Operative Gold inlays / onlays Indications Inlays No specific indication for a gold inlay amalgam or composite can be used

sed in virtually every situation a gold inlay can be used. Large carious lesions or defective restorations - when restoration replaces more than 2/3 of the intercuspal distance. o It only surrounds the cusp and holds it to prevent tooth split. Cracked -teeth- incomplete vertical fracture of teeth (i.e. fracture not propagated into pulp chamber). o an onlay will hold the 2th together unless the crack goes down to the pulp chamber. Endodontically treated teeth- after RCT teeth dehydrate and become more prone to fracture; cuspal coverage is a must after endo treatment. Re-establishment of occlusal plane- can significantly adjust plane of occlusion for a single tooth or entire arch without placing full coverage. Prevention of galvanism- gold is very resistant to tarnish and corrosion; if pt. already has numerous gold restorations, continue to use gold. Patient Preference- gold more esthetic than silver; no mercury:

Advantages Strength- little possibility of fracture or marginal breakdown over time; can support occlusal forces. (Gold is strong, but soft) Wear- will not damage adjacent teeth under occlusal load; will deform over time under sufficient loading. (does not undergo marginal breakdown) Anatomy- laboratory fabrication allows control of contact contour and anatomy; more control with large restorations and when margins are subgingival. Conservative Preparation- much more tooth structure conserved vs. preparation for full coverage. (crown) Cementation- can be cemented with fluoride releasing glass ionomer cement. Disadvantages: Cost- less than a crown, but not routinely covered by insurance providers at full cost. Time- technique sensitive; requires two patient visits because of laboratory fabrication. Esthetics- not as esthetic as porcelain or composite restorations When to Onlay Cusp Whenever bucco-lingual width of the cavity preparation is: o 1/2 the way between central groove and cusp tip - consider cuspal coverage. o 2/3 of the way between central groove and the cusp tips - must onlay the cusps when cusps are undermined after caries removal. when both marginal ridges have been compromised, consider cuspal coverage. when patient has a history of fracture

Preparation External Form o Similar to amalgam preparation with important modifications: Occlusal outline of inlay prep extended to include all non coalesced fissures Buccal and lingual walls of box have secondary flare and are divergent occlusally. No reverse S present on buccal. 30, 0.5 to 1.0 mm bevel present on gingival floor (placed with a fine grit diamond bur) ; bevel blends with secondary buccal and lingual flares. The counter bevel is bigger than the normal bevel on the functional cusp Internal Form o Occlusal depth is approximately 1.5mm o All walls prepared with a 2 - 5 occlusal divergence (prepared with a #169 and #271 fissure bur).

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Rounded internal line angles produced by #271 relieve internal stresses in tooth. 30 bevel at occlusal cavosurface aids in seating and makes gold margins bumishable. Remaining caries or old restoration is removed with a round bur or spoon. Pulpal and axial wall depths placed entirely in dentin just inside the DEJ.

Traditional Gold Inlay Preparation (cuspal coverage) Functional cusp - reduce 1.5 mm with depth cuts to preserve the incline angle; place counter-bevel to allow adequate thickness of metal (30) over cusp tip. Non Functional cusp - Reduce 1.0 mm with depth cuts; counter-bevel placed. Internal buccal / lingual walls less than 1 mm tall have only 2 occlusal divergence.

Bases and Liners Placed only on axial wall and pulpal floor when necessary. CaOH placed only in deepest part of preparation to protect pulp (upon exposure, then covered with glass ionomer). Glass lonomer or zinc phosphate cement placed as a base to build the prep to ideal depth and form Base must be smooth and retained during impression. Should build the prep to ideal form. No-Nos of bases and liners: o Should not be placed on the gingival floor. o Should not extend onto facial or lingual enamel walls. o Should not be relied on for support of restoration. o Should not be relied on for retention.

lmpressions Use any crown and bridge quality impression material. Place two layers of retraction cord in the sulcus adjacent ti the gingival margin, removing one cord prior to impression. Custom trays the most accurate. Provisional Restorations: IRM- zinc-oxide eugenol placed for any inlay preparation. o Can also be used for onlays if the permanent restoration is delivered within 2 weeks (quickly). o Acrylic temporary: 3 types of acrylic: *Exam Polymethylmethacrylate (Jet / PMMA) Vinylpolyethylmethacrylate (Trim, Snap / VPMMA) Bis-acryl composite- Pro-Temp II, Integrity the most used o Indirect method - acrylic provisionals are formed outside the mouth on stone cast using a template; very time consuming, but, can be very accurate; used to: Long span bridge provisionals Provisionals left in place for a long time. Direct method- acrylic provisionals formed in the mouth at time of prep using template (i.e. preformed crown, alginate impression, stent). Both types can be cemented with Tempbond or IRM (eugenol does not interact well with acrylic); Tempbond NE or other non-eugenol temporary cements are a better choice. Durelon (permanent acrylic cement) can be used if retention might be a problem CaOH can be used when retention is good (very weak as a cement) Provisionals should be placed with light occlusion to prevent supereruption of tooth and prevent destruction of the provisional by heavy occlusal forces. Post-op for patients: Patient should be able to function normally with provisional in place with the following modifications:

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Floss only in a gingival direction, removing the floss buccally below the contact. Avoid sticky foods that might pull the provisional restoration from the tooth. Avoid hard foods that could crush the provisional.

Seating of Casting: Before pt arrival: o Check crown margins and contacts on the die to ensure proper fit. o Inspect internal surface of casting for obvious blebs or bubbles that might interfere with seating. o Disinfect casting with surface disinfectant. Even though they may have done so in the lab. (Good idea) After pt. Arrival: o Remove provisional - elevate with spoon just below the contact. o All intra-oral manipulation of casting should be accomplished with 2 x 2 gauze placed at back of throat to help prevent misadventures. o Remove any remaining temporary cement from surface of tooth, leaving any bases in place. o Place the restoration on the tooth and check proximal contacts with lightly waxed floss, Relieve any heavy contacts with a 12 flute finishing bur. o Inspect restoration margins - looking for open margins. If open margins are found, reinspect internal surface and adjust as necessary. Reseat and inspect the margins- If open persist, : remove casting and apply Fit-Checker or Occlude to internal surface; replace-casting on tooth. Have patient close first in maximum inter cuspation then on a cotton roll. Remove casting, dry, inspect carefully, adjust any prematurities with the appropriate sized round bur on a slow sp handpiece. Reapply Fit Checker or Occlude, replace casting on tooth and reinspect marginal fit; Repeat these steps until margins are closed or the casting is rejected. Occlusion: o Initially check occlusion with Accufllm by marking the bite without the casting in place, then with the casting seated; Red ink side is more visible on gold. o Occlusal markings should be found posterior to and anterior to the restoration; Adjust occlusion as necessary until proper markings are obtained. o Use a boley gauge to check casting thickness prior occlusal surface adjustment. If less than .5 mm thick, may need to adjust opposing dentition. o Check lateral and protrusive excursions by the same method. o Ensure the bite is acceptable to the patient. o Use mylar strips as a final check of occlusion; a snagging or tearing contact should be found anterior to the restoration; If the strip pulls through an area that was previously in contact, further adjustment is necessary.

Seating of Casting: Polishing Casting o Burnishing- burnish margins while on the die or tooth, with any burnisher, working from gold to tooth; This thins the gold and leaves virtually undetectable margins. o Slightly short margins can be closed using this method. o A bitewing radiograph can be taken to verify fit o Casting should fit more tightly after burnishing. o Re-define occlusal anatomy with: Small round burs on slow speed and Finishing burs on high/slow speed; Check casting thickness with boley gauge before starting and during adjustment to prevent perforation. o Restore original finish using shofu points, tripoli, and rouge. Cementation o Clean casting with steam if necessary to remove debris from seating process; disinfect.

Cement casting using any permanent crown and bridge cement, ZnPO4, Rely X, Ketac Cem.

Seating of Casting (Post OP) o After removal of excess cement, advise patient: Not to eat or drink for at least an hour. Eat only soft foods on the side of restoration for the next 24 hours. o Post Cementation Appt. should be scheduled one week later to verify all cement was removed.