
(Kuraray), Scotchbond MP (3M), etc.
helpful. The wax is rubbed onto the inner
surface of the matrix band, and excess is rubbed
off with a gloved finger.
257 Chapter 9 Amalgam Restorations 257

Condensation when amalgam bonding

resins are used

 Although all walls of the cavity preparation

should be coated, caution should be exercised
to minimize the amount of bonding resin placed
on the walls. One study demonstrated that a thin
coat of amalgam bonding resin provided
attachment of the restoration to tooth structure
that was as strong as that provided by a thick
coat, but without the problems caused by a thick
coat.
 One problem resulting from excess bonding
resin is the reduction of the amalgam strength
by incorporation of large amounts of resin into
the bulk of the amalgam. Another potential
problem is the creation of voids in the proximal
amalgam due to excess resin being pulled from
the restoration during matrix removal.
 After the bonding resin has been applied to the
walls of the preparation, the amalgam is placed
in the preparation and condensed against all
walls within 1 minute.
 After amalgam has been condensed into the
resin on all walls, it should be added in
increments as described for nonbonded
amalgam restorations.

Figure 9.43(a) acid-etching&dual-cure adhesive

system application.

Figure 9.43(b) amalgam condensation over the

Amalgam bonding agent Panavia 21 (Kuraray).

Figure 9.43(c) initial result.

258 Clinical Operative Dentistry 258

 Recently ‘bonded amalgam restorations’ are

showing promising results. Bonding agent is
applied on all the surfaces and the defect is
restored with amalgam.

Figure 9.43(d) restoration after the polishing.

REPAIR OF DEFECTIVE AMALGAM

RESTORATION
Finishing and polishing of an old amalgam
restoration.
 When an amalgam restoration has a defective
area but the remainder of the restoration is HYGIENE RECOMMENDATIONS FOR
adequate, a repair procedure may be the most MERCURY IN DENTISTRY
appropriate treatment. For instance, if a cusp
that was left in place adjacent to an amalgam  Mercury containing products should not be
restoration has fractured but the remaining stored in open but in closets or cabinets to
amalgam restoration is serviceable, it might be minimize local concentration in rest of the office.
appropriate to simply build a new cusp with Storage locations should be near a vent that
amalgam. Or, if an amalgam fracture has exhausts air out of building.
occurred in the mesial box portion of a mesio-  Local spill or spatters of triturated materials
occlusodistal restoration but the remaining should not be collected with a vacuum
disto-occlusal portion involves a very gingivally aspiration.
deep distal margin, the most conservative and  Avoid carpeting/floor coverings in dental office
simplest treatment might be to replace only the as there is no way of removing mercury from the
mesio- occlusal portion of the restoration. carpet.
 For a small localized marginal defect,  To control the vapors of mercury during
recontouring and repolishing should be the first placement and condensation procedures,
choice. rubber dam should be used to isolate the patient
 Application of sealant around the defective and high volume evacuation should be used to
margins can also improve the life span of the old prevent intraoral vapour from diffusing.
restorations. However in high caries risk  Scrap dental amalgam from condensation
patients the caries usually extends beneath the procedures should be collected and stored
restoration, hence the application of sealant, under water, glycerin or spent x-ray fixer in a
etc. will not be useful. Repair process is justified tightly capped jar.
only if the patient is or can be brought to low  Silver mercury has a very low melting point and
caries status. easily melts during finishing producing mercury
 Amalgam restorations are repaired by cutting rich liquid phase, so amalgam should be
the required defect and making the area self- polished at slow speed using water spray.
retentive.  Instruments used for inserting, finishing,
 It has been reported that the total strength is polishing or removing dental amalgam may
decreased by 45% in such contain some amalgam material on their
restorations.(Attachment of new amalgam to old surface. During instruments sterilization this
can be achieved, but the attachment strength is material may be heated and release mercury
only 30% to 60% of unrepaired amalgam. vapour. Therefore, it is advisable to properly
Additional mechanical retention should be isolate or vent air from sterilization areas.
considered).
259 Chapter 9 Amalgam Restorations 259

 Provide proper ventilation in work place by

having fresh air exchanger and proper
replacement of filters, which may act as trap of
mercury.
 Amalgamators should be covered.
 Skin contact with mercury or freshly prepared
amalgam should be avoided.
 Change masks after removing amalgam
restorations.
 Mercury contaminated items should be
deposited in sealed bags.
 Spilled mercury should be cleaned with trap
bottles, tapes or fresh mixes of amalgam.
 In dental operatory, professional clothing
should be worn.
 Avoid manual mixing
261
263 Chapter 10 Diagnosis and Treatment of Root Caries
CLINICAL APPEARANCE AND
LOCATION OF ROOT CARIES
LESIONS
 A caries lesion on a root surface is seen as a
clearly demarcated, light brown, dark brown, or
black discolored area on the root surface or at
the cementoenamel junction.
 A root caries lesion can be initiated only if the
root surface is first exposed to the oral
environment.
 Clinically lesions appear saucer shaped.
 A root caries lesion appears as a softening
and/or cavitation in the root surface with no
initial involvement of the adjacent enamel.
These lesions generally begin at or slightly
occlusal to the free gingival margin where dental
plaque more frequently accumulates
undisturbed but can extend into the gingival
sulcus and/or undermine the coronal enamel as
the lesion progresses (Figure 10.1).Lesions also
begin at the margins of restorations that have
their cervical interfaces on root structure.
Figure 10.1 Root caries undermining enamel.
 Because dental plaque frequently accumulates
at the gingival margin around the tooth, an
active root caries lesion, if left untreated, can
spread laterally, encircling the tooth. (Figure
10.2)
263
Figure 10.2 Active root caries extending laterally.
 Early-stage lesions can be difficult to diagnose
by appearance, because color changes are
frequently not obvious until some progression
of the caries lesion has occurred.
 New lesions may appear as small, well-defined
areas of a yellowish to light brown color.
 On probing, the dentin in an active lesion is
softer than adjacent, unaffected cementum or
dentin and can be removed with a sharp
excavator.
 Advanced lesions appear darker brown to black
and, if arrested, may be as hard or harder than
the normal root surface.
 Prevalence:
- Caries lesions may occur on any exposed root
surface, but initial lesions on the facial and
proximal surfaces are most common. This
increased incidence of root caries is likely due
to limited access to the cleansing forces of the
oral cavity (e.g., tongue) and the loss of the
protective interproximal tissue, allowing
increased food and bacterial retention.
- Lingual/palatal locations are seen much less
frequently as isolated lesions. (Figure 10.3)
Figure 10.3 root caries in lingual aspect.
264 Clinical Operative Dentistry 264

- In the mandible, molars appear to be the most
susceptible to root caries, followed
premolars, canines, and incisors.
- In the maxilla, the order is reversed.
- It is common for many of these lesions to be
obscured by plaque and food debris,
accurate detection is best accomplished after
thorough debridement and prophylaxis.
- The caries process on root surfaces is very
similar to that in coronal caries. Plaque bacteria
capable of metabolizing dietary carbohydrates
into acids produce a drop in pH that lowers the
plaque fluid saturation, initiating
demineralization of the tooth structure.
- Dentinal tubules are more in coronal dentin than
in root dentin thus progression of caries may be
slower in roots.
- Root surfaces are more vulnerable to chemical
dissolution than enamel surfaces.
- Because root caries lesions can be initiated only
when root surfaces are exposed to the oral
environment, the population presumed to be
most at risk are older adults. However, younger
patients with periodontal problems
susceptible as well.
Root caries.
Root caries on tooth gingival recession.
RISK FACTORS FOR ROOT CARIES
by
 Exposure of root surfaces: Attachment loss,
Gingival recession, Periodontal pocketing.
so  Inadequate oral hygiene, Physical impairment,
Cognitive impairment, Cariogenic diet.
 Previous caries lesions/restorations,
Removable prosthesis.
 Diminished salivary flow and/or buffering
capacity, chronic medical conditions,
Medications, Surgical/radiation therapy.
 Smoking, alcoholism, drug use.
 Physiologic aging & advanced age.
 Low socioeconomic status, Low educational
level.
 Male sex.
DIAGNOSIS
 Although clinicians detect root caries lesions by
judging changes in color (yellow, brown, black),
texture (soft, hard), and surface contour
are (regular, irregular), examination strategies
should focus on patients at risk for root caries.
 Therefore, the first step in the diagnosis of root
caries is early identification of contributory
factors and oral hygiene practices.
 Because plaque and debris often severely limit
the visibility of root surfaces, a thorough dental
prophylaxis should precede any clinical
examination of patients at risk for root caries.
Gentle tissue displacement with an air syringe
and retraction with hand instruments can offer a
better view of subgingival and interproximal
areas, while the use of transillumination and/or
lighted mirrors as well as intraoral cameras can
also enhance visibility and improve diagnostic
capability.
 It was found that texture to be the best predictor
of microbiologic activity in root caries lesions.
Tactile exploration should be done carefully with
only moderate pressure, because the root
surface is inherently softer than enamel. The
gradient in tactile sensation between sound and
carious cementum / dentin is much less than
that between sound and carious enamel.
 Active lesions are: (Figure 10.4)
- Close to the gingival margin and plaque
covered.
- Soft or leathery in consistency while offering
some resistance to removal of the explorer tip.
- May or may not display obvious cavitation.
265 Chapter 10 Diagnosis and Treatment of Root Caries 265

Figure 10.4 Active root caries.

 Arrested lesions are: (Figure 10.5)
- Often at some distance from the gingival margin and not covered with plaque.
- As hard as the surrounding healthy root surface.
- Color is unreliable in differentiating active from inactive lesions. While arrested lesions may be dark, so may
be the soft dentin in some active lesions.

Figure 10.5 Arrested root caries.

 It was demonstrated that an alteration in the explorer tip (producing a 30-degree angle at the tip of the
explorer) increased the ability of the operator to detect root caries lesions.
 A root surface lesion is cavitated if there is loss of surface integrity or if the depth of the cavity is 0.5 mm .If
there is no loss of surface integrity or if the depth of the cavity is less than 0.5 mm the lesion is noncavitated.
 However, for those lesions that might be treated preventively, rather than restoratively, it is important to
conduct the tactile exploration gently to avoid or to at least limit damaging the lesion surface, which increases
the chances for remineralization.
 Radiographs can be useful in identifying early proximal root lesions but occasionally
 Can be prone to misinterpretation because of cervical “burnout” artifacts. Vertical bitewing radiographs
permit better evaluation of the proximal root surfaces in persons with significant loss of attachment. (Figure
10.6)

Activity assessment criteria for root caries lesions.

266 Clinical Operative Dentistry 266

 When a root caries lesion has progressed such

that restoration of lost structure is necessary (a
cavitated lesion may endanger the pulp, may be
sensitive, and may hinder plaque control), the
dentist faces difficulties that differ considerably
from those posed by many coronal lesions. The
challenges to the restorative dentist include:
- Impaired visibility
- Difficult access
- Moisture control
- Pulpal proximity
- The nature of the dentinal substrate itself.
 These factors tend to compromise the ideal
Figure 10.6 Root caries in radiograph.
restoration, which should conserve remaining
tooth structure and provide long-term integrity
PREVENTIVE AND of marginal seal.

CHEMOTHERAPEUTIC STRATEGIES  There is general agreement today that, when

possible, adhesive fluoride-releasing restorative
materials are preferred.
 Clinical observations and studies strongly  Isolation is the key to long-term success in root
suggest that root caries lesions can be arrested, surface restorations (Figure 10.7). The inability
obviating restorative therapy. Numerous studies to obtain a dry operating field, unobstructed
have demonstrated success in preventing access, and good visibility frequently result in a
and/or arresting root caries through plaque compromised restoration. The use of a rubber
removal, diet modification, topical fluoride dam and retractors, retraction cord, and/or
application, and use of antimicrobials. surgical exposure will usually satisfy the
 Mechanical plaque removal using a fluoride necessary criteria. At times, to obtain a
dentifrice alone has been shown to play an satisfactory result, the isolation procedure may
important role in arresting active root caries. take more time than the actual preparation and
Therefore, topical fluoride is accepted as an restoration
appropriate chemotherapeutic agent in the
management of root caries.
 Prevention/arrest of root surface lesions has
been demonstrated using fluoridated water,
fluoride solutions, fluoride gels, fluoride
mouthrinses, fluoride dentifrices, fluoride
varnishes, fluoride chewing gums, and intraoral
fluoride-releasing devices.
 Chlorhexidine rinses have been suggested for
the management of root caries because of their
ability to reduce levels of oral bacteria.
RESTORATIVE TREATMENT Figure 10.7 Isolation is the key to long-term
success in root surface restorations.
 Preparation should involve removal of
 Clearly, many teeth with root caries lesions do demineralized tooth structure with only minimal
not need restorative treatment. Accessible, removal of sound tooth tissue for access and
shallow lesions can be made caries-free and retention.
easy to clean through debridement with hand  A brief review of the available restorative
instruments, finishing burs, and/or polishing options shown in the following:
disks.
 Arrested lesions with a hard to leathery surface Amalgam
are often amenable to treatment with topical It may still be the material of choice when isolation
fluorides in combination with a chlorhexidine is a problem. (Figure 10.8)
rinse.
267 Chapter 10 Diagnosis and Treatment of Root Caries 267

Glass-ionomer cement/resin-modified glass-

ionomer cement

 Glass-ionomer cement is the material of choice

for most root caries lesions.
 The material offers adhesive bonding, long-term
fluoride release, and the ability to “recharge” or
take up fluoride when exposed to an external
source (e.g., topical application, mouthrinse).
 Clinical studies have demonstrated successful
10- year longevity as well as reasonable success
in xerostomic patients. (Figure 10.10)

Figure 10.8 Amalgam restoration of root caries.

Resin composite

 With the advent of relatively reliable dentin

 bonding systems, resin composite materials,
 including compomers (polyacid-modified resin
 composites) and flowable composites, have
 become extremely popular with dental
 practitioners.
 Unfortunately, all of these materials exhibit a
degree of polymerization shrinkage that can
severely stress the adhesive interface provided Figure 10.10 Showing conventional GI
by dentin bonding systems. When this is restoration of root caries after 10 years.
combined with the difference in coefficient of Note that detailed description of restoration of root
thermal expansion between these materials and caries will be included in chapter 12.
tooth structure, the result can be a loss of
marginal seal and microleakage.
 Fluoride release is less than that of glass
ionomer, and these materials do not currently
offer any fluoride recharge capability.
 They are primarily indicated in root caries
situations in which esthetics is of major
importance. (Figure 10.9)
 Microfilled or hybrid resin composites appear to
offer advantages over compomers and flowable
composites.

Figure 10.9 Composite restoration of root caries.

269
271 Chapter 11 Fluoride Releasing Materials 271

ANTICARIOGENIC EFFECTS OF physical, mechanical, and setting properties.

FLUORIDE These include
- Resin composite.
- Compomer.
Fluoride plays several significant roles in any caries- - Giomer.
prevention program. These include: - Resin-modified glass ionomer (RMGI).
- Conventional glass ionomer.
 The formation of fluorapatite, which is more acid  Fluoride-releasing resin composites are on one
resistant than hydroxyapatite. end of the continuum and release the least
 The enhancement of remineralization. fluoride, while conventional glass ionomers are
 Interference with ionic bonding during pellicle on the other end and demonstrate the highest
and plaque formation. levels of fluoride release.
 The inhibition of microbial growth and  Compomers are more similar to resin
metabolism. composites, and RMGIs are more similar to
 High concentrations of fluoride (such as those conventional glass ionomers.
used in tray applications of fluoride) are  Giomers are a new class of material and are
bactericidal, while lower concentrations positioned between resin-modified glass
enhance remineralization; all levels produce ionomers and compomers.
fluorapatite crystals.  The longevity and success of dental restorations
 Even when fluoride is present at low depend on their ability to bond as well as to seal
concentrations, the oral fluids (saliva, plaque the marginal interface (adhesion).This seal is
fluid) are supersaturated with fluorapatite, affected by several of the properties of the
inducing the precipitation of the mineral phase restorative material, namely dimensional change
fluorapatite in the tooth structure. Therefore, during curing and the mismatch in thermal
fluoride-releasing materials are essential in expansion between the material and the tooth.
treating the high-caries-risk patient. (Both work to compromise the bond and seal):
 Low fluoride levels are insufficient to initiate - Glass ionomers chemically bond to dentin by an
dentin remineralization but are adequate to ionic bond with hydroxyapatite.
facilitate enamel remineralization. - The bond of conventional composites,
 Restorative materials that release fluoride are compomers, and giomers to dentin is through
often recommended for caries on root surfaces, micromechanical interlocking with collagen
because root structure is primarily composed of fibrils (hybrid layer formation) mediated by a
dentin and these lesions require significantly dentin adhesive.
greater amounts of fluoride than enamel caries - RMGIs contain components of glass ionomers
lesions to promote remineralization. as well as resin composites. Because of their
hybrid nature, RMGIs bond to dentin through
both an ionic (chemical) bond and mechanical
Do Fluoride-Releasing Materials Inhibit interlocking.
Caries? - Polymerization shrinkage of four materials
ranked as follows: RMGI > compomer > resin
Fluoride released from restorative materials can
composite. However, glass ionomers generate
inhibit development of caries lesions through all of
less polymerization shrinkage stress than do
these previous mechanisms, although it seems
resin composites.
likely that enhancement of remineralization is the
- The coefficient of thermal expansion (CTE) of
most important mechanism of action for fluoride
glass ionomers is similar to that of human
released from restorative materials.
enamel and dentin, whereas composites have
THE FLUORIDE-RELEASING CTEs approximately twice that of human enamel
MATERIALS CONTINUUM and dentin.
- Another important property of glass ionomers is
fluoride release, which can potentially help to
mitigate the effects of less-than-perfect marginal
 Fluoride-releasing materials may be classified
adaptation. However, fluoride release
into five categories based on similarities in
diminishes with time. Fortunately, glass
272 Clinical Operative Dentistry 272

ionomers have the ability to replenish leached Glass ionomers

fluoride when exposed to topically applied high
fluoride–containing solutions. This property,  These materials are adhesive(The carboxylic
known as recharge, has the potential to provide ions also chelate with calcium (Ca2+) ions in
a continuous low concentration of fluoride in the hydroxyapatite, allowing the material to
saliva because the replenished fluoride can be chemically bond to tooth structure).Since
released back to the oral environment. removal of smear layer results in better
adhesion, it is always preferred to condition the
tooth surface before placing GIC restoration.
Commonly used conditioner is 10 to 25%
polyacrylic acid applied for 10 to 15 seconds.
 They release comparatively high levels of
fluoride. Fluoride release shows peak in the first
24 hours after the mixing. After this, rate of
fluoride release decreases over weeks and
finally it stabilizes at a constant level in 3 to 4
months.
 Factors affecting fluoride-releasing ability of
glass ionomers:
- Hand mixed glass ionomers release less fluoride
Patient with high caries risk that need restoration than mechanically mixed glass ionomers.
that release fluoride.
- Covering of GIC restoration with a sealant
reduces fluoride release.
 They have CTEs similar to that of tooth
structure.
 They have poor mechanical properties and wear
resistance.
 Early brand-name glass ionomers are still widely
used today despite their relatively poor
mechanical properties and wear resistance.
 A newer generation of high-viscosity glass
ionomers (Ketac Molar [3M ESPE] and Fuji IX
[GC America]) has improved mechanical
properties and provides higher levels of fluoride
release compared with traditional glass
ionomers. Although wear resistance is
The fluoride-releasing material continuum. Fluoride
release and recharge increase from left to right improved, these materials are still inferior to
among the materials. resin composites and should not be used to
restore load-bearing areas in the permanent
Resin composites dentition.
 They are opaque in nature: Opacity of glass
Fluoride can be incorporated into resin composites.
ionomer cement makes it less esthetic than
composites.
Fluoride-releasing resin composites, compared with
 They usually appear radiolucent on
other materials in the continuum, have:
radiograph .Conventional glass ionomer is not
 Superior mechanical properties.
inherently radiopaque.
 Better wear resistance.
 They have water sensitivity during setting.
 Inherent adhesive properties (they need a
Therefore, to prevent moisture contamination
bonding agent to adhere to tooth structure).
and desiccation of freshly placed cement,
 Greater CTEs.
surface of restoration should be covered by low
 Have the lowest fluoride release and are least
viscosity bonding resin, varnish or Vaseline.
capable of being recharged.
273 Chapter 11 Fluoride Releasing Materials 273

 RMGIs, like conventional glass ionomers,

should not be used for restorations in occlusal
load–bearing areas in the permanent dentition
where heavy occlusal forces are present.
However, the results of a 1-year clinical study
suggest that RMGIs may be an acceptable short-
term alternative to amalgam in pediatric
restorations with respect to failure rate.

Conventional restorative glass ionomer.

Resin modified glass ionomer (powder &

liquid form)

A newer generation of high-viscosity glass

ionomers

Resin modified glass ionomer (capsule form)

Light-cure restorative glass ionomer.

Compomers
Resin-modified glass ionomers
 Compomers (polyacid-modified resin
RMGIs contain elements of conventional glass
composites) are also blends of resin
ionomers and light-cured resins but have properties
Composites and conventional glass ionomers.
most similar to conventional glass ionomers:
However, they are primarily composite in
 RMGIs develop bond strength primarily through
composition, and their physical and mechanical
a chemical interaction with the hydroxyapatite in
properties are more similar to those of the
the tooth, but evidence for hybrid layer
fluoride-releasing resin composites.
formation exists as well.
 Compomers require a dentin bonding system
 A smoother restoration surface.
and acid etching of tooth structure to achieve a
 Increased fluoride release.
clinically acceptable bond.
274 Clinical Operative Dentistry 274

 These materials release more fluoride than resin

composites but less than conventional glass
ionomers or RMGIs.
 Their abrasion resistance is intermediate
between RMGIs and resin composites.
 Improvements have produced materials with
increased fluoride release and improved
mechanical properties.

Giomer

CLINICAL CONSIDERATIONS

 Although the inhibition of recurrent caries is

evident for fluoride-releasing materials, their
clinical effectiveness has been questioned
based on the durability of the materials.

Compomer  Compomers should not be used in Class 1 or

Class 2 load-bearing areas in the permanent
dentition. However, as the wear resistance and
Giomers (glass-ionomer and polymer) fluoride recharge of compomer restorative
materials continue to improve, it is now
apparent that they can be used with success in
 The advantage of giomers is the enhanced
both Class 5 and Class 2 open sandwich
availability and accessibility of the fluoride
restorations.
within the PRG fillers compared with that in
 Treating the high-caries-risk patient requires
resin- based materials (such as compomers and
special selection of restorative materials. RMGIs
certain resin composites).In Giomer materials,
and compomers are recommended as the
the PRG fillers are more accessible to release
esthetic restorative materials of choice in Class
fluoride and recharge with fluoride. These are
5 restorations in xerostomic patients and other
also known as PRG composites (Prereacted
patients at high risk for caries. This is because
Glass Ionomer Composites).
of the fluoride-release and fluoride-recharge
 Giomer materials have fluoride recharge,
capabilities of these materials.
biocompatibility, a smooth surface finish,
 Because RMGIs and compomers have poorer
excellent esthetics, and clinical durability, which
wear resistance than resin composites, a resin
have made them popular for restoration of root
composite should be used for restorations in
caries, noncarious cervical lesions, Class 5
load-bearing areas.
cavities, and lesions in primary teeth.
 The physical and mechanical limitations of glass
 A clinical trial of Class 1 and Class 2 giomer
ionomers and compomers, especially poor wear
restorations in permanent teeth reported no
resistance; staining and discoloration with
failures of 41 restorations at the 8-year recall.
products such as coffee, tea, wine, or exposure
 Giomers are available in the market as one paste
to daylight; and maintenance of surface gloss,
form. They are light polymerizing and require
contribute markedly to restoration failure.
bonding agents for adhesion to tooth structure.
Currently available Giomers are: Reactmer
(Shofu, Japan) and Beautifil (Shofu, Japan).
275 Chapter 11 Fluoride Releasing Materials 275

Isolation

 Saliva control is important for successful glass

ionomer restorations. If moisture contaminates
the cement during manipulation and setting, the
gel will weaken and wash out prematurely.
 Commonly used methods for isolation are
rubber dam, retraction cords, cotton rolls and
saliva ejectors.
Tooth Preparation

Restoration of class V lesions using GIC Tooth preparation for glass ionomer cement is done
in two ways:
Guidelines for recommended use of  Mechanical preparation: the tooth preparations
fluoride-releasing materials for either of these clinical indications are the
same as previously described for composite
Glass ionomer: restorations, except bevels are rarely used.
Provisional restorations or caries control for  Chemical preparation (conditioning).
patients with high caries risk; Class 3 and Class 5
restorations; cores or buildups when half or more of
the tooth remains; ART; sealants for erupting teeth. Mechanical Preparation
Glass ionomer can be used for class III, class V,
RMGI: small class I and II tooth preparations.
Provisional restorations or caries control for
Class III Tooth Preparation
patients with high caries risk; patients with moderate
salivary flow; Class 3 and Class 5 restorations;
Indications for class III glass ionomer restorations:
buildups when half or more of the tooth remains;
 In patients with high caries index.
ART; open sandwich technique; sealants for
 When caries extend onto the root surface
erupting teeth.
(Glass ionomer is the material of choice to
restore the class III lesion when caries extends
Giomer/compomer:
onto the root surface).
High-caries-risk patients with diminished salivary
 In areas with low occlusal stress.
flow; primary teeth; permanent Class 3 and Class 5
 When labial enamel is intact.
restorations.
Outline form:
 Using a small inverted cone bur, make an
Fluoride-releasing composite:
access through lingual marginal ridge. Extend
Long-term provisional restorations; conservative
the bur towards incisal or gingival area
Class 1, 2, 3, 4, 5 restorations; core buildups
depending on caries. This helps in maintaining
esthetics and exposing less material to
dehydration. Do not try to break the contact,
STEPS FOR PLACEMENT OF GIC
this helps in preserving the facial enamel.
RESTORATION
 Prepare butt-joint cavosurface margins since
glass ionomer is a brittle material, it cannot be
 Isolation placed over the bevels.
 Tooth preparation Retention and resistance form:
 Mixing of GIC  Since retention in glass ionomer is chemical in
 placement nature, so placing undercuts and dovetail is
 Surface protection not mandatory.
 Finishing and polishing  For retention, deepen the outline to provide at
least 1 mm bulk for the cement.
 Pulpal protection: Any area where less than 0.5
mm of remaining dentin is present, fast setting
276 Clinical Operative Dentistry
calcium hydroxide liner is placed for pulp
protection.(glass-ionomer should not be
placed over a direct exposure of the pulp.)
 Class-III cavities are best restored with light
cure glass-ionomer for better aesthetics than
with conventional chemical cure cement.
However, the auto cure cements positively
have superior fluoride release than the light
cure cement.
Class I Tooth Preparation
Indications
 Deep pits and fissures (Glass ionomers are
only used for small pit and fissure lesions,
which do not have high occlusal stresses).
 Recently erupted teeth in patients with high
caries index.
Outline form:
 Use a small round bur to enter in the fissure
and remove carious dentin.
 After this, use fine tapered fissure bur to widen
the fissures. This fissure widening helps in
better flow and increased retention of glass
ionomer cement.
Retention form: Since glass ionomer cement bonds
chemically to tooth structure, so no special retention
aid is required.
Chemical preparation (conditioning)
 Polyacrylic acid is applied for about 10 to 20
seconds and then washed away.
 Light activated glass-ionomers have an
additional step of priming the tooth surface. The
proprietary priming agent is applied in two or
more coats as suggested by the manufacturers.
It is then spread to a thin layer with gentle blast
of air and light activated for 20 seconds.
Polyacrylic acid conditioner.
276
Mixing of Cement
 The best method of mixing and placing glass-
ionomer cement is to use the capsulated cement
that can be used with a syringe technique.
 Mixing should be done using powder/Liquid
ratio as recommended by the manufacturer.
 Mixing should be done at room temperature for
30 to 60 seconds on a cool and dry glass slab or
paper pad with the help of a flat and firm plastic
spatula.
 When dispensing the powder shake the bottle
lightly first to fluff up the powder. See that the
spoon is quite full of powder and level off the
surface using the lip on the bottle, which is
provided for the purpose. The powder is
dispensed first on to the slab and divided into
two halves with the spatula. The liquid bottle is
then tilted horizontal to allow the liquid to
displace the air through the nozzle and occupy
the nozzle. Now the bottle is oriented vertically
and gently squeezed to dispense the required
ratio of liquid at only one drop at a time, without
the inclusion of an air bubble.
 One half of the powder is mixed at a time by
rolling the powder into the liquid to wet the
surface of the powder particles. Do not
vigorously spatulate (use folding motion) The
first half of the powder should be all wet within
10 to 15 seconds. Roll the remaining powder into
the mass. Do not spread the mix around the pad.
The mixing is then completed in about 30 to 60
seconds.
 Mixing should be completed within 30 to 60
seconds. Working time is normally 60–90
seconds for traditional glass ionomer and about
3 minutes for resin modified glass ionomer.
Loss of gloss on the surface of mixed cement
shows end of working time and start of setting
reaction. Cement should be used before it loses
its glossiness. If gloss is lost, the cement would
not wet the tooth surface well and bond strength
will be reduced.
 For restoration, bring the mix together. One
should be able to pick up the mix without
sticking to the instrument.
 Note that If the liquid has become more viscous
over time it can be thinned down by immersing
the bottle in water at 70 degrees centigrade for
15 minutes. Allow it to cool again before using
the liquid.
277 Chapter 11 Fluoride Releasing Materials
Dispensing the powder. See that the spoon is
quite full of powder and level off the surface
using the lip on the bottle, which is provided
for the purpose (Eliminating excess glass
ionomer powder).
Dispensing the liquid. The liquid bottle is tilted
horizontal to allow the liquid to displace the air
through the nozzle and occupy the nozzle.
The bottle is oriented vertically and gently
squeezed to dispense the required ratio of
liquid at only one drop at a time
277
A) Dispensed powder and liquid. B) Mix ready to
use.
Placement of GIC
 The technique for placement of an auto-cure or
resin modified glass-ionomer restoration is
essentially the same.
 Both the chemical cure cement and the light
cure cement are carried in one bulk for
placement into the cavity.
 The gross excess is quickly removed and the
filling contoured.
 The use of a matrix is always desirable because
it will assist in positive placement of the cement
on to the tooth surface and will also lead to a
reduction of voids and porosities within the
restoration.
 A syringe dispenser like the Centrix syringe is
an excellent and superior alternative. Syringing
out the cement into the prepared cavity help to
fill the cavity without entrapment of air bubbles
in the cement and give absolute control of the
quantity of the cement placed in the tooth. The
tip of the syringe is placed to the floor of the
cavity and the cement ejected into the cavity as
the nozzle is withdrawn out.
 After placing the cement, the gross excess is
removed immediately and initial contouring is
done.
278 Clinical Operative Dentistry 278

 Initial contouring may be done using sharp

instruments like Bard parker blades, gold foil
knives or diamond points in high speed.
 The chemical cure cement is held with matrix till
it attains initial hardness and the light cure
cement is photo-activated for rapid set.
Restoration should be subjected to longer
exposure than suggested to avoid deficient light
activation due to the distance of the light from
the restoration. Large restorations are exposed
again for a total of 60 seconds. A fully light
activated resin modified glass-ionomer is
resistant to water uptake after completion of
light activation, but it is still possible to
dehydrate the cement.

Placing the capsule into the syringe barrel &

syringe ready to use.

Different Centrix syringe tips.

Glass ionomer application using Centrix syringe

Loading the mix into the capsule

Fitting of the cervical matrix

Surface Protection

 Moisture sensitivity during the first hour is very

Placement of the plug
critical, therefore the cement is coated with
279 Chapter 11 Fluoride Releasing Materials 279

either varnish, cocoa butter, copal ether or Post-operative Sensitivity

unfilled resin.  Post-operative sensitivity is usually associated
 Resins such as enamel bonding agents afford with poor manipulation and/or poor
the best surface protection to the cement. It fills powder/liquid ratio. This is also related with
the irregularities on the surface and gives a moisture contamination during setting of the
smooth finish for a longer period compared to cement leading to hydraulic effect on dentinal
varnish and petroleum jelly. Resins are also fluid.
more impermeable compared to even varnish.  However, the menace of post-operative
Cocoa Butter and petrolatum are easily washed sensitivity is less affected with light cure glass
away in a short period while optimum period of ionomers and compomers.
protection is 24 hours.
 The newly placed cement should be sealed
immediately after removal of the matrix to OPEN SANDWICH TECHNIQUE
prevent water exchange.
 If the seal remains for the first 24 hours the
cement will have matured sufficiently to develop  Another strategy for Class 2 and Class 5
full translucency. In case the surface is not restorations that extend gingivally below the
protected during maturation, it will lead to the cementoenamel junction is the open sandwich
crack formation at the surface. technique.
 In this technique, the fluoride-releasing material
is placed along the gingival margin of a
Finishing and Polishing preparation (the proximal box of a Class 2
preparation) when the gingival margin extends
 As we know, surface of glass ionomers is to cementum or dentin. The RMGI is cured, and
sensitive to both moisture contamination and resin composite is placed in increments to
desiccation. During initial phase of cement restore the occlusal surface for adequate wear
setting, it is always preferred to delay finishing resistance.
and polishing of glass ionomer cements. It is  The open sandwich technique was clinically
delayed for at least 24 hours after the cement successful at the 5-year recall of Class 2
placement. But in case of resin modified glass composite restorations placed in patients with
ionomer cements, finishing is started after their moderate to high caries risk.
placement. After placing the restoration, gross
finishing is done following the matrix removal.
Before starting the finishing procedure, the
surface of restoration is coated with protective
agent.
 The final finishing is done using discs with
different gradation of abrasives from coarse to
fine, in a series. Super fine diamond points,
silicon abrasives embedded in rubber in various
shapes and abrasive strips are available to
finish the various areas of the restorations. The
finishing using abrasive has to be carried out in
moist condition. Dry cutting will dehydrate the
surface and give it a porous and mottled
appearance and result in early disintegration of
Open sandwich technique
the cement.
 At the end of the initial contouring as well as Steps of Sandwich Technique (figures 11.1
final finishing of the surface the cement surface a-d)
has to be protected with varnish, proprietary
coats or resinous glaze material.
 Isolate the tooth to be prepared.
 Prepare the tooth. Keep the cavosurface
margins involving dentin as butt joint. Bevel the
280 Clinical Operative Dentistry 280

enamel margins to increase the composite resin

bonding.
 Provide pulp protection using calcium
hydroxide base, if indicated. Usually it is
avoided since it reduces the area for adhesion
of glass ionomer cement.
 Condition the prepared tooth using polyacrylic
acid for optimal adhesion of GIC.
 Place freshly mixed fast setting GIC in the
prepared tooth.
 It is only necessary to etch a GIC with acid if the
restoration has been in place for some time and
has fully matured. If the GIC is freshly placed Figure 11.1(a) Condition the prepared tooth using
and is immature, bonding can be achieved polyacrylic acid for optimal adhesion of GIC.
simply by washing the GIC surface because
water causes washout of GIC matrix from
around the filler particles which gives
microscopically rough surface to which the
composite will attach.
 Now coat the surface of prepared tooth either
with an unfilled resin or a dentin bonding agent
for optimal adhesion and cure it for 20 seconds.
 Place composite and cure in usual manner.
 Do finishing and polishing of the restoration and
finally recure it for 20 seconds.
 To achieve optimal results from sandwich
technique, following should be done: Figure 11.1(b) Place freshly mixed fast setting GIC
in the prepared tooth.
- Use high strength glass ionomer available.
Conventional glass ionomers are less
successful in the open sandwich technique.
- Because of increased fluoride release compared
with that of resin composite, better handling,
and a likely enhanced solubility resistance in an
acidic environment, compomers have been
suggested for this application.
- Before placing glass ionomer, condition the
tooth preparation for better adhesion.
- Avoid placing sub-base like calcium hydroxide
as it reduces surface area of adhesion.
- Before placing composite over glass ionomer,
let the glass ionomer set fully.
- Place composite restorative in sufficient bulk to
Figure 11.1(c) etch tooth & GIC with acid.
provide the flexibility and resistance form to the
restoration.
- Before placing composite, remove glass
ionomer from margins to expose the enamel as
composite-enamel bond is strongest.
- Glass ionomer cement should be radio-opaque
in nature.
- Contact area should be built with composite
resins, not glass ionomers.
281 Chapter 11 Fluoride Releasing Materials 281

Disadvantages:
 Technique sensitive.
 Time consuming.

Figure 11.1(d) coat the surface of prepared tooth

either with an unfilled resin or a dentin bonding
agent for optimal adhesion and cure it for 20
seconds. & Place composite and cure in usual
manner.

Advantages:
 Open Sandwich technique used for deep class II
forms where the cervical margin lacks enamel,
has shown improved resistance to microleakage
and caries in comparison to resin bonding at
dentin margins.
 Fluoride release from GIC.
 Reduced bulk of composite resins pose less
polymerization shrinkage.
 Use of GIC eliminates acid etching of dentin and
thus reduces postoperative sensitivity caused
by incomplete sealing of etched dentin.
283
285 Chapter 12 Class V (Cervical) Restorations 285

CLASS V CARIES LESIONS

Clinical features

 They include carious lesions on gingival third of

facial and lingual or palatal surfaces of all teeth.
 These are probably the most straight forward
lesions for assessment because they are the
most visible.
 Of all lesions, these are the ones most likely to
be arrested by preventive treatment alone.
 The following features indicate lesion activity:
- White spot lesions close to the gingival margin
that have a matte or visibly frosted surface;
these are often plaque covered.
- Cavitated, plaque-covered lesions with or
without exposed dentin; if dentin is exposed and
Showing smooth facial class V caries.
soft, the dentin is heavily infected and the lesion
is active.
 The following features indicate that the lesion is
arrested:
- Shiny white or brown lesions, often well
exposed due to gingival recession; the lesions
are not plaque covered.
- Cavitated lesions, often dark brown, with hard
dentin at their bases; the lesions are not plaque
covered and are often remote from the gingival
margin.

Cavitated active cervical lesion.

Class V lesion

Matt, white active cervical lesion.

286 Clinical Operative Dentistry
Shiny, white arrested caries.
Arrested cervical caries.
Brown arrested cervical lesion.
Restore or not restore?!
The decision to restore or not a cervical lesion on the
buccal and facial surfaces is based on several
factors:
 If it is a white spot lesion, which is a
subsuperficial carious lesion without cavitation,
preventive measurements can be applied to
reduce the caries disease activity and arrest the
lesion, such as biofilm control, dietary changes,
and fluoride use, promoting its remineralization.
A restorative intervention is not indicated. The
caries infiltration technique may also be applied,
completely stopping the lesion progression.
 If there is cavitation, the area must be restored,
unless it is too superficial and the patient is able
to clean, mechanically removing the biofilm
from inside the cavity with the toothbrush, and
there is no esthetic commitment.
286
 The inactive cervical caries lesions may be
stained (brownish or black) and shiny,
sometimes presenting sclerotic dentin with high
mineral density, in which the dentin tubules are
obliterated by mineral deposition and an
increased layer of peritubular dentin. They are
more resistant to the acid etching, impairing a
proper bonding to the restorative material. The
increase of the etching time may be desired on
this situation or a gentle removal of the
superficial sclerotic layer with round burs,
exposing an underlying less sclerotic substrate.
 If there are old faulty restorations, they are
removed with a round diamond point on high
speed. In case of large old restorations,
sometimes it must be advisable to remove only
the defective part and to perform a repair
AMALGAM RESTORATION OF CLASS
V LESIONS
Tooth preparation (Figures 12.1 a-h)
 They are preparations performed on the cervical
third of the tooth crown.
 Nowadays, the use of amalgam on this type of
cavity is restricted to the posterior teeth, when
there is no esthetics involvement, especially on
molars.
 They can be shallow lesions on the mechanical
point of view, but they are deep on the biological
point of view, due to the proximity to the pulpal
chamber, and special care should be taken to
avoid an accidental pulpal exposure.
Outline Form
 In general, this kind of lesion is already open due
to the collapse of the carious enamel.
 If the lesion is closed, with only a white or dark
spot and intact surface, it is subsurfacial and
has to be treated only by preventive measures.
 The outline is performed with a cone-shaped
rotary instrument positioned perpendicular to
the surface. The sides of the instrument create
the surrounding walls of the preparation, and its
tip creates the axial wall, maintaining the depth
of penetration of the rotary instrument at 0.5 mm
further than the DEJ, even if still there is carious
tissue further than this region.
 This creates a preparation depth of 1–1.25 mm
on the gingival cavosurface angle.
287 Chapter 12 Class V (Cervical) Restorations 287

 On the case of gingival margins on the
cementum, the penetration can be only 0.75 mm.
 On the large lesion, the mesial and distal
margins generally reach the buccomesial and
buccodistal or linguomesial and linguodistal
axial angles.
 In general, those preparations take an oval or
kidney shaped. However, the dentist must keep
in mind that the final dimensions and the shape
of the cavity must be a result of the lesion shape
and the extension, with maximum preservation
of the healthy remaining tooth structure.(Figure
12.2)
 If the preparation is large on the gingivoocclusal
direction, the axial wall can also follow the
curvature of the tooth.
 In narrow cavities, the axial wall is generally flat
on the gingivoocclusal direction.
 The surrounding walls must be divergent toward
the external surface of the Tooth, to obtain a 90°
cavosurface angle. They must be flat, uniform,
and smooth.

Contour of the axial wall in small and large

preparation, respectively, in relation to the
mesiodistal direction

Figure 12.2 Variations on the outline form of the

Class V preparation. The outline must be the most
conservative as possible, involving only the tooth Axial wall should follow the contour of the tooth
structure affected by the lesion. (not flat)
Resistance Form
 The axial wall should follow the contour of the Retention Form
external surface of the tooth on the mesiodistal  Due to the non-retentive shape of the
direction, creating a homogeneous thickness of surrounding walls, additional retention must be
the restorative material. prepared.
 For that, retention grooves are prepared along
the entire extension of the occlusoaxial and
288 Clinical Operative Dentistry 288

gingivoaxial line angles, on the occlusal and

gingival walls.
 It is done with a short inverted cone point
(No.1031) or carbide bur (No. 33 ½), positioned
with its long axis perpendicular to the axial wall,
or with a round diamond point (No. 1011) or
carbide bur (No. ½), with a depth of 0.25 mm,
which corresponds to half diameter of the rotary
instrument head.
 To verify the retention quality, the tip of an
exploratory probe is placed inside the retention
groove and pulled toward the external surface.
Removal of the Remaining Carious Tissue

 On this stage, any remaining carious tissue can

be removed with a large round bur at low speed,
of a diameter compatible of the preparation size,
or with an excavator spoon.
 The undermined or irregular areas of the
remaining tooth structure can be filled with GIC Figure 12.1 (b) beginning of the preparation of the
and the geometrical shape prepared over the occlusal wall with the conical diamond point
base material.
 If a base is necessary, the retention grooves
must be prepared after its placement, in a way to
avoid its closing during the base material
application.

(The following shows step by step cavity

preparation for class V amalgam
restoration)

Figure 12.1(c) preparation of the mesial, distal and

gingival walls

Figure 21.1(a) Initial aspect of the caries lesion

289 Chapter 12 Class V (Cervical) Restorations 289

Figure 12.1 continue (c) preparation of the mesial, Figure 12.1(f) preparation of mechanical
distal and gingival walls
retentions on the axiogingival line angle.

Figure 12.1(d) removal of the remaining carious

tissue with the round bur

Figure 12.1(g) preparation of the retentions on

the axioocclusal line angle

Figure 12.1(e) treatment of the dentin and flattening Figure 12.1(h) aspect of the preparation
of the axial wall with a glass ionomer cement finished
290 Clinical Operative Dentistry 290

Restoration placement (Figures 12.3 a-l) of the surface in two planes, according to the
direction of the remaining surface, reproducing
the curvature of the region.
The amalgam restorations on Class V preparations
 The under-contour will result in the trauma of
are indicated on areas where
the gingiva, while the over-contour will result in
 Esthetics is not a concern.
the reduced gingival stimulation and self-
 The access and the visibility are limited.
cleaning of the tooth surface during the
 The moisture control is difficult. mastication.
 Then, the burnishing of the area is started with
The cavosurface angles of the gingival wall in Class the No. 6 Hollenback burnisher or No. 33 Bennett
V preparation are many times located inside the
burnisher. Egg- or round-shaped burnisher
crevice, beyond the gingival margin. On those must not be used because they may deform the
situations it may require the displacement of the restoration and result in a concave contour.
gingiva with a retraction cord or a rubber dam (The following shows restoration of class V cavity
isolation, associated with cervical retraction clamps, using window matrix)
to allow the access while controlling the crevice fluid
flow.

Most Class V preparations may be restored without

the use of matrix. On this case:
 The amalgam is condensed first toward the
retentions with a small condenser.
 Then toward the mesial and distal walls.
 After that, the central part is filled.
However, on the case of large preparation, the
condensation becomes harder, because the
amalgam tends to escape, due to the fact that the
applied portions are not held by the surrounding
walls or because the axial wall is convex. On this Figure 12.3(a) Cavity prepared ready for restoration.
case:
 A window matrix must be prepared.
 To do that, a universal matrix is placed around
the tooth, with a matrix retainer located on the
opposite surface to the one that will be restored.
 The position of the preparation is marked on the
band with an instrument with a sharp tip.
 It is then removed, and a “window” is opened
with a cylinder diamond point, with dimensions
smaller than the preparation but large enough to
allow the application of the restorative material.
 The matrix is once again placed in position. Figure 12.3(b) application of the universal matrix
 In case it is not stable enough, wedges may be around the tooth
placed in the interproximal spaces on both
sides.
 Then, the application of the restorative material
into the preparation is started, condensing it
toward the mesial and distal walls, with a small
diameter condenser, until the preparation is
completely filled.
 The condensation on the region of the window
opening can be performed with an instrument of
a larger diameter.
 The matrix is immediately removed, and the
restoration is burnished, following the carving
Figure 12.3(c) marking the place of the preparation
291 Chapter 12 Class V (Cervical) Restorations 291

Figure 12.3(d) opening of the “window” with the Figure 12.3(h) Condensation of the amalgam after
diamond point the entire filling of the preparation

Figure 12.3(e) window matrix positioned

Figure 12.3(i) pre-carve burnishing

Figure 12.3(f) application of amalgam

Figure 12.3(j). Carving in two planes

Figure 12.3(g) condensation of the amalgam in the
areas covered by the matrix
292 Clinical Operative Dentistry 292

margins should be extended to include all

demineralized areas, using an round diamond
point, restricted to the enamel tissue on the
necessary depth to remove the lesion.
 Due to the proximity of the pulpal chamber, the
Class V carious lesions are shallow on the
mechanic point of view, but deep on the
biological point of view, since a pulpal tissue
exposure may easily happen. This must be
avoided at all cost, and a stepwise excavation
can be indicated when the dentist realizes that,
if the preparation continues, pulpal exposure
may happen.
 Although not mandatory, a bevel can be
performed on places where there is enamel on
the cavosurface angle, at 45° with the external
tooth surface, using a No. 1111 conical shaped
or a flame-shaped diamond point in high speed,
helping to mask of the tooth-restoration
interface.
 On the gingival margin, due to the lack of access
Figure 12.3(k) post-carve burnish
for the proper positioning of the conical or
flame-shaped points, a No. 1011 or 1012 round
diamond point can be used. However, when the
amount of remaining enamel is very small in this
area, no bevel should be performed due to the
risk of its complete removal.

Figure 12.3(L) finished restoration after the

polishing

Note that Cavity outline form is determined by the

extent of caries
COMPOSITE RESTORATIONS FOR
CARIOUS CERVICAL LESIONS
(The following shows step by step cavity
preparation for class V composite restoration)
Tooth preparation (Figures 12.4 a-f)

 The tooth preparation is restricted to the

removal of the carious tissue in the most
conservative way. The final dimensions are
determined by the size, shape, and location of
the lesion, as well as the necessary extension to
obtain access to the walls.
 When there is a cavitated lesion reaching dentin,
surrounded by a white or brown spot lesion on
enamel that extends over the tooth surface, Figure 12.4(a) Patient with several
beyond the preparation outline, after finishing carious lesions on anterior teeth
the preparation on the cavitated area, the
293 Chapter 12 Class V (Cervical) Restorations 293

Figure 12.4(b) close view of the central incisors

Figure 12.4(e) bevel placement

Figure 12.4(c) Removal of carious dentin tissue

with round bur

Figure 12.4(f) finished preparations

Pulp protection

Figure 12.4(d) removal of carious enamel with  On the cases of very deep preparations, an area
round diamond point
with pink discoloration on the axial wall
indicated that a remaining dentin layer of less
than 0.5 mm exists, probably associated with
clinically undetected microscopic pulp
exposures. On this situation, a thin layer of
calcium hydroxide cement is applied, only over
the pink dentin, with the goal to stimulate the
formation of tertiary dentin.Then, a protective
layer of GIC should be applied.
 On the case of deep cavities, without any pink
discoloration area, only a thin layer of the GIC
should be used, restricted to the regions close
to the pulp.
 On a shallow or medium-depth preparation, the
application of any protective material is not
necessary.
294 Clinical Operative Dentistry
Application of adhesive
 The etching using 37% phosphoric acid gel is
applied first on the enamel and then extended to
the dentin, remaining for 15 s.
 Then, the preparation is rinsed with air/water
spray for 20–30 s and blot dried, using small
cotton pellets, followed by the adhesive system
application.
Restoration placement (figures 12.6 a-h)
Composite selection
 For Class V restorations, conventional viscosity
or flowable composite can be used.
 It is important to select a restorative material
that provides good polishing, reducing the
biofilm deposition and gingival irritation.
 The microfilled composites are an excellent
option for the cervical restorations. Besides
producing a smooth surface, they have a low
elastic modulus due to its reduced filler content,
being more flexible and capable to dissipate
internal stress generated during the masticatory
loads, generally responsible for restoration
displacement.
 The microhybrid, nanohybrid, and nanofilled
composites are also good options for Class V
restorations.
 The flowable composites also have the same
advantages related to the low elastic modulus,
in a similar way to the microfilled ones. Besides
improving retention, it also improves
adaptation of the restoration to the preparation
walls.
Incremental placement
 Small portions of composite material are taken
with a non-stick composite filling instrument
and adapted into the preparation.
 The composite should be placed by using rapid
shallow strokes, as if you were thumping the
composite in place, reducing the chance of
detaching from the cavity wall, which can create
voids.
 Each layer must be light-cured for at least 20 s
with an adequate light source.
 Each layer should not be more than 2 mm thick,
to obtain an adequate polymerization on bottom
of the increment.
294
 It should also be avoided to connect more than
two preparation walls at the same time on each
increment, due to the C-factor.
 The light beam must reach the preparation on a
right angle with the tooth surface, where the
preparation access was made, and the light
guide tip must be placed as close as possible,
almost touching the surface. The distance
between the light guide tip and the tooth surface
must never be larger than 1 mm.
 On shallow Class V preparations, restricted to
enamel, a single increment is generally enough,
considering the maximum layer thickness of 2
mm for obtaining a proper light curing.
 For preparations with all the margins on enamel
but with loss of dentin tissue, generally two
increments are indicated. The first layer fills the
lost dentin covering the axial wall, using an
opaque composite. The second replaces the
enamel using a more translucent material.
 The composite is applied using a hand
instrument, adapted on the preparation walls by
gently thumping action with the instrument nib,
instead of rubbing it over the surface.
 After applying some increments into the
preparation, the composite can start to stick on
the filling instrument. When the instrument is
taken away from the preparation, it can pull the
composite back, and a gap is formed between
the material and the wall. After curing, it will
generate a permanent interfacial defect.
Therefore, it is extremely important to avoid the
composite sticking to the instrument.
the  On preparations with gingival margins on
cementum, if the composite is inserted in a
single increment, as the bond strength to
enamel is higher than to the dentin, the
shrinkage stress would break the interface
between the composite and the dentin, on the
gingival margin, instead on enamel margin,
resulting in marginal gaps on the gingival
cavosurface angle. A way to reduce this problem
is to apply the first increments on the cervical
and middle thirds of the preparation, in a way
that they do not contact the enamel. (figure 12.5)
Resin composite is placed in incremental
manner
295 Chapter 12 Class V (Cervical) Restorations 295

Finishing & polishing

 The restorations must be analyzed in relation to

the presence of flash or overhangs using a
dental explorer, mainly on the gingival margin
where usually more overhangs are detected.
 The explorer must be placed inside the gingival
sulcus, touching the root surface, and moved
incisally.
 Any overhang detected must be removed with a
thin fine grit conical-shaped diamond point, with
non-cutting tip,
 A scalpel blade can also be used to trim flashes
and overhangs.
 The polishing may be performed with abrasive
rubber point, abrasive discs, or felt discs with
polishing pastes.

(The following shows step by step composite

Figure 12.5 on preparations with gingival margins restoration of class V cavities)
on cementum, if the composite. Is inserted in a
single increment, as the bond strength to enamel
is higher than to the dentin, the shrinkage stress
would break the interface between the composite
and the dentin, on the gingival margin, instead on
enamel margin, resulting in marginal gaps on the
gingival cavosurface angle.
 Large cervical restorations may require the use
of a darker shade on the cervical third and a
lighter one on the middle and incisal thirds.
 The opaque dentin shade selected must partially
cover the bevel when performed, helping to
mask the transition between the restorative
material and the remaining tooth structure. At
the end, dentin shade material must be
completely covered with a translucent enamel Figure 12.6(a) preparation complete
shade composite, recovering contour of the
external tooth surface.
 The last layer may be contoured with a flat
brush.
 The surface of the last composite layer of a
restoration will not be completely cured,
compromising its mechanical properties,
especially if the surface does not receive a
proper polishing. To overcome this problem,
after the polymerization of the last increment,
the surface can be covered by a transparent
glycerin-based oxygen blocking gel and light-
cured through it, eliminating the oxygen and
allowing a complete polymerization, leaving a
glazed aspect. The gel is then removed with an
air/water spray.

Figure 12.6(b) Acid-etching

296 Clinical Operative Dentistry 296

Figure 12.6(c) blot drying with cotton pellets & Figure 12.6(e) application of opaque dentin shade
glistening aspect of the wet dentin composite

Figure 12.6(f) application of translucent enamel

shade composite & contouring of last composite
layer with a flat brush

Figure 12.6(d) application of the adhesive system

Figure 12.6(g) immediate result

297 Chapter 12 Class V (Cervical) Restorations 297

material enough to fill the preparation is applied

on a single increment.
 Due to its viscosity and sticky characteristics,
the GIC or RMGIC are difficult to contour and
sculpt. For this reason, cervical matrices are
widely indicated for Class V restorations,
because they contour and maintain the material
in position during the setting or curing.
 When a conventional GIC is selected, metallic

Figure12.6 (h) after finishing and polishing. matrices can also be used. However, when the
light-cured materials are chosen, clear plastic
matrices must be selected, holding the material
GIC RESTORATIONS FOR CARIOUS
while the light-curing is performed during the
CERVICAL LESIONS
time recommended by the manufacturer.
 After its removal, the major excesses are
trimmed with a No.12 scalpel blade.
The cervical lesions can also be restored with
 A thin layer of cavity varnish or a light-cured
conventional GIC or RMGIC, being specially
adhesive must be applied over the restoration
indicated to elderly patients with high caries risk.
surface, receiving a soft air stream to create a
The tooth preparation is the same as for composites, thin coat. When an adhesive is used, its light-
with exception that no bevel is performed: curing is performed for 10 s. This procedure
 Adhesive quality of the glass ionomer cements prevents the dehydration and cracks of the
dictates that an ultraconservative approach be restorations or water sorption from the saliva
adopted. during the initial setting stages.

 No undercuts or dovetails are necessary.  The RMGIC is generally more resistant to

dehydration or water sorption and does not
 Cavosurface margins should be butt joint and
require protection. This is due to the fact that its
not beveled.
resinous components immediate polymerization
provides an umbrella effect, protecting the
PROCEDURE ongoing acid-base setting reaction. However,
the manufacturer’s instructions must be strictly
 Note that GIC should never be placed directly
followed for each material.
over exposed pulp otherwise pulp necrosis will
 The GIC restoration can be finished and
occur.
polished only after the end of the setting
 Before the application, the preparation walls are
reaction, about 24 h the placement into the
etched with 10–11.5% polyacrylic acid for 20–30
preparation. However, the RMGIC may be
s, followed by rinsing and drying.
immediately finished and polished.
 For the RMGIC the application of a primer can be
 Even after the final setting, care must be taken
recommended, according to each
to not dehydrate the GIC restoration surface
manufacturer’s instruction.
during the finishing and polishing procedures.
 The material is placed into the preparation on a
 Conventional rotary instruments can be used
single increment, and the excesses are quickly
under water spray. Rubber points and discs may
removed with hand instruments.
be used lubricated with glycerin gel or
 To take the material into the preparation, it is
petroleum jelly.
possible to use a calcium hydroxide placement
 Polishing pastes and felt discs can also be used.
instrument, which has a small sphere on the nib.
 Another option is to use a gun design Centrix
syringe: The material is mixed and back loaded
into capsule, no more than half full, followed by
the plug, which must be fully inserted. The
capsule is then placed into the syringe barrel.
For the application, the syringe is squeezed with
a slow and steady pressure. An amount of the
298 Clinical Operative Dentistry 298

NCCL

ETIOLOGY

It is now generally accepted that NCCLs have a

multifactorial etiology comprising erosion (low pH),
abrasion (friction) & abfraction (occlusal forces).

Not necessarily, any one etiology can be isolated,

Class V glass ionomer restoration but two or more may act together to initiate and
promote the development of lesions.
NONCARIOUS CERVICAL LESIONS
(NCCL) Erosion

Defined as the loss of tooth structure from chemical

dissolution (low pH) not involving bacteria.
DEFINITION:

Any gradual loss of tooth structure characterized by According to source of acidity may be either:
the formation of smooth, polished surfaces, Intrinsic erosion: It occurs due to involvement of
irrespective of their etiology. Clinical picture of these endogenous acids, mainly due to regurgitation of
lesions can vary from shallow grooves to broad gastric acid into the oral cavity. This may occur in
scooped out lesions, to large notched or wedge- certain conditions such as:
shaped defects.  Eating disorder: Anorexia nervosa, Bulimia
nervosa.
Failure to appropriately prevent and treat NCCLs can  Vomiting: Recurrent vomiting, Drug-induced
result in vomiting.
 Progressive loss of tooth structure.  Pregnancy morning sickness.
 Tooth sensitivity.  Gastrointestinal disorder: Peptic ulcer,
 The need for endodontic therapy. Gastroenteritis, Hiatus hernia.
 Tooth loss.  Chronic alcoholism.
 The occurrence of additional lesions.
299 Chapter 12 Class V (Cervical) Restorations
Extrinsic erosion. It Occurs due to acids from either:
 Environmental origin: Professional wine
tasters, battery, electroplating chemical
manufacturer & Swimmers.
 Dietary origin: High intake of Citrus fruit and
juices, carbonated beverages.
 Medicinal origin: Aspirin Vitamin C, Iron tonics
& Acidic mouthwashes.
Note that Regurgitated acid is the most common
cause of erosion and causes the most damage.
Special considerations
 Healthier diets, which include the consumption
of more fruits and vegetables are an important
factor in the etiology of dental erosion.
 Also, during fasting, the combination of acidic
drinks and reduced salivary flow contribute to
increased risk of erosion.
 Fruits seem to affect anterior teeth while fruit
juices may affect premolars and molars.
 Cervical surfaces are most prone areas as they
are close to the gingiva and less cleansable, and
foods and beverages may harbor in their
proximity for longer periods of time.
 Both quantity and quality of saliva are known to
control the extent of dental erosion. In mouths
with decreased salivary flow and decreased
buffering capacity, erosion is expected to be
higher.
 It is important to emphasize that people involved
in sports and exercise may be at risk of
developing dental erosion due to
 The consumption of sport drinks,
replenishers, fruit juices, and other acidic
beverages.
 Exercise increases the loss of body fluids and
may lead to dehydration and a reduction of
decreased salivary flow.
 It is important to instruct the patients, not to
brush their teeth immediately before consuming
acidic food or drink because it removes the
acquired pellicle, thus leaving teeth less
protected.
 Habits such as lemon sucking and soft drink
swishing expose enamel and dentin to an acidic
environment for a longer period of time, which
may cause greater demineralization.
 Phosphoric acid, usually found in soft drinks, is
three times more erosive than organic acids
(Citric, maleic acids and Tartaric acid). Citric and
maleic acids are predominantly found in fruits
299
while Tartaric acid is present in grapes and
wines.
Abrasion
Defined as the loss of tooth structure by mechanical
or frictional forces.
May occur due to either:
Faulty oral hygiene practice (Most common cause):
 Horizontal brushing technique or improper
brushing technique.
 Overzealous brushing.
 Use of toothbrush with hard bristles.
 Use of abrasive toothpaste.
 Excessive time, force and frequency of
brushing.
 Excessive use of interproximal brushes.
Abnormal oral habits:
 Use of toothpicks ( cause Cervical abrasive wear
on the proximal surfaces )
 Finger nail biting
Ill-fitting clasps of partial dentures are also known to
induce localized abrasion lesions.
The higher prevalence and severity of cervical
lesions in the older age can be explained as
following:
 With increasing age, gingival recession exposes
the cementum.
 Generally enamel is quite hard and not easily
abraded; therefore, it serves as a protection for
the underlying dentin, which is abraded 25 times
faster. Cementum is the softest of all tissues and
shows an abrasion rate of 35 times higher than
enamel. As a result of gingival recession the
tooth becomes highly susceptible to abrasion
even under the previously non-damaging oral
hygiene measures.
Abfraction
 The loss of cervical tooth structure occur due to
abnormal occlusal forces.
 Defined as wedge type defects present in
cervical areas of tooth due to excessive occlusal
stresses or parafunctional habits such as
bruxism. A few authors have also termed these
lesions as ‘idiopathic cervical erosions’.
300 Clinical Operative Dentistry 300

 Abnormal habits: e.g. Bruxism, clenching,

grinding or any other habit which poses
deleterious effect on occlusion should be asked
about.

Clinical Examination

Morphologic presentation of NCCLs can perhaps aid

the practitioner in discovering their etiology as
following:

Morphologic presentation of Erosion

Abfraction occurs when tooth flexes under
occlusal loading resulting in microfracture of
enamel and dentin.
DIAGNOSIS OF NONCARIOUS
CERVICAL LESIONS
A careful history taking and proper clinical
examination are mandatory to reach at correct
diagnosis.
History of the Patient
Diagnosis of noncarious cervical lesions starts with
history taking.
While taking history of the patient, following things
are kept in mind:
 Dietary habits of patient: e.g. Overconsumption
of citrus fruits, aerated drinks, pickled food and
vitamin C sources can cause erosive tooth loss.
 Occupation of patient: e.g. Erosion is most
commonly seen in patients working in metal
plating or battery manufacture industries.
 General health of patient: e.g. Erosion is most
commonly seen in patients with gastrointestinal
ulcers and hiatus hernia.
 Brushing habits: e.g. Dentist should ask about
brushing technique, brush, type and nature of
dentifrice.
 Erosion lesions are most of the times observed
as broad shallow saucer shaped excavations or
depressions present in enamel and/or dentin,
but with no sharp line angles and less well
defined margins in the cervical area usually on
the facial tooth surface.
 They appear smooth, hard and polished.
 They are generally glazed and has no
demarcation from adjacent surface.
 Intrinsic erosion is most likely seen on lingual
surfaces of anterior teeth especially the
maxillary teeth.
 Extrinsic erosion frequently present on the
facial surfaces of anterior teeth.
 Although regurgitation usually first affects the
palatal surfaces, it often also causes strange
unexplained cupped out lesions in molar teeth,
starting with the tips of cusps.
 The tooth is sensitive to chemical, physical and
mechanical stimuli.
 Erosion rarely is a factor that operates alone in
causing tooth loss. Generally, such a lesion is
multifactorial, i.e. once the surface of the tooth
has been hypomineralized by erosion, wear
resistance of dental hard tissues is lessened
and they become more prone to damage by
mechanical abrasion and possibly abfraction.
301 Chapter 12 Class V (Cervical) Restorations 301

Erosion of teeth making smooth polished

surfaces.

Erosive lesions

Erosive lesions most commonly seen on facial

surfaces of anterior teeth.

Multiple erosive lesions in patient with high acidic

diet.

Erosive lesions on lingual surfaces.

302 Clinical Operative Dentistry 302

Although regurgitation usually first affects the

palatal surfaces, it often also causes strange
unexplained cupped out lesions in molar teeth,
starting with the tips of cusps

Morphologic presentation of Abrasion

 Abrasion lesions generally are saucer-shaped
or wedge-shaped that have sharply defined
margins, and hard smooth surfaces with
burnished appearance. Occasionally, the
surface may exhibit scratches.
 Abrasion may affect one or more teeth, or the
Multiple abrasive lesions.
entire dentition. Abrasion lesions are usually
generalized and most commonly seen to Morphologic presentation of Abfraction
damage facial surfaces of maxillary teeth,
 Abfraction lesion appears as a wedge-shaped
whereas lingual surfaces are rarely affected. The
defect with sharp line angles. It may appear as
canines and the premolars exhibit the highest
minor irregular crack or fracture line or wedge-
frequency.
shaped defect in the cervical region of the tooth.
 The frequency with which the lesions occurred But in later stages, it appears as groove
was in the following decreasing order of the extending into the dentin.
affected teeth: upper and lower first premolars‹
 Associating wear facets (attrition) with NCCLs is
upper canines‹ upper and lower second
an important component in this theory.
premolars‹ lower canines and incisors, and
 Usually a single tooth is involved in abfraction
molars. Premolars were more susceptible to
lesion. Most commonly seen on the buccal
abrasion probably because they were placed
surface of mandibular teeth.
slightly protruded in the dental arch.
 Much greater in the mesiobuccal segment
 Occasionally, localized lesions may be present
(under tension) than in the distobuccal segment
on teeth/tooth placed facial to the remaining
(under compression).
dental arch.
 Abfractions are commonly found in cases where
 The higher prevalence and severity of cervical
malaligned canine causes initial lateral
lesions in the older age (Usually occurs on the
guidance forces to be exerted on the lingual
exposed root surfaces).
incline of the buccal cusp of the maxillary
 Males were comparatively more affected than
premolar.
females.
 Most commonly seen toothbrush abrasions are  Look for any abnormal signs of traumatic
unilateral in nature. occlusion:
- If a tooth has an abfraction, the occlusal loading
on the tooth can be tested in centric occlusion
and in excursive movements with occlusal
marking paper. The tooth with abfraction will
303 Chapter 12 Class V (Cervical) Restorations 303

show a heavy marking on one of the inclines of
a cusp.
- In patients with abnormal occlusal problems and
subsequently cervical tooth loss, following can
be seen on the radiographs ‹Vertical bone loss
& Thickening of lamina dura.
 Some patients present with no symptoms while
others may complain of highly sensitive teeth.
Severe lesions may affect the vitality of pulp and
threaten the structural integrity of the tooth.
TREATMENT APPROACHES OF NCCL

Management of noncarious cervical lesion is done in

two phases:

Preventive management.
Restorative management.

Preventive Management

Primary objective of preventive management is

removal of the etiological factors. Only after
determining the probable causes, should any
treatment commence. The first goal of any treatment
is to remove the causes of the NCCL(s). Once the
etiologic factors for a patient are determined, the
dentist can help the patient to understand them and
to change those that are under his or her control.

After taking history regarding dietary habits,

brushing habits, abnormal habits like bruxism,
Abfraction lesion: a wedge-shaped defect with following preventive measures should be taken to
sharp line angles.
prevent unusual tooth loss:
 Proper toothbrushing technique using soft
bristle toothbrush.
 Use of less abrasive dentifrice.
 Correct occlusal disharmony to reduce occlusal
stresses.
 Restrict intake of acidic foods and acid
producing diet.
 ‘Drink only’; do not sip or swish acid beverages.
 Do not brush immediately before or after an acid
intake because if brushing is performed
immediately before acid intake, tooth pellicle
Abfraction lesions due to heavy orthodontic that protect tooth from acid will be lost. Do not
force. brush immediately after an acid intake because
NOTES:
loss of dentin is greatly increased when
brushing is performed immediately after
 When the dentin is exposed, tubular
exposure of the tooth surface to dietary acids.
calcification frequently occurs and
 Use of sodium bicarbonate mouthrinse {(0.75–
discoloration often is seen. Hypersensitivity
2.0 gm.) thrice a day} in patients with gastric
may be marked in rapid forms or in lesions
regurgitation.
where dentin is exposed with no underlying
 Use of orthodontic appliances to prevent
tubular calcification.
bruxism and clenching.
 In some instances caries may supervene and the
 Correct ill-fitting metal clasps or denture.
characteristic features of erosion are lost.
 Rounded lesions are less frequently  Correction of abnormal habits like holding pins
or pipes, nail biting, etc.
encountered than angular ones.
304 Clinical Operative Dentistry 304

 Topical fluoride application. Access and Isolation of NCCLs

 Enhance defense mechanism of the body by  When cervical lesions occur supragingivally,
increasing salivary flow; for example, by access to the area for preparation and
chewing sugar free chewing gum. restoration is often easily obtained. But if the
 Psychiatric consultation in patients with lesion has progressed to or below the free
anorexia nervosa. gingival margin, isolation for tooth preparation,
restoration placement, and finishing can be
difficult.
Restorative management  When the lesion is a noncarious lesion with a
margin apical to the gingival crest. Here the
 If a patient is experiencing acute sensitivity restorative goal is to protect the remaining root
associated with one or more lesions, treatment surface from further damage from
to alleviate the sensitivity should be toothpaste/toothbrush abrasion without
accomplished. This treatment could involve damage to the gingival attachment. A
desensitizing the tooth, restoring the tooth, or restoration that is smooth but finishes short of
possibly performing a periodontal procedure, the subgingival portion of the lesion might be a
such as a connective tissue graft, to cover and good conservative answer. Finishing short is
protect the affected area. almost certainly superior to placing an
 Because of the location of Class V lesions, overhanging restoration into a healthy gingival

access for restorative treatment is often sulcus. It is well established that a restoration

troublesome, moisture control can be overhang can adversely affect periodontal

exceedingly difficult to obtain and maintain, and health.

soft tissue surgical approaches may be

required.
 Because of the sclerotic nature of the tooth
structure in a cervical lesion and the physical
properties of restorative materials, long-term
retention of the restoration presents a unique
challenge.
 If a decision is made to place a restoration, some
lesions can be treated without cavity
preparation, and others require preparation to
obtain adequate retention of the restoration. Problem of isolation occurs when part of lesion is
subgingival.
 It is generally believed that NCCLs should be
treated to
- Protect remaining tooth structure if the amount
of tooth structure lost is extensive or
progressing.
- To restore esthetics if it is compromised.
- Or to control sensitivity not relieved by less
invasive procedures.
 However, the preferred treatment for a minimal
lesion is to eliminate the causes and stop lesion
progression. This prevents initiation of the
“rerestoration cycle,” that is, the repetitious Locations of NCCLs relative to gingival margin:
replacement of lost or defective restorations a) subgingival b)supragingival
with increasingly larger ones.
 In contrast, a few clinicians believe that all Nonsurgical retraction
noncarious Class 5 lesions require restorative  While a rubber dam is the ideal method of field
treatment and describe many reasons for doing isolation and moisture control for all direct-
so. placement restorations, many Class V lesions
can be adequately treated using retraction cord
& cotton rolls.
305 Chapter 12 Class V (Cervical) Restorations 305

 If the lesion extends to or below the gingival

margin, a rubber dam is useful to retract the
tissue. Often an additional rubber dam–
retracting clamp placed directly on the tooth to
be restored will provide additional gingival
retraction. A no. 212SA clamp is effective for this
purpose, but modifications to the clamp may be
necessary to provide adequate retraction.
 The clamp must be stabilized to keep it from
moving and possibly damaging the restoration
or the tooth surface during the operative
procedure. Modeling compound is the
traditional stabilizing material used. If lesions in Clamp retraction
two adjacent teeth are to be treated, modified no.
212SA clamps can be used to provide field Surgical retraction
isolation.
Miniflap

 As described in chapter 3, the use of miniflaps

can often provide sufficient access to
subgingival lesions.
 One or two small incisions are made in gingival
tissue, beginning at the gingival margin at the
mesial and/or distal aspect of the lesion. Each
incision is first directed at a right angle to the
gingival margin and extended approximately a 1
mm; the scalpel is then turned so that the
remainder of the incision is vertical,
approximately parallel with the long axis of the
tooth. It is essential that the entire lesion is
Clamp No. 212 SA exposed, including all demineralized tooth
structure.
 The incision(s) should not be extended past the
mucogingival junction. This will allow the small
flap of keratinized tissue to be reflected for
access, then replaced to the same position after
completion of the restoration.
 Sutures are usually not necessary. If the flap
extends past the mucogingival junction, sutures
may be required after the restorative procedure
has been completed.

A no. 212SA clamp stabilized with modeling

compound.
306 Clinical Operative Dentistry 306

a) A plastic instrument is used to displace tissue to evaluate the lesion extent and the need for a miniflap.
(b) Mesial and distal miniflap incisions are made at (right angles to the gingival margin. These two
incisions are connected with a sulcular incision. (c) The lesion is isolated with a rubber dam and a no.
212SA retracting clamp. (d) Postoperative appearance of the restoration and the gingival tissues after 1
week. No sutures were used at the completion of the operative procedure. (e) Short vertical incisions are
made within the keratinized tissue at right angles to the gingival margin and at the line angles of the
tooth. If needed, vertical incisions are made parallel to the long access of the tooth. This allows
additional tissue retraction with minimal trauma to the tissue or attachment apparatus. (f and g) The no.
212SA retracting clamp and rubber dam are shown in place. This clamp will often need to be stabilized
with modeling compound or a similar material.

Conventional flap surgery  In some cases, repositioning the envelope flap

to its original location will provide the optimal
 On occasion, a miniflap would provide
result for esthetics and function. In other cases,
insufficient access, so a larger mucoperiosteal
the flap will need to be apically positioned.
flap is required for a cervical restoration.
 While it is important to remember that the flap
 If restorations on two adjacent teeth are to be
will not predictably reattach to the newly placed
placed simultaneously and both require a
restoration, there is some evidence to indicate
surgical procedure for adequate access, a
that both soft and hard tissue attachment to
miniflap cannot be used; instead, a
glass ionomer or resin-modified glass ionomer
mucoperiosteal flap is necessary.
(RMGI) does occur. While amalgam has
 Surgical crown lengthening with ostectomy may traditionally been used in these applications in
be necessary to provide sufficient access to the posterior teeth, when a restoration is being
lesion. A mucoperiosteal flap should be placed in conjunction with a flap, placement of
reflected and ostectomy performed as needed. an all-RMGI restoration or an open sandwich
restoration with the apical aspect of the
307 Chapter 12 Class V (Cervical) Restorations
restoration restored with RMGI provides an
environment most likely to be conducive to
tissue reattachment.
NON CARIOUS CERVICAL
RESTORATIONS: MATERIALS,
DESIGN, AND RETENTION
Restoration of noncarious cervical lesion is
important for the following reasons:
 To maintain the structural integrity of the tooth.
 To treat sensitivity of the tooth.
 To maintain esthetics.
 To protect pulp.
 To maintain the health of the periodontium.
 To prevent caries.
An often-overlooked treatment that may improve
restoration longevity is occlusal adjustment to
reduce eccentric loading of the tooth with the Class
V restoration. Occlusal adjustment could decrease
the dislodging forces placed on the cervical
restoration during tooth flexure.
Amalgam
Amalgam preparations will be the same whether the
lesion requiring restoration is carious or noncarious.
Preparation for NCCLs:
 Requires the removal of sound tooth structure
to create a box form for amalgam bulk and
retention.
 The use of adhesive materials is usually
preferred.
 There is no need to create sharp internal line
angles or to remove sound dentin for axial depth
greater than 1 mm.
 The cavosurface margins should be as close to
90 degrees as possible.
 Cavosurface bevels are contraindicated
because amalgam is brittle material.
 With this design, the walls of the Class 5
preparation often diverge because of
curvature of the tooth surface.
 For nonbonded amalgam restorations, grooves
should be placed in the dentin of both the
occlusal and gingival walls to help retain the
amalgam.
 In large preparations, pins or other retentive
devices may also be beneficial. Bonding is an
excellent method to retain amalgam.
307
Matrix application:
 If the mesial and distal walls are flared so that
the amalgam has no lateral walls to confine it for
condensation, a custom matrix may be used to
facilitate restoration placement and
condensation.
 The simplest method for a facial Class V
amalgam restoration is to use a hand
instrument. If the preparation wraps well into the
proximal areas, this method may not suffice.
After the amalgam has been carved to proper
contours, a smoother surface may be attained with
burnishing and then smoothing with a rubber cup
and a fine abrasive paste. Although polishing has
been shown to have no effect on marginal ditching,
a smooth surface tends to be less plaque retentive.
A hand instrument may be used as a matrix for
Class 5 amalgam restorations.
Resin composite (Figures 12.7 a-l)
 The extent and depth of the lesion should
determine the outline and depth of the
preparation for resin composite, whether the
lesion is carious or noncarious.
 For NCCLs, little or no preparation is required. It
is demonstrated that V-shaped cavities are
preferable over box shaped cavities as in the
former the volume/ area ratio is less and hence
the amount of polymerization shrinkage of
the
composite and subsequent gap formation is
reduced. Since most of these cervical lesions
are notched or V-shaped, the need for
converting them into box shaped cavities is not
required.
 If the margins of the restoration will be
completely on enamel, the retention of bonded
restorations should be predictably successful.
Beveling of enamel margins is recommended
when it would expose the ends of the enamel
308 Clinical Operative Dentistry 308

rods to provide better etch and bond and/or to  The highest luster may be achieved with
improve esthetic blending of the resin microfilled and nanofilled composites,
composite with the tooth structure. Beveling the microfilled composites are the material of
gingival margin that ends on cementum is not choice for restoration of cervical lesions.
recommended. Microfilled composites are esthetically better,
 Retention of a resin composite restoration is offer better finish and have low modulus of
primarily due to the bond, so the bonding elasticity which allows them to flex during tooth
system must be used Meticulously: flexure. These qualities make them suitable
- Although roughening the surface of a choice for restoring cervical lesions where
noncarious lesion has been thought to enhance cervical flexure can be significant.
the bond by removing some sclerotic dentin,
one clinical trial found no increase in retention
when sclerotic lesions were roughened with a
bur.
- An increase in etch time for some etch- and-
rinse adhesive systems improves the bond to
sclerotic dentin, but depending on the degree of
sclerosis, this risks overetching dentin.
- The current self-etching adhesive systems
appear to have inferior bonds to sclerotic dentin
when matched against dentin bonding systems
that require washing away of the etching gel
- The use of multiple coats of primer if necessary,
the application of primer or adhesive with an
active scrubbing motion when indicated, the use
or non-use of the air syringe for drying, and all
other product-specific instructions are
recommended.
 For small restorations, the resin composite may
be inserted and cured in one increment unless
esthetic considerations call for layering to
achieve appropriate shading.
 For restorations that are moderate to large in
size, the first increment of resin composite
should be placed from about the midpoint of the
gingival floor to the incisal or occlusal
cavosurface margin and light polymerized. The
second increment can then fill the remainder of
the preparation.
 Larger preparations may require more than two
increments. Resin composite should be placed
in increments no thicker than 2 mm to ensure
adequate penetration of light for polymerization.
Classification of NCCLs according to their depth.
 To preserve the cementum or dentin at the
gingival margin, careful finishing with a no. 12 or
12B scalpel blade is recommended. Diamond
burs, carbide finishing burs, or aluminum oxide
disks may be used for contouring. Polishing
may be performed with progressively finer-grit
disks or abrasive-impregnated rubber points or
cups.
 Rebonding is recommended for Class 5
restorations.
Incremental layering technique.
309 Chapter 12 Class V (Cervical) Restorations 309

(The following shows step by step

composite restoration of NCCL)

Figure 12.7(a) non-carious cervical lesion

Figure 12.7(b) shade determination

Figure 12.7(c) rubber dam isolation using a No. 212M

retraction clamp Figure 12.7(e) acid etching, rinsing & blot drying

Figure 12.7(d) .bevel on enamel margin Figure 12.7(f) Application of the adhesive system
310 Clinical Operative Dentistry 310

Figure 12.7(g) application of increments of dentin shade composite

Figure 12.7(h) application of enamel shade composite and surface smoothening with a flat brush

Figure 12.7(i) application of an oxygen blocking gel and light-curing through it; s after the polymerization, it can
be observed the absence of the superficial shiny oxygen inhibited layer

Figure 12.7(j) marginal finishing of the with a fine grit conical diamond point with non-cutting tip. Note that To
preserve the cementum or dentin at the gingival margin, careful finishing with a no. 12 or 12B scalpel blade is
recommended.
311 Chapter 12 Class V (Cervical) Restorations 311

Figure 12.7(k) polishing

Figure 12.7 (l) final result

Flowable resin composite Restoration of non-carious cervical lesion with

flowable composite.

Flowable resin composites have been recommended Glass ionomer and RMGI (Figures 12.8 a-i)
for Class 5 restorations with the suggestion that, as
Traditional glass-ionomer materials suffer surface
the tooth flexes, the less rigid restoration might be
degradation rather rapidly, especially in the
able to accommodate the change in cavity shape and
presence of acidic foods.
therefore be more difficult to dislodge.

Tooth preparation:
 The preparation for glass-ionomer restorations
is similar to that for dental amalgam but without
the mechanical retention (no box shape).
 Cavosurface bevels are not recommended for
the preparation because glass ionomer is a
brittle material that requires bulk for strength.
 A 90-degree butt joint approximately 1 mm deep
is a reasonable minimum thickness.
312 Clinical Operative Dentistry 312

Light cure type:

 After cavity conditioning and placement of RMGI
material into the preparation, it is light activated
in a manner similar to light curing of resin
composite. The use of a clear cervical matrix is
optional.
 Most instructions for use recommend a delay of
2 to 5 minutes before polishing.

Self-cured type:
 Placement of cement under moderate pressure
is desirable to ensure optimum adaptation of the
cement to the underlying tooth structure. For
this, a preformed soft tin matrix is
recommended. Before mixing, a matrix of
suitable size and shape is selected and curved
slightly to confirm to the contour of the tooth.
 The material is inserted into the lesion either
with a hand instrument or by a syringe and the
matrix held in position until the cement shows
an initial set.
 In certain cases the contour attained is such that
no further adjustments are needed and the high
gloss is retained.
 The restoration surface in its initial stages of
setting is protected by applying cavity varnish
or light cure resin bonding agents.
 Only gross excess at the margins should be
Restoration of NCCLs using conventional GIC.
removed at this appointment. The restoration is Note that GIC is opaque and relatively
finally contoured and polished after at least one unaesthetic.
day and if possible after one week.
 Class V RMGIs were retained, which exceeded (The following shows step by step GIC
the success of composites and far exceeded restoration of NCCL)
that of conventional glass ionomers. A review of
Class V restorations concluded that glass-
ionomer materials (both conventional and resin-
modified) showed the highest retention rates.

Both self-cured and light cured types of glass

ionomers are available. But resin modified light
cured glass ionomers are preferred because of their:
 Extended working time.
 Improved physical properties.
 Better esthetics.

Figure 12.8(a) initial aspect of the non-carious

cervical lesions
313 Chapter 12 Class V (Cervical) Restorations 313

Figure 1 Clear Cervical matrices (TDV) Figure 12.8(d) positioning of the matrix before
light-curing

Figure 12.8(e) restorative material application

using Centrix syringe

Figure 12.8(b) placement of the gingival retraction

cord

Figure 12.8(f) fitting test of the cervical matrix

Figure 12.8(g) application of the glaze coating

Figure 12.8(c) primer application (Vitremer, 3M)&

light-curing of the primer coat
314 Clinical Operative Dentistry 314

Figure 12.8(h) polishing with abrasive rubber

(Silicone tips, Microdont) after 7 days

Figure 12.8(i) final result of using RMGI in

restoration of NCCLs.
Glass-ionomer sandwich technique

 Because autocured glass-ionomer materials

often provide less-than-optimal esthetics, some The sandwich technique combines a glass-
ionomer base with a veneer of resin composite.
clinicians use the sandwich technique.
 Glass ionomer is used to replace the missing Compomer
dentin, reduce leakage, improve the potential for
tissue attachment for subgingival restorations, Most physical properties of compomers are inferior
and potentially increase retention. A veneer of to those of conventional resin composites however,
resin composite is placed to enhance esthetics, compomers have very favorable handling
increase color stability, improve marginal characteristics. Specifically, their lack of
performance, provide a smoother surface, and “stickiness” has brought them ready acceptance in
increase abrasion resistance. the marketplace. However, the marginal integrity of
 In one clinical study using the sandwich compomers has been worse than that of resin
technique, a 100% retention rate was reported composites in long-term clinical trials.
after 3years demonstrating the success rates
attainable with this type of restoration.

Sandwich restoration.
315
317 Chapter 13 Dentin Hypersensitivity 317

DEFINITION ETIOLOGY

 Dentin hypersensitivity is defined as short and

sharp painful sensitivity, triggered by tactile,  Dentin hypersensitivity may occur when dentin
thermal, chemical, osmotic, or evaporative is exposed to the oral environment, as a result
stimuli applied to exposed dentin. either of enamel loss or of root exposure with
 It is not related to any other pathology, so loss of cementum.
conditions with similar symptoms, i.e., cracked  The main reason for enamel loss is tooth wear
tooth syndrome, chipped teeth, fractured by erosion, abrasion, abfraction, and/or attrition.
restorations, postoperative sensitivity, or  Especially, patients with gingival recessions are
pulpitis, have to be excluded. affected from dentin hypersensitivity.
 Dentin hypersensitivity can also occur as
consequence of periodontitis or periodontal
treatment.
 Scaling and root planning might lead to
hypersensitivity in symptom-free teeth and
increased hypersensitivity in already affected
teeth.
 However, exposed dentin is not necessarily
associated with hypersensitivity, as
permeability is reduced in sclerotic dentin.

Scanning electron microscopic image of a dentin

surface with open tubules

EPIDEMIOLOGY

 Premolars are more often affected from dentin

hypersensitivity than molars and canine.
 It is slightly more prevalent in the upper jaw than
Recessions at mandibular incisors due to
in the lower jaw. exaggerated brushing
 It is more prevalent on patients with periodontal
problems.
 A peak of dentin hypersensitivity can be
observed in patients around 30 to 40 years. In
older patients, dentin hypersensitivity is
probably reduced due to tertiary dentin
formation and a lower number of teeth.
 There is higher prevalence of dentin
hypersensitivity in female patients, which might
exhibit a more healthy lifestyle (e.g., more
extensively brushing, higher consumption of
“healthy, “potentially erosive food) compared to
men.
Patient with severe erosive tooth wear due to
bulimia
318 Clinical Operative Dentistry 318

Hydrodynamic theory causing dentin sensitivity

due to dentinal fluid movement.

Abrasive tooth wear and recession due to tooth

brushing with self-made very abrasive toothpaste

Erosion of cementum and exposure of

dentinal tubules.

Various stimuli causing dentinal fluid movement

DENTIN HYPERSENSITIVITY and dentin sensitivity
MECHANISM

The most accepted mechanism defining dentin DIAGNOSIS

hypersensitivity is based on the hydrodynamic
theory:
 Pain characteristics should be recorded:
 This theory proposes that dentin - Stimulus: (drinking or eating hot, cold, or acidic
hypersensitivity is the result of rapid fluid drinks or food or during tooth brushing).
movement in the dentin tubules due to external - Site, severity, duration, character.
stimuli, typically thermal, tactile, evaporative,
 Then, information about personal behavior
osmotic, and chemical triggers.
patterns (consumption of acidic food or drinks,
 Stimulus-induced fluid flow might activate nerve intrinsic erosion, toothbrushing) and about
endings at the dentin-pulp interface.
previous dental treatment (restorative
 The sudden movement of dentin fluids might be treatment, dental bleaching, periodontal
directed outward or inward, depending on the treatment) should be obtained before a clinical
kind of stimuli. Cooling, drying, evaporation, examination is undertaken.
and hypertonic solutions produce an outward
 During clinical examination, conditions with
flow, which generates more pain than inward
similar symptoms, i.e., caries, fracture
flow due to heat application.
restorations, teeth, postoperative sensitivity,
microleakage, or pulpitis, must be excluded.
 If dentin exposure due to enamel loss or root
exposure can be detected, tactile (dental
319 Chapter 13 Dentin Hypersensitivity 319

explorer) and thermal/evaporative stimulation  Restrict intake of acidic foods and acid
(air stream) should be performed. Ideally, two producing diet.
different stimuli should be applied to confirm the  ‘Drink only’; do not sip or swish acid beverages.
diagnosis.  Do not brush immediately before or after an acid
 Osmotic stimulation can be tested by the intake.
following: After isolation of the test tooth, a  Correct ill-fitting metal clasps or denture.
cotton applicator saturated with the sucrose  Correction of abnormal habits like holding pins
solution is applied to the root surface of the or pipes, nail biting, etc.
tooth and allowed to remain in place for 10  Topical fluoride application.
seconds. The tooth surface is later rinsed with  Enhance defense mechanism of the body by
warm water. increasing salivary flow; for example, by
chewing sugar free chewing gum.

MANAGEMENT OF DENTIN Non and Minimally Invasive Treatment

HYPERSENSITIVITY
 The noninvasive treatment of dentin
hypersensitivity comprises the occlusion of
The management of dentin hypersensitivity usually
dentinal tubules or nerve desensitization.
follows a stepwise approach based on the extent and
 For Partial obliteration of dentinal tubules, a
severity of the condition:
smear layer can be formed by Burnishing of
 Potential risk factors for tooth wear and gingival
dentin with a toothpick or orange wood stick.
recession (diet, intrinsic erosion, oral hygiene,
(Smear layer consists of small amorphous
etc.) must be identified and eliminated or at least
particles of dentin, minerals and organic matrix-
modified (dietary advice, oral hygiene advice).
denatured collagen).
 Non- and minimally invasive strategies include
 For occlusion of dentinal tubules by mineral
the application of products, which aim to
precipitation, various products containing
suppress the pulpal nerve response or to
strontium, arginine, stannous fluoride, or
mechanically occlude dentinal tubules;
calcium compounds have been developed.
products can be self-applied at home (e.g.,
 Nerve desensitization is induced by agents
toothpastes) or professionally applied (e.g.,
containing potassium salts.
sealants) in the dental office.
 At-home treatment of dentin hypersensitivity is
 If dentin hypersensitivity persists and goes
mainly done by desensitizing toothpastes.
along with a cervical defect or gingival
Toothpastes containing potassium, stannous
recession, restorative treatment or
fluoride, calcium sodium phosphosilicate,
mucogingival surgery can be considered.
arginine, and nano-hydroxyapatite presented a
 Prior to treating sensitive root surfaces, hard or
significant desensitizing effect due to mineral
soft deposits should be removed from the teeth.
precipitation in the dentinal tubules, while
Root planing may cause considerable
strontium or amorphous calcium phosphate-
discomfort, in that case teeth should be
containing toothpastes were less effective.( the
anesthetized prior to treatment. The teeth
use of desensitizing toothpastes require
should be isolated and dried with warm air.
continuation of use for weeks or months, or
longer, to maintain the therapeutic effect).
Elimination or Reduction of Etiological  Oxalates: Oxalates are relatively inexpensive,
Factors: easy-to apply and well-tolerated by patients.
Potassium oxalate and ferric oxalate solution
Following preventive measures should be taken to make available oxalate ions that can react with
prevent unusual tooth loss: calcium ions in the dentin fluid to form insoluble
 Proper toothbrushing technique using soft calcium oxalate crystals that are deposited in
bristle toothbrush. the apertures of the dentinal tubules.
 Use of less abrasive dentifrice.  A large number of prophylaxis pastes and
 Correct occlusal disharmony to reduce occlusal varnishes are available for professional
stresses. application. Prophylaxis pastes containing
arginine and calcium carbonate or calcium
320 Clinical Operative Dentistry 320

sodium phosphosilicate were shown to have

some effect on dentin hypersensitivity.
 Varnishes form a waterproof film on the surface
leading to some physical occlusion of the
dentinal tubules. Fluoride varnishes (Duraflor)
form calcium-fluoride precipitates and
fluorapatite which occlude dentin tubules and
reduced dentin hypersensitivity for several
weeks.
 Finally, dental adhesives or sealants can be
used for physical occlusion of dentinal tubules.
The area of sensitive dentin is cleansed and
Commonly used home care products for dentin
etched with an acid conditioner for 5 seconds. hypersensitivity.
The dentin is then dehydrated with a continuous
blast of air for at least 15 to 20 seconds in order
to dry the outer part of the dentinal tubules. A
drop of a bonding agent is then applied to the
dentin and cured.
 GLUMA is a dentin bonding system that
includes glutaraldehyde primer and 35% HEMA
(hydroxyethyl methacrylate). It provides an
attachment to dentin, i.e. immediate and strong.
GLUMA has been found to be highly effective
when other methods of treatment failed to
provide relief.

Application of a desensitizing dental adhesive for

mechanical blocking of dentin tubules. a Drying of
dentin surface with air stream, b product
application, c slight drying, d light-curing, e cervical
area covered by the material.

Invasive Treatment

 If dentin hypersensitivity is associated with a

significant loss of dental hard tissue, restoration
Desensitizing agents. of the defect is a valid option, especially if non-
and minimally invasive treatment failed. The
restoration of non-carious cervical lesions can
be done with various materials such as resin
modified glass ionomer and resin composite.
 Chapter 13 Dentin Hypersensitivity
321

 In case of gingival recession, surgical

therapy for root coverage can be performed,
leading to significant reduction of dentin
hypersensitivity.
 If gingival recessions are associated with
non-carious cervical lesions, a combined
restorative surgical approach can be
considered.
323
325 Chapter 14 Cracked Teeth 325

DEFINITIONS

 Cracked teeth belong to longitudinal tooth

fractures, which can be subdivided into craze
lines, fractured cusps, cracked teeth, split teeth,
and vertical root fractures.
 Cracked tooth syndrome describes a group of
clinical signs and symptoms associated to the
presence of incomplete fractures involving
enamel and dentin, often extending to the pulpal
chamber and/or periodontal area, usually
directed mesio-distally.
 Craze lines extend over marginal ridges and
buccal and lingual surfaces in posterior teeth
and appear as long vertical lines in anterior teeth
but are confined to enamel.
 Fractured cusps, cracked teeth, and split teeth
begin occlusally and extend apically.
 Fractured cusps are defined as complete or
incomplete fracture involving at least two
aspects of the cusp and extending to the
cervical third of the crown or the root.
 In contrast to fractured cusps, cracked teeth are
centered and the depth on the root varies.
 Progression of a cracked tooth results in a split
tooth, which is defined as complete fracture
initiated from the crown and extending to the
middle or apical part of the root.
 Vertical root fractures are initiated from the root
and may involve one or both buccal and lingual
proximal surfaces.

Cracked teeth. A) Incomplete fracture with

mesiodistal direction observed on the pulpal and
gingival walls of tooth 46 after removal of an
extensive restoration; b) mesiodistal incomplete
fracture on upper molar observed after removal
of an occlusal amalgam restoration; c)tooth 17
Craze lines in enamel
presenting partial loss of amalgam restoration
and the presence of a crack line with buccal-
lingual direction. D) Tooth 16 after removal of
extensive restoration. The fracture lines can be
observed on the lingual groove and on the
linguogingival line angle (arrows)
326 Clinical Operative Dentistry 326

EPIDEMIOLOGY

 Cracked teeth are more prevalent at middle-aged

and older patients.
 Molars are more often affected than premolars.
Mandibular molars are the most frequently
involved.
 It is also discussed that higher masticatory
forces in men might be responsible for a higher
prevalence of cracked teeth.
 Cracks occur in intact and restored teeth. If
cracks occur in restored teeth, those with
nonbonded restorations, such as gold and
amalgam, are more often affected than teeth
with bonded restorations (composite) or
crowns.

ETIOLOGY

Cusp fracture. A) Fractured lingual cusp of

 Natural predisposing factors responsible for the
symptomatic tooth , disclosed by caries lesion
indicator solution (5% basic fuchsin), B)cusp development and progression of cracks in intact
fracture on gingival level was confirmed during teeth include morphological and physical
the restorative procedure factors, such as sudden biting on hard
substances, eccentric contacts and
interferences, wear, bruxism, malocclusion and
anatomic form of the cusps, and the occlusal
morphology (so-called wedging effect).
 Eating course food, chewing on hard objects,
and unilateral mastication were identified as risk
factors for cracked teeth.
 The fracture resistance of teeth is also reduced
in the presence of carious lesions, requiring
extensive preparation and resulting in large
and/or deep cavities.
 Occlusal load stress during mastication and
repeated thermal expansion of restorative
Split tooth. Mesiodistal fracture extending to the material might cause an increased cuspal
apical part of the root flexure inducing stress at sharp internal line
angles of the cavity (gold, amalgam) and
AIM OF CRACK IDENTIFICATION producing microcracks.
 Stress concentration due to pin placement,
physical forces during luting of indirect
An early diagnosis and correct treatment plan thus: restoration, non-incremental placement of
composite restorations, etc. might predispose
 Treating the tooth and maintaining its vitality crack formation.
and function. Note that:
 Avoiding the fracture progression which would  Intact, non-restored teeth often exhibit tooth
lead to complete fracture and possible tooth cracks at the surface, developing in enamel or at
loss. the DEJ, which might progress into dentin, but
are less likely to cause tooth fracture.
327 Chapter 14 Cracked Teeth 327

 Tooth fracture is more likely to occur from  Visual detection of cracks is improved by using
dentin cracks, which might be a result of magnifying loupes/microscopes, dyes,
restorative procedures (e.g., removal of tooth fiberoptic transillumination, or light-induced
structure) or fatigue caused by the restoration fluorescence.
geometry.  In case of restored teeth, especially in case of
amalgam fillings or gold restorations, removal of
restorations is necessary to detect fracture
DIAGNOSIS lines. Then, wedging forces can be applied to
determine if tooth segments are separable (split
tooth) or not (cracked tooth).
 pain:
 As differential diagnosis dentin hypersensivity,
 The main clinical signs and symptoms of
postoperative sensitivity, fractured restorations,
cracked teeth are acute pain of short duration on
occlusal trauma or parafunctions must be
biting/chewing and sometimes on the release of
considered.
pressure (rebound pain) and/or sensitivity to
cold thermal stimuli.
 Also pain may occur after taking sugar or grainy
food.
 Symptoms might be present for periods ranging
from weeks to month, and patients might have
difficulties in identifying the affected tooth.
 In the absence of pulpal inflammation, vitality
testing usually gives a positive response, but an
exaggerated response to cold thermal stimuli is
possible.
 The pulpal and periapical diagnosis depends on
the extent and orientation of the crack. Cracks
might become colonized by bacteria arranged in
biofilms, which might reach the pulp and
periodontal ligament if the crack progresses.
Cracks with pulpal involvement might result in
pulpitis or pulp necrosis, which makes the
diagnosis of cracked teeth sometimes
challenging.
 Periodontal probing is necessary to disclose the
Instrument for detecting cracked teeth. A) The
depth of the crack. Cracked teeth with instrument (FracFinder) presents a flat and non-
periodontal probing depths exceeding 4 mm are skid surface to rest on the opposing tooth of that
more likely to show pulp necrosis than cracked being tested. The opposite surface presents a
concavity that can be adapted to the suspected
teeth with a periodontal probing depth of 3 mm
cusp, concentrating the load on the individual
or less. cusp. B) Test being performed on buccal cusp of
 Radiographic examination rarely improves the tooth 24. c) Test being performed on the same
tooth but on lingual cusp
detection of cracks, as fractures in mesiodistal
direction are usually not visible, but is essential
to determine the periodontal and periapical
status.
 Symptoms can be provoked by loading of
individual cusps (so-called bite test) by specific
instruments (Tooth Slooth – Professional Result
and FracFinder – Denbur). Each cusp should be
tested separately.
 Biting tests can be also performed with wood
sticks or cotton rolls, but instruments were
shown to be more reliable.
328 Clinical Operative Dentistry 328

Tooth Slooth bite test.

Tooth 46 presenting incomplete fracture and rebound

pain reported by the patient during mastication. A)
Clinical aspect of the occlusal surface showing a class
I amalgam restoration; b) lingual view of the tooth,
showing a clinically detected fracture line at the
lingual groove extended gingivally (arrow); c) fracture
line observed after removal of the restoration at the
linguogingival line angle on the distolingual cusp
(arrow). The fracture was evinced by a plaque
disclosing solution

Load test and devices used to stimulate painful

symptoms during the detection of cracked teeth. a
Test performed with wooden tongue depressor; b
test being performed with cotton roll. Both tests
might detect teeth with fracture, but specific
detection of the involved cusp is not clear
329 Chapter 14 Cracked Teeth 329

MECHANISM OF PAIN CAUSED BY

CRACK

 The pain associated with loading or loading

release is explained by the movement of
dentinal fluid due to movement of fractures sites
(hydrodynamic theory).
 In this case, the painful response is fast and
intense due to activation of Type A myelinated
nerve fibers.
 Pain related to pulp inflammation is
characterized by a short, sharp pain, indicative
of A-delta fiber activation, followed by a
prolonged, dull ache, indicative of C-fiber
activation.

MANAGEMENT OF CRACKED TEETH

 Early diagnosis is very important to reduce

Fiber-optic transillumination for detection of progression and, thus, involvement of pulp and
cracks. A) Aspect of the cracked teeth under periodontium.
natural light; b) fractures clearly visible under
 Ideally, predisposing factors should be
transillumination
controlled to avoid the formation of cracks.
 Treatment of longitudinal fractures depends on
the extent and depth. Root canal treatment
might be necessary in case of pulpal
inflammation/ necrosis. If the crack extends to
the root surface and leads to extensive
attachment loss, extraction or – in case of multi
root teeth– hemisection/root amputation must
be considered.
 Restorative treatment of incomplete coronal
fractures not involving pulp or periodontium
aims to immobilize and bind the fractured
segments. If possible, the margins of the
restoration should cover the crack to its full
extent.
 Alternatively, the placement of direct composite
splints for short-term management of cracked
teeth is suggested, but comes along with
transient side effects e.g., problems with
chewing.
 In many cases, initial treatment can be
performed by placing intracoronal composite
restorations to control crack progression. If
treatment leads to an improvement or complete
Observation of tooth cracks by light-induced relief of symptoms. Composite restorations can
fluorescence using intraoral QLF camera
be also considered for permanent treatment. No
(Qraypen, Inspektor Research Systems). A) m
Tooth illuminated by white light. B) Tooth failures were observed when composite
illuminated by blue light, showing red restorations were performed with cuspal
fluorescence in the cracks due to the bacterial coverage. 70% were free of any symptoms
penetration
330 Clinical Operative Dentistry 330

during the observation period. Another study

evaluated cracked teeth restored with indirect
composite onlays and found 93% of teeth free of
symptoms after an observation period of 6
years.
 Others prefer full coverage crown on cracked
tooth.

Prognosis

 In vital and asymptomatic or newly symptomatic

teeth, pulpal inflammation is considered
reversible, and restorative treatment of the
cracked tooth is in focus.
 However, late diagnosis or crack propagation
might lead to irreversible pulpitis or pulp
necrosis making root canal treatment
necessary.
 The prognosis is less favorable in teeth with
deep probing depth, which indicates that the
crack progressed into the root surface. Teeth
with a probing depth of more than 6 mm again
had a worse prognosis compared to teeth with a
probing depth of less than 6 mm. Moreover,
cracks with extension onto the pulpal floor
increased the risk of the tooth being extracted.