FACULTY OF DENTISTRY

UNIVERSITY OF TORONTO

RESTORATIVE DENTISTRY
CLINIC MANUAL

2017
Contents
RESTORATIVE DEPARTMENT PHILOSOPHY.................................................................................... 2
DIAGNOSIS AND MANAGEMENT OF EARLY CARIES IN THE PERMANENT DENTITION.................. 7
DENTINAL CARIES......................................................................................................................... 14
MANAGEMENT OF DEEP CARIES ................................................................................................. 18
PULP PROTECTION PROCEDURES ................................................................................................ 27
DECISION MAKING IN RESTORATION REPLACEMENT ................................................................. 33
SILVER AMALGAM ALLOYS .......................................................................................................... 40
AMALGAM MATRICING PROCEDURES ........................................................................................ 45
AMALGAM POLISHING PROCEDURES .......................................................................................... 58
PIN RETAINED COMPLEX AMALGAMS ......................................................................................... 62
Core Restorations for Vital Teeth prior to Full Crown Coverage ................................................ 69
VITAL TOOTH BLEACHING ............................................................................................................ 72
DENTIN BONDING AND TREATMENT OF CERVICAL LESIONS ...................................................... 78
CLASSIFICATION OF PROPRIETARY DENTIN BONDING SYSTEMS ................................................ 81
Dentin Hypersensitivity ............................................................................................................... 91
COMPOSITE RESIN RESTORATIONS ............................................................................................. 93
FREEHAND (DIRECT) RESIN VENEERS......................................................................................... 102
POSTERIOR COMPOSITES .......................................................................................................... 105
CURRENT DENTAL FILLING MATERIALS – PATIENT INFORMATION .......................................... 107
ROOT CARIES AND CLINICAL USE OF GLASS IONOMER RESTORATIVE CEMENTS ..................... 114
RESTORATION OF THE ENDODONTICALLY TREATED TOOTH .................................................... 122
DIRECT POST AND CORE PROCEDURES ..................................................................................... 127
CAST POST AND CORE PROCEDURES ......................................................................................... 142
Summary of Current Guidelines for Restoration of the Endodontically Treated Tooth ........... 149
CAST RESTORATIONS, CASTING ALLOYS & FINISH LINES ........................................................... 150
PFM CROWN MARGINS ............................................................................................................. 153
TEMPORIZATION AND IMPRESSION PROCEDURES ................................................................... 159
CLINICAL PROCEDURES FOR TEMPORARY CROWN REMOVAL ................................................. 167
CLINICAL PROCEDURES FOR GINGIVAL RETRACTION ................................................................ 169
TAKING THE IMPRESSION .......................................................................................................... 176
CEMENTATION PROCEDURES AND LUTING AGENTS ................................................................ 181
CROWN CEMENTATION PROCEDURES ...................................................................................... 184
CLINICAL USAGE OF LUTING CEMENTS in Faculty Clinics .......................................................... 197
ALL-CERAMIC SYSTEMS.............................................................................................................. 201
Trimming and Polishing Systems Available in Faculty Clinics .................................................... 212
CERAMIC INLAYS and ONLAYS ................................................................................................... 214
PORCELAIN VENEERS ................................................................................................................. 216
REMOVAL OF A SINGLE PORCELAIN BONDED TO METAL CROWN ........................................... 231
APPENDICES ............................................................................................................................... 234
THE SAFETY OF SILVER AMALGAM RESTORATIONS .................................................................. 235
HEALTH CANADA POSITION STATEMENT ON DENTAL AMALGAM 1996 .................................. 243
RESTORATIVE DEPARTMENT PHILOSOPHY

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 RESTORATIVE DEPARTMENT PHILOSOPHY
Teaching in the Operative/Restorative discipline strongly supports and endorses a philosophy
of MAXIMUM CARIES PREVENTION, MINIMAL INTERVENTION DENTISTRY and MAXIMUM
CONSERVATION OF TOOTH STRUCTURE.

This approach is consistent with:

1) The reduced overall incidence and prevalence of dental caries.

2) The increased awareness of the limitations and possible negative effects of operative
intervention.
3) The recognition of the microbial nature of dental caries and the efficacy of disease
management through effective prevention of patient-specific etiology.

The department recognizes three current generalized dentition generations or types which
relate to fluoride exposure and for which treatment needs will differ:-

THE POST-FLUORIDE DENTITION

 Typically under 50 years of age

 Full benefits of optimal fluoride exposure (toothpaste, water etc)
 Vastly decreased caries incidence
 Requires maximum conservation and ongoing prevention

Examples of conservation include: non-operative treatment of non-cavitated lesions, the

preventive resin restoration, the proximal slot preparation, indirect pulp capping techniques
etc.

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THE PRE-FLUORIDE DENTITION

 Typically over 50 years

 Teeth present largely due to restorative care. Heavily restored, requiring careful
maintenance. High tooth fracture risk due to age and extent of restorations.
 Treatment needs complicated by periodontal, endodontic, prosthodontic and aesthetic
considerations.
 High risk of further caries. Require maximum prevention.
 Conservative principles still apply.

Examples of conservation include:

a) maintenance of existing silver amalgam and composite restorations as long as possible
replacing only if caries/fracture or other pathology present
b) avoidance of endodontic treatment through conservative management of deep caries and
appropriate pulp protection
c) reduced need for anterior crowns after endodontic treatment
d) optimal usage of bonding technology
e) avoidance of over-treatment, etc.

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THE GERIATRIC DENTITION

 Aging and pre-fluoride population, retaining greater numbers of teeth.

 Caries, particularly root caries continues to be a significant problem.
 Requires prevention of dentition deterioration in the face of medical and physical
limitations.
 Treatment needs will include provision of function, mouth comfort, freedom from
pathology and adequate aesthetics.
 Conservative principles still apply.

Examples of conservatism include, minimal operative intervention, use of preventive

restorative materials (eg GI) where possible, recognition of the advantages of sound repair
techniques, the importance of root caries prevention, maintenance of existing restorations as
long as possible, patient education etc.

THE RE-RESTORATION CYCLE

 Is the major negative consequence of operative intervention
 Significantly weakens teeth
 Causes increasingly complex restorations
 Increases the incidence of pulp pathology
 Can cause premature tooth loss

Restoration of the tooth does not cure the cause or the disease.

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Restoration failures occur due to:

1. Operator factors  Quality of Care

 Appropriateness of care decisions

 Accurate diagnosis/current knowledge of caries process
 Quality of restorations (margins, peripheral seal, proximal contour and contact,
avoidance of overhangs/damage to pulp/adjacent tooth etc.)

-#25 small proximal distal caries -aggressive over preparation axially and
-decision to treat or observe? gingivally

-irreversible pulpitis necessitated endodontics

-post core and crown now required
-#35 also overtreated now as well!

2. Patient factors  Ongoing caries risk/parafunction etc.

3. Material factors  Properties/technique sensitivity etc

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DIAGNOSIS AND MANAGEMENT OF EARLY CARIES IN
THE PERMANENT DENTITION

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DIAGNOSIS AND MANAGEMENT OF EARLY CARIES IN THE PERMANENT DENTITION

I. Early proximal caries

Diagnosis of early proximal caries is typically achieved through examination of current

bitewing radiographs. In some situations, visual examination of dry teeth under
optimum lightening is used. However, this is not useful in the very early stages of
proximal caries. The following classical line diagram (Figure 1) by IA Darling illustrates
the progress or developmental stages of proximal caries as it starts at the outer surface
of enamel and progresses through enamel into dentin. The diagram correlates
histological findings (top row) with radiographic images (middle row) and clinical
findings (bottom row). Note that true cavitation takes place very late in the progress
of lesion development (stage 6). Before true cavitation occurs, there is always an
opportunity for the lesion to be reversed through remineralization.

Figure (1)

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Once proximal caries is detected, one of the following treatment options must be followed:

a) The lesion can be observed for a period of time while instituting the following preventive
measures to enhance the chances of remineralization:

1. Topical application of fluoride by the dentist

2. The use of fluoride-containing mouthwash at home on routine basis.
3. Review and stress oral hygiene instructions with the patient particularly careful flossing
of the surface where the lesion is located.
4. Dietary analysis to reduce or minimize the intake of sugars/carbohydrates.

On recall examination the lesion should be re-examined (on a bitewing radiograph) to

determine what changes took place, if any, and the situation reassessed accordingly.

b) Elimination of dentinal caries lesion (where cavitation) through operative intervention, ie.
cavity preparation and restoration with a suitable restorative material.

Treatment decision-making

The following conditions represent two possible clinical case scenarios:

Condition A:

A carious lesion appears on bitewing radiograph to be confined to enamel (Figures 2A, 2B and
2C), only preventive treatment (or monitoring) should be instituted in such situation to give a
chance for the decalcified enamel to remineralize and the lesion to “arrest”. Progress of
caries through enamel is a fairly slow process. Enamel caries lesions do not progress into
dentin and can arrest when the milieu is altered and remineralization conditions are provided
(50% of lesions in clinical studies do not progress).

A B C D C

B A D
Figure (2)

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 Condition B:

Operative intervention should only be considered if a carious lesion appears on the bitewing
radiographic image to have penetrated through enamel and a minimum of 0.5 mm into
dentin on a good quality radiograph (Figures 2D). The most conservative operative treatment
should be instituted (slot resin composite or slot amalgam restoration if the occlusal surface is
intact).

Factors to be considered for decisions with regards to dentinal caries:

1. Age of the patient

Preventive treatment is associated with less risk in older than younger individuals. There is
tendency for caries to progress more quickly in teeth of young individuals with poor oral
condition and high sugar diet.

2. Caries susceptibility
Individuals who previously had caries as evidenced by the presence of restorations or who
have numerous active carious lesions are at greater risk of caries progression. Optimal
preventive education, treatment and compliance will be required to change specific caries risk
factors to effect disease arrest and reduction.

3. Oral hygiene condition

Persistent poor oral hygiene may be a contraindication for a preventive treatment option in
borderline situations. However motivation to improve oral hygiene is also necessary to
prevent recurrent caries.

4. Patient's attendance at the dental office

It is difficult to monitor irregular attenders and they may not be good candidates for the most
conservative decision with regards to operative treatment of early dentinal caries. It is
essential that the patient be informed of the presence of early lesions and the consequences
of lack of compliance with preventive advice.

All the above risk factors should be considered as a whole when making decisions and
treatment decisions should never be based on one single factor. Restorations surgically
remove the diseased tooth structure but alone do not address the risk of further disease.
Recurrent caries around restorations and replacement restorations provide the major
operative work in practice today.

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II. Early occlusal caries

Diagnosis of occlusal caries is challenging and all diagnostic techniques provide false
positives and negatives. Diagnosis of early occlusal caries is best achieved through
careful visual and gentle tactile examination of very dry and well-illuminated
surfaces of clean teeth. The visual signs most indicative of dentinal involvement are
CAVITATION and/or the presence of marked decalcification (white) of the fissure wall.
Stained fissures or fissure contents are not a good indicator of caries. Quality bitewing
radiographs are essential to aid in judging the possibility and extent of dentinal
involvement.

In all clinical situations the explorer should be used gently or not at all. In the occlusal
situation the explorer can be useful to carefully remove plaque and debris from
fissures and to feel gently for soft tooth structure or cavitations. However forceful use
of an explorer is contraindicated because such use:

a) can cause iatrogenic cavitation and effect future tooth destruction

b) is capable of introducing or implanting cariogenic bacteria into the fissures
c) adds little or no additional diagnostic information to increase sensitivity or specificity.

Treatment options

a. Preventive treatment as with early proximal caries, however, deep pronounced fissures
and grooves should be sealed with a fissure sealant particularly in the younger individual.
b. Conservative operative intervention involving the placement of a small restoration (PRR) if
signs of dentinal caries are present.

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Treatment decision-making

Condition A
Where there are susceptible, suspicious grooves and/or enamel-only caries and bitewing
radiographs show no evidence of dentinal involvement, only preventive treatment should be
instituted.

Condition B
Where there is cavitation and/or bitewing radiographs show some evidence of dentinal
involvement, conservative operative treatment should be instituted. A small resin composite
restoration is preferred over amalgam as it requires only minimal removal of tooth structure
and can seal the remaining occlusal fissures. There is substantial evidence in the literature
that even early dentinal fissure lesions will not progress further if the occlusal fissures are
optimally sealed.

III. Early facial and lingual caries

Diagnosis is achieved in this case through careful visual examination of dry well-illuminated
surfaces of teeth. The use of the explorer should be done with great care in order to avoid
causing cavitation in an early carious lesion that could have been otherwise treated non-
invasively through the preventive approach. Bitewing radiographs are of little or no value at
the early stages of facial and lingual caries (teeth #42, 41, 31).

Treatment options

1. Preventive treatment as with early proximal caries.

2. Conservative operative intervention involving the placement of a small
restoration.

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Treatment decision-making
In the case of a white spot lesion, distinction has to be made between a developmental white
spot and a carious white spot.
A developmental white spot will be visible when the tooth is either wet or dry. No treatment
is required for the developmental white spot unless requested by the patient for esthetic
purposes.
A carious white spot at its early stages is visible only when the tooth is dried and may
disappear on wetting the tooth. As demineralization advances deeper into enamel, a carious
white spot is visible without drying. For the active carious white spot (ie. not arrested),
preventive treatment should be instituted.

Condition A
Where there is evidence of minimal cavitation with hard enamel floor as evidenced by lack of
softness on gentle tactile examination, only preventive treatment should be instituted.

Condition B
Where there is cavitation with a soft floor (teeth #13, 14, 43, 44 above) conservative operative
treatment should be instituted. A resin composite, glass ionomer or amalgam restoration
should be placed.

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DENTINAL CARIES

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 DENTINAL CARIES

Carious process has progressed through enamel to dentin

Enamel surface may at first be relatively intact (non-cavitated and re-mineralizable)
Enamel surface gradually collapses (cavitation), allowing increased ingress of bacteria
Rate of dentinal destruction increases. Operative treatment now necessary
Bacteria invade deeper dentin, moving more quickly down tubules
CARIOUS PROCESS in DENTIN  Three merging ZONES can be identified:
I Outer Destruction Zone. “Destroyed” dentine (area 4 on figure)
Dentin structure destroyed
Bacterial flora break down collagen
Bacterial invasion extensive
“Dentine” very soft and caseous

II Penetration Zone. “Infected” dentine (area 3 on figure)

Bacteria along tubules in chains
Lactobacilli predominate
Demineralized/softened and infected

III Demineralization Zone. “Affected” dentine (area 2 on figure)

Advancing front of lesion
De-mineralized but not infected, or not heavily infected
No, or few, bacteria
Poor supply of nutrients

(In slow progressing decay there may be a layer of defensive sclerotic dentin between the affected
layer and normal [area 1 on figure] dentin).

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DETECTION:

Transillumination. Light directed through tooth to ascertain cavity “shadow”

Radiography. Interproximal lesions best detected with bitewing film
Dental Explorer on root surfaces. Used gently to feel integrity of surface

DIAGNOSIS:

Diagnosis is not solely detection but involves determination of caries extent and activity.
Diagnosis and appropriate management decisions (encompassing preventive care of
reversible lesions as well as surgical excision of tooth substance) require further information
based on patient factors/disease risk/past history etc.

 Detection does not distinguish active from passive disease, nor acute from chronic.
 Detection must be interpreted very carefully as false positives and negatives occur.
 Particular care is required interpreting the cervical area where no enamel and no bone
(i.e.“cervical burnout”).

TREATMENT OF DENTINAL CARIES

Diagnosis of definite, active, coronal dentinal decay (minimum 0.5mm into dentin on
radiograph) generally indicates the need for cavity preparation and restoration because such
a lesion is cavitated, invariably progresses and non-intervention could lead to the possibility of
symptoms and avoidable pulpal involvement. Early treatment of the active dentinal lesion
should also allow more conservative cavity preparation which, if carried out meticulously, will
conserve tooth structure and should promote tooth longevity. However, it must be
appreciated that operative intervention does not treat the underlying disease. The cause
(etiology) of the presence of decay should always be ascertained in discussion with the
patient and a preventive program initiated or upgraded.

CARIES REMOVAL

1. Soft dentine texture/Lack of normal dentine hardness are major indicators of decay
penetration and soft, infected dentine must be removed
2. Colour of dentine may also be used as a guide but a) acute (rapidly progressing) caries
may be tooth coloured and b) hard, discoloured dentine should not be removed.
3. The objective is to remove all infected and softened dentin. However, clinical judgment
required, and partial caries removal is preferable in deep lesions.
4. Peripheral carious dentin always completely removed first
5. Carious dentin in vicinity of pulp always removed last
6. Total eradication of infection at the dentino-enamel junction is considered critical.
Total eradication of infection in the vicinity of the pulp is not as critical.

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Note: Caries detector dyes are not utilized at the faculty. Although such dyes do stain
carious dentin, they also stain sound circum-pulpal dentin and normal dentin at the
enamel-dentin junction! Susceptibility to dye staining is a feature of reduced mineral
content and has no specificity for infection. "Use of these dyes may result in the
unnecessary removal of sound dentin." (Yip HK et al. Brit Dent J 176: 417-421, 1994).

17
MANAGEMENT OF DEEP CARIES

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 MANAGEMENT OF DEEP CARIES
First priority is preservation of pulp vitality. Two-stage caries excavation must be utilized if
the carious lesion is deep and approaches the pulp on radiograph. (See next section)

The size of a carious lesion is not a reliable indicator of the pulpal condition. Deep
radiographic caries in an asymptomatic, vital tooth can be associated with a relatively normal
pulp condition.

Every precaution should be taken to avoid pulpal exposure, bacterial contamination, heat
production and/or prolonged dehydration.

Cavities can be prepared close to the pulp without permanent damage using burs at any
speed provided that appropriate coolant is used, the subsequent restorative material is non-
irritant, there is removal of significant bacterial contamination and the restoration is well
sealed.

TREATMENT TERMINOLOGY (in order of increasing preparation depth)

1) Sedative Temporary Restoration or Dressing

Simple, quick and expedient placement of ZOE temporary, following removal of
superficial peripheral and central caries, to eliminate pain due to active caries in a vital
tooth, or to halt rampant caries when all significantly carious teeth are temporized
initially and followed by sequential final restoration when there is more time to place
final restorations (3 month minimum does not apply).

2) Stepwise Two-Stage Excavation

Definitive, two-stage removal of deep caries, designed to promote lesion arrest by
changing the cariogenic environment at the initial stage. The initial excavation (60-
80%) does not approach the pulp, thereby reducing the risk of pulp exposure. This is
the preferred approach. All vital, asymptomatic teeth with deep caries on radiograph
should receive definitive 2-stage caries management.

3) Indirect Pulp Capping

Conservative management of deep caries when vicinity of the pulp is approached during
final stages of cavity preparation [rightly or wrongly, a stepwise two-stage excavation was
not planned]. A thin layer of residual infected dentin, which if removed may result in a
pulp exposure, is left in the vicinity of the pulp in order to avoid pulp exposure and the
associated massive bacterial pulp contamination. Re-entry may not be necessary if
remaining infected dentin was minimal and expected to arrest.

4) Direct Pulp Capping

a) Mechanical or Traumatic Pulp Exposure
Pulp exposed accidentally or inadvertently during cavity preparation

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 b) Carious Pulp Exposure
Pulp chamber exposed during caries removal. May be surrounded by infected or
affected dentin. A frank carious exposure with infected dentin at the periphery has
doubtful, if any, reparability. Treatment involves either endodontic therapy or
extraction. A major objective of restorative caries management is to avoid pulp
exposure and maintain tooth vitality by use of 2-stage treatment wherever possible.

I. STEPWISE TWO-STAGE CARIES MANAGEMENT

RATIONALE:

INTENTIONAL 2-STEP PROCEDURE DESIGNED TO MAINTAIN THE VITALITY OF A TOOTH

WITH DEEP CARIES ON RADIOGRAPH by

1. arresting the carious process,

2. avoiding any possibility of pulpal exposure at the initial appointment (i.e. trying
to remove all the deeper layers of decay approaching the pulp),
3. providing a sedative initial temporary restoration,
4. encouraging remineralization of remaining carious dentin and,
5. promoting reparative (3o) dentin formation.

INDICATIONS:

- deep carious lesion in a VITAL TOOTH (largely asymptomatic but which may
have history of sensitivity to temperature changes, sweet foods – even a
pulpitis).
- but exhibiting no persistent and frequent spontaneous pain (e.g. middle of the
night)
- no pain to percussion associated with non-vitality and no radiographic evidence
of periapical pathology, etc.

TECHNIQUE:

- rubber dam must be in place prior to deep dentinal caries management

- establish outline form according to lesion location
- ensure all peripheral (non-pulpal) walls of the preparation are totally devoid of
caries (i.e. all peripheral dentinal caries particularly at the D-E junction)
- remove all obvious, soft, destroyed and heavily infected dentin (60-80%) of
caries
- place adequate thickness of fast-setting Ca(OH)2 if in the vicinity of the pulp

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- temporize with fortified ZOE

- leave for a minimum of 3 months.

- on re-entry, 3 months later:
- with rubber dam in place, carefully remove all the ZOE and Ca(OH)2 to check
appearance of dentin, which in favourable circumstances is changed (increased
mineralization) in texture.
- Carefully remove residual soft caries but leave arrested decay or affected
dentine in the vicinity of the pulp to avoid pulpal exposure wherever possible.
Restore tooth using fast setting Ca(OH) 2 cement in the vicinity of the pulp in all
cases.
- Add a resin-modified cement lining over the calcium hydroxide and use optimal
dentine bonding for the subsequent composite restoration or bonded amalgam
procedure.
bonding - resin or amalgam

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Partial decay removal 6 months after CaOH, ZOE Final caries removal

ZINC OXIDE AND EUGENOL CEMENT ZOE IS IRRITANT IF DIRECTLY ON PULP

i) antibacterial (persistent)
ii) thermal insulation
iii) sedation, palliative to pulp through dentin
iv) chronic irritant if applied directly to pulp (pulp exposure)

Note: (The chief beneficial effect is that ZOE is palliative to the pulp when placed on
dentin, believed to be due to persistent antibacterial properties and “NSAID-like”
effect. Viable bacteria are never found at interface of ZOE and tooth.)

Currently one ZOE cement is available on the clinic floor, for use as a temporary
dressing:

I R M. (Intermediate Restorative Material) (Caulk/Dentsply)

For use as a temporary dressing only. The zinc oxide powder in this type of reinforced ZOE
contains 10-40% finely divided synthetic resins, e.g. polymethylmethacrylate and the liquid is
eugenol with accelerators. Mixed as directed (1 scoop powder to 1 drop liquid) this material
mixes cleanly to give a superior, smooth, long lasting temporary dressing, provided adequate
tooth support is present. Always fluff the powder before dispensing. Drops and scoops can be
variable in amount. What is important is that there is adequate powder to develop a thick,
firm mix. As with all ZOE materials unless the optimum amount of powder is used, strength
properties will be severely reduced. The setting time is too long to recommend this material as
a base material, it is intended only as a temporary or sedative dressing. The compressive
strength of the set material is in the range 5000-8000 p.s.i. (350-560 Kgm/cm2).

SETTING TIME TOO LONG TO RECOMMEND AS BASE MATERIAL

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II. INDIRECT PULP CAPPING

RATIONALE

CONSERVATIVE MANAGEMENT OF DEEP CARIES WHEN VICINITY OF PULP IS

APPROACHED DURING FINAL STAGES OF CAVITY PREPARATION by:
1. avoiding massive bacterial contamination and trauma to pulp associated with pulp
exposure
2. arresting the carious process and placing final restoration without re-entry OR
3. encouraging caries arrest and dentin remineralization by performing a 2-stage procedure
and
4. promoting reparative (3o) dentin formation.

A. If performed as a final restoration – ensure only a minimal amount of infected

dentin or affected dentin remains in vicinity of pulp and all peripheral
softened/infected caries has been removed.

B. If performed as a 2-stage Indirect Pulp Capping procedure:

- There was a significant amount of infected dentin left in the vicinity of the pulp that
should not be left under a final restoration
- At re-entry, gently remove the superficial aspects of the carious dentin that was retained
at first appointment.
- Small amounts of affected or lightly infected dentine generally is changed in character by
the technique and may be sufficiently remineralized to retain. [LEAVE THE
REMINERALIZED DEEPEST LAYER, deep to which there will have been deposited a minimal
amount of 3° dentin]
- BE VERY CAREFUL in instrumenting on re-entry. Even the combined thickness of the
remineralized dentin and 3o dentin may not be more than 0.5 mm and can be readily
broken through with "heavy-handedness".
- Restore with Ca(OH)2 lining, and appropriate additional pulp protection according to the
restorative material utilized (e.g. glass ionomer, DBA sealed composite, resin ‘bonded’
amalgam).
- Re-entry is basically a check to ensure no infected dentin has been left to progress. With
experience a dentist may decide to place a permanent restoration at the first visit.

CRITERIA FOR SUCCESS:

i) Continued pulp vitality (symptomless; verification with pulp tests)
ii) Direct clinical examination of remineralization (if re-entry) and an improved
situation with no exposure on final instrumentation.
iii) Radiographic evidence of obvious remineralization can be cited as a third criterion of
success but only if a radiograph is considered necessary. This may be for other clinical
reasons (e.g. recall bitewings or if substantial caries was left at the first visit). A
radiograph is not mandatory if the tooth is vital and the clinical procedure uneventful.

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III. DIRECT PULP CAPPING

The intent with direct pulp capping is a) to generate a dentin bridge composed of
tertiary or reparative dentin and b) to maintain a vital pulp. The mechanism is initiated
either by a pure calcium hydroxide paste or (preferably) a proprietary hard-setting
calcium hydroxide cement. Clinical results for direct pulp capping will depend on 1)
the capability of the pulp 2) the extent of infection and 3) the presence of a well-
sealed restoration.

[In recent years the concept of pulp capping with dentin bonding (condition, prime,
bond) materials directly applied to the pulp has been suggested. Such an approach
provides no antibacterial effect and has, as yet, no scientific backing. The research
results are equivocal and very variable. IT IS NOT RECOMMENDED]

FACTORS AFFECTING OUTCOME OF PULPAL EXPOSURE

I. PREVIOUS STATE OF PULP. SIGNS and SYMPTOMS.

II. CONTAMINATION. SALIVA/PLAQUE/CARIOUS DENTIN.
III. SIZE OF EXPOSURE. NO MUTILATION BY BUR.
IV. TREATMENT INITIATED. APPROPRIATE MATERIALS.
V. ANATOMICAL POSITION. POTENTIAL FOR CONSTRICTION.

If a pulp perforation occurs, direct pulp capping procedures can only be considered provided:
A. The pulp is VITAL and there are no signs or symptoms of degeneration in the pulp.
B. The exposure has the following characteristics:
1) The exposure is pinpoint (carious) or small (mechanical)
2) The hemorrhage is slight and controllable.
3) The dentin around the exposure is non carious.
C. The field of operation has been kept reasonably uncontaminated.

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 PROCEDURE FOR DIRECT PULP CAPPING

1. Exposure should be avoided and, if occurs, it should be the last event in complete
cavity preparation. Optimal moisture control (best is dental dam) should already be in
place.

2. Cavity floor and exposure site are gently washed with sterile bland solution
(anaesthetic carpule is convenient).

3. Dry gently with sterile cotton pellets around exposure.

4. Flow calcium hydroxide cement over area of perforation.

5. Place RMGI lining (eg Vitrebond) to wider periphery over calcium hydroxide and adjacent
dentin. RMGI provides a better seal than calcium hydroxide.

6. PLACE FINAL RESTORATION (DBA COMPOSITE OR BONDED AMALGAM) THE SAME

DAY. DO NOT TEMPORISE. There is no value to a temporary restoration in this
situation – there is no purpose to re-entry. A permanent restoration means the tooth
will not be submitted to further drilling trauma and, if endodontic treatment
becomes necessary, there is an adequate seal and restoration already present.

7. Advise patient of situation and prognosis. Provide emergency number.

8. Patient note should include:

- site of pulp exposure
- type of pulp exposure (mechanical or carious)
- size of pulp exposure (in mm)
- degree of pulpal hemorrhage and control
- pulp status (Previously symptomatic or asymptomatic? Results of pulp tests)

9. Provide appropriate follow-up diagnostic treatment.

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 SUMMARY OF MANAGEMENT OF DEEP CARIOUS LESION

I. 2-STAGE CARIES REMOVAL ZOE TEMPORARY

3 MONTH RE-ENTER

PERMANENT RESTORATION

II. MECHANICAL EXPOSURE PINPOINT CARIOUS EXPOSURE

DIRECT PULP CAP + PERMANENT RESTORATION

FOLLOW- UP PROTOCOL

III. FRANK CARIOUS EXPOSURE

PULP EXTIRPATION OR EXTRACTION

26
PULP PROTECTION PROCEDURES

27
 PULP PROTECTION FOR AMALGAM RESTORATIONS (Permanent teeth)

Persistent bacterial residue and/or chronic microleakage are considered the major source of
pulpal pathology associated with any restoration. Pulpal protection is designed to minimize
endogenous and exogenous bacterial sources. Other therapeutic effects are associated with
the following alternates:-

A. Cavity Varnish (2 coats):

i) seals tubules
ii) prevents initial microleakage at interface of
iii) helps prevent discolouration of tooth structure

B. Fast Setting Calcium Hydroxide Cement

i) antibacterial (short term)

28
 ii) stimulates reparative (3o) dentin in vicinity of the pulp
iii) stimulates remineralization of affected and/or lightly infected dentin
iv) thermal insulation

Note: (greatest drawback is low physical properties - never use extensively or in bulk where occlusal
loading might result in fracture of overlying restoration).

C. Glass Ionomer (Conventional or Resin-Modified)

i) antibacterial (short term)

ii) chemical bond to dentin without conditioner

29
 iii) low shrinkage
iv) contain/release fluoride and may be anticariogenic
v) thermal insulation
vi) low modulus of elasticity (rigidity) (do not use extensively or in bulk)

D. Amalgam “Bonding” (Resin mediated)

i) seals tubules
ii) creates hybridization layer
iii) allows thin layer of coalesced resin and amalgam
Note: Use for very deep, extensive or large pinned amalgam restorations [See Amalgam
bonding section], particularly those as foundation for extra-coronal coverage [provides
increased short-term retention and minimizes chance of initial symptoms].

30
 SUMMARY OF PULP PROTECTION UNDER AMALGAM RESTORATIONS:

i) CONSERVATIVE TO MEDIUM DEPTH PREPARATIONS -

VARNISH ONLY (2-3 coats)

ii) MEDIUM TO DEEP PREPARATIONS -

G.I. and VARNISH (If extensive perform “bonded” amalgam)

iii) PREPARATIONS IN PROXIMITY TO PULP

Ca(OH)2, G.I. and RESIN “BONDED” AMALGAM

iv) EXTENSIVE, PINNED PREPARATIONS

RESIN-BONDED AMALGAM

NOTE:
- Pulp protection materials should be used with the minimum thickness to achieve the
desired result.

- A base should not be used to replace all lost dentin in an attempt to simulate an ideal
preparation. This adds little benefit and undoubtedly weakens the resistance of the
overlying amalgam to fracture.

31
PULP PROTECTION FOR RESIN RESTORATIONS:

- Marginal microleakage of resins due to polymerization shrinkage and thermal cycling has
been most dramatically reduced by improvements in enamel/dentin bonding techniques;
indeed, optimal bonding procedures can be considered pulp protection.
- The availability of efficacious dentin priming and bonding has decreased the need for
habitual use of lining cements to protect dentin. Brief conditioning followed by
appropriate primers provides a sealed dentinal surface, certainly in the short term. Lining
cements are used in particular clinical situations for their therapeutic properties (e.g.
antibacterial nature of calcium hydroxide in deep situations and glass ionomer
anticariogenic properties) and where bonding procedures are less likely to be successful
(i.e. deep dentin).

Glass Ionomer Lining Cements

GI not directly on pulp
- Glass ionomer liners may be used where deemed appropriate. They are antibacterial,
cariostatic and stronger than calcium hydroxide cements. However, due to their low pH
they are not used directly in the immediate vicinity of the pulp.

For Posterior Composite Resin Restorations:

- Always use resin-modified glass ionomer (Vitrebond 3M) as liner/base in moderate to
deep preparations because of the high risk of future microleakage due to larger size and
greater occlusal masticatory forces on the restoration.
- Calcium hydroxide liner is required under glass ionomer cement if preparation is very close
to the pulp.
- Ensure adequate peripheral dentin is left uncovered to allow sealing with dentin priming
and bonding (resin impregnation).
- Liners must never be placed on, or inadvertently left on enamel walls of cavity preparation
(any cavity preparation, resin or amalgam) – they are soluble in oral fluids and this will
ensure microleakage. Further, for the composite resin restoration cement or liner on
cavity walls prevents enamel/dentine bonding at the site.

32
DECISION MAKING IN RESTORATION REPLACEMENT

33
 DECISION MAKING IN RESTORATION REPLACEMENT
Criteria for the replacement of existing restorations.

Restorations should not be replaced unless 1) the new restoration will significantly improve
the situation 2) the tooth is in danger of continued decay or fracture or 3) the existing
restoration is an etiological factor detrimental to the health of the adjacent teeth or gingival
tissues.

A. Amalgam - Decisions for replacement

i) Major reasons:
a. recurrent caries
b. isthmus fracture
c. tooth fracture
d. significant cervical overhang

Diagnosis:

Recurrent caries is the primary reason for amalgam replacement. Recurrent caries and
cervical overhangs may be detected by examination of bite wing radiographs or by direct
visual and tactile examination. For amalgam restorations 93% of all secondary decay occurs at
the cervical (highest incidence) and approximal margins. Only 7% of all secondary decay
occurs occlusally.

Isthmus fracture and tooth fracture are generally detected by visual and tactile examination.
Sub-clinical fractures (alternate terms - cracked tooth, green stick fracture) may be
problematical to diagnose. Diagnosis may depend upon any or all of the following: visual
examination, history of complaint, sporadic biting sensitivity with or without thermal
sensitivity, simulated function (tooth sleuth) and direct inspection after restoration removal.

34
ii) Minor reasons:
a. marginal degradation
b. poor anatomical form
c. porous surface
d. other reasons

Diagnosis: By visual and tactile sensation

Treatment decision making:

1. Recurrent caries, tooth fracture and isthmus fracture require the removal of the
amalgam, removal of disease if present, modification of preparation and re-restoration
with amalgam.
2. Cervical overhangs, particularly interproximal, are best corrected by restoration
removal and replacement. When access permits, overhangs may be removed with
careful use of rotary instruments (e.g. 7901 F.G.) or abrasive strips. Care must be
taken to avoid damaging cementum or the periodontium.
3. Although marginal breakdown is the second most cited reason for amalgam
replacement in most studies, there is a poor correlation between gaps or size of gaps
at the tooth/margin interface and the presence or absence of caries. Invariably the
interface is “self-sealed” with corrosion products at the crevice base. Replacement
therapy should not be instituted unless there is clear evidence of decalcification in the
marginal area as determined by tactile softness with an explorer.

Treatment Options:

1. In selected situations amalgam restorations with associated defects can be

satisfactorily repaired if the existing restoration is deemed to be otherwise sound.
Examples could include:

a. extensively restored teeth with multiple pins. Total replacement could eliminate
these retentive elements and possibly preclude satisfactory restoration.
b. teeth with recurrent caries, primary caries or minor tooth fractures where access
is direct or convenient and a repair would not alter the clinical acceptability of
the existing amalgam.

2. Defective margins should be observed at periodic recall. Polishing defective

margins which are small may retard the breakdown process.

B. Composite Resins - Reasons for Replacement

a. caries
b. fracture
c. wear
d. postoperative sensitivity

35
 e. open contacts
f. defective margins
g. marginal staining
h. unacceptable body colour
i. poor contour
j. other

Diagnosis:

By visual and tactile sensation (general) and inspection of bite wing radiographs for
radiopaque posterior restorations.

Treatment decision making:

1. Caries is the most serious problem associated with resin restorations: i) when margins
are not located on enamel in Class III, IV and V situations and ii) Class II situations. Any
dark, deep, discoloured region below the surface adjacent to the restoration can be
assumed to be carious.

2. Cavosurface margin or interfacial staining is a common problem associated with

composite resin restorations and is usually an indication of microleakage. The greater
the depth to which discolouration has occurred, the greater the probability that
recurrent caries may develop thus necessitating restoration replacement. Therefore the
decision to retreat should not be based solely on the presence of marginal
discolouration but also on the depth. Many restorations with stained margins can be
left safely as long as they are carefully examined on a regular recall basis. Polishing
stained margins may eliminate the cause and correct the problem in some situations
(e.g. flash).

3. Excessive wear and loss of anatomic form are problems more commonly associated with
posterior composite restorations particularly in large restorations with multiple centric
stops and with some of the earlier composite materials. Excessive generalized wear, as
evidenced by significant exposure of the cavosurface margins and loss of anatomic form,
is an indication for replacement with alternative wear resistant restorative materials.
Localized wear in centric holding areas is difficult to quantify with direct inspection
methods.

36
 4. Marginal fracture or ditching on surfaces subject to high stress, such as the lingual of
Class IIIs and the occlusal surface of posterior composites, is not a serious defect.
These defects do not appear to jeopardize the longevity of the restoration or
encourage recurrent caries. However margin defects in critical areas where a seal may
be absent (gingival margins on cementum, gingival margins of posterior restorations)
should be viewed with a high degree of suspicion.

5. Post operative sensitivity is rarely associated with anterior restorations but is a

significant problem with bonded esthetic posterior restorations. Sensitivity occurs
almost immediately. (Centric and eccentric occlusion should be checked carefully and
adjusted.) Sensitivity may gradually diminish or disappear within a month. Sensitivity
that persists after six weeks can be considered permanent and an indication for
replacement.

6. Colour is a subjective consideration between the operator and the patient.

Treatment Options:

1. Minor defects, not affecting the clinical acceptability of the restoration, may be
repaired (e.g. voids, minor marginal defects in non critical areas). Newly added
composite will not bond well to old composite. Therefore, a retentive preparation, fresh
enamel for bonding and/or microleakage issues must be considered.

37
C. Cast Restorations - Reasons for replacement:
a. recurrent caries
b. loss of retention
c. improve periodontal health
d. material failure (e.g. porcelain fracture, excessive wear)
e. tooth fracture
f. perforation

Diagnosis:
By visual, tactile evaluation and radiographs.

Treatment decision making:

1. Recurrent caries is a significant problem. The radiopaque nature of the restoration

minimizes the operator’s ability to gage the extent of the problem. Replacement
therapy and treatment of the carious condition is generally indicated.
2. Adverse periodontal effects as a result of open margins, over/under contour, closed
embrasures or overhangs generally indicate re-treatment to overcome the problems.
3. Restorations that come off in service, without any associated fracture of the
underlying support structure, are retentive failures. Retention failures are generally
related to the preparation (excessive taper, inadequate length), and to the failure of
the luting material. The preparation should be carefully examined for clinical
acceptability. If inadequate, re-preparation for a new restoration should be
undertaken. Recementation of unacceptable restorations is generally followed by
repeated failures.

Treatment options:

1. Minor marginal defects (recurrent caries, open) in accessible locations can be repaired
with glass ionomer restorative cement or possibly amalgam as long as the restoration is
deemed to be otherwise clinically acceptable.

38
 2. Some porcelain fractures can be repaired. Success rate is generally low and not highly
predictable. Success will depend upon: location of fracture, cause and mode of
fracture (cohesive, adhesive exposing the metal), size, and occlusion. Patient should
be informed about the guarded prognosis for the repair and the possibility of
retreatment as an elective consideration.

References
Mjör, L.A. Frequency of secondary caries at various anatomical locations.
Oper. Dent. 10: 88-92, 1985.

Anusavice, K.J. Quality Evaluation of Dental Restorations, Criteria For

Placement and Replacement, Chicago, Quintessence Pub. Co., 1989.

39
SILVER AMALGAM ALLOYS

40
 SILVER AMALGAM

2 TYPES AVAILABLE:

1. BLENDED (ADMIXED) ALLOYS:

- lathe-cut particles of AgSn blended with AgCu spherical additive (which is the
"dispersed phase")

- Cu content 11-30% optimum 12-20%

- requires 50-52% Hg

The blended alloy available in Clinics is PERMITE (SDI) (15.4% Cu)

- purple top, double spill
- pink top, single spill more Hg needed
- capsules not self-activating
- trituration time: varies according to triturator brand (recommended times are posted
at the clinic dispensary and at other locations in the clinic).

2. SPHERICAL ALLOY:
- mainly a single component system of spherical particles

41
 - each spherical particle consists of Ag Sn Cu (.. "ternary")
Cu content 11-30%, optimum 12-20%.
-
- requires 43-45% Hg less Hg needed
The spherical available in Clinics is TYTIN (Dentsply) (13% Cu)
- grey and blue, double spill
- double blue, single spill
- capsules not self-activating
- trituration time:
double spill: 7 seconds
single spill: 5 seconds

HANDLING CHARACTERISTICS:

1. PERMITE:
Due to the irregular shaped lathe-cut particles, admixed (blended) alloys handle quite
differently than the spherical alloys. They are commonly known to have 'positive
pack', offering a definite resistance to the condenser point during condensation. The
operator should use smaller condenser heads and greater condensation pressure.
This type of alloy is more conducive to the production of a tight contact in Class II
situations. Again proper wedging is essential. The manufacture and particle
morphology also allows a greater working time than spherical alloys (approximately 9-
11 minutes). Permite is the amalgam of choice for all routine restoration of vital teeth
in the clinic. The operator using any amalgam alloy should caution a patient with a new
restoration to refrain from biting/chewing in the first few hours after placement. Fluid

permite = greater working time 42

 nutrition (soup, milk, yoghurt etc.) is usually recommended, if necessary, immediately
following treatment.

2. TYTIN: more likely to have shit contact and overhangs

Tytin is typical of spherical alloys as it produces a highly plastic, easily condensed mix
that is faster setting. The condensing technique should not be the same as that used
for lathe-cut alloys and admixtures. The operator should use a large condenser and,
while these alloys may allow less condensing pressure due to their relatively high
plasticity, they do require adequate technique to ensure good adaptation. Since
condensation resistance is low, special precautions must be taken with a matrix band.
Precontouring of the band and proper wedging are essential to prevent production of
inadequate contact areas and gingival overhangs. The potential for such problems is
greater with this type of alloy.
large condenser, faster setting
Particle shape also influences microleakage. The spherical alloy Tytin has been found
to have a greater tendency for post-operative sensitivity and in-vitro microleakage,
most likely due to its documented setting shrinkage. Although this tendency for
greater microleakage can be overcome by conscientious technique, including angled
condensation, burnishing and post-curve burnishing, spherical alloys are not used
routinely on vital teeth in the clinic. Properly handled Tytin will give a 1-hour
compressive strength of 35,000 psi and at 1 week, 77,000. It is a relatively fast setting
alloy available in fast set, working time 4 minutes (-not available in Faculty) and
regular, working time 6 - 7 minutes. In many instances, this is insufficient working time
for students performing a larger restoration.

Spherical alloys are utilized in the clinic for direct post-core techniques in posterior non
vital teeth, either as an all amalgam post-core or in conjunction with a parapost. Such
post-core restorations can be completed on the same day as crown preparation only if
adequate facial and lingual walls are present and only if a minimum of 1 1/2 - 2 hours
time has lapsed (i.e. a.m. and p.m. sessions). It is better to begin crown preparation on
a subsequent day. Notwithstanding its high early strength, micro-fractures are
introduced into the amalgam mass and this seriously compromises the integrity of the
amalgam.

RESIN-MEDIATED "AMALGAM-BONDING" In recent years, a technique of resin

mediated attachment of silver amalgam to tooth structure has been developed, in an
attempt to utilize proven resin bonding technique to provide tooth reinforcement with
silver amalgam. Essentially the prepared cavity is conditioned, the dentin is primed
and a very thin layer of auto-curing bonding resin (base/catalyst) is used to coat all
internal aspects of enamel and dentin. Immediately, the freshly triturated amalgam is
inserted onto the unset resin and the restoration is completed as usual. An
intermingling of set resin and amalgam creates a mechanical linkage between the two
of 6-8 MPa. The long-term ability of this attachment to withstand biting stresses is

43
tytin = inc'd microleakage
& post op sensitivty --> higher shrinkage
unknown. The true significance of this technique may be the provision of a superior
initial seal by dentin priming, particularly if a spherical alloy is being used.

Spherical amalgam alloys have been documented to show increased microleakage in

vitro and are also associated with a higher incidence of clinical sensitivity. This is
probably due to a higher setting shrinkage and can be off-set by increased lateral
packing and post-carve burnishing.

Clinical experience with the resin-mediated amalgam “bonding” technique has been
positive for the last few of years and it is a valuable adjunct to the clinician. The only
drawback is the cost of the materials (expensive) and it cannot be used if adequate
isolation cannot be achieved. As the true cost-benefit is unknown and as there are no
clinical studies as yet, this procedure remains uncovered by most insurance plans.

In the Faculty clinic this technique is being used only in two specific clinical situations:

a) teeth with pulpal exposures or near exposures, after Ca(OH)2 and rmGI
b) teeth requiring large complex, pinned amalgams.

The auto-cured resin to be utilized is Bond-IT (Jeneric-Pentron).

44
AMALGAM MATRICING PROCEDURES

45
 MATRICING FOR AMALGAM

STUDENTS MUST HAVE THE MATRIXED AND WEDGED TOOTH EXAMINED BY THE
DEMONSTRATOR BEFORE BEGINNING TO CONDENSE. At this stage any problems with
matricing can be intercepted and the necessary modifications made to ensure a satisfactory
restoration. Proper wedging and stabilization of the matrix band are essential.

MATRICING AVAILABLE

A) CONTINUOUS - TOFFLEMIRE
- AUTOMATRIX
- COPPER BAND OR ORTHODONTIC BAND

B) SECTIONAL (not routinely used at the Faculty for amalgam restorations)

A) CONTINOUS - MATRIX BAND IS CONTOURED

(Preferably before it is placed in
Tofflemire retainer) and WEDGED

N.B.- if the matrix is not rigid (as is often the case when the preparation presents with wide
proximal boxes), compound or composite may be used for stabilization.

46
CORRECT PLACEMENT OF WEDGE

If the wedge is placed too high it

collapses the matrix. An unacceptable
contact area and under-contoured
amalgam restoration is the result.

The wedge may require customizing.

47
If an extensive MO, DO or MOD presents with the problem of the Tofflemire matrix band
(when tightened sufficiently to secure its seating) collapsing away from the contact with the
adjacent tooth:

i) with wedge securely in place

- release Tofflemire retainer until matrix band can achieve contact
- then stabilize the band with compound or composite from facial and lingual
or
ii) - condense 1st increment of amalgam on to the gingival seat of the proximal box
- release Tofflemire retainer a small amount to bring the matrix band a little closer
towards contact
- condense another increment of amalgam
- release Tofflemire retainer until the matrix band is closer still to contact
- place another small increment of amalgam and condense well
- release Tofflemire a little more ... and repeat above procedure in just such an
incremental fashion until contact is securely closed. (N.B. for procedure to be
successful wedge must always be securely in position.

NEVER OVERTIGHTEN the Tofflemire to secure the matrix band; studies have shown that, with
such overtightening, the facial and lingual walls of the tooth flex -- squeeze together up to 20
µ and after the amalgam is placed and matrix band removed, these walls spring out that 20 µ
increasing MICROLEAKAGE.

48
MATRIX BANDS

The picture below shows the Regular #1 matrix band at the top. The second band #2 is
for deep proximal restorations. When using the #2 matrix band for an MO or DO with
a very deep gingival seat REMOVE the flange from the proximal area that does not
have the box preparation, otherwise the unnecessary flange:

i) prevents the band from seating

ii) and/or slices the gingiva

number 1

49
 AUTOMATRIX SYSTEM (from Dispensary)

Includes rachet for tightening the automatrix and shielded nippers to cut autolock after use

Autolock loop

Lock-release hole Coil

Indications:
- if several cusps are missing e.g. for a pin-amalgam "build up" with no
cusps or wall remaining. (This is a situation which might call for a
spherical alloy to take advantage of its higher early compressive
strength).
- if attempt at using Tofflemire is unsuccessful.

50
Auto-matrix must be wedged and secured with compound or composite. INSTRUCTOR WILL
DEMONSTRATE ITS USE WHEN REQUIRED.

COPPER BAND (OR ORTHODONTIC BAND) (from Dispensary)

Indications: - same as Automatrix

- can be shaped with contouring pliers (some bands may require prior softening; they can
be softened by heating to redness in a flame and then quenching in water)
- the area of contact must be thinned out with e.g. a green stone.

51
BUT if the pin amalgam build-up is preparatory to a subsequent crown preparation, then:

a) shaping with contouring pliers is not essential

b) thinning out the band is not essential
c) removal of the band at same appointment as amalgam insertion is not essential
- band can be removed in a week or two or at the time the crown preparation is
being done. Check occlusion!!

- (an alternative to the copper band is the circumferential stainless steel preformed
orthodontic band)

COPPER BAND IS REMOVED BY CUTTING BAND WITH A BUR

52
SECTIONAL MATRIX (from Dispensary)

- Cut roll of strip matrix and customize. Stabilize with properly contoured wedge.
- Not routinely used at the Faculty for amalgam restorations

53
PROXIMAL CONTACTS (All Restorations)

If you achieve an inadequate contact, the restoration must be redone. Your instructor is
there to show you a more suitable way to matrix, if you have difficulties.
Multiple restorations. Adjacent restorations must be restored one at a time, i.e. one tooth is
restored (check proximal carefully for overhang and contour), then the second tooth is
matrixed, wedged, restored.
Do not fill two adjacent teeth at the same time, with matrix bands around both: you will not
achieve optimal contacts and this necessitates redoing the restorations

CORRECT EMBRASURE FORM

OVERCARVING AN EMBRASURE UNDER CARVING EMBRASURE -

(Point contact – food impaction (Lack of embrasures – food impaction
Periodontal inflammation). periodontal inflammation).

FACIAL-LINGUAL CONTOUR OF CONTACT AREA

54
PROXIMAL CONTOUR (All Restorations)

One requirement of a matrix for restoration of a Class 2 cavity is to provide proper contour and
contact. The band should establish the anatomic contour and contact so that minimal carving or
contouring of the restoration is needed. Contour is placed in the band with a burnisher or a
contouring instrument. The band must be appropriately wedged and stable.

Non-anatomic contour and marginal overhang/flash are common causes of restoration failure.
The proximity of the proximal gingival cavo-surface margin to the inter-dental gingival tissue, and
the high rate of plaque retention in this locale can cause secondary caries, gingivitis and
periodontal problems if contour and contact are sub-optimal.

The contact point is an important feature of a stable dentition. As the dentition matures, it
stabilizes and the contact points wear into contact areas.

Contact areas:

1) contribute to arch stability - PHYSIOLOGIC SPLINTING

2) prevent food impaction by location and width – PERIODONTAL HEALTH.

Their protective mechanisms become evident when the travel of opposing cusps in a protrusive
and idling excursion is reviewed. Viewed occlusally, contact areas are situated more facially in the
posterior mandibular region and relatively more lingually in the maxillary posterior region.

55
EMBRASURE FORM

An embrasure is defined as the triangular shaped space or area between adjacent teeth where
their proximating surfaces diverge from the area of contact facially (facial embrasure), lingually
(lingual embrasure) occlusally (occlusal or incisal embrasure) and gingivally (gingival embrasure)
etc. Inclines of adjacent marginal ridges form the occlusal embrasures which channel the food off
the contact areas. Incorrectly designed occlusal embrasures foster food impaction in the delicate,
dynamic and protected environment of the interproximal space. When adjacent teeth contact
one another in the arch and the interproximal space is created, a CANOPY is formed to house the
interdental tissue.

Interproximal embrasure space formed by correct contact areas between adjacent teeth
should possess the following features:

1) contact areas should be located at the junction of the occlusal and middle one third of
the proximal surfaces and closer to the facial on mandibular posterior teeth etc. They
should not be located within the occlusal one third.

2) the proximal surfaces should be mirror images in most locations so that a

SYMMETRICAL CANOPY is formed. Most embrasure spaces demonstrate bilateral
symmetry.

3) adjacent marginal ridges are generally and optimally the same height.

4) adjacent cemento-enamel junctions are generally and optimally at the same height.

5) adjacent transitional line angles are symmetrically positioned. A common error in

restorative dentistry is the failure to recognize the transitional line angle location and
form. When this area is overcontoured in a coronal restoration, EVICTION of the
interdental tissue results.

6) a positive contact area (2 mm occlusal-gingiva height) to prevent food impaction and

which contributes to the arch stability.

Correct crown contour and embrasure form prevents debris and plaque retention. These
important features facilitate normal processes of detergent mastication and must be faithfully
addressed whenever possible in restorative dentistry. The contours of the matrix are subject
to the control of the operator and most often they simulate the original tooth form. Specific
clinical considerations may occasionally demand non anatomical form. These decisions will be
determined by clinical judgment.

56
USE OF WEDGES

There is no universal wedge. Wedges must be fitted or customized for the individual intended
space. Pre-operative wedging provides easier access to the gingival seat during preparation
and provides retraction to protect the interdental tissues from laceration and the nuisance of
hemorrhage.

During matricing procedures, the wedge must always be placed well clear of the contact if it is
not to produce a deficient contact. It must not restrict the band from bulging outward to
develop the contact area. A wedge that is too high produces a gingival embrasure that is too
large which displaces the contact occlusally which in turn will encroach on the occlusal
embrasure space. A high wedge then interferes with the development of the physiologic
contact area. Visually check this feature using the mirror.

When correctly positioned against the gingival margin, the wedge serves three functions:

1) to adapt and stabilize the band below the gingival wall to resist any compaction forces
and to avoid any gingival excess.
2) to provide slight separation of the teeth in order to develop a positive contact by
allowing for the thickness of matrix material. [Hellie (1985) has demonstrated the
maximum amount of separation obtained using the wedge is 90 µm for posterior
teeth, with a rebound effect of 33% while the wedge is in place. Once the wedge is
removed the rebound effect is 91% within 60 secs.]
3) to retract and protect the interdental soft tissues and/or rubber dam during tooth
preparation.

Always check for visual proximal contact and appropriate matrix contour before proceeding
to restoration insertion – particularly for composite materials which are not at all packable.
Take time to wedge carefully. Interproximal overhangs are difficult to eliminate due to poor
access and they must not be ignored because of the serious periodontal consequences. If an
overhang is present on a previously placed restoration it is generally more efficient and
economical of time to redo the restoration rather than to traumatize the delicate
interproximal area.

57
AMALGAM POLISHING PROCEDURES

58
 AMALGAM POLISHING

Amalgams cannot be polished until 24hrs have elapsed since amalgam insertion. The purpose of
amalgam ‘polishing’ procedures at the Faculty include:

1. Provision of a smooth, well marginated restoration. (The novice clinician may not achieve
this at insertion).

2. Assurance of a quality restoration with good proximal contact, occlusion and contour with
absence of cervical overhang. (Again, the novice clinician may not achieve this at insertion.
This procedure assures quality restorations leaving the Faculty. Defective restorations
should be modified, repaired or replaced).

3. Provides student an opportunity for self-assessment of work and motivation for clinical
improvement.

NOTE:
An amalgam that is not well condensed will never polish well. An amalgam must be carefully
finished at insertion, carved (including delineation of subtle grooving, margination) and
burnished. An amalgam that is well condensed, carefully carved and burnished requires no
more than a few minutes to ensure good margination and an adequate polish with a blunted
steel finishing bur.

AVAILABLE IN CLINICS FOR AMALGAM POLISHING:

Amalgam polishing bur block:

Contains: .009 round steel finishing bur (for grooves) (pictured below), #4 round steel finishing
bur (pictured below), a pear shaped steel finishing bur (pictured below), large flame shaped
steel finishing bur, narrow flame shaped steel finishing bur, large wheel shaped steel finishing
bur, large round shaped steel finishing bur

59
The only refinement that may be necessary for the proximal of Class II amalgams is the use of a
very narrow gapped abrasive strip (may be necessary to cut strip lengthwise to achieve desired
narrowness so that strip will function gingival to contact area). However this can be painful,
may necessitate L.A. and is best avoided by appropriate insertion procedures and avoidance of
gingival excess.
[N.B. When polishing cervical amalgams or resins or when doing a prophy remember that CEMENTUM ABRADES 35x
faster than enamel and that the cement thickness at the C-E junction is only 20 - 30 microns. Rubber polishing
instruments create high heat after only 10 seconds continuous polishing >150°F which can damage pulp. Extreme
care is required plus non continuous use.]

Amalgam after initial placement

Amalgam after polishing

60
CRITERIA FOR EVALUATION OF FINISHED AND POLISHED RESTORATIONS

1. Anatomy The remaining cuspal planes and grooves should serve as a

guide to carving/contouring. The marginal ridge and triangular
fossa should approximate the anatomy of the natural tooth.

2. Contour It should conform closely to the original contour of the

proximal surface. It will be influenced by the contour of the
matrix band.

3. Contact Should be tight enough to prevent food impaction and pass

dental floss with definite "snap" (do not try this at the
insertion appointment of silver amalgam because of the
danger of compromising the contact). The location and area of
the proximal contact will be determined by the anatomy of the
tooth and tooth alignment.

4. Margins Should blend with the adjacent enamel/root so that the

margins are imperceptible to the tine of an explorer passed
over the surface of the enamel and restoration. No flash or
overhang should be tolerated at the gingival margin.

5. Occlusion The occlusal contact areas and the intensity of the contact
during occlusion as determined by the use of articulating paper
should be the same as other teeth. The new restoration must
not interfere with the occlusion of other teeth. Always use
shimstock on adjacent teeth to ensure occlusal contact is
maintained.

6. Consistency The polished surfaces should be smooth and free of scratches,

porosities, pits, and gross irregularities. An ultra-smooth
surface is particularly desirable adjacent to gingival tissues.

7. Post-operative lavage The oral cavity should be free of all particles of restorative
material and other debris.

61
PIN RETAINED COMPLEX AMALGAMS

62
 PIN RETAINED COMPLEX AMALGAMS

Indications
To replace the dentinal portion of crowns that are so damaged that amalgam, acid etch
composite resins or cast metal veneer restorations lack adequate retention.

Locations for Pin Placement

a) General Considerations

- Prior to pin placement, radiographs of the tooth should be analysed for the
size, number and inclination of the roots.
- Additionally, the tooth should be assessed clinically for rotation or tipping.

b) Favourable Locations

- According to Gourley, the most favourable location for pins in all teeth is in the
line angle areas.
- These areas provide the greatest bulk of dentin between the pulp and external
root surface and the greatest avoidance of internal or external perforations.

c) Unfavourable Locations

- The middle of the buccal and lingual areas. (Abrupt change in root angulation
apical to CEJ or possible furcation involvement).
- Middle of mesial and distal (possible furcation involvement or external root
concavities).

Avoid:
• Midlingual and midfacial of man. Molars
• Mesiobuccal corners of 1st molars (pulp horns)

63
Avoid:
Mesial concavity of max. 1st premolar

Avoid:
Midmesial, midfacial of max. molars
(bifurcations)

Location Related to DEJ

- According to Caputo, pins should be surrounded by 1 mm of sound dentin to avoid pulp or

root perforations.
- Therefore the periphery of the pin channel should be 0.5 (minimum) to 1.0 mm (ideal)
within the DEJ and from any axial wall.

Placement of Pins

a) Gingival Seat
- Pins should be placed on a flat gingival seat and not one inclined to the long
axis of the tooth.

64
b) Countersink
- Before placing pin channel, place a small countersink (dimple) in the centre of
the proposed pin channel with a #1/4 round bur (latch angle) to avoid "skating"
of the twist drill.

c) Twist Drill
- .021" MAX (purple shank) or 0.21" TMS. (plain)* twist drills are not
interchangeable.
- Make sure that the handpiece is set to rotate in the forward position. If you cut
the pinhole with the handpiece set to rotate in the backward position, the
pinhole will be too large to retain the pin.
- Discard dull twist drills.
- Start channel in countersunk hole.
- Cut channel to desired depth using slow speed (200 R.P.M.) to avoid undue
temperature rise in pulp chamber (Cooley).
- Prepare pin channel (keep drill rotating to prevent stalling!) to full depth.
- When doing multiple pins, always finish one pin preparation AND placement,
before proceeding to the next pin preparation. If there are problems with the
twist drill (eg. set in backward position), you will find out when you place the
first pin, and hopefully avoid the same problem with the subsequent pin.

65
Embedment Depth

Optimal depth is 2 mm with 2 mm of pin projecting into the restorative material.

Twist Drill Alignment

Twist drill should parallel the external root surface - obtained by holding the twist drill or a flat
bladed instrument along the external surface of the tooth or root apical to the gingival seat,
next to planned pin placement.

Types of Pins Available:

a) MAX (0.21") self shearing (recommended for general use)

b) Link-Plus (0.21") self shearing.
c) Regular (0.27”) - used when 0.21 pin channel becomes over-enlarged.

Number of Pins

Maximum of 1 pin for each missing line angle, e.g. bicuspid missing 1 cusp - 1-2 pins;
maxillary molar missing all cusps – 3-4 pins. Careful consideration of remaining tooth
structure, clinical situation and functional needs is required to determine optimal number.
Objective is the minimum number of pins for the clinical situation.

Pin Placement Technique (Rubber Dam Mandatory)

a) MAX (0.21") Self-shearing (used with contra angle run at slow speed)
b) Hand Wrench (available from dispensary)

- Place pins to base of channel and, if not self-shearing, give 1/4 to 1/2 turn back to
reduce internal stresses in dentin.

66
Bending of Pins after Placement max pins cant be bend
- Pins may have to be bent so that they will be well within the matrix and any proposed
future axial reduction for veneer coverage. (NOTE: MAX pins cannot be bent).
- A pin bending instrument is available from the dispensary. Bending with a blunt
instrument (e.g. amalgam condenser) can lead to pin fracture.
- Pins can be shortened to permit a 2 mm overlay of amalgam with a high speed diamond
bur. You must stabilize the pin with a mosquito haemostat.
- Only rarely should pins be placed without rubber dam isolation and in those situations an
18" length of floss should be secured to the handwrench.

Pin Perforations

a) Pulpal
- If a mechanical pulp exposure occurs under a dry, well-sealed rubber dam, calcium
hydroxide in the pin channel followed by the placement of the pin to a depth of 2 mm.
will provide a hermetic seal and a favourable prognosis.

b) Periodontal Perforations

i) Occlusal to gingival attachment.

- lower the cavity floor to eliminate pin hole using small box preparation to permit the
placement of amalgam into the box cavity design.

ii) Apical to gingival attachment

- No optimal treatment exists.
- Consult with Periodontal instructor.
- Consider placement of pin flush with root surface and maintain a long term
periodontal reassessment.
- Document all perforations in the daily record!

Guidelines For Teeth Requiring Extensive Restoration

A. Posterior Teeth

When an extensive complex, cusp-replacement restoration is required, either as an initial

restoration or as a replacement, amalgam is preferred for the following reasons:
i) superior physical properties
ii) self sealing
iii) ease of establishing proper contacts, axial contours and occlusal morphology
iv) reduced incidence of post-operative sensitivity
v) documented superior clinical longevity

67
The amount and type of tooth structure remaining will determine the potential to retain a
permanent amalgam restoration. Amalgam restorations rely principally on dentin walls to
provide resistance/retention form. When inadequate dentin remains after preparation,
auxiliary mechanical retention is required and can be provided by pins, grooves, slots or
potholes.

Although there are more risk factors associated with the use of pins compared to more
conservative intracoronal mechanical retention mechanisms, they do offer excellent, reliable
retention. Pin retention should be considered for any tooth requiring an extensive restoration
if the tooth is a candidate for a full coverage restoration now or in the future. The retention
provided by the pin(s) or other intracoronal mechanisms becomes more important as the
amount of dentin is reduced by full coverage restoration. Note: Amalgam bonding is
indicated for all extensive amalgam restorations. Bonding provides a superior initial seal and
the potential for some micromechanical bonding but is not a substitute for mechanical
retentive features. Note: large complex restorations involving loss of a facial cusp in
maxillary bicuspid teeth may require extracoronal coverage consideration for esthetic
reasons. Cusp replacement with composite resin tends to provide low longevity and an
interim solution only.

B. Anterior Teeth

Composite resin is the direct restorative material of choice for anterior teeth and bonding is
the principal form of retention. Depending on the amount and type of tooth structure
remaining, auxiliary pin retention may be required particularly if a full coverage restoration is
indicated e.g. large Class 4's.

68
 Core Restorations for Vital Teeth prior to Full Crown Coverage
Teeth extensively weakened by caries, previous restorations or fracture often require a crown.
Existing restorations require careful assessment. Many older, deteriorated restorations should
be removed and a core “build-up” placed prior to crown preparation. This permits:
i) caries detection
ii) assessment of remaining dentin
iii) provision for auxiliary retention as required
iv) a better determination of pulpal status

When an apparently sound pinned amalgam restoration is present, removal may be

contraindicated. Crown preparation and re-assessment of the existing restoration may be
advantageous in such situations.

Because tooth and restoration coverage will be provided by the final crown, in many cases
there is a choice of material usage for the core build-up.

Materials for Direct Core Build-up

COMPRESSIVE TENSILE ELASTIC

STRENGTH MPa STRENGTH MPa MODULUS GPa

DENTIN 232-305 50 17-20

SILVER AMALGAM 431-510 48-64 34
COMPOSITE RESIN 300-400 70-90 7-20

Silver amalgam and composite resin can be used as core materials. Amalgam should be
considered for extensive posterior core restorations that are not performed concurrently with
crown preparation, particularly molars and where pins are involved. Resin composite can be
considered in many less extensive core restorations, particularly if concurrent with crown
preparation. A lower incidence of sensitivity is associated with amalgam core restorations.

A. Silver Amalgam

Advantages:
i) superior physical properties, particularly modulus of elasticity (rigidity). This is
particularly useful in extensive core restorations with minimal tooth structure.
ii) superior handling properties providing packability permitting excellent adaptation
around pins, posts and into grooves, and also carvability and easier contact formation.
This is particularly useful if there will be a delay before the crown is done and the
amalgam core will be used as a functional interim restoration.
iii) silver amalgam is self sealing thus providing a protective mechanism in the event of
microleakage at crown margins
iv) associated with few sensitivity problems. Less technique sensitive
v) less expensive

69
Disadvantages
i) silver amalgam is slow setting with a recommended 24 hour set time prior to
crown preparation.
ii) dark colour precludes use of translucent all-ceramic crowns and
may discolour roots of endodontically treated teeth thus adversely affecting esthetics
iii) patients who are amalgam phobics
iv) weak in thin section
v) not intrinsically adhesive

B. Composite Resin

In clinical situations where a tooth requires a crown and the tooth is not extensively restored
or more moderate caries is present, composite resin permits a core build-up at the crown
preparation stage. Existing restorations or remaining caries can then be removed easily and
the decision to place a core build-up or to modify the preparation can be made. Minor
defects can be managed in one of the following ways: i) accept areas that are slightly deeper
than ideal ii) modify axial box forms to conform to the path of insertion iii) place composite
resin or resin modified glass ionomer in small cervical undercut areas.

Advantages
i) immediate crown preparation potential eliminates need for a separate core build-up
appointment
ii) easier to form crown preparation anatomy
iii) resin bonding enhances retention potential
iv) tooth coloured
v) bonding potential
vi) no mercury

Disadvantages
i) composite resin is technique sensitive requiring proper adaptation, incremental build-
up and extended curing times. More difficult to form proximal contacts/ lack of
carvability.
ii) tooth sensitivity problems. Sealing and bonding procedures must be impeccable..
iii) difficult to distinguish between tooth and core. Composite resin with a high contrast
colour which is readily distinguishable from tooth structure is desirable to facilitate
finish line tooth placement on sound tooth structure.
iv) resin core build-ups must be well lubricated with water soluble lubricant while
fabricating resin provisionals, especially BIS-GMA based resins e.g. Integrity, to prevent
inadvertent bonding.

Glass Ionomer
Resin-modified glass ionomer cements are contraindicated for large build-ups. Resin modified
glass ionomer have improved physical properties but are only adequate for small undercuts
and minimal - moderate core build-ups (provided ferrule in tooth structure).
70
REFERENCES

Gourley, JV. - Favourable Location for Pins in Molars. Operative Dentistry 5: 2-6 1980.

Caputo AA,Standlee JP. - Pins and Posts. Why, When and How. Dent Clin N. Am 20:299, 1976.

Cooley, RL , Barkmeier, WW. - Temperature Rise in the Pulp Chamber Caused by Twist Drills. J.
Pros. Dent. 44:426-429, 1980.

Fujimoto, J., Norman,DN. Dykema, RW and Phillips, RW A Comparison of Pin Retained and
Composite Resin Cores. J. Pros. Dent. 39:512-519, 1978.

Hormati, AA, Denehy,GE. - Microleakage of Pin-Retained Amalgam and Composite Resin

Bases. J. Pros. Dent. 44:526-530, 1980.

71
VITAL TOOTH BLEACHING

72
 VITAL TOOTH BLEACHING

Two methods of vital bleaching have been introduced to the clinic floor (1999). All bleaching
treatment must be pre-approved and treatment planned by a CCP Coordinator.

INDICATIONS

1) vital or nonvital intact teeth with sound tooth structure

2) discoloured teeth, especially yellowing from aging, fluorosis, endodontic treatment,
trauma
3) whitening before esthetic restorations eg. composites, veneers, crowns
*if bonding is to be performed after bleaching, a period of at least 1 week should
separate the bleaching and bonding appointments!

CONTRAINDICATIONS

1) symptomatic or sensitive pulps

2) multiple restorations (resins will not whiten)
3) large areas of exposed dentin
4) patients with unrealistic expectations/non-compliant patients/potential for abuse!
5) pregnancy/nursing women
6) children
7) soft tissue oral pathology, xerostomia (primarily contraindication for home bleaching
technique)

TECHNIQUES

1) Patient-Applied (Home) Bleaching

The patient-applied (home) bleaching technique using a custom-made vacuum-formed

bleaching tray is considered the most effective bleaching technique. A reservoir within the
bleaching tray and a good fit at the gingival margin help to retain a sufficient amount bleach
for effective bleaching and reduce ingestion of the bleach material. A 0.5 mm thick application
of LC Block-Out resin on the facial surfaces of the teeth to be bleached is placed on study
model for the reservoir.

The clinical instructor should check the study model for accurate tooth reproduction
and no bubbles (especially at the gingival margin) before signing the requisition and lab
prescription. Materials for tray fabrication will be available in the dispensary with the
signed requisition. Block-out resin is used to build reservoirs within bleaching tray.
The lab will generally make the bleaching tray if you bring them the materials and a
signed prescription.

73
 Keep reservoir below incisal and occlusal surfaces.

Reservoirs on facial aspect only, approx. 0.5 mm thick.

Keep reservoir approx. 2mm from gingiva

Trim tray to the gingival margin on both buccal and lingual.

The vacuum-formed ethyl vinyl acetate 1mm thick tray should be neatly trimmed to avoid all
soft tissue contact. This should be checked intraorally before obtaining the bleaching gel from
the dispensary (signed requisition form needed).

Opalescence (Ultradent) bleach is a viscous 10% carbamide peroxide product (equivalent to

approx. 3.3% hydrogen peroxide). The majority of clinical studies supporting the safety and
effectiveness of vital tooth bleaching have been conducted using 10% carbamide only. There
are far fewer studies using higher bleach concentrations. It has been shown that a 10%
product can achieve a degree of tooth whitening that is equivalent to higher concentrations,
with less tooth sensitivity (slower gentler approach).

In consultation with the instructor and patient, one of two treatment regimens may be
selected: (i) DAYTIME – 2X1-hr separate or consecutive daily applications (consider the
material to be active for 1hr maximum, therefore the material must be replaced after 1 hr) for
a cumulative total of 14 days; or (ii) OVERNIGHT – nighttime wear (consider the material to be
active for approximately 4 hrs) for a cumulative total of 14 nights.

74
The student should counsel the patient re: material placement, tray wear and side effects. An
“instructions to patients” form (see below) should be given to each patient.

TOOTH SENSITIVITY
The most common (50-75% incidence) side effect of bleaching is tooth sensitivity due to
hydrogen peroxide entering the pulp causing a transient pulpitis. Other causes of tooth
sensitivity associated with bleach treatment relate to open dentinal tubules and tooth
dehydration.

It is hard to predict if a patient will get tooth sensitivity during bleach treatment, but those
with pre-existing tooth sensitivity or exposed dentin are at greater risk. The use of a
desensitizing toothpaste (eg. Sensodyne) starting at least 2 weeks BEFORE the start of bleach
treatment is recommended.

Patients may proceed with bleach treatment if the tooth sensitivity is mild or moderate. If the
tooth sensitivity is moderate or severe, treat by:

i) Reduce bleaching time (eg every other day or less time per day) or concentration.
ii) Apply desensitizing materials, eg fluoride in office or at home, desensitize exposed
root surfaces, use desensitizing toothpaste.
iii) Recommend analgesics prn.
iv) Discontinue bleach treatment.

2) Dentist-Applied (In-Office) Bleaching

The dentist-applied (In-Office) bleaching technique utilizes a higher hydrogen peroxide

concentration for a shorter application time than the patient-applied (home) bleaching
technique. Multiple appointments are usually needed to achieve a satisfactory degree of tooth
whitening, and the whitening “endpoint” is usually LESS than that achieved by the home
bleaching technique. Tooth sensitivity is greater. Whitening regression is reported to be
quicker. Therefore, the dentist-applied (In-Office) bleaching technique should be reserved for
patients who will not comply to wear a bleach tray, who need only specific teeth bleached,
who need/want avoidance of any bleach application to soft tissues, or as a “quickstart” to
subsequent patient-applied (home) bleaching.

1. Protective gloves, glasses, aprons.

2. Rubber dam: MUST BE CHECKED BY THE INSTRUCTOR
3. Prophy teeth with pumice. Rinse and dry. Re-ensure good rubber dam seal.
4. Bleach application: Opalescence Boost (Ultradent) dentist-applied bleaching gel
This is a 40% hydrogen peroxide gel which must be handled with extreme care.
The material should be freshly mixed. Carefully apply bleaching gel to labial

75
 surfaces of all teeth to be bleached. Optionally, direct the curing light onto each
tooth 30 seconds sequentially until each tooth has been light-cured for 2-5minutes.
Rinse under high volume suction. The bleaching gel can be reapplied for 2-3
applications in one session. If the patient experiences pulpal sensitivity during the
procedure however, the bleaching application should be halted for this
appointment. It may be necessary to repeat the bleaching treatment sessions.
This should be done at intervals of 1-2 wks depending on the results
achieved/desired.

Procedure Codes:

97111 Bleach Vital Tth Chairside 1 unit (To be used for dentist-applied in-office
(Opalescence Xtra) bleaching only). Use for each separate in-office bleach appointment.

97211 Home Bleach Max or 97212 Home Bleach Mand (To be used for patient-applied
home bleaching. The Lab fee must be added to these Professional fee codes whether or not
the bleach tray is student- or lab-fabricated. The 97122 code does NOT need to be added.

97122 Take Home Bleach Materials (To be used ONLY when the patient already has a
bleach tray from previous bleach treatment and is now getting more bleach material for
further bleach treatment.)

76
PATIENT INSTRUCTIONS FOR AT-HOME BLEACHING

- brush and floss teeth prior to use

- half-fill indicated tooth forms in tray with gel
- insert tray and wipe away excess bleach with tissues
- do not smoke/eat/drink during use
- wear as prescribed (CHECK ONE)

o DAYTIME: 1 hour twice a day for 14 days (cumulative)

o NIGHTTIME: overnight for 14 nights (cumulative)

OTHER:

- after removing tray, rinse mouth thoroughly with water

- mild tooth sensitivity is a common side effect, if significant tooth sensitivity should occur:
refrain from bleaching for one or two days as needed and/or:

- you may elect to discontinue the bleaching treatment at any time

- please contact the dental student if any questions or problems arise during
treatment at

- please return for a follow-up appointment on:

77
DENTIN BONDING AND TREATMENT OF CERVICAL
LESIONS

78
 DENTIN BONDING

The acid-etch bonding technique for enamel is predictable and consistent - capable of
providing high clinical bond strengths. This is due to the fact that enamel is an inorganic
substrate and that a dry, clean, highly polar, etched surface can be achieved. A strong
micromechanical attachment can be attained using any polymerised hydrophobic adhesive
dental resin. The strength of the attachment has provided dentistry the capability for
orthodontic movement (resin bonded brackets), caries prevention (fissure sealants) and
minimally invasive restorative dentistry (preventive resin restoration), esthetic repair of
fractured teeth, conservative restorations, esthetic veneers.

Dentin Composition

50% collagenous gel 50% hydroxyapatite

Dentin has a significantly greater fluid content than enamel (22% vs 4%)

Bonding Problems and Microleakage

Provision of a secure, strong bond to dentin is a highly desirable objective in dentistry which
has provided researchers with an extremely difficult challenge over the years. Such a bond
must provide clinical longevity and prevent microleakage between the oral environment and
the pulp. Unlike enamel, vital dentin is inherently moist, it has a collagen-rich composition and
the dentinal tubules containing the cytoplasmic odontoblast extensions are in direct
continuity with the pulp.

The potential consequences of inadequate clinical dentin bonding are serious. Unsuccessful
dentin bonding will cause tooth sensitivity and pulpal inflammation – even pulp death - in the
short term and marginal staining and recurrent caries in the long term.

BACTERIAL MICROLEAKAGE

Marginal staining Secondary caries

POSTOPERATIVE
SENSITIVITY

PULPAL PATHOLOGY

79
 CLINICAL DENTIN BONDING

The key to successful dentin bonding is the incorporation of a hydrophilic “primer” resin,
successful dentin priming and meticulous attention to detail at each stage of the bonding
process. Clinical dentin bonding involves 3 steps:

1) Dentin conditioning,
2) Primer resin and,
3) Adhesive resin.

The primer is a resin-solvent mixture that includes hydrophilic and hydrophobic moieties
carried onto the tooth in a solvent that must be evaporated prior to use of the more
hydrophobic adhesive resin layer.

It is essential that the type of solvent (acetone, ethanol or water) is understood by the
clinician. Acetone solvents require the dentine to be left slightly moist after conditioning and
washing – they are more technique sensitive because “moist” cannot be defined accurately.
Primers incorporating water solvents are less technique sensitive – however, water takes
longer to evaporate than acetone and it is essential that all water is evaporated prior to
application of the adhesive resin.

The adhesive resin step is important and provides a bonded intermediate layer between
hybridization layer and composite. The adhesive resin should be polymerized prior to
application of composite to consolidate the bond to the dentine.

Commercial Products

There are currently over 80 proprietary dentin bonding materials on the market! They can be
divided basically into 2 types on the basis of whether there is a separate etch step or not, prior
to the application of the resin components (“Etch and rinse” and “Self-etch”). Within each
major type there are 2 basic sub groups depending on the formulation of the materials used in
the subsequent steps. The commercial situation is complex and confusing – practitioners
must utilize a proven material and understand the usage parameters.

“A comparison of contemporary adhesives reveals that the three-step, ethanol-water-based

etch-and-rinse adhesives remain the ‘gold standard’ in terms of adhesion durability. Any kind
of simplification in the clinical application procedure results in a loss of bonding effectiveness.
Only 2-step self-etch adhesives most closely approach this standard and have additional
clinical benefits such as ease of manipulation and reduced technique sensitivity”.

[De Munck et al. A Critical Review of the Durability of Adhesion to Tooth Tissue: Methods
and results. J Dent Res 84(2):118-132, 2005]

80

ethanol water based = gold standard

 CLASSIFICATION OF PROPRIETARY DENTIN BONDING SYSTEMS

A. SEPARATE ACID ETCHING (CONDITIONING) STEP.

(“ETCH AND RINSE” MATERIALS)
I. CONVENTIONAL 3-STEP (3 BOTTLES)

1. ETCH (CONDITION)
Removal of smear layer and light demineralization of dentin surface
2. PRIMER
Impregnation of dentine surface (hybridization) with bi-functional resin monomer
3. ADHESIVE
Completion of hybridization with layer of adhesive bonding resin

II. 2-STEP (2 BOTTLES) – PRIMER AND ADHESIVE COMBINED

1. ETCH (CONDITION)
2. PRIMER/ADHESIVE COMBINATION

B. NO SEPARATE ACID ETCHING (CONDITIONING) STEP.

(“SELF-ETCH” ACIDIC MATERIALS)

I. 2-STEP (2 BOTTLES) – ETCH AND PRIMER COMBINED

1. SELF-ETCHING PRIMER
2. ADHESIVE

II. 1-STEP (1 BOTTLE) - ETCH, PRIMER AND ADHESIVE COMBINED

1. SELF-ETCHING PRIMER/ADHESIVE COMBINATION

81
 CURRENT COMMERCIAL DENTIN BONDING MATERIALS
In-vitro bond strength tests are published but many are 24 hours only and there is a great deal
of realization and evidence that such in vitro studies may be misleading due to a) the
artificially dry conditions in the laboratory with extracted teeth and b) the 1-dimensional
nature of the test apparatus as opposed to the 3-dimensional nature of in-vivo restorations.
There is evidence to suggest that the dentin bond is subject to significant chemical and
enzymatic degradation over time as a result of water sorption and hydrolysis, incomplete
infiltration of the demineralized dentin and proteolysis, repeated mechanical loading and
temperature cycles, etc. Long-term data is more useful to determine the resistance of the
dentin bond to degradation than short-term data.

The clinician should focus on optimizing the bond to resist degradation. Methods include
maximizing the use of enamel bonding, bonding to sound dentin rather than decayed dentin
particularly at the periphery, minimizing the risk of incomplete resin infiltration, having a
hydrophobic outer layer, and using MMP inhibitors. The clinical situation is complicated and
there is a great deal of difference between, for example, a Class V abrasion lesion in a 50 year
old patient and a freshly cut MOD cavity in a 16 year old. Dentin is more permeable when
freshly cut, in the young and over the pulp horns and therefore there is more chance of
postoperative sensitivity if bonding is not completely successful in these situations.

Current generation 3-step products produce a HYBRID LAYER or resin reinforced zone on the
dentin surface, 2-5 microns thick, combined with penetration of resin into the dentinal
tubules. This diffusion into surface inter-tubular dentin together with intra-tubular
penetration are thought to be necessary for a successful micromechanical bond to dentin.

There is little evidence of any true chemical bond to dentin. No significant (i.e. clinically useful)
true chemical bonding to tooth, porcelain or metal has been demonstrated with any current
resin bonding agent (except, perhaps, those containing MDP or 4 META chemistry).
Spectroscopic studies have provided no evidence of primary chemical adhesion. All clinically
useful techniques aim to provide a micromechanical attachment with optimum wetting of the
substrate.

CONVENTIONAL 3-STEP BONDING (TOTAL ETCH AND RINSE)

3-step adhesive systems conditions and bonds to enamel and dentin using a total-etch
technique. Such systems (i.e. Optibond FL, Scotchbond M-P, All Bond 2, etc.) create a
micromechanical attachment to dentin by removal of the smear layer and infiltration into the
partially demineralized intertubular dentin.

Although some advocate 15 sec etch for enamel, the etch pattern is less definite, and the
Restorative Department favours a longer etch of 30-45 sec. Place etchant on major enamel
periphery for first 15-30 secs then carry into dentin for final 15 secs. DO NOT OVERETCH
DENTIN. If dentin is demineralized to a greater depth than primer penetrates, a weak under-
layer results which will cause early bond failure.

82
The healthy pulp can withstand brief acid conditioning provided the resulting dentinal surface
is subsequently sealed. Careful use of such a technique actually decreases the incidence of
postoperative sensitivity in posterior composites. Smear layer removal without subsequent
provision of a complete seal (i.e. careful application of primer and adhesive) could however
increase postoperative complications. Liners and bases will continue to be used for their
therapeutic properties where indicated (i.e. Calcium hydroxide liners in deep cavities or
wherever antibacterial properties and remineralization capabilities required. Glass ionomer
liners where long term fluoride release will be beneficial eg posterior composites.). However,
where resin dentine bonding primers are being utilized, less dentin will need to be covered
with liners.

OPTIBOND FL
The commercial product available for general bonding use currently in the clinics is Optibond
FL (Kerr).

1. ETCHANT Apply etch to enamel periphery first.

38% Phosphoric Acid Etch dentin 15 seconds maximum.
Rinse thoroughly and dry lightly.
Do not dessicate dentin. Optimal dentin surface is slightly
moist.
2. PRIMER Yellow capsule.
HEMA 15 second application with light scrubbing.
GPDMA Evaporate solvent (5 second air dry).
MMEP
water
ethanol
CQ
BHT Facilitates wetting of the adhesive onto the prepared t
3. ADHESIVE Black capsule
BISGMA Apply uniform layer using applicator or light air-stream (do
HEMA not create bald patches or pooled regions with excessive air-
GPDMA stream).
CQ 20 second light-cure.
ODMAB
48 %wt filled (SiO2, barium
aluminoborosilicate,
Na2SiF6)
HEMA Hydroxyethylmethacrlate MMEP Mono-2-methacryloxyethyl-phthalate
GPDMA glycerol phosphate dimethacrylate ODMAB 2-ethylhexyl-4-dimethylamino benzoate
CQ camphoroquinone BHT butylhydroxy toluene

83
1. Etch enamel/dentin with phosphoric acid for 15 seconds. Rinse thoroughly and dry
gently. Do not dessicate.
2. Grip Unidose by wings and twist until seal is broken. Discard section with stem. Dip
applicator into capsule.
3. Apply Prime with light agitation for 20 seconds. Air dry 5 seconds.
4. Using same applicator, apply Adhesive with light brushing motion for 15 seconds. Air
thin for 3 seconds. Light cure for 20 seconds.

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CLEARFIL SE2
The commercial product available for alternate or additional bonding use currently in the
clinics is Clearfil SE2 (Kuraray). This is a 2-step (2 bottles) adhesive with a self-etching primer
and separate adhesive component. It should be used in the Faculty Clinics for select situations
where post-operative sensitivity is a significant potential issue and avoidance of “aggressive”
dentin etching from the total-etch technique of Optibond FL is preferred.
Clearfil SE2 contains MDP. MDP is a functional monomer which can form chemical bonds to
hydroxyapatite (hydroxyl ions bind to calcium) and to metal oxides (phosphate esters bond to
oxides of aluminum, chromium, titanium, zirconium). For this reason, Clearfil SE2 can also be
used in the Faculty Clinics for select situations where bonding to metal oxides is needed (see
Cementation of Resin bonded Bridges and Bonding to Metal in Microabrasion Technology
section).

1. self-etch PRIMER pH =2
MDP 20 second application with light scrubbing.
BISGMA Evaporate solvent (5 second air dry).
HEMA
hydrophilic DMA
CQ
water Facilitates wetting of the adhesive onto the prepared t
2. ADHESIVE Apply uniform layer using applicator or light air-stream (do
BISGMA not create bald patches or pooled regions with excessive air-
HEMA stream).
MDP 10 second light-cure.
hydrophobic DMA
CQ
colloidal silica
HEMA Hydroxyethylmethacrlate DMA Dimethacrylate
MDP 10-methacryloyloxy-decyl-dihydrogen phosphate CQ camphoroquinone

85
1. Selective etch for enamel. Apply phosphoric acid etch to enamel for 15 seconds. Rinse
thoroughly and dry gently. Do not dessicate.
2. Apply Primer for 20sec. Air dry 5 seconds.
3. Apply Bond in uniform layer. Light cure 10 seconds.

86
 ‘BONDED’ AMALGAM RESTORATIONS
In recent years, a technique of resin-mediated attachment of silver amalgam to tooth structure
has been developed, in an attempt to utilize successful, proven resin bonding techniques to
provide tooth reinforcement with dental amalgam. Such a “bonded amalgam” technique has
shown superior sealing ability in many in-vitro studies due to the presence of resin-impregnated
conditioned dentin, particularly when spherical alloys are utilized. It has also been shown to
increase the fracture resistance of silver amalgam restored teeth in vitro, though only 24 hr,
monotonic, static loading studies have been reported.

Clinical studies are lacking, however anecdotal, collective, clinical experience does indicate
reduced initial post-operative sensitivity in many situations. One may consider the technique as
providing a ‘super-seal.’ This is the major advantage. The increased fracture resistance of teeth
and increased retention is as yet unproven clinically over the long term. It is considered
particularly advantageous for large, pinned and/or extensive amalgam restorations that will be
crowned – parts of the restoration appear less likely to dislodge during crown preparation.

In Faculty Clinics the technique is utilized only in deep or extensive restorations, in an attempt to
BONDED provide a more profound initial seal:-
AMALGAM 1. Direct or Indirect pulp capping restorations
2. Extensive, pinned restorations

A self-cured adhesive resin is essential for this technique. Currently ‘Bond-It’ (JENERIC PENTRON)
is available in the clinic.

87
Utilize fast-setting calcium hydroxide cement in the vicinity of the pulp. Leave adequate
peripheral dentin for resin-impregnation. ZOE is contra-indicated.

a) Condition enamel 15 sec. then dentin for further 15 seconds. Wash and lightly dry.

a) b) c)

b) Mix 2 component primer (Primer A and Primer B). Prime dentin with multiple (5-7) coats of
‘Bond-It’ primer. Dry.
c) Mix 2-component adhesive resin and apply very thin layer to cavity preparation.
d) Triturate amalgam simultaneously and insert amalgam immediately onto unset adhesive. The
amalgam becomes micromechanically interlocked to the adhesive layer as the self-cure
adhesive sets.

bondit
primer a+b = 5-7 coats
2 part resin = thin layer

88
CLASS V EROSION/ABRASION LESIONS (NON-CARIOUS)

Caused by erosive factors, occlusal problems or improper brushing technique, lesions are
characteristically wedge-shaped with the gingival margin in cementum and the occlusal
margin in enamel. The first question to be answered is "Should the lesion be restored”? This
will depend on the SIZE of the lesion, whether it is SENSITIVE and the AESTHETICS of the
situation. If the lesion is a minor irregularity and the patient's habits have been altered it may
be ignored. If a minor irregularity but sensitivity exists then:

a) burnishing with fluoride paste

b) application of Duraflor varnish and/or
c) use of desensitizing toothpastes may be carried out. Only where significant depth of
erosion, abfraction or abrasion is present, (i.e. greater than 1.5 mm) should restoration be
considered.
>1.5 class v = RESTORE
A. LESIONS IN HIGHLY AESTHETIC LOCATIONS -
microfill or polishable hybrid
RESTORE WITH MICROFILLED COMPOSITE RESIN OR POLISHABLE HYBRID COMPOSITE
COMBINED WITH DENTIN BONDING AGENT

Provided sufficient depth is present and sufficient enamel on occlusal margin, then no cavity
preparation is necessary. A gingival retention groove is necessary for ALL non-retentive lesions
and lesions with a history or restoration debonding.
gingival retention groove for
NON retentive lesions
- otherwise no prep needed

89
Technique:

a) Clean surfaces carefully with pure pumice on rubber cup (Avoid traumatizing gingiva).

b) Wash thoroughly.

c) Apply rubber dam or utilize retraction cord to prevent seepage of gingival crevicular
fluid.

d) Apply calcium hydroxide only to any very deep areas.

e) Use Optibond FL system AS PREVIOUSLY described.

f) Restore with composite.

g) An easily maintained, high gloss surface should be achieved through sequential use of
multi-fluted carbide bur (7901) and of finishing discs (Sof-lex). Use carefully to avoid
damaging root surface or gingiva.

B. SHALLOW ABRASION/EROSION LESIONS

a) Not Sensitive
Determine the cause and attempt patient education. The situation should be
monitored at recalls. Restoration is often NOT indicated. If occlusal factors are
suspected (abfraction lesions) they should be addressed. Are individual teeth over
loaded? Has the patient a bruxism habit? If so, teeth should be protected with a night
bruxism appliance.

b) Sensitivity present
Desensitize using a dentin primer “varnish” (Microprime or Hurriseal or equivalent).
[Mild sensitivity could even be treated with Duraflor varnish over one or two visits
when other procedures are being performed]. Ask patient if highly acidic diet (citric
fruits, vinegar dressings, phosphoric acid soft drinks etc)

90
 Dentin Hypersensitivity
• Cervical hypersensitivity is common - associated with exposed root and acidity in
diet
• Also common after successful treatment of periodontal disease due to increased
exposure of root structure with improved periodontal health
• Common after use of acidic haemostatic agents (eg Hemodent - aluminum chloride
pH 1.7) used on retraction cords during impressions
• Condition is due to exposure of open dentinal tubules.
• Over time there can be a natural process for obliteration of open tubules by
calcification crystals

Reference
Yoshiyama M, Masada J, Uchida A, Ishida H. Scanning electron microscope characterisation of sensitive
versus insensitive human radicular dentin. J Dent Res 1989; 68:1498-1502

• Open dental tubules provide a pathway for the transmission of painful stimuli from
the tooth surface to the pulp (i.e. the hydrodynamic theory).
• There are simple, non-invasive, effective treatments that can be used in-office by
the dentist or hygienist to physically block the open tubules using resin primers.

91
Treatment of Cervical Hypersensitivity

• Fluoride varnish
– Requires repeated applications
– Only moderate effects initially
• Dentin primers/adhesives
– Extremely effective immediately
– Lasts for many months
– Can be re-applied at recalls if necessary
• Desensitizing toothpastes
– Adjunctive only
– Least effective

Available in Faculty Clinics:

No mixing or curing. No prior conditioning.

Ensure area to be treated is clean.
Apply using disposable brush for approx 30 seconds over sensitive areas. Use gentle
air stream to evaporate solvent. (This is a good test of efficacy. Repeat 1-2 times until
no sensitivity.)

• Can apply to areas of sensitive dentin (due to open dentinal tubules) of cervical
erosion or gingival recession
• Can apply prior to placement of temporary crowns [particularly if Hemodent
(pH 1.7) was used on cord]
• Can be used on areas of gingival recession prior to whitening if sensitivity
anticipated

92
COMPOSITE RESIN RESTORATIONS

93
 COMPOSITE RESINS

COMMERCIAL PRODUCTS AVAILABLE IN FACULTY CLINIC

I MICROHYBRID – Z250 (3M Espe)

MICROHYBRID Z250 = POSTERIORS

- highly filled

Z250 is a heavily filled (82%wt, 0.04-3.5 m zirconia/silica clusters and 20 nm silica

particles in a BisGMA, UDMA, TEGCMA and bisEMA matrix), polishable hybrid
composite available to be used primarily for POSTERIOR composite restorations in the
Faculty Clinics. A1, A2 and A3.5 shades (matched to the Lumin Vac Shade Guide) will
be available.

II NANOHYBRID – Filtek Supreme Ultra (3M Espe)

FILTEK (NANOHYBRID)
- heavily filled
- polishable hybrid
- ANTERIORS
- b, d, e

94
Filtek Supreme Ultra is a heavily filled (72.5%wt, 4-11 nm zirconia and 20 nm silica
non-agglomerated and agglomerated particles in a BisGMA, UDMA, TEGCMA and
bisEMA matrix), polishable hybrid composite available to be used primarily for
ANTERIOR composite restorations in the Faculty Clinics owing to their improved polish
retention, improved fluorescence, and extended shade availability (compared to Z250).
A1B, A2B, A3B, A3.5B, B1B, B2B, C1B, C2B (matched to the Lumin Vac Shade Guide)
and Extra White shades will be available. These shades are all considered “body”
shades with an average level of translucency/opacity. The Extra White shade can be
used when a high contrast in shade is desirable to help distinguish resin from tooth
structure.

Opaque and translucent shades will be available in the Clinic 1 Dispensary (by signed
requisition only). These additional shades are indicated in demanding esthetic
situations, when opaque and translucent resins are needed or when adequate shade
matching cannot be achieved with the composites generally available in the clinic. The
shade of the composite is matched to the Lumin Vac Shade Guide while the relative
opacity/translucency of the specific shade is denoted by “D” for dentin (opacity is
similar to that of dentin), “B” for body (opacity/translucency level is medium or
average), or “E” for enamel (translucent), ie. shade A2D (opaque) will have the
hue/chroma and value for A2 and will be more opaque than A2B (medium), which in
turn will be more opaque than A2E (translucent). A1D, A2D, A3D, A4D, B3D, WD
opaque shades and A1E, A2E, A3E, B1E, D2E and WE translucent shades will be
available for the older Filtek Supreme Plus material. A1D, A3D, C4D, A1E, A2E, A3E and
WE will be available for the newer Filtek Supreme Ultra material.

Opaque -------------------> translucent

D (dentin) -> B (body) -> E (enamel)

95
 MICROFILL - DURAFILL
- enamel like lustre
- critical esthetics
II MICROFILL – DURAFILL (Kulzer)
- free hand composite veneering
- radiolucent

Durafill VS (78%wt, .04 1.5 m particle size) is available in several shades matched to
the Lumin Vac Shade Guide. [For proprietary reasons the Durafill shades are a factor of
10 higher. e.g. A Durafill A20 is a Lumin Vac shade A2 and a Durafill A35 is a Lumin Vac
A 3.5]. This material is indicated where an enamel-like lustre is desired and where
esthetics are critical. Although nanohybrids can be polished to high gloss, they cannot
achieve the lustre of a microfill. A microfill resin is the material of choice for free-hand
composite veneering. As microfilled materials are not radiopaque they are not the
material of choice for Class III cavities, nor for Class IV situations due to their reduced
mechanical properties when compared to more heavily filled hybrid composites. Some
authorities feel microfilled composites should be used for Class V abrasion/abfraction
lesions as they are more flexible than hybrids. This hypothesis is unproven. An opaquer
is available in each clinic for opaquing out stains, when veneering discoloured teeth or
masking metal.

GENERAL NOTES OF COMPOSITE RESIN USE

1. Shade selection should be carried out before the tooth is dehydrated. Select shade early
in the appointment session (e.g. while awaiting onset of L.A.).This is particularly
necessary if aesthetics of final restoration is critical. For esthetic cases, a small portion of
material can be precured on the unetched tooth or held intra-orally to ensure suitability.

2. Mixing of shades of light curing composites is highly undesirable as mixing introduces

considerable porosity (lack of porosity is one of the major advantages of
photopolymerization). If the desired shade cannot be achieved, a two-layer technique
with the most superficial layer a translucent microfill, as modifier, produces a good
result.

96
3. Strict isolation of teeth is mandatory. Utilize the rubber dam! For cervical abrasions or
root caries, use cervical rubber dam clamp and ensure stabilization if retraction of
gingiva is necessary. Contamination by gingival-crevicular fluid is essential - it is a
common cause of microleakage!

4. It is undesirable to use either alcohol or bonding resin on placement instruments as a

separating agent. With alcohol, contamination of the restoration may occur and with
bonding resin, the overall percentage filler content will be lowered (i.e. - weaker
restoration with greater polymerization shrinkage). Adhesive resin (not primer-
containing) may be used sparingly on the surface of an anterior restoration.

Ways to prevent composite sticking to instrument are:

a) Use clean, smooth insertion instrument. Wipe clean with dry gauze as necessary.
b) Condense composite towards wall of preparation with placement instrument sliding
off onto tooth structure.
c) Tamp material with light, quick strokes using a small-tipped instrument initially.
Remember, the composite will stick to the surface with which it is in greater contact.
Therefore, the contact area of the composite with the instrument should always be
less than the contact area of the composite with the tooth.

5. Caution with multifluted high speed finishing instruments! Care and concentration are
required to prevent over-reduction of restoration and/or destruction of enamel –
particularly if the bur is new. The lingual surface is more safely finished with the use of
large slow speed round burs and Enhance (Dentsply) composite finishing abrasives. Do
not use Sof-Lex discs at too high a speed as this will produce excessive heat.

97
6. Ensure you have fully photopolymerized the restoration. Greater uniformity of
polymerization is achieved if the light source is applied from both the labial (20 secs) and
the lingual (20 secs) where appropriate. Sometimes the gingival aspect of a restoration
is undercured if the aperture of the light source is small. Check with an explorer. Useful
depth of cure is not more than 2mm generally.

DEPTH OF CURE BY MICROHARDNESS

98
 CLASS IV RESTORATIONS

Class IV restorations are demanding procedures requiring maximum aesthetics, fracture resistance,
periodontal acceptability and clinical longevity. Two clinical situations are differentiated:-

I. RESTORATION (OR RE-RESTORATION) OF INCISAL FRACTURE DUE TO TRAUMA

Retention is provided entirely by acid etched/bonded enamel. A 2-2.5 mm chamfer must be
produced in sound enamel using a chamfer diamond. (Around the entire periphery of the
fracture where possible). In depth the chamfer should involve half the enamel thickness.

Note: Pins are not indicated for routine Class IV restorations, even where both incisal
corners are involved. They can cause cracking and or discolouration of tooth
structure and discolouration of composite due to leakage and corrosion. The use of
pins is only indicated where anterior core build up of a vital tooth is required prior to
crowning (to provide adequate preparation length and retention).

II. CLASS IV RESTORATION (OR RE-RESTORATION) INVOLVING PRE-EXISTING CLASS III

PREPARATION/COMPOSITE (fracture of incisal corner subsequent to Class III restoration)
Increased retention is provided by the internal pre-existing Class III cavity preparation,
particularly if an adequate length gingival groove is placed. This must be supplemented with
an adequate width enamel chamfer. Labial enamel is often thin in these cares and the
retention requirements for each case must be individually assessed. Thin, friable enamel plate
should be removed to provide appropriate chamfers for adequate retention.

99
INSERTION OF COMPOSITE MATERIAL

FOR CLASS IV, USE OF ODUS PELLA or equivalent CROWN FORM, appropriately
trimmed to the size of the restoration is the PREFERRED TECHNIQUE. Please note: the
current version of Odus Pella crown form is thicker than previously – it may require
thinning carefully with a Sof-Lex disc at the contact area prior to use to ensure a good
contact.

Such a method a) greatly facilitates insertion of the composite, particularly if extensive

b) provides anatomically contoured restoration proximally and c) is more conducive to
providing a void-free restoration. Certain brands of crown form are too thick and rigid
for this technique. The Odus Pella brand is the thinnest available which is conducive to
positive restoration of the contact area – however thinning of the contact area may be
required.

The following is taken from the book "Esthetic Composite Bonding" by Dr. R. Jordan:-

The crown form should be carefully adapted to the prepared tooth with the following in mind:

1. A minimum of labial finishing should be necessary after the composite material

has polymerized.
2. A thin film of composite excess should extend no more than 1 mm beyond the
marginal periphery of the chamfer-shoulder preparation.
3. Vent holes should be placed palato-incisally in order to allow for air escape
during insertion.

100
The crown form matrix is filled with composite material and seated into position over
the prepared tooth. An anatomically contoured wooden wedge is then placed into the
gingival embrasure to compress the matrix form into tight adaptive contact with the
proximo-gingival surface and to ensure a slight amount of separation to allow for the
thickness of the matrix. The crown form matrix should be lightly compressed by the
operator’s fingers labiolingually. This expands the proximal portion of the matrix form
into tight adaptive contact with the adjacent tooth, thereby ensuring tight proximal
contact.

Crown form filled Seated and compressed with fingers

101
 FREEHAND (DIRECT) RESIN VENEERS
NOTE THAT INDIRECT PORCELAIN VENEERS ARE EXTREMELY TECHNIQUE SENSITIVE AND
CAN ONLY BE PERFORMED BY STUDENTS IN DDS4 – AFTER SPECIFIC LECTURES. CASES MUST
BE REVIEWED PRE-OPERATIVELY BY RESTORATIVE FULL TIME STAFF AND CARRIED OUT WITH
ONE INSTRUCTOR, PROFICIENT IN THE TECHNIQUE, FROM START TO FINISH.

A veneer is an esthetic restoration that is bonded onto the labial enamel of an

unattractive tooth via the acid-etch technique. There is an increasing demand for
conservative cosmetic dentistry. Dentists may frequently encounter patients with
teeth that are discoloured or unsightly, but otherwise strong and healthy. The
significant tooth reduction required for crowns is totally undesirable. Recent
developments in dentistry now allow us to directly place an esthetic restorative
material over unsightly enamel and thus enhance the patient’s overall appearance. In
all cases the most conservative option for the particular situation should be chosen.

TREATMENT OPTIONS
1. vital bleaching (most conservative but limited changes possible if very discoloured).
2. direct (freehand) composite resin veneers (requires artistry, skill and time).
3. indirect composite resin veneers (high debond rate – not currently utilised)
4. porcelain veneers (best aesthetics, more expensive. Excellent 10-12 year results are
possible if performed correctly.)

INDICATIONS
1. discoloured teeth (tetracycline-staining, fluorosis, age, endodontics, cracks)
2. enamel hypoplasia or hypocalcification
3. slight irregular tooth positioning or tooth shape
4. closing slight diastemas (If tooth not discoloured use diastema closure technique.)

CONTRAINDICATIONS
1. poor oral hygiene
2. occlusal problems (e.g. Class III relationship. Parafunctional activity if incisal involved)
3. large areas of exposed dentin
4. structurally compromised teeth – multiple class 4 restorations.

102
PREOPERATIVE VISIT
At preoperative appointment:
1) take alginate impressions to provide permanent record of original shape of
teeth
2) practice shades on unetched teeth

3) explain procedure fully to patient. (Longevity of direct composite veneer is

approximately 3-5 years and will require maintenance by dentist from time to
time to re-finish or re-furbish).

TECHNIQUE
1. Shade selection (Durafill)
2. Rubber dam or gingival retraction
3. Tooth preparation -
a) allows for an adequate thickness of veneer without over-contouring or
increasing the labial - lingual thickness of the tooth
b) provides a clearly defined margin for fabrication and finishing of veneers
c) enhances bonding

d) OUTLINE FORM - Axial depth is .5 mm or one-half the depth of enamel. The

769-T-9M, 778-8P diamonds may be used for the depth grooves and final
preparation. The outline is extended on sound tooth structure to the crest of
the incisal edge, to the gingival margin and just facial to the mesial and distal
contact areas.
103
4. Place mylar strips.
5. Etch enamel (if enamel has NOT been prepared, need minimum 60 seconds etch).
6. Apply thin layer of bonding resin (primer theoretically not needed if no dentin bonding
needed) and cure.
7. DISCOLOURED TEETH
Use thin layer of opaquer resin over cured bonding resin to mask discolouration or
metal. See "Colouring with Resins". by Feigenbaum, N.L. and Mopper, K.W. Chapter 4
in the Jordan's Esthetic Composite Bonding. C.V. Mosby, 1988, Pps 144-155.
8. Apply preselected shade of microfilled composite resin (in one bulk strip or button
sufficient for whole veneer) Tamp to shape with plastic instrument ensuring no voids
at periphery, gingivally and proximally. Photocure.
9. Finish to approximate contour using multifluted finishing bur 7901 and coarse Sof-lex
disc. (Refer to pre-operative model to assist).
10. Polish with Sof-lex discs (accessible areas) and Enhance polishing instruments.

104
 POSTERIOR COMPOSITES
The combination of the public’s and the profession’s interest in esthetic restorations and
reduced public confidence in the safety of silver amalgam has led to a significant decline in
amalgam usage. Improved resin composite and dentin bonding materials, as well as increased
understanding of their optimal usage and improved insertion techniques, have led to
increased use of composite restorations for the posterior dentition. This is despite the fact
that clinical practice studies show decreased longevity of composite compared with silver
amalgam and that the safety of silver amalgam restorations has survived intense scientific
scrutiny. Anecdotal opinions differ widely in private practice regarding the use of composite
for the posterior dentition. The teaching in the Restorative Discipline is based on the current
evidence, recognizes the advantages and limitations of each material and encourages
balanced use of both materials, as appropriate for the particular patient and clinical situation.

Posterior composite restorations are considered to be technique-sensitive and great care is

needed during placement.

Recommended Reading:
-Tam, LE (2011) Posterior Composite Restoration- techniques and materials for direct
placement.
http://www.dentistry.utoronto.ca/dpes/restorative/professionals/class-ii-composite-
restorations-pro

Hilton, T.J. Direct Posterior Esthetic Restorations. Chapter 10 in Fundamental of Operative

Dentistry – a contemporary approach. 3rd Ed. Edited by Summit J.B., Robbins J.W. & Schwartz
R.S. Quint. Pub Co. 2006

Potential Problems with Posterior Composites

They are non-packable, leading to voids and inadequate proximal contacts. Specific composite
matricing and insertion techniques are required. Post-operative sensitivity is more common.
Meticulous bonding procedures and incremental composite insertion are necessary.
Proximal contour, occlusal embrasure form and finishing are more difficult due to non-
carvable material. They require specific contour development during insertion.

Indications

Consider patient caries risk, lesion size (width and gingival extent) of lesion, position of lesion,
esthetics and patient requests. Composites can be ideal for all initial minimal Class 1 and 2
restorations with margins on enamel. They are also more appropriate for esthetic locations.
Composite is not recommended for extensive restorations, cusp replacements, pinned
restorations (unless core for crown), patients with poor oral hygiene, high caries risk etc.
Patients must be informed of the limitations of composite materials in large restorations,
particularly in molars and any gingival margins on root surface.

105
Patients should be informed about the available filling materials during initial treatment
planning and any concerns with respect to silver amalgam addressed rationally and
scientifically. (See subsequent “Patient Information Sheet)

Note that the wholesale removal of sound silver amalgam restorations and replacement
with composite resin is not permitted at the Faculty.

**Further information on safety of silver amalgam restorations – See Appendices**

106
 CURRENT DENTAL FILLING MATERIALS – PATIENT INFORMATION
This document is intended to provide patients with information regarding the material used to
fill teeth. Two types of directly inserted (one-appointment) filling materials are currently
available for fillings in the back of the mouth, silver amalgam and tooth-coloured resin
composite. Each material has advantages and disadvantages which determine the indications
for use in different mouth situations.

 Silver amalgam is an alloy (mixture) of silver, copper, tin and mercury which has a long
clinical history. Current alloys have undergone several decades of refinement to provide a
stable, corrosion resistant and durable filling. It is the usual material of choice for larger
back fillings, because of its proven record of providing fillings that are comfortable, long
lasting and affordable, particularly in molar teeth.

 Silver amalgam allows total adaptation to all of the prepared cavity, is carvable to an ideal
shape and seals the tooth well. All clinical studies have shown that silver amalgam fillings
are more durable and last longer than resin composite. This is an important issue as every
time a filling is replaced, more tooth structure is lost and the tooth further weakened.

 Resin composite is a tooth-coloured, filled plastic (methacrylate) that is hardened

(polymerized) in the mouth. These materials have been used in smaller fillings in the front
of the mouth for over 20 years. Only in recent years have products been developed that
can withstand chewing forces in selected situations in back teeth.

 Resin composite materials work best in small to moderate cavities, can bond to tooth
structure and provide aesthetic fillings. They are, however, more difficult to work with than
silver amalgam to achieve a successful filling, take more time and are more expensive than
silver amalgam fillings. They are associated with greater incidence of post-treatment
sensitivity and are not advised in large or complex fillings in molars. They may not be
covered by dental insurance. Although the life of all fillings is dependent on good patient
oral hygiene to prevent new decay at the edges, this is particularly so with the tooth-
coloured composites.

 Recent scientific evidence is showing that all direct filling materials are not as inert as was
once thought. Minute amounts of mercury vapour are released from silver amalgam
during chewing and tooth-brushing. Also, resin composites are quite complex plastics
which allow release of minute amounts of monomers over a period of time. Both materials
contain possible allergens but this has not been a significant problem with either material.

107
 The safety of any material to be used in the mouth is of utmost concern to dentists. It is
important to remember that millions of both types of fillings are placed annually in Canada.
The fact that dentists, who are occupationally exposed on a daily basis to greater
concentrations of the constituents of both materials, show good health and longevity in
epidemiological studies, also attests to the safety of these materials in patients.

Recent Health Canada Review of the Safety of Dental Amalgam

In recent years the issue of mercury release from silver amalgam has received attention.
Health Canada has completed (1996) a review of the safety of dental silver amalgam and have
stated that “current evidence does not indicate that dental amalgam is causing illness in the
general population.” Some recommendations have been made to modify the use of silver
amalgam in a small number of vulnerable, medically compromised or hypersensitive patients.

Treatment planning at the Faculty of Dentistry will consequently involve selection of the
most appropriate materials with maximum benefit/prognosis for the particular clinical
situation in your mouth. In some clinical situations there may be a choice of material.

Other Alternative Filling Materials

Alternatives to silver amalgam and resin composite are available but involve manufacture in
the dental laboratory on a model of your tooth (indirect method). Such materials include cast
precious metal alloys (gold, platinum or palladium), ceramics (e.g. porcelain) or a laboratory
cured filled resin composite.

Due to the time, precision and complexity involved these indirect fillings are much more
expensive than direct silver amalgam or resin composite. They are used to provide a more
ideal filling when a large amount of tooth structure has been lost.

Patients requesting tooth-coloured materials or alternatives to silver amalgam for large fillings
will be provided with an alternative treatment plan using indirect restorative materials
(crowns/caps, inlays or onlays) as necessary.

If you have a strong material preference you should indicate this to your dentist. The patient
must however understand and accept the limitations of alternative material selection. These
may include: additional costs, longer treatment time, greater chance of failure and
subsequently increased treatment requirements.

108
POSTERIOR COMPOSITES: ADDITIONAL ARMAMENTARIUM

Glass Ionomer Lining Cement (Vitrebond 3MCo). Contour Matrix Band ("Dixieland Band"),
.0015 (Teledyne Getz), or Palodent matrix band with 3D Garrison/Bitine/ Triodent v3 ring.
Z250 (3M Espe) Posterior Composite. H379 (7404) & OS2 or H247 Multifluted Finishing Burs
(Brasseler Inc.).

TECHNIQUE

1) Pre-wedging with wooden interproximal wedges to effect slow separation of teeth.

2) Conservative classical cavity preparation. (The only difference between this and an
amalgam preparation is the absence of retention grooves). In a new lesion keep proximal
tear-drop in shape with rounded outline form. (Adhesive preparation).

3) No bevels on occlusal surface. Need for proximal bevel is equivocal in literature. We

generally do not bevel but cavosurface must be smooth and sound. Use gingival margin
trimmer for proximal gingival.

4) Place glass ionomer liner (Vitrebond) on medium depth preparations. If preparation is

deep or near pulp, then the deeper areas must be lined first with a fast-setting calcium
hydroxide cement. Leave adequate peripheral dentin for sealing with dentin primer.

5) Careful attention to matricing with Palodent sectional matrix used with 3D Garrison,
Triodent V3 or Bitine OR precontoured, thin (0.0015") Dixieland Band. [With latter re-
wedge tightly to ensure maximum separation). Do not over tighten matrix band. Burnish
to tight, adaptive contact with adjacent proximal surface.]

NOTE: Ensure no gap between band and adjacent tooth at proximal contact. A
sectional matrix band used with a ring separator is the most successful

109
 matricing system for posterior composites. Unlike with amalgam, no positive
packing is possible. Lack of a positive tight contact in final restoration is
common occurrence and will necessitate replacement. The separating ring may
be used with a circumferential matrix band as well as a section matrix.

6) Use Optibond Fl dentin bonding agent.

7) Place 1 mm gingival increment of resin. Ensure composite is well adapted to gingival

floor using ball burnisher in step-wise tamping fashion. Polymerize 40 seconds.

NOTE: This step must be carried out thoroughly.

8) Add second proximal increment of composite resin. The burnishing instrument may be
used to ensure proximal contact/contour by holding out the matrix band during
photopolymerization (care instrument does not become trapped in cured composite!).
Polymerize 40 seconds. Each additional increment should be no thicker than 2 mm.

9) Add occlusal increment and perform occlusal shaping by lay-on technique in fissures
and draw towards enamel. Do maximum excess removal and shaping prior to
polymerization for 40 second. This saves an inordinate amount of time shaping and
finishing after curing.

110
 PROXIMAL INCREMENTAL PLACEMENT OF POSTERIOR COMPOSITE

PREFERRED TECHNIQUE

1) HORIZONTAL (INCREMENTS 1 & 2) 2) VERTICAL (INCREMENTS 3 & 4)

NOTE: If preparation is wider than minimal facio-lingually, perform composite insertion in

2-3 vertical increments to minimize effects of polymerization shrinkage.

10) Use football shaped multi-fluted bur (H379 (7404) for gross contouring and then,
multi-fluted bur (OS2 or H247-009) for occlusal anatomy and detailing. L.A. round
burs may also be utilized. Use FG 7901 interproximally (carefully) for gross excess or
small Sof-lex discs. Finish with Enhance finishing and polishing system. Check
occlusion carefully as high spots are not so easily seen and are a common cause of
post-operative sensitivity. Use shimstock on adjacent teeth.

H379 (7404) H247 (OS2) Enhance Finishing

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 Composi-Tight 3D (Garrison Ring) (New 2009)

 Contoured tips with adaptable silicone

to “hug” the band to the tooth
 Proximal anatomy better. Reduced flash
 Slotted base fits over the wedge
 Tips are wider than standard
 Reinforced over-mold
 Useful for regular shaped arch only

In an MOD restoration, only one proximal side is filled at one time….

A B

A. Mesial proximal sectional matrix + wedge + Garrison 3-D Ring

B. Distal proximal ready with sectional matrix and wedge only

C D E

C. Mesial proximal resin insertion complete.

D. Garrison 3-D Ring transferred to distal.
E. Distal proximal resin insertion complete.

112
With a regular shaped arch Garrison 3-D Ring helps minimize finishing and
allows easier, and more stable, placement over wedge.

113
ROOT CARIES AND CLINICAL USE OF GLASS
IONOMER RESTORATIVE CEMENTS

114
 ROOT CARIES

As more and more patients are keeping their teeth into older age, root caries has become
more prevalent. Increasing vigilance is required as the patient ages and at recall examination
of elderly patients allowing early diagnosis and management/treatment of root caries.

 The aging adult population will continue to present an unprecedented volume and
variety of restorative treatment needs
 Maintaining the aging dentition will require complex restorative therapy, often in areas
of difficult access
 The number of teeth at risk may double from 1992-2030

Public Health statisticians have stated that dentists will be treating significantly increasing
amounts of root caries. This may be:

a) Simple root caries (lesions involving only one surface) or

b) Compound root caries (lesions involving more than one root surface).

Both types are usually almost entirely in dentin and cementum. Once restored these lesions
are liable to suffer recurrent decay, particularly if a restorative material with no inherent
protection is utilized or if oral hygiene or dietary habits are not improved. The carious process
is essentially the same as that in coronal tooth structure – the factors and the substrate are
different:

DIFFERENCES IN DEMINERALISATION pH

ROOT 6.2

CROWN 5.5

ROOT CARIES RISK FACTORS

1. Exposed Root Surfaces (Recession, treated and untreated periodontal disease)

2. Reduced Salivary Flow (Medications, area radiation, decreased buffering and sugar
clearance)
3. Increased Cariogenic Diet (easily digested fermentable carbohydrates, slow dissolving
sugar candies etc)
4. Poor Oral Hygiene (high plaque scores, decreased dexterity, motivation etc)
5. High Mutans Streptococci and Lactobacilli (elevated salivary counts and presence on
root)
6. Low Fluoride Exposure (lifelong residence in low-fluoride area, avoidance of fluoride
etc)
7. Smoking.

115
TREATMENT OF ROOT CARIES

I. SUPERFICIAL ROOT CARIES – FLUORIDE VARNISH AND INTENSE BASIC PREVENTIVE

CARE

II. EARLY SURFACE ROOT CARIES DESTRUCTION – SURFACE DISCING, FLUORIDE

VARNISH AND INTENSE BASIC PREVENTIVE CARE

III. CAVITATION –

a) NON-ESTHETIC, HARD TO ACCESS LOCATIONS – USE SILVER AMALGAM plus

fluoride varnish and intense basic preventive care.
b) MORE ESTHETIC REASONABLY ACCESSIBLE LOCATIONS – USE RESIN MODIFIED
GLASS IONOMER CEMENT plus basic prevention.
c) ANTERIOR ESTHETIC LOCATIONS WITH GOOD PATIENT COMPLIANCE-- USE
COMPOSITE RESIN plus fluoride varnish and intense basic preventive care.

116
Note: The three common types of restorative material for this kind of problem can be ranked
with regard to their ability to prevent a recurrence in the following way:-

GLASS IONOMER (High fluoride content - Good sealing but technique sensitive)
AMALGAM (Easier to insert and carve, well adapted and self sealing. No inherent caries
protection)

COMPOSITE RESIN (No inherent caries protection and technique sensitive).

A) SIMPLE ROOT CARIES IN A NON AESTHETIC AREA

UTILIZE SILVER AMALGAM IF MORE IDEAL PLACEMENT CAN BE ASSURED WITH USE OF
CONDENSABLE MATERIAL OR RMGI if situation suitable.
Choice will therefore depend to a large extent on access. In both cases technique will
utilize conventional cavity preparation. As little enamel is involved, cavity walls may be
parallel and no retention grooves are usually necessary for glass ionomer unless
preparation is very shallow (< 1.5 mm) or covers a large area (judgment decision).
Shallow, saucer-shaped preparations do not provide adequate retention for amalgam
or glass ionomer.

B) SIMPLE ROOT CARIES IN AN AESTHETIC AREA

UTILIZE PRIMARILY RESIN-MODIFIED GLASS IONOMER CEMENT. (ONLY UTILIZE
COMPOSITE RESIN WHERE AESTHETICS ARE OF MAJOR CONCERN AND PATIENT
FACTORS (O.H. etc.) ARE OPTIMAL.) Technique as above with standard cavity
preparation, parallel walls with or without grooves depending on depth. In patient
with root decay a small sacrifice in aesthetics may be justifiable to gain fluoride release
and improved marginal seal.

NOTE:
A and/or B may involve crown margin repair. If simple root caries is present adjacent
to an otherwise sound full crown and the area is accessible (i.e. facial or lingual) then
repair may be attempted and the material of choice is glass ionomer cement, to
prevent further recurrence. Silver amalgam may be more appropriate in difficult
access, non-aesthetic areas.

117
 GLASS IONOMER CEMENTS

CONVENTIONAL GLASS IONOMER CEMENTS:

As the name implies, the material is a cement with a glass powder and a polyacrylic acid liquid
which react together in an acid-base type reaction.

ALUMINO-SILICATE GLASS + POLYACRYLIC ACID = CONVENTIONAL GLASS IONOMER

ADVANTAGES

1) High fluoride release. Imparts resistance against recurrent decay.

2) Chemical adhesion to tooth structure. (low bond strength 3-5 MPa).
3) Strong antimicrobial properties. Good sealing ability.
4) Hydrophilic (Not repelled by water).
5) Biocompatible.

LIMITATIONS

1) Long setting time and maturation process.

2) Need to keep cement protected from dehydration and moisture contamination for
at least 60 minutes and preferably longer.
3) Translucency and aesthetics does not match that of composites.
4) Material is brittle. Cannot be used in thin sections, or in occlusal loaded situations.

Despite these disadvantages they have been accepted worldwide for use in specific clinical
situations for at least 20 years and good formulations have performed well in clinical
investigations (Walls et al, 1988; Knibbs, 1987 and 1988; Teo, 1986)

118
RESIN-MODIFIED GLASS IONOMER CEMENTS:

In recent years a new class of photopolymerized GI materials has been developed which are a
hybrid of glass ionomer and composite resin technology. Such materials provide improved
handling characteristics. Resin-modified glass ionomers are powder/liquid materials. The
powder is very similar to that of a conventional G.I. The liquids involve novel polyacrylic
(polycarboxylic) acid polymer chains grafted with pendant methacrylate groups or have a
proportion of resin (e.g. HEMA) added to the polycarboxylic acid liquid. In a true light-cured
glass ionomer two setting reactions occur 1) the light activated free radical polymerization of
various methacrylate monomers (e.g. MMA, HEMA) and 2) the customary acid-base reaction
between the fluoroaluminosilicate glass and the polyacrylic (polycarboxylic) acid of a
conventional GI. These materials therefore combine adequate working time with command
cure. A third setting reaction is a chemical cure of the methacrylate monomer using a redox
catalyst system.

ADVANTAGES (over Conventional Glass Ionomers)

 Greater ease of use (although still dispensed as powder/liquid materials). Command cure.
 Superior strength properties, including higher fracture toughness and tensile strength.
Better aesthetics.
 Comparable fluoride content release and tooth uptake.
 Improved bond strengths. Some products use a conditioner, others use a primer.

Currently the RMGI restorative cement in the clinics is FUJI 2 LC. Glass ionomers of either type
are the material of choice for ROOT DECAY IN AESTHETIC LOCATIONS.

119
TECHNIQUE FOR CLINICAL USE

1) Select appropriate shade

2) Isolate using rubber dam wherever possible. Alternatively use retraction cord for moisture
control A cervical retraction clamp can be advantageous to improve access to subgingival
lesions

3) Cavity preparation:-

a) Root caries. Standard box-form cavity preparation. No accessory retention

grooves are necessary unless box-form not achievable. No bevels.
b) Abrasion/abfraction. Clean with pumice and rubber cup. Many of these lesions
do not require restoration - indeed a restoration may cause different problems.
Lesions require a depth of greater than 1.5 mm for G.I.

4) Apply calcium hydroxide cement to pulpal aspect of freshly cut dentin if cavity deep.
Wash cavity and dry lightly.

5) Restoration:-

Can be used with or without a clear cure-thru cervical matrix. Matrix does ensure
good adaptation and contour. Enamel cavo-surface may be conditioned with
supplied citric acid/ferric chloride etchant. Dentin bond strength is not improved
with conditioner. Conditioner is not normally recommended however, if used to
‘cleanse’ cavity, allow only 5-10 seconds. Dispense correct P:L, mix quickly and
place in Centrix syringe for ease of insertion into washed and lightly dried
preparation. Light cure for 40 seconds.

120
6) Finishing:-

Resin-modified GI. Can perform immediate wet finishing with Sof-lex discs or slow-
speed bur. If considerable excess is present, careful use of multi-fluted finishing
bur (7901) in high speed handpiece with water can be carried out. The material is
however initially somewhat soft and extreme care is required. For greater
protection from dehydration and moisture after final finishing, apply finishing gloss
(if supplied), or apply bonding resin and photocure.

FAILURES OF BONDING OCCUR OCCASIONALLY WITH STUDENTS. SUCH FAILURE IS DUE TO:

1) Inadequate box-form for root caries (saucer-shape is inadequate)

2) Inadequate depth for abrasion lesion (if depth is < 1-1.5 mm glass ionomer glass
ionomer is inappropriate as a permanent restoration – it is brittle in thin sections)
3) Late application of cement (if lost gloss, already setting). Discard and mix anew.

121
RESTORATION OF THE ENDODONTICALLY TREATED
TOOTH

See http://www.rcdso.org/dispatch/PeakFM2008.pdf for review (D.McComb)

122
 SUMMARY OF CURRENT PHILOSOPHY AND GUIDELINES
General
- The fracture resistance of endodontically treated teeth to horizontal and vertical forces is
related to the amount of healthy dentin remaining (Nayyar 1983). The prognosis is largely
dependant on the presence of adequate (2mm height, 1mm thickness) circumferential
tooth structure (ferrule) to allow crown and root to act as one unit, with normal transfer
of occlusal forces to the periodontium.

- All endodontically treated teeth that require extracoronal coverage also require a coronal-
radicular restoration with consideration of necessity for a post. The purpose of the
coronal-radicular restoration (with or without a post) is to replace lost dentin, provide
internal support and retention for the extracoronal restoration and ensure adequate
resistance form against cervical tooth fracture for narrow diameter teeth (e.g. maxillary
laterals and bicuspids).

- Where inadequate ferrule exists, occlusal stresses are transferred directly to the post-core
with high likelihood of tooth, root or post fracture or post dislodgement. It is for this
reason that the practice of “elective” endodontic treatment for teeth with inadequate
ferrule, in an attempt to gain “retention from the root”, is doomed to failure. Adequate
circumferential tooth structure can be gained by a) slight subgingival preparation b)
prolonged temporization of more subgingival preparation (to allow natural recession) c)
surgical crown lengthening or d) forced orthodontic eruption.

Specific
- The clinical longevity of endodontically treated maxillary and mandibular molars and
premolars is significantly improved with coronal coverage (Sörensen, 1984). A coronal-
radicular restoration followed by a full coverage restoration is generally required for all
premolars because of the risk of catastrophic tooth fracture and high occlusal loads in the
posterior region of the mouth. It is Faculty policy to provide endodontically-treated
posterior teeth with a coronal-radicular build-up (molars rarely require a post) and some
form of cusp coverage, unless there is only minimal dentin loss (eg. occlusal access with no
or minimal proximal involvement). Sound clinical judgment is essential.
- The clinical longevity of endodontically treated maxillary and mandibular anterior teeth
is not significantly improved with coronal coverage (Sörensen, 1984). A full crown is only
required when 1) substantial loss of coronal tooth structure has occurred or 2) the tooth is
unesthetic, doesn't respond to bleaching techniques or is an unsatisfactory candidate for
more conservative techniques e.g. veneer. Sound clinical judgment is essential.
- Anterior teeth and premolars generally require a post for core retention. Minimal canal
preparation is advised when stock posts are utilized. Current guidelines advocate minimal
tooth weakening by adjusting the post to fit the canal rather than preparing the canal to
the full post dimensions.

123
 SIGNIFICANCE OF THE FERRULE (DENTINAL COLLAR)

Applies to all post-cores (direct and indirect)

Ferrule Present

 Ferrule effect provided by

coronal tooth structure
 Functional forces on crown are
distributed by ferrule largely to
the periodontal ligament
 Without ferrule forces are
distributed largely to the post

When a crown is placed on a post-core treated tooth with at least 2 mm of sound dentinal collar,
the occlusal forces transmitted to the restored tooth are shared between the post and tooth. The
loading is thus more readily transferred to the periodontal ligament.

The benefits of the ferrule effect to a post/core are:

a) increased retention of post- dentinal support for the post is provided by radicular
extension (7-9 mms, equal to restored crown length) plus coronal extension of residual
dentin (dentinal collar).

b) increased resistance to displacement forces, thus less risk of

i. dislodgment
ii. post distortion, microleakage
iii. root/post fracture

The presence of a dentinal collar or ferrule significantly increases the clinical success
rate/longevity of the post-core/crown restored tooth.

124
Ferrule Absent

When no coronal dentin remains after crown preparation, the eventual crown will be
supported entirely by the post and core, therefore all forces will be transmitted to the post.
The hammering effect of repeated occlusal loading can give rise to early fatigue by:

a) root fracture

Vertical root fracture is common in

restored endodontically treated teeth
with no ferrule.
Catastrophic root fracture is
particularly likely to occur if:

i) the root is anatomically thin

ii) the canal has been excessively
enlarged or
iii) the post is short and has a wide
diameter.

A tooth with root fracture will require

extraction.

b) post dislodgement (fatigue of cement lute)

“As a pneumatic drill breaks up

concrete, so a hammering effect
can break the lute that retains a
post”.
(Pitt Ford)

125
 c) post distortion or fracture

 Thin posts or posts with

casting porosities are
particularly vulnerable.
 Even posts with a
satisfactory diameter can
fracture if occlusal forces are
heavy and a ferrule effect is
absent

Recommendations

Every attempt should be made to retain as much coronal dentin as possible when preparing a
tooth for a post-core/crown restoration. The dentinal collar should ideally be a minimum of
2.0 mm in height and 1.0 mm in thickness.

Inability to provide a ferrule lowers the prognosis considerably in most instances unless the
tooth is a satisfactory candidate for either surgical crown lengthening or orthodontic forced
eruption. Absence of a ferrule totally contraindicates using the tooth as a bridge or denture
abutment.

126
DIRECT POST AND CORE PROCEDURES

127
 DIRECT POST AND CORE PROCEDURES

A coronal – radicular restoration provides the foundation for the subsequent crown, and
internal support and resistance against cervical tooth fracture. Retention of the coronal –
radicular restoration is provided by:

1) the tooth itself, and/or

2) bonding, and/or
3) prefabricated posts, and/or
4) self threading pins

In all cases, clinical success and longevity is dependent on the presence of adequate
circumferential tooth structure (i.e. ferrule). This ensures occlusal forces are distributed
externally through the root to supporting structures (periodontal ligament/bone) and
prevents internals stress concentrations within the root.

1) Tooth
Many clinical situations present with substantial coronal tooth structure remaining,
particularly molars, where radicular retention can be provided by the pulp chamber
itself or extensions into the canals. Adequate tooth ferrule is always necessary for any
tooth, whether or not posts are required.

2) Bonding
The acid etch technique in conjunction with a dentin bonding system is indicated for
direct post and composite core build up techniques to provide additional
micromechanical retention and an improved radicular seal. Resin bonding may also be
used in conjunction with amalgam post and core build ups in selected cases but

128
 potential bond strengths are low (see ‘Bonded’ Amalgam Restorations). In either
situation, adhesive bonding is not a substitute for primary macromechanical retentive
features.

3) Prefabricated Posts
Posts tend to weaken the root and canal over-preparation for parallel sided posts
carries a significant risk of root perforation and consequent loss of the tooth.
Appropriately sized and placed posts are used judiciously to retain core build ups
and/or to reinforce the crown-to-root junction at the cervical of smaller diameter
teeth in:

i) single rooted teeth (preferred technique)

ii) two rooted bicuspids
iii) molars (rarely) with inadequate remaining coronal tooth structure.

Currently the self-etch resin luting cement Unicem (3M-ESPE) is recommended at the
faculty for post cementation as it provides a less technique sensitive clinical application
(than total-etch resin cements) and a resin interface for subsequent bonding to the
core.

4) Pins no pins for endo treated teeth

Pins create high stress concentrations in surrounding dentin and their retentive
potential may be diminished or lost if contacted during crown preparations. They are
contraindicated for endodontically treated teeth due to the risk of pin induced
fractures, periodontal perforations and the availability of safer alternatives.

[Note: Sound pin restorations placed prior to loss of vitality or endodontic therapy
may be incorporated as part of the core build up procedure.]

No single post and core technique is suitable for all clinical situations!

129
 SINGLE CANAL TEETH - ANTERIORS AND BICUSPIDS
Prefabricated Post - Composite Resin Core

This is the preferred technique over the cast post and core. In appropriately selected cases
this technique provides:

- significantly greater retention than smooth tapered posts

- less risk of root fracture with potential for less removal of tooth-structure (undercuts)
and better stress distribution along the length of the post
- one appointment procedure
- no post impression required
- no laboratory fee
- simplified temporization
- reduced chair time, number of appointments and cost

Indications:
1. Single canal teeth with straight bulky roots, generally;
-maxillary centrals and selected maxillary laterals
-maxillary and mandibular cuspids
-single root bicuspids

2. Minimum 2 mm remaining coronal tooth structure (ferrule effect)

3. Conservative endodontic therapy performed

Contraindications:
1. Thin roots +/- thin canals (caution for narrow maxillary laterals, mandibular incisors,
selected single root bicuspids)
2. Curved roots
3. Widely flared or ribbon shaped canals

130
Technique:
1. Apply rubber dam when possible.
2. Reduce tooth for desired crown preparation
Note: This is the preferred first step because it allows you to properly assess remaining
tooth structure for the core and subsequent crown. However, you must be prepared to
fabricate a temporary crown at this appointment. Novice clinicians may not have the
time to do (i) a crown preparation, (ii) a post-core restoration AND (iii) a temporary
crown within the same appointment. A post-core restoration can be done first (to full
anatomy with proximal contacts), followed by a crown preparation and temporization at
a subsequent appointment. If the post-core restoration will act as a functional interim
restoration, ie. there will be a delay before crown preparation, cusp capping on
remaining cusps is strongly advised to prevent premature tooth fracture.

3. Remove existing restorations. Gain access to pulp chamber and remove all gutta percha.
Assess remaining coronal tooth structure and determine the most appropriate coronal
build up technique. Reduce the height of unsupported dentin walls to achieve a minimal
1mm thickness.

4. Remove gutta percha in the canal either by: i) preparing a tracking channel with a #2
Gates Glidden bur or ii) a heated instrument, followed by increasing diameter Gates
Glidden or Peeso burs. Gutta percha should offer only minimal resistance to penetration. If
significant resistance is felt, reassess angulation by either visual or radiographic means to
ensure that you are removing gutta percha and not dentin.

Gates Glidden burs

131
5. Establish a post channel depth:
i) equal or greater than the restored crown length
ii) minimum 7-9 mm from canal orifice
iii) 4 mm gutta percha seal

6. Use increasing diameter Peeso burs at the established post channel depth to remove
remaining gutta percha until a clean and smooth canal wall surface is achieved. Ideally the
canal should be negligibly enlarged to permit the placement of the smallest possible
matching diameter post.

Peeso Burs

Note: Do not try to totally convert an elliptical canal to a circular shape. Contact with
opposing walls may be sufficient.

132
 INSTRUMENT SIZES

DIAMETER 0.5 0.7 0.9 1.0 1.1 1.3 1.4 1.5 1.7
(mm)

Gates #1 #2 #3 #4 #5 #6
Glidden

Peeso Reamer - #1 #2 #3 #4 #5 #6

Paraposts - - Brown Yellow Blue Red Purple Black

(1.14mm) (1.25mm)

Ideally the canal should be minimally enlarged with increasing diameter Gates Glidden to
permit the placement of the smallest diameter post possible

Parapost drills and paraposts

7. Place the corresponding Para Post. Assess fit and retention. If seating is incomplete or if
post is slightly too large, do not enlarge canal, - adjust apical portion of post with high
speed diamond to produce slight taper. (Smoothen cut edge of post on apical end with a
disc, for easy seating).

133
8. Reduce post length at apical end as required to permit optimal coronal extension (min
2mm) and space for composite core. Take a radiograph with the post in place.

9. Cement post (see Post Cementation Procedures in Cementation Procedures and Luting
Agents section). Parallel posts (Parapost) are serrated and do not require venting.
A resin luting cement [e.g. Unicem preferred (3M-ESPE) or Calibra (Dentsply)] provides
the advantage of allowing immediate core build-up concurrent with composite. It is
particularly useful if canal opening is flared. The cement is dual-cured allowing
immediate polymerization of uppermost portion once post is sealed. Removal of minor
excess cement is not required which avoids disturbing post during cement set which can
occur with conventional cements. Bonding procedures for canal and core are performed
simultaneously.

10. Etch remaining coronal tooth structure, apply dentin bonding resins, light cure and
construct composite core using a freehand incremental build up technique and thorough
light curing.

11. Finalize the crown preparation and fabricate temporary crown.

Note: Apply a thin film of lubricant to resin core prior to temporization to prevent
inadvertent bonding.

134
 TWO-ROOTED BICUSPIDS

A. Prefabricated Post - Composite Resin Core (Preferred Technique)

This is the preferred technique in all cases where the patient is committed to the complete
restoration of the tooth with a coronal coverage restoration. It offers the same advantages as
the Prefabricated Post/Composite Core technique for single canal teeth.

See previous Technique for Single Canal Teeth- Prefabricated Post and Composite Resin Core.
Only prepare the largest and straightest canal for the prefabricated post (usually the lingual
canal). Remove 2mm (max) of gutta percha from the other (usually buccal) canal to provide
additional resistance/retention form if needed.

B. Prefabricated Post - Amalgam Core (Alternate Technique)

This technique may be preferable in cases where a multi-surface interim restoration with
proper proximal contacts is needed, and a crown preparation cannot be performed at the
same appointment or must be delayed. If this will be a functional interim restoration, it is
important that cusp capping is performed on remaining cusps, when an occlusal access plus
one or both missing proximal surfaces exists to prevent tooth fracture.

See upcoming Technique for Molars- Prefabricated Post and Amalgam Core. Only prepare the
largest and straightest canal for the prefabricated post (usually the lingual canal). Only
prepare the largest and straightest canal for the prefabricated post (usually the lingual canal).
Remove 2-3 mm of gutta percha from the other (usually buccal) canal to provide additional
resistance/retention form.

135
 MOLARS
I. Pulp chamber retention
This technique is conservative of tooth structure. It is highly successful in molar teeth due to
the greater circumference and bulk of tooth and core material. Retention is provided by 1)
the remaining dentin walls 2) the pulp chamber and 3) optional extensions into canals and 4)
dentin bonding. Evidence of clinical longevity with amalgam has been documented at the
Medical College of Georgia since its inception there in 1976. “Adequate coronal dentin” for
retention cannot be truly defined - your instructor will assist you in developing careful clinical
judgment.

METHODS OF RETENTION

PULP CHAMBER ONLY PULP CHAMBER PLUS

EXTENSION INTO CANALS
Guidelines for amalgam core: Guidelines for amalgam core:
When pulp chamber > 4.0mm When pulp chamber < 4.0mm
Adequate undercuts Inadequate undercuts

lec says 6 mm

136
PULP CHAMBER RETENTION
Indications

1. Molars with adequate coronal dentin remaining and a retentive pulp chamber (4 mm or
greater in height, adequate undercuts).

2. Multi- and single- rooted molars.

3. Canal(s) with an irretrievable, fractured post.
4. Widely flared, tapered canals.

A. Composite Resin Coronal-Radicular Restoration [composite core with or

without extension into canals]

This technique allows post and core construction AND crown preparation at one appointment.

1) Apply rubber dam where possible.

2) Reduce tooth for desired crown preparation
Note: This is the preferred first step because it allows you to properly assess remaining
tooth structure for the core and subsequent crown. However, you must be prepared to
fabricate a temporary crown at this appointment. Novice clinicians may not have the
time to do (i) a crown preparation, (ii) a coronal-radicular restoration AND (iii) a
temporary crown within the same appointment. A coronal-radicular restoration can be
done first (to full anatomy with proximal contacts), followed by a crown preparation and
temporization at a subsequent appointment. If the coronal-radicular restoration will act
as a functional interim restoration, ie. there will be a delay before crown preparation,
cusp capping on remaining cusps is strongly advised to prevent premature tooth
fracture.

3) Remove existing restorations. Gain access to pulp chamber and remove all gutta
percha. Assess remaining coronal tooth structure and determine the most appropriate
coronal build up technique. Reduce the height of unsupported dentin walls to achieve
a minimal 1mm thickness.

4) Preserve the height of the pulp chamber and natural undercuts.

5) The need for extensions into canals for additional retention for the bonded composite
coronal-radicular restoration requires clinical judgement. If additional retention is
required, remove gutta percha from each of the canals to a maximum depth of 2mm.
with a heated instrument or Gates - Glidden burs. Enlarge small diameter canals to
1.25 - 1.5 mm. with Gates-Glidden drills. (Ensure no sharp line angles (stress
concentration) between canal and pulp chamber).

137
restin: remove gp to depth
of 2 mm max
6) Apply a matrix if needed.

7) Using a dentin bonding resin system, composite resin and an incremental build up
technique, build up core to slight excess of contour. The shade of the composite
should contrast dentin rather than match dentin. Ensure complete polymerization in
deeper more inaccessible locations. A translucent composite will cure more easily than
an opaque composite.

8) Finalize crown/onlay preparation

Note: Apply a thin film of lubricant to resin core prior to temporization to prevent
inadvertent bonding.

B. Amalgam Coronal-Radicular Restoration [amalgam core with or without extension

into canals]
This technique may be preferable in cases where a multi-surface interim restoration with
proper proximal contacts is needed, and a crown preparation cannot be performed at the
same appointment or must be delayed. If this will be a functional interim restoration, it is
important that cusp capping is performed on remaining cusps, when an occlusal access plus
one or both missing proximal surfaces exists to prevent tooth fracture.

Material Considerations

Use Tytin spherical amalgam - easily condensed, excellent adaptation, fast setting, high 1-hour
strength. Ask for assistance when ready to restore.

Technique
1) Apply rubber dam.
2) Remove existing restorations. Gain access to pulp chamber and remove all gutta
percha. Assess remaining coronal tooth structure and determine the most
appropriate coronal build up technique. Reduce the height of unsupported cusps
to achieve a minimal 1mm dentin thickness and 2mm height of cusp-capping.

3) Preserve the height of the pulp chamber and natural undercuts.

4) The need for extensions into canals for additional retention for the amalgam coronal-
radicular restoration requires clinical judgement. Extensions into canals for additional
retention for an amalgam core are required if i) pulp chamber is less than 4 mm in
HEIGHT and ii) an undercut is not present or cannot be provided with additional
preparation. Remove gutta percha from each of the canals to a depth of 2-3 mm with a

138 amalgam: remove gp depth of

2-3 mm
 heated instrument or Gates - Glidden burs. Enlarge small diameter canals to 1.25 - 1.5
mm. with Gates-Glidden drills. (Ensure no sharp line angles (stress concentration)
between canal and pulp chamber).

5) Place a well adapted matrix band. The Tofflemire matrix may not be well suited for
severely broken down teeth - use a custom fitted copper band, ortho band, or
Automatrix, stabilized with compound and wedges. Bands which are unstable should be
trimmed in height so that they are out of occlusion, cemented with Rely X Luting Plus
cement and removed 24 hours after amalgam insertion and carving.

6) Carefully condense spherical amalgam (Tytin) into each canal with a # 9 - 11 endodontic
plugger followed by larger conventional condensers. Once the canals are filled, use
whole amalgam mixes for a rapid build up of the pulp chamber and core segments.

7) Remove matrix (if same day removal) and complete carving. Large amalgam build-ups
are highly susceptible to fracture from tensile forces induced by early removal of the
matrix. If the risk of fracture from matrix removal is considered high then wait 1 ½ - 2
hours (patient available for A.M. plus P.M. sessions) or till next appointment for removal.
Orthodontic bands and copper bands can only be removed by sectioning.

139
 MOLARS

II. Prefabricated Post Retention

A post is used when there is insufficient coronal dentin or pulp chamber anatomy to retain
the coronal-radicular restoration.

A. Prefabricated Post & Resin or Amalgam Core

Technique

1. Apply rubber dam when possible

2. Reduce tooth for desired crown preparation
Note:
This is the preferred first step because it allows you to properly assess remaining tooth
structure for the core and subsequent crown. However, you must be prepared to
fabricate a temporary crown at this appointment. Novice clinicians may not have the
time to do (i) a crown preparation, (ii) a coronal-radicular restoration AND (iii) a
temporary crown within the same appointment. A coronal-radicular restoration can be
done first (to full anatomy with proximal contacts), followed by a crown preparation
and temporization at a subsequent appointment. If the coronal-radicular restoration
will act as a functional interim restoration, ie. there will be a delay before crown
preparation, cusp capping on remaining cusps is strongly advised to prevent premature
tooth fracture.

3. Remove existing restorations. Gain access to pulp chamber and remove all gutta
percha. Assess remaining coronal tooth structure and determine the most appropriate

140
 coronal build up technique. Reduce the height of unsupported dentin walls to achieve
a minimal 1mm thickness.

4. Select the largest straightest canal to receive a post.

Mandibular molar: distal canal

Maxillary molar: palatal canal

5. Remove gutta percha in the canal either by: i) preparing a tracking channel with a #2
Gates Glidden bur followed by increasing diameter or Peeso burs or ii) a heated
instrument. Gutta percha should offer only minimal resistance to penetration.

6. Establish a post channel depth:

i) equal or greater than the restored crown length
ii) minimum 7-9 mm from canal orifice
iii) 4 mm gutta percha seal
7. Use increasing diameter Peeso burs at the established post channel depth to remove
remaining gutta percha until a clean and smooth canal wall surface is achieved. Ideally
the canal should be negligibly enlarged to permit the placement of the smallest
possible matching diameter post.

8. Remove 2-3 mm of gutta percha (2mm max for composite resin core) from the other
canals to provide additional resistance/retention form. Enlarge small diameter canals
to 1.25 - 1.5 mm. with Gates-Glidden drills. (Ensure no sharp line angles (stress
concentration) between canal and pulp chamber).

9. Place the corresponding Para Post. Assess fit and retention. If seating is incomplete or
if post is slightly too large, do not enlarge canal, - adjust apical portion of post with
high speed diamond to produce slight taper. (Smoothen cut edge of post on apical end
with a disc, for easy seating).

10. Reduce post length at apical end as required to permit optimal coronal extension (min
2mm) and space for composite core. Take a radiograph with the post in place.

11. See Post Cementation Procedures in Cementation Procedures and Luting Agents
section

12. Place matrix as needed. Complete coronal-radicular restoration as per Composite or

Amalgam CoreRestoration.

141
CAST POST AND CORE PROCEDURES

142
 CAST POST AND CORE PROCEDURES
This procedure is largely currently discouraged at the faculty. Cast posts are not superior to
direct posts. They require more removal of sound dentin (undercuts), two patient visits and are
more expensive. Direct posts are preferable.

Indications

Only if the canal is widely tapered and the canal cannot be safely prepared for a stock post.
They are required if a change in crown angulation is desired or if there is inadequate clearance
for the core.

Contraindications

Multi-rooted teeth with divergent canals. These teeth present the problem of either obtaining
a casting with a single path of insertion or separate interlocking castings.

Types

A. Custom Tapering Cast Post

B. Parallel Cast Post

A. Custom Tapering Cast Post

Advantages
1. Universal application.
2. Conservative of root structure.
3. Reduced risk of perforation
4. Canal morphology (elliptical, triangular) generally provides built in anti-rotation
mechanism.

143
 Disadvantages
1. Least retentive post design.
2. Produces a wedging effect and high shoulder stress concentrations.
3. Two appointment procedure
4. Expensive

B. Parallel Cast Post

Advantages (vs. custom tapering cast post)

1. Superior retention
2. Stress distribution along length of post.
3. Simplified impression procedures.
4. Accuracy of fit.

Disadvantages (vs. custom tapering cast post)

1. Invasive procedure - removal of root structure required to achieve parallelism.
2. Increased risk of ledging, root perforation.
3. Anti-rotation mechanism required.

Preparation and Impression Procedures

A. Custom Tapering Cast Post

Core Preparation

1) Place rubber dam when possible.

2) Reduce occlusal height of tooth by 1/2 to 2/3. Prepare remaining coronal tooth
structure for the final restoration (usually a PFM crown).
3) Remove existing restorations. Gain access to pulp chamber and remove all gutta
percha. Assess remaining coronal tooth structure and determine the most appropriate
coronal build up technique. Reduce the height of unsupported dentin walls to achieve
a minimal 1mm thickness.

Post Preparation

1. Remove gutta percha in the canal either by: i) preparing a tracking channel with a #2
Gates Glidden bur followed by increasing diameter or Peeso burs or ii) a heated
instrument. Gutta percha should offer only minimal resistance to penetration.

2. Establish a post channel depth:

i) equal or greater than the restored crown length
ii) minimum 7-9 mm from canal orifice
iii) 4-5 mm gutta percha seal

144
3. Use increasing diameter Peeso burs at the established post channel depth to remove
remaining gutta percha until a clean and smooth canal wall surface is achieved. Ideally the
canal should be negligibly enlarged to provide a smooth, non undercut, tapering
preparation.

4. Take a radiograph of the prepared canal.

Post and Core Temporization

Procedure

1. Select a wooden Q-tip (NOT A PARAPOST) and customize it so that it fits the canal
loosely and is of adequate length.

2. Select a stock plastic crown form (acetate or polycarbonate) that fits the prepared tooth
and trim accordingly.

145
3. Adjust the length of the customised Q-tip so that it fits within the crown form.

4. Lubricate cervical 1/3 of root canal and the occlusal of root with small amount of
lubricant (Vaseline).

5. Make a small mix of temporary crown and bridge resin, place in canal to a depth of 2 - 4
mm, and insert customised Q-tip.

6. Monitor the setting of the resin within the canal. When it is firm but still plastic, confirm
that the customized wooden post with attached resin collar can be withdrawn from the
canal. Reinsert into canal.

7. Fill the crown form with another mix of temporary crown and bridge resin and place it
over the preparation with the post in place.

8. Remove the crown form with the incorporated customized wooden post before the resin
sets completely.

9. Trim excess gingival resin, adjust crown contours and correct occlusion.

146
10. Cement crown with temporary ZOE cement (Tempbond) - do not place cement on post
or in the canal.

Impression Procedures - Tapering

Indirect Technique – Polyvinyl siloxane Impression

- Prepare a "shepherd's crook" from a serrated paper clip.

- Adjust to length by trial insertion in canal. Ensure that the shepherd’s crook wire can be
inserted to the full length of the post preparation and that the custom tray can be
inserted without contacting the shepherd’s crook.
- Coat the wire and custom tray with adhesive and set aside (minimum 10 minutes prior
to impression procedure).
- Inject light bodied material into canal orifice and lentulate material up the canal to
assure complete filling and avoid air entrapment. Always keep lentulo spinning when
withdrawing from canal.
- Insert the paper clip and complete impression.

Direct Technique - Duralay Resin Pattern

- Obtain a 14 gauge solid plastic sprue (Williams)

- Use a sandpaper disc to roughen the sides and to taper the rod so that it will fit easily
into the canal and reach the end of the post preparation. * Note - there must be
sufficient space laterally for the Duralay resin.
- Cover a #2 Peeso reamer with a cotton pellet.
- Coat the pellet with Vaseline, insert the cotton covered reamer into the canal and apply
a light lubricating film.
- Make a thin mix of Duralay resin in a dappen dish.
- Apply a small spindle shaped mass of the wet resin to the rod and mold roughly to form.
- When the acrylic is in a stiff, doughy stage, insert it into the canal.

147
 - When the resin reaches its initial set gently pump the rod in and out of the canal until
final polymerization is reached.
- Examine the post for undercut areas and remove with an abrasive disc.
- Fill any voids in the pattern with soft utility wax or yellow sticky wax and reinsert into the
canal as above.
- Add a fresh mix of resin to the exposed rod to form the core portion.
- With rotary instruments, shape the resin core into a crown preparation.
- Crown margins should be on tooth structure - not on the core.
- Remove pattern and invest. *Note: Use Water with the investment powder and omit
ring liner to minimize setting expansion.

Castings

- Post and cores cast in Type IV silver - palladium alloy (Maestro - 2 DWT required)

Cementation

- See Post Cementation Procedures in Cementation Procedures and Luting Agents

section).
Venting is not required for tapered posts.

parallel (parapost) posts dont require venting either?

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Summary of Current Guidelines for Restoration of the Endodontically Treated Tooth

 Molar endodontically treated teeth rarely require a post. A composite or amalgam core with
or without extensions into the canals is usually indicated. The more minimal the ferrule, the
greater the indication for amalgam.
 Most single rooted endodontically treated teeth requiring crowns, as well as two-rooted
bicuspids, are very slender at the cervical, requiring a post for core retention. Choice of type
of post will depend on the clinical situation and the following criteria:-
 Stock paraposts are used if the canal can be safely prepared for adequate fit, particularly if
optimal ferrule exists. It is safer in many instances to modify the post to fit the tooth rather
than machining the tooth to fit the post. Judgement and care are required. A bonded
composite or amalgam core should reinforce the internal aspect of tooth ferrule and fully
envelope the coronal portion of the post within the pulp chamber.
 Cast posts are indicated only if the canal is widely tapered and the canal cannot be safely
prepared for a stock post. They are required if a change in crown angulation is desired or if
there is inadequate clearance for the core.
 Cast posts are not superior to direct posts. They require two patient visits and are more
expensive. Direct posts are preferable.
 Instructors should fulfill teaching objectives by clearly indicating the reasons a particular
technique has been chosen for each clinical situation.

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CAST RESTORATIONS, CASTING ALLOYS & FINISH
LINES

150
olympia - PFM
maestro - cast posts & cores
midas - cast gold (crowns, onlays)
CAST RESTORATIONS
The following outline will give you some guidance. For simplicity, OLYMPIA IS USED FOR
ALL PFM RESTORATIONS, MAESTRO FOR ALL CAST POSTS AND CORES, and MIDAS FOR ALL
CAST GOLD RESTORATIONS SUCH AS FULL CROWNS, ONLAYS OR 3/4 CROWNS WHICH
REQUIRE A TYPE III ALLOY. These alloys are also used in fixed prosthodontics.

ALLOY CHART

BRAND NAME DESCRIPTION USE

OLYMPIA (Jelenko) HIGH NOBLE METAL CONTENT PFM CROWNS

GOLD PALLADIUM,
type 4
TYPE IV STRENGTH

MAESTRO (Jelenko) SILVER PALLADIUM POST & CORES

TYPE IV STRENGTH
type 4

MIDAS (Jelenko) LOW GOLD ONLAYS,

TYPE III STRENGTH 3/4 CROWNS,

type 3
FULL CROWNS

MODULAY (Jelenko) MODULAY (Jelenko) SMALL INLAYS

TYPE II PROPERTIES
type 2

ALLOYS FOR PORCELAIN FUSED TO METAL RESTORATIONS

Gold Palladium alloys consisting of 50% gold, 40% palladium and small amounts of gallium
and indium or tin and indium are used for porcelain bonded to metal crowns in the clinic.
At the present none of the alternatives, such as nickel-chromium or palladium-chromium
alloys, is used. The student should specify that a GOLD PALLADIUM alloy is to be used
when the prescription is written. The brand name does not need to appear.

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ALLOYS FOR FULL GOLD CROWN, 3/4 CROWNS, ONLAYS AND CAST POST/CORES

A gold alloy in the 40-50% gold content range is used in the clinic for gold castings requiring
Type III strength characteristics. Jelenko "Midas" has been specified as an alloy representative
of this group at the Faculty for some time. In this case the brand name should appear on
prescriptions.

ALLOYS FOR INLAYS

Simply specify that a Type II gold alloy is to be employed when writing the prescription.
However, there are cases of large MOD inlays where a Type III alloy is desirable. The decision
must be based on clinical judgment.

FINISH LINES FOR 3/4 CROWNS AND FULL METAL CROWNS

Feather Edge - This is a very shallow finish line that gradually fades out of the tooth, leaving in
most cases, an undulating margin that is difficult to see on the tooth and hard to locate on the
cast. This margin should not be used for restorations in the undergraduate clinic.

Half Chamfer - This margin results in a finish line approximately 1/2 mm. in width. This may
vary from a very shallow chamfer to one that is greater than 1/2 mm. but less than 1 mm. in
depth. The student should operate conservatively, keeping the margin shallow but distinct,
and easily detected on the tooth. This will allow the impression to be assessed more easily
and permit the student to identify without error, the margins on the dies.

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PFM CROWN MARGINS

1. Porcelain/Minimal Metal Margin

(Routine use of PFM where esthetics are not critical)

Alternate Term
- disappearing metal margin

Preparation Requirements
- full chamfer (preferred) with approximately 1.2 mm axial depth to provide
appropriate thickness of metal and porcelain

Fabrication
- thin metal margin produced by either waxing to a fine feather edge or by metal
grinding

Recommendations
- This type of margin can be fabricated on a variety of preparation finish lines eg. full
chamfer, shoulder and sloping shoulder. These preparations result in a 1.2 mm or
greater axial depth and permit the fabrication of a crown with porcelain that is not
overcontoured and an almost imperceptible display of metal. The minimal display
of metal can be completely avoiding by placing the margin slightly below the
gingival seat. When a more conservative preparation is required to avoid pulpal
complications (eg. roots), a half chamfer can be used however the resulting
porcelain at the margin may be either i) slightly overcontoured or ii) thin and less
esthetic.

153
 Common Problems and Misconceptions

With these finish lines, technicians can provide an accurately fitting thin metal margin
which is discrete although almost not visible. In the early years of porcelain fused to metal
technology, there was concern that fusing porcelain to thin metal margins could result in
open margins from contraction forces during the sintering process. Several studies have
shown that the application of porcelain does NOT distort the margins of castings
fabricated from modern alloys, regardless of margin design.

2. Porcelain Butt Margin

Clinical situation requiring optimal esthetics

Alternate Terms
- porcelain labial margin, collarless margin

Preparation Requirements
- A smooth full chamfer or shoulder with the following requirements:

i) 90o or slightly greater (never less) exit margin

ii) well defined cavosurface
iii) 1.2mm minimum axial depth

Note: if the finish line is not near 90o or clearly defined, a minimal metal margin is
required.

154
 Fabrication Requirements
- coping is generally extended on to chamfer or shoulder leaving at least 0.5 mm axial
depth for porcelain margin
- shoulder is constructed with low shrinkage “shoulder porcelains” (various
manufacturers)

Recommendations
The porcelain butt margin is the recommended margin design for esthetically critical areas,
namely- the maxillary anterior region from tooth 14 to 24.

Indications: 1) maximum esthetics required

2) thin, friable gingival tissues
3) pronounced gingival recession
4) high lip/smile line.

Common Problems
- open and/or rolled margins due to porcelain shrinkage from firing
(multiple correction additions and firings are often required)
- marginal accuracy is technically difficult to achieve yet it is crucial
- maximum precision is required from the operator and technician

3. Metal Collar (Full chamfer with thin, beveled or slightly chamfer extension)

Preparation Requirements
- full 1 mm width shoulder or chamfer with finish line extended apically using a very
conservative axial reduction in the form of a bevel or light ½ chamfer.

155
Fabrication
- the apically extended finish line area does not provide sufficient space for both metal
and porcelain therefore a 1.0 mm wide (occlusal gingivally) metal collar is fabricated.
- the metal collar can be highly polished.

Recommendations
This finish line can be used for PFM crowns on posterior teeth when a metal collar is
desired along the gingival margin. The metal collar can be highly polished and thus aid in
the reduction of plaque accumulation.

Common Problems
- no porcelain should be applied to metal collar to prevent:

1) overcontoured, unphysiologic margins

2) possible fracture of thin porcelain if underlying metal distorts

156
 Porcelain Occlusal Coverage

If there are no cosmetic requirements or patient demands, PFM crowns are constructed with
metal occlusal surfaces on the posterior teeth and metal lingual concavities on the anterior
teeth.

Preparation Requirements
i. Anterior
- 1.0 mm (minimum) lingual reduction
ii. Posterior
- 1.5 - 2.0 mm occlusal reduction. Note: Green indicator wax is 0.32 mm thick.
Therefore, can ask the patient to bite on 5 (approx. 1.6mm thick ) or 6 (approx. 1.9mm
thick) pieces of wax to assess for adequate occlusal clearance.

Recommendations
The ideal requirements for porcelain occlusal surfaces on posterior PFMs are:

1) 1.5-2 mm occlusal reduction possible without compromising retention/resistance form

or pulp vitality
2) excellent anterior guidance

Common Problems
- inadequate occlusal reduction results in occlusal porcelain which is thin, unesthetic
and devoid of morphological features
- post insertion occlusal adjustment may result in exposure of the opaque porcelain
which is abrasive and cannot be polished
- opposing occlusal surfaces are subject to accelerated wear if occlusal porcelain (i.e.
body) is not assiduously smoothed and polished with rubber abrasives (Shofu Polishing
Kit for Porcelain) and/or Sof-lex discs after occlusal adjustment

157
 Problems With Crown Preparations

 Inadequate retention of existing amalgam restorations.

 Non retentive preparation - inadequate cylinder of parallelism.

Note: Prophylactic endodontic therapy is irrational and ineffective as a means for

augmenting retention. It is not condoned in the Faculty.

 Inadequate 2 phase buccal and lingual reductions.

 Inadequate occlusal reduction. Occlusal clearance not verified in centric and eccentric
positions.

 Margins - unreadable, discontinuous, rough, irregular, dual margins, lipping.

 Porcelain margins - shoulders lacking i) 90o configuration ii) minimal 1.0 mm width iii)
sharply defined cavosurface margin.

 Damaged or flattened adjacent proximal surfaces. If iatrogenic damage inadvertently

occurs, the surface should be carefully recontoured or polished prior to final
impression.

 Inadequate ferrule. A ferrule is important for all crowns BUT critical in pinned
amalgam and post-core situations.

158
TEMPORIZATION AND IMPRESSION PROCEDURES

159
 PROVISIONAL (TEMPORARY) CROWNS

Methods:

A matrix technique is preferred to stock crown forms for most single crown situations where
the unprepared tooth has acceptable; morphology, occlusion and proximal contacts. When
the existing unprepared tooth exhibits major defects (e.g. fractured cusps, open contacts,
improper occlusion etc./the tooth can be modified prior to the fabrication of a matrix by one
of the following methods:

i) Direct – add periphery wax or composite (unbonded!) to tooth and shape accordingly
or
ii) Indirect (available study cast)
- add periphery or inlay casting wax prior to fabricating a silicone putty matrix, or
light cured composite resin for the acetate shell or wax matrix technique.

A. Matrix Techniques

1) Alginate
- use either an anterior or posterior sectional impression tray
- remove excess peripheral and interseptal alginate material (except proximals of
unprepared tooth), wrap in 2 layers of wet paper towel and set aside.

Advantages
- accurate, inexpensive and quick

160
 - can provide extra thickness of resin by scooping out/carving alginate material (e.g.
teeth in infra-occlusion)
- satisfactory study model not available

Disadvantages
- distortion if not reseated accurately or allowed to dry out (dimensional instability)
- single application use (generally)
- voids cannot be detected.

2) Acetate Shell (e.g. Sta-Vac)

Advantages
- fabrication prior to preparation appointment
- can be used multiple times without loss of accuracy detect voids
- visual detection of proper seating alignment, incorporation of voids
- use with either autocure or light cure provisional resins

Disadvantages
- requires an acceptable study model and a vacuum forming machine
- not suitable for models with diagnostic wax-ups/wax modifications unless models have
been duplicated in stone

3) Wax Matrix (Beauty Pink Wax – 2 layers)

Advantages
- no special equipment required
- ease of fabrication, accurate, inexpensive
- can be used multiple times
- modifiable by scooping out wax where additional resin thickness required

161
 Disadvantages
- required a satisfactory diagnostic model
- not suitable for models with diagnostic wax-ups/wax additions (if
- voids cannot be detected

4) Silicone Putty Matrix

Advantages
- accurate and dimensionally stable
- reproducible results with multiple use
- suitable for models with diagnostic wax-ups/wax modifications
- can be fabricated indirectly (study model) or directly if used with a stock tray.

Disadvantages
- more expensive than alginate or wax
- voids cannot be detected

B. Crown Forms

Stock crown forms are available for situations where: i) a satisfactory matrix is not available ii)
a provisional crown with greater durability/fracture resistance is required.

1) Polycarbonate Crown (ION – 3M)

162
 Advantages
- dense, void free, highly polished, durable resin surface
- proximal dimensions can be modified (reduced)

Disadvantages
- monochromatic – cannot modify shade with reline resin
- limited range of crown shapes and sizes
- relatively thick walls may require internal adjustment to prevent binding on minimally
reduced teeth
- cervical portion requires trimming to approximate gingival finish line
jet not integrity
- crown requires relining with a methacrylate resin (e.g. Jet) but NOT a bis-acryl
composite (e.g. Integrity) which will not chemically unite with the polycarbonate resin

2) Acetate Crown (Swissdent)

Advantages
- Integrity (preferred) or Jet (alternative technique for special circumstances) can be
used for relining

Disadvantages
- limited range of crown shapes and sizes
- cervical portion requires trimming to approximate gingival finish line
- increased potential for open proximal contacts
- lingual surface usually requires extensive occlusal correction

163
3) Anatomic Metal Crown Form (Anodized Aluminum – 3M)

Advantages
- molars/bicuspids with minimal occlusal reduction where a resin only temporary crown
would be fracture prone
- partial coverage preparations (¾ crowns, onlays)
- if final restoration will be full/partial metal coverage crown then reduced
likelihood of patient esthetic dissatisfaction with final restoration

Disadvantages
- limited range of sizes
- requires resin relining
- increased difficulties in modifying proximal contact dimensions.

164
Resins for Provisional (Temporary) Restorations
1) Bis - Acryl - Composite Resin (e.g. Integrity)

integrity
bis acryl
RO

Advantages
- RADIOPAQUE
- low polymerization shrinkage and exotherm
- distinct rubbery stage which permits an adequate and controlled removal time from
mouth
- virtually no shrinkage after removal
- easy to manipulate
- good repair potential - with fresh mix of Integrity or flowable composite resin
- trims easily to well defined margins, satisfactory polishability
- good mechanical and thermal properties, well suited to long term temporization

Disadvantages mech and thermal good

- limited polishability
- low tear strength in intermediate set condition
- available in 3 shades only
- expensive
- brittle

Recommendation

“Integrity” is the Restorative

Department’s recommended material
for the majority of single tooth temporization
procedures.

165
2) Polymethylmethacrylate (e.g. Jet)

Jet
PMMA
Radiolucent

Advantages
- inexpensive
- most colour stable of temporary resins (particularly if laboratory heat - processed)
- wide range of colours
- excellent repair potential (best of all temporary resin materials)
- trims easily with well-defined margins
- good wear characteristics, well suited for longer-term temporization

Disadvantages wear good

- RADIOLUCENT
- excessive exothermic heat of polymerization
- comparatively high polymerization shrinkage (8%)
- rapid setting after onset of exothermic reaction
- must be placed on and off preparation during setting and simultaneously chilled
otherwise unrestricted polymerization shrinkage will result in poor fit and/or
exotherm can irritate pulp
- high concentration of free monomer in the setting material which is a chemical
irritant to the pulp and produces an objectionable odour
* N.B. Freshly cut dentin should be protected with a cavity varnish
- all of the above factors make this material better suited for the indirect technique

better for indirect

166
 CLINICAL PROCEDURES FOR TEMPORARY CROWN REMOVAL
A temporary crown cemented with temporary cement should be fairly easily removable. The
following instrumentation may be used:

1) HAND INSTRUMENT eg. large spoon excavator, scaler

The end of the instrument is engaged under a margin of the temporary crown and force is
applied in an occlusal direction. This should be repeated at different regions of the crown
margin until the temporary crown dislodges.

2) HEMOSTAT
The beaks of the hemostat are gently applied to the temporary crown and force in the
occlusal direction is applied. Maintain forces to be parallel to the long axis of the tooth.
Avoid excessive twisting or off-axis wiggling forces.

3) CROWN TAPPER (requisition required)

The crown tapper has a sliding piston that acts like a hammer to apply a force in the
occlusal direction. Different tips can be attached to the crown tapper. The tip of the crown
tapper is engaged under a margin of the temporary crown while the piston is slid
occlusally along the shaft in a series of short quick taps against the top of the crown tapper
until the temporary crown dislodges. The patient should be warned that there will be
tapping noises and reassured that the tapping is actually occurring outside of the mouth.

167
All of the above techniques for crown removal can be associated with discomfort for the
patient if the patient is not anesthetized. There is a risk of damage to the core restoration or
underlying tooth during temporary crown removal if excessive forces are applied, especially if
core retention is not optimal or the size of the tooth preparation is small. In such cases,
sectioning of the temporary crown may be a safer (although destructive to the temporary
crown) method. If the temporary crown is not easily dislodged, please consult your instructor.

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 CLINICAL PROCEDURES FOR GINGIVAL RETRACTION
General Guidelines
(Also see of DPES teaching video on Impressions by Dr. Tam)
Tam, LE (2009) Dental Impression Technique for Indirect Restorations.
http://www.dentistry.utoronto.ca/dpes/restorative/professionals/dental-impression-technique-
indirect-restorations-pro)

After the preparation for an indirect restoration is completed, a method of temporarily

reflecting the gingival tissues is required to give the impression material access to prepared
subgingival margins. Retraction and haemostasis should be considered as separate
procedures although it may be necessary to combine both in a single procedure when
haemorrhage control is essential. Plain (unmedicated) cords reduce the potential damage to
intersulcular tissues compared to astringent impregnated cords (aluminum sulphate,
aluminum chloride etc.) and are the recommended cords in this Faculty. Plain cords should be
moistened with water and the excess removed prior to placement by pressing the cord against
a cotton roll. Dry cords can adhere to sulcular tissue and can initiate haemorrhage when
removed. For situations requiring haemostasis, plain cord can be placed in an astringent
solution (Hemodent - 25% buffered aluminum chloride) and the excess solution expressed
onto a cotton roll. Ultrapack plain cord is available in 4 sizes (00, 0, 1, 2). Use the smallest
diameter cord possible. Larger cords tend to tear the delicate gingival tissues, strip the
epithelial attachment and increase the risk of haemorrhage.

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Materials for Gingival Retraction

1) Saliva ejector
2) Cotton rolls
3) Hemodent (optional)
4) Half Hollenback carver used gently (alternatives: Sherman cord packer, periodontal
probe, plastic instrument)
5) Scissors
6) Hemostat or cotton pliers

Collect all materials before starting. A local anaesthetic is usually required.

Isolation

1. Clean Operating Field

Flush the gingival sulcus and adjacent teeth with water spray to clean the operating field
of debris. Evacuate the water and dry the area.

2. Dry Operating Field

In the mandible place one cotton roll on the lingual of the preparation(s) and one in the
buccal vestibule. In the maxilla place one rolls in the buccal vestibule. If excess salivary
flow is a problem, also place a dri-angle over the parotid duct.

Change cotton rolls whenever they appear moistened and be sure the saliva ejector is
operating effectively.

3. Place cord(s). Remove excess water or Hemodent from cords as described. Cord should
be moist but not wet. The hemostat or cotton pliers can be either to the buccal or lingual
of the teeth. Using the retraction instrument, the cord is pressed into the gingival sulcus
with a controlled force. Slight pressure is required but care is exercised to avoid tearing of
the gingival attachment. Once placement has been started, step the retraction instrument
along the cord moving at about 1 mm at a time. When placement has been completed,
you should be able to see the margin around the circumference of the preparation. Place
dry cotton rolls just before taking the impression to ensure that the operating field will be
dry.

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Cord Placement Technique

1. Single - Cord Technique

For healthy tissues with a 3 mm pocket or less, a carefully placed single cord can
provide excellent results. The single cord is removed before the impression is taken.
In a deep sulcus the tissue can collapse over the single cord thus preventing proper
tissue reflection and access for impression material. The double cord technique should
be used for the deep sulcus situation.

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 2. Double - Cord Technique (Preferred) preferred
The first cord has a small diameter and is placed at the base of the sulcus. When the cord
placement has encompassed the entire tooth circumference, the cord is cut with scissors
and the FLUSH ends gently packed into the sulcus. A larger diameter cord is then packed
on top of the first cord to further compact it to the base of the sulcus and to further
reflect the tissue. After 10 minutes (5 minutes minimum), only the larger diameter cord
is removed prior to the impression. The cord should be moist upon removal to prevent
tearing of the sulcular epithelium. The smaller diameter cord is left to prevent sulcular
seepage and hemorrhage. Removing both cords significantly increases the risk of
hemorrhage and a failed impression.

Minor Tissue Surgery

On some occasions hyperplastic tissue may exist that will fall back on the margin when
the cord is removed. Your instructor may decide to remove this by electrosurgery or
with a periodontal knife. If an electrosurgery unit is used, your instructor will use the
instrument.

Some authors suggest a more routine use of electrosurgery, but thin, soft tissue does not
allow electrosurgical "retraction" without loss of tissue height (recession), as for example on
many anterior teeth.
20% ferric sulphate = viscostat
Management of Excessive Haemorrhage
Viscostat Clear (25% aluminum chloride) can be used as an adjunctive and effective
hemostatic agent. It may be applied, before placement of retraction cords, using the
“DentoInfusor” tip. A rubbing action with moderate to firm pressure against the cut bleeding
gingival tissues is needed while the Viscostat solution is slowly expressed. If bleeding
continues, repeat Viscostat application until hemostasis is obtained.

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Hemodent - 25% buffered aluminum chloride
On some occasions hemorrhage cannot be controlled sufficiently for impression procedures at
the same appointment as the preparation is completed. In these cases a temporary
restoration is placed for one week and a separate appointment is made for the impression.
Remember that a temporary restoration must fit meticulously. THIS IS CRUCIAL! An
overcontoured, poorly finished temporary crown will cause even greater problems with tissue
management at a subsequent appointment.

IMPRESSION MATERIALS

1) Addition Reaction Silicone (polyvinylsiloxane)

 suitable for most clinical situations requiring indirect restorations (i.e. crowns,
inlays bridges etc.).
 excellent dimensional stability (up to 1 week) and only minimal dimensional
changes after multiple pours.
 excellent accuracy, flow, flexibility and elastic recovery properties when used
correctly
 Moderate to high tear resistance
 moderate working time (2½ - 3 minutes), setting time in mouth (5-6 minutes)
 available in 3 viscosities (putty, heavy body, light body).

Note: Some PVS materials have added surfactants which improve the wettability of the set
impression material. This improves the quality of the stone casts that are poured up
from these impressions. Although these PVS impression materials are marketed as
“hydrophilic”, they are not truly hydrophilic and cannot compensate for poor moisture
control and a wet environment during impression-taking.

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 Technique

i) Auto mixed (e.g. Aquasil, Caulk/Dentsply)

- custom tray(s) required.

- adhesive applied 10 minutes (minimum) before impression.
- light body material can be dispensed directly onto the preparation with the use of a tip
on the mixing gun or a separate impression syringe.
- heavy body is dispensed directly into the tray just prior to impression taking.

ii) Putty/Wash (e.g. Express)

- only permissible when securing an impression is deemed essential and a satisfactory
explanation can be provided for the absence of custom trays.
- best results achieved with the use of tray adhesive but clean - up of stock metal trays is
time consuming.
- putty should be mixed with vinyl gloves to prevent the polymerization inhibition that
occurs with the use of some latex gloves and is placed into the tray just prior to
impression taking.
- light body material is dispensed into a syringe and additional material is dispensed into a
thumb size depression made in the loaded tray material and corresponding to the
preparation site(s).
- putty/wash impressions are technique sensitive and consistent results are difficult to
achieve for inexperienced operators.

2) Polyether (e.g. Impregum-F, Impregum Penta)

- used for removable prosthodontic impression procedures but with light body material
can be used for crown and bridge impressions.
- monophase material supplied in tubes or from Penta automatic mixer for denture
impressions.

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- slightly shorter working time (2½ minutes) and setting time (4½ minutes) than addition
reaction silicones.
- dimensionally stable (up to 1 week) if impression kept dry. Distorts if left too long in
disinfectant solution or moist environment.
- stiffer than addition reaction silicones necessitating increased spacer thickness (2-4
mms) for custom tray fabrication. DANGER OF LOCKING IN UNDERCUTS!
- apply polyether tray adhesive 10 minutes (minimum) prior to impression.
- thixotropic properties are useful for border molding.

POLYETHER = THIXOTROPHIC for border molding

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 TAKING THE IMPRESSION
Inform your instructor if you are taking your first clinical crown impression so that she/he can
review procedure, check each stage during procedure and stand by

1) Have study models (not necessarily mounted) and TWO custom trays prepared. The use
of a custom tray is ideal because it is rigid, custom-fitted and allows control of the
thickness of impression material. Properly constructed custom trays maintain a relatively
uniform 2-4mm cross section of impression material thus ensuring uniform
polymerization shrinkage and optimal impression accuracy.
Self-cured (PMMA) trays undergo prolonged setting shrinkage and therefore need to be
fabricated at least 24 hrs prior to use. Occlusal stops within your tray should not be more
than 2 mm high. NEVER INCLUDE PALATE except in cases requiring a simultaneous
impression of an existing partial denture.

2) Paint custom tray (interior and outer 1mm surface) with adhesive at least 10 min prior to
appointment.

3) Inspect the arch for significant undercuts, eg. bridges, wide interdental gingival
embrasures, that will impede tray removal. These undercuts must be blocked using
peripheral rope wax prior to taking the impression.

4) Temporary crown and all traces of cement removed - place gingival retraction - change
cotton rolls if soggy! Patient draped to protect clothing, sitting up. Dental assistant
ready to mix - mouth kept dry with fresh cotton rolls, "Dry-Angles" and saliva ejector.

5) Assistant mixes syringe material: you remove outer retraction cord gently, rinse and dry
area, and inspect: all margins should be visible, clean and dry. If significant
haemorrhage present, abort the procedure and obtain demonstrator’s advice. Slight
seepage of blood: place fresh retraction cord immediately and leave 3-5 minutes. Very
small point of haemorrhage MAY be controllable by application of a few seconds air
from syringe (gently). THERE IS NO POINT IN PUTTING PATIENT THROUGH AN
UNCOMFORTABLE IMPRESSION PROCEDURE IF THE MARGIN IS NOT CLEAN, DRY AND
VISIBLE AT THE START OF INJECTION OF IMPRESSION MATERIAL.

6) Use an impression syringe for the light body material. Do not try to syringe the material
directly from the mixing gun because it is heavy and awkward. Inject syringe material
carefully around margins - keep tip of syringe approximating margin in one slow
circumferential movement (minimizes air pockets). In most instances this technique
with the additional second stage heavy bodied material in tray adapting the light bodied
material closely to the preparation ensures a successful impression. (If it is felt that the
light bodied material on syringing alone has not securely reached the marginal area then
a LIGHT CONTROLLED application of air MAY be used from the air syringe. TAKE CARE

176
 not to cause inclusion of air voids within the material by too strong air pressure which
will fold material over on itself).

7) Seat tray - posteriorly first, then over incisors - hold passively for 5 minutes. You must
hold the tray and NEVER LEAVE PATIENT UNATTENDED.

8) Remove the impression tray with a snap removal of the posterior segment followed by
the anterior segment.

9) Errors on the margins of the impression include:

a) incomplete capture of margins, caused by inadequate displacement of

gingival tissues, or when the circumferential application is incomplete;
b) bubbles, caused by the entrapment of air when the syringe is lifted away
from the margin of the tooth during circumferential application, or by
blowing air at the impression material;

177
 c) defects of impression material, caused by saliva or blood contamination,
and
d) tearing of impression material, caused by too thin a section of impression
material or slow removal of the impression tray. The impression may still
be acceptable if a small defect is in a noncritical area, away from the
margin.

10) Remember to remove the retraction cord from the gingival sulcus after the
impression. Rinse the site to remove traces of the residual chemical agents.

Note re. Dual Arch Impressions:

Full-arch trays are recommended to facilitate proper articulation of the casts during
mounting procedures. The use of a segmental or quadrant impression, such as the
dual-arch impression technique, is discouraged because it is difficult to verify mounting
when there is no recording of the contralateral arch.

The dual-arch impression technique is a sectional impression where the impression of

the prepared tooth is taken as the patient closes to simultaneously record the
opposing teeth in centric occlusion. This technique is contraindicated when there are
more than 2 crowns being made simultaneously, when the prepared tooth (teeth) are
not bounded by intact and opposed teeth, if the patient cannot close directly into a
stable and reproducible intercuspal position, and if the tray interferes with patient
closure. Accuracy of the dual-arch technique is compromised if the patient does not
close fully into maximum intercuspation or if a flexible tray is used. In most instances,
the perceived simplicity of this technique does not outweigh the sensitivity of the dual-
arch impression technique to errors.

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Problems with Impressions

 Unhealthy periodontal tissues.

 Inflamed tissues from poor provisional restorations.

 Aggressive retraction cord procedures. Inappropriate cord diameter selection.

 Inadequate homeostasis - traumatized tissue, cords not dampened with hemostatic agent,
early removal of cords.

 Too many crowns in one impression taken by inexperienced operators often results in
multiple retakes. Patient subjected to too much trauma and post operative discomfort.

RESTORATIVE DEPARTMENT PROTOCOL FOR IMPRESSION PROCEDURES

 Provisional restoration must be completed prior to impression.

 Student must come prepared with 2 custom trays (clean and trimmed).

 For a student’s first 4 crowns each crown must be prepared and impressed singly. After
this the Department will allow a maximum of 2 crowns in one quadrant. Even then, do not
begin a second preparation in the same patient until the first crown is completely
prepared and temporized.

 Anterior crowns require individual consideration and for esthetic reasons may require
preparation and impression in pairs. If the clinical situation demands 4 crowns
simultaneously the case must be delayed until the student has adequate crown
experience.

 Impression is washed, dried and critically assessed by student prior to assessment by

instructor. Do not take impression to the laboratory for assessment. In general practice,
it is the dentist that is responsible for assessment of the impression.

 All work submitted to the Undergraduate Technical Services Lab must be accompanied by
a fully documented prescription signed by an instructor.

 Students are strongly urged to keep crown and bridge impressions after they have been
poured. Should there be difficulty at subsequent fitting and try-in appointments, the
impression will be helpful in determining where the problem lies.

 All work must be properly disinfected before submitting to the lab!

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 Mounting and Lab Procedures

 All cases must be mounted in centric occlusion by the student after the
poured-up and approved models are picked up from the lab.
 Single crowns may be mounted on a hinge articulator. Two or more crowns
must be mounted on a Hanau.
 Remove any stone blebs on the occlusal surfaces of your models. These will
prevent proper mounting.
 A tripod of occlusal support is needed to mount full-arch opposing models. If
this tripod is present, NO bite registration material is needed. In fact, the use of
bite registration material could introduce inaccuracies during mounting if there
is already a tripod of occlusal support.
 If a tripod of occlusal support is not present due to missing teeth/irregular
tooth positions, etc., a bite registration using wax, Duralay, PVS (Take 1 Bite or
Regisil) or an occlusion rim is needed. Remember to take this bite registration
at the impression appointment before you cement the temporary crown to
avoid having to bring the patient back for a separate bite registration
appointment. A minimal amount of bite registration material should be used
(use only where it is needed to complete a tripod of occlusal support).
 Verify your articulator mounting by comparing it with hand articulation (or
patient articulation if you can remember it). Use shimstock on your articulator
mounting to verify that opposing teeth do articulate where they should. Bring
your mounted case (with shimstock for the instructor to use to verify your
mounting) and your written prescription to a Restorative Instructor.

Time frame for lab work

 Coping/metal try in: 5 working days

 Application of porcelain: 5 working days
 PFM straight to finish/insertion: 7 working days
 *When a crown is to be an abutment for an RPD framework, the master cast
must be surveyed for proper placement of guide surfaces, undercuts, rests etc.
The waxed crown is returned for inspection by the Prosthodontic instructor
prior to casting. Allow 3 extra working days for this procedure.

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CEMENTATION PROCEDURES
AND LUTING AGENTS

181
RMGI = Rely X Plus
Self etch resin = Unicem
Conventional resin = Calibra (most retentive)
POST CEMENTATION PROCEDURES
Zinc phos
Cement options:
 Zinc phosphate
 Resin-modified glass ionomer cement (Rely X Luting Plus)
 Self-etch Resin luting cement [Unicem, (3M-ESPE)]. Preferred.
 Conventional Resin luting cement [Calibra (Dentsply)]

A resin-luting cement provides the advantage of bonding to the subsequently-placed

composite core material (if composite is used as the core material). This bonding is particularly
useful if canal opening is flared. The cement for post cementation should ideally be rigid and
if a resin-based cement, it should be a dual-cured cement for immediate light polymerization
of the uppermost cement and immediate post stabilization, followed by later complete self-
curing in the light-inaccessible regions. There has been some controversy regarding the
absorption of water by resin-modified glass ionomer cements in post cementation situations
that may lead to cement expansion and root stresses. When retention is questionable, the
conventional resin luting cement is recommended as the most retentive cement. However,
the use of conventional resin luting cements in post situations is very technically demanding.

Technique:

1) The matrix system, if needed, should be in place prior to cementation.

2) Wash site using air-water syringe. Use paper points to dry canals.
3) If Conventional Resin luting cement [Calibra] is being used (Omit this step for Resin-
for Modified glass ionomer cement or Self-Etch resin cement):
a. Use Prime&Bond NT as the dentin bonding agent. This simplified dentin
calibra bonding agent utilizes a combined primer/adhesive component has a thinner
only film thickness than separate primer and adhesive materials that together, may
prevent full seating of the post after polymerization.
b. Apply phosphoric acid etchant to the canal(s) and surrounding dentin.
c. Use paper points to dry the canal(s) after etch and wash step.
d. Apply Prime&Bond NT combined primer/adhesive component to the canal(s)
and surrounding dentin. Use paper points to apply the primer/adhesive
component within the canal.
e. Use dry paper points to remove excess primer/adhesive component and to
AVOID pooling that will prevent subsequent full seating of the post within the
canal.
f. Use air to evaporate remaining solvent from primer/adhesive component.
g. Light-cure.
4) Mix luting cement according to cement directions.
5) Lentulate cement into canal. The lentulo should still be spinning slowly (in the forward
direction) as it being withdrawn from the canal. The technique of using of a lentulo to
fill the canal with cement followed by post insertion thoroughly coats the canal walls

182
 and produces fewer voids than the technique of applying cement to the post only and
then inserting the post.

However, the input energy of the spinning lentulo can accelerate the cement set,
especially for Unicem. Therefore, for Unicem, use the endo fill tip to apply the cement
within the canal.

endo fill tip for Unicem

6) Optionally coat the post with mixed cement. Insert the post and core with a slow
pumping action to prevent a sudden build up of hydraulic pressure and potential root
fracture. Ensure that it is fully seated.
7) Remove gross cement excess cement using microbrush or instruments.
8) Light cure cement 40 seconds. Wait 6 minutes prior to further instrumentation for
complete set of cement that is not exposed to light.
LIGHT CURE

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Resin cement required for ceramic reinforcement
Calibra for non-vital teeth
Unicem for vital CROWN CEMENTATION PROCEDURES

Also see DPES video

(McComb, D. (2009) Crown cementation.
http://www.dentistry.utoronto.ca/dpes/restorative/professionals/crown-cementation-pro)

Introduction

The finished crown will be fabricated according to the prescription that was provided
to the laboratory together with the impression and all other necessary records, and
returned ready to insert into the mouth.
If an optimal impression, appropriate opposing model and all other necessary
information have been correctly provided to the laboratory, and if the tooth has been
effectively temporized to maintain its position within the arch, adjustments should be
minimal and the cementation appointment relatively straightforward.

The objectives of the final cementation process are to:

a) permanently secure the crown against dislodgement (i.e. to secure the inherent
retention provided in the preparation design)
b) permanently seal the prepared tooth against marginal leakage (i.e. to seal the
preparation margin and internal dentine from ingress of oral fluids and
bacteria) and, for vital teeth,
c) ensure continued pulp vitality.

Background on Major Causes of Failure of Crowns

Clinical studies have shown that recurrent caries and lack of retention are the major
causes of failure of traditional crowns and bridges.1,2,3 Recurrent caries is the foremost
cause of failure but displacement of crowns can occur earlier. Optimal marginal
accuracy and preparation retention form are therefore two of the most important pre-
requisites for crown longevity that are under the control of the dentist.

Recurrent Caries
A smooth, well-marginated crown, with confluent tooth to crown continuity (no open
margin and no marginal discrepancies) will provide maximum resistance to plaque
accumulation around the crown margin. Caries prevention over the long-term also
requires good patient oral hygiene for regular removal of plaque from crown margins.
Other patient caries risk factors will also affect the potential for new decay at crown
margins. It is well recognized, moreover, that even with the most optimal clinical and
technical procedures, a microscopic cement line will be exposed to the oral
environment at the crown margin. The smaller this cement line is, and the more
resistant the enclosed luting cement to dissolution, the better - in order to prevent

184
 development of an open margin due to cement loss, with consequent plaque retention
between crown and tooth. Laboratory technique that utilizes the use of die spacer to
provide cement space can substantially facilitate complete seating of crowns during
cementation.4

Crown Retention
With regard to crown retention, it is well accepted that most conventional luting
cements only secure the retention provided by optimal crown preparation, designed to
ensure maximal preparation length, minimal occlusal taper and the presence of an
optimal circumferential “cylinder of parallelism” on sound tooth structure. No cement
can compensate over the long-term for inadequate retention form in the crown
preparation.

Background on Dental Luting Cements

International Standards stipulate that permanent luting cements be capable of forming films
of 25 microns or less.
Traditionally zinc phosphate cements were used for cementing but, although used
quite successfully for decades, these cements show some shortcomings in strength,
solubility and lack of adhesion.5, 6 They also are extremely acidic when first mixed and
require the use of varnish for vital pulp protection.
In an effort to provide improved clinical success, different classes of luting agents with
improved physical properties, adhesion possibilities and potential therapeutic
capabilities have been developed. Currently, four types of luting cement are commonly
utilised. Each has different advantages and disadvantages.

1. Glass Ionomer Luting Cements.

Conventional glass ionomer cements provide fluoride release and show low, but
stable, adhesion to dentine. They have been implicated in untoward pulpal sensitivity
due to the low initial acidity when mixed, which is compounded if too low powder-
liquid ratio is used during preparation.7 However, clinical studies have shown the
material to be extremely effective when used appropriately.8 They have largely been
superseded by the resin-modified glass ionomer cements.

2. Resin-Modified Glass Ionomer Luting Cements. ****

More recently developed, the resin-modified glass ionomer luting materials also
provide fluoride release but show increased resistance to dissolution and improved
physical and biological attributes over the conventional glass ionomers. They are easy
to use and are widely used in general practice for routine cementation of crowns and
bridges. They do not require any tooth pre-conditioning, provide stable bonding to
tooth structure and have intermediate physical and mechanical properties. They have
not been associated with increased levels of post-operative sensitivity.

185
 The current routine luting cement for crowns in clinics is currently a resin-modified glass-
ionomer – Rely X Luting Plus (3M-ESPE)

ADVANTAGES of GLASS IONOMER CEMENTS

1. Cariostatic potential due to high fluoride ion content and sustained release
2. Good marginal seal due to chemical bonding to tooth surface
3. Low solubility/erosion in-vivo (compared with zinc phosphate, zinc polycarboxylate) when
fully set (protect from moisture during setting phase)
4. Simplicity of use
5. 20 years (GI) and 10 years (RMGI) clinical availability and usage
6. Low post-operative sensitivity documented with RMGI
[Note: Conventional glass ionomer luting cements can be a source of prolonged acidity
during setting, and have been implicated as a cause of post-cementation pulpal sensitivity,
a serious clinical phenomenon that may, or may not be, reversible]
conventional = pulpal
DISADVANTAGES sensitivity
Lower modulus of elasticity (rigidity) than zinc phosphate cement possibly allowing
microscopic movement in some clinical situations (eg long span fixed bridge with less than
ideal retention).

3. (Conventional) Resin Luting Cements

The success of current-day dentine bonding materials and resin composite materials
has led to the development of resin luting cements with the potential to provide
greatly increased bonding capability, retention potential and resistance to dissolution. 9
Composite resin luting is not a straightforward clinical procedure and therefore it is
indicated only for specific clinical situations where adhesive luting is absolutely

186
 necessary to provide adequate retention (non-retentive crowns/posts) and/or fracture
resistance (ceramics).. Resin luting cements involve multiple steps and are much more
technique sensitive than conventional water-based cements. Critical usage factors and
idiosyncrasies make the use of resin cements for routine procedures more difficult and
these cements are not a guarantee against postoperative sensitivity.13 They are not
essential for cementation of routine metallic-based crowns and bridges with adequate
retention form. A resin luting cement is available in the clinic for low retention crown
and/or post clinical situations.
Introduced to the clinics in 1999, Calibra (Caulk/Dentsply) is a dual-cure resin luting
cement with good self-curing capability. This material is a relatively simple resin luting
material which has adequate working time and when combined with the use of
dentin/enamel bonding agents, permits adhesive luting to tooth structure. It is crucial
to follow the instructions for each specific clinical application to prevent problems or
failures.

4. Self-Etch Resin Luting Cements

In order to overcome the technique-sensitivity of most resin-based luting cements,
which require additional tooth conditioning, priming and bonding procedures, a self-
etching resin cement was first introduced in 2002. Such cements do not require any
additional bonding procedures prior to use and offer a simpler, less technique-
sensitive, one-step approach to resin luting and bonding. Although described as a
single “class” of materials, substantial differences in properties and performance exist
between the different proprietary products, some of which have been very recently
introduced to the market-place.14 Further investigation of properties and performance
will be required for these and other new proprietary materials of this type as they are
introduced. Only use of products with substantive evidence of appropriate properties
is recommended. Good examples of such cements offer excellent potential for
improved cement performance. RelyX Unicem (3M-ESPE) is the self-etch/self-prime
resin luting cement in the Faculty Clinics.

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Background on Sealing and Desensitization of Dentine

The use of dentinal resin primers alone can provide extremely effective sealing and
desensitization for freshly cut vital dentine after crown preparation. Tooth reduction
and exposure of large areas of freshly cut dentine during crown preparation can lead
to increased permeability and risk of pulpal inflammation.15,16 Dentinal primer/sealers
have been recommended to decrease sensitivity caused by increased permeability
and/or microleakage. At the faculty the resin primer/sealer “Hurriseal” is available for
this purpose. Such procedures are best carried out at the tooth preparation
appointment, after fabrication of the temporary crown and prior to temporary
cementation. They also may be performed immediately prior to permanent
cementation, especially when using acidic conventional luting cements - to prevent
postoperative sensitivity. Current proprietary haemostatic agents, often used prior to
the impression, have been shown to have an extremely low pH, can remove the
dentinal smear layer opening up dentinal tubules on the root surface which can
potentiate the effect of any subsequent cement acidity.17 If acidic haemostatic agents
have been used, a dentine primer-sealer is recommended in all cases to seal the
dentinal tubules of vital teeth. Resin sealers can be used successfully with glass
ionomer and resin-modified glass ionomer cements without reducing crown
retention.18

Permanent Cementation Procedure

1. Trial Fit of Crown (“Try-In”)

a) Extra-oral assessment
The delivered crown will first be assessed on the working die and model that was
poured by the laboratory from the final impression. While seated on the die the

188
appropriateness of the overall anatomic form in relation to the adjacent teeth and
arch, the adequacy of the proximal contacts, the general surface smoothness and the
quality of the crown margins should be assessed. Ideally the restoration should be
checked on the model before the patient appointment.

The working die will have been “trimmed” by the technician to clarify the exact
margins of the crown preparation. It is considered advisable (and is expected at the
faculty) to request an “untrimmed sectional pour” from the same impression that will
be available to assess the accuracy of the trimming process and to confirm the
marginal accuracy of the finished crown on the prepared tooth. The internal surface of
the crown, sometimes called the intaglio surface, should also be examined. There
should be no evidence of pitting, voids or discrepancies that are not present on the
crown preparation. Evidence of internal adjustments should be minor.

In most teaching institutions, as part of the learning process and for quality assurance
reasons, the metal coping of a PFM crown will be assessed at an initial try-in
appointment. Assessment at this stage will include ensuring that the metal coping
provides optimal thickness for strength, appropriate marginal finish and adequate
space for porcelain build-up to ensure optimal esthetics and contour of the finished
crown. Intra-oral assessment will include the relevant elements of fit and form
appropriate to the metal coping. ALL STUDENTS ARE EXPECTED TO DO THE METAL
COPING TRY-IN APPOINTMENT FOR THEIR FIRST CROWN.

b) Intra-oral assessment
If satisfactory on the model, the crown will next be assessed intra-orally. Note that all
copings and completed crowns should be placed in an appropriate disinfectant for 3
minutes prior to placement in the mouth. At the faculty the all-purpose laboratory
disinfectant “Lab-X” is available for this purpose.
The prepared tooth should be asymptomatic. Do not attempt cementation if the tooth
displays any untoward symptoms or the patient has discomfort. The cause should be
ascertained and treated to resolve any symptoms. The temporary crown may be
inadequate and should be checked to ensure that all prepared tooth structure is
covered, that the contacts are satisfactory and that the occlusion is not “high” in
centric occlusion or in lateral movements of the jaw. If pulpal symptoms are present
that are subsiding, it is advisable to allow a prolonged period of temporization for total
resolution. If persistent pulpal symptoms are present and attempts at resolution are
unsuccessful then endodontic treatment may be required.

[Note: It is sometimes recommended that the permanent crown be temporarily

cemented where symptoms are present or where certain aspects of the crown
(esthetics or gingival response) are being monitored. This is considered ill-advised for
the reason that a well prepared crown preparation with a well fitting crown is
invariably impossible to remove when the decision is made to perform permanent
cementation. Temporary cementation of the permanent crown is therefore not

189
allowed at the faculty. A prolonged period of temporization should be provided with
an optimal temporary crown.]

The need for local anaesthesia for the cementation process is both patient and tooth
specific. The presence of anaesthesia can prevent the patient assisting in assessment
of the occlusion, however many prepared teeth can be extremely sensitive.
Endodontically-treated teeth will not usually require anaesthesia. Vital teeth with
extensive freshly-prepared dentine will typically require anaesthesia, particularly in the
young patient, teeth with large pulps and for patients who tend to have sensitive
teeth. Previously restored teeth in older patients with receded pulps are typically less
sensitive. The use of dentine primers for dentine sealing prior to the placement of the
temporary crown can significantly reduce the need for anaesthesia at the cementation
appointment. For resin luting cements that require acid conditioning of the prepared
dentine, anaesthesia will definitely be necessary.

The temporary crown should be carefully removed and all temporary cement
fragments thoroughly cleaned from the tooth using hand instruments. No visible
remnants at all should remain as they may interfere with accurate seating and cement
attachment. The effect of eugenol containing temporary cements on the bond
strength of resin luting cements has been implicated in reduced bonding with resin
cements. However, microscopic remnants of temporary cements in general, rather
than eugenol-containing cements in particular, have been implicated in reduction of
bonding of adhesive cements to tooth structure.19 Eugenol-containing cements
provide anti-bacterial effects and have a unique sedative effect on the prepared tooth
and therefore can be extremely effective in preventing post-operative problems after
crown preparation.

Prior to placing the crown in the mouth the patient should be advised of the fact that a
try-in of the crown will occur and that to avoid crown dislodgement the patient should
not try to talk, nor move suddenly. Further, it should be explained to the patient that
he/she should remain alert and should the crown slip from the tooth he/she should
immediately bring his/her head up and discharge the crown into their own hand.
Safety during the try-in is extremely important to avoid the patient swallowing or
inhaling the crown. The patient should be in a semi-supine position and the position of
the crown is should be maintained with a finger placed on the occlusal surface at all
times.

Assessment of margins.
The fit of the crown margin is first assessed using the tine of an explorer around the
total margin periphery, ensuring that the crown remains completely seated on the
tooth. There should be a relatively smooth transition from crown to tooth with no
visible crown opening, overhang or other discrepancy. The crown should be “flush”
with the tooth surface and adjacent contours of the crown should be continuous with
the contours of the tooth. A totally imperceptible margin is not possible. It has been

190
suggested that because the smallest detectable ledge is 100microns, this is a useful
criterion for evaluating adequate marginal fit.20

If the margin appears to be open along at least one surface the crown may not be
completely seated. The commonest cause of non-seating is overly tight proximal
contacts. These should be assessed using dental floss and adjusted if hindering the
seating of the crown. Other causes of non-seating include remnants of temporary
cement or other debris on the tooth surface, trapped gingiva and/or other
discrepancies on the internal surface of the crown (eg. sharp line angels on die
rounded off during lab procedures). The latter should be carefully assessed and, if
necessary, the internal fit can be confirmed using a coating or disclosing medium to
reveal areas of binding. The internal surface is coated and the crown seated and
removed. Areas where the metal shows through the coating can be adjusted to allow
accurate seating.

“DeMark” coloured disclosing solution is available at the faculty which dries quickly on
contact and is the preferred method for accurately locating proximal contact and
internal interferences. The use of disclosing powder sprays (eg “Occlude”) is
discouraged due to the widespread travel of the coloured spray. If contacts and
internal surface are satisfactory and an open margin persists that cannot be overcome,
a new impression will be necessary for fabrication of a new crown.

Assessment of proximal contacts. The proximal contact of the new crown should
provide optimal tightness against the adjacent tooth as well as appropriate contact
area and contour. There should be a definite “snap” as the floss traverses the contact.
Care should be taken during this process to ensure that the crown does not displace
during the procedure. One finger should always be kept firmly on the tooth. If
difficulties are encountered, a dental assistant should be asked to provide assistance.

To assess the contact area the floss should be wrapped around the contact and the
ends held parallel a) towards the occlusal surface to assess the bucco-lingual width and
b) towards the facial surface to assess the occluso-gingival width. Contact
measurements and placement should be harmonious with other contacts in the
patient’s mouth. Typically the width of the floss bucco-lingually should approximate
one-third the width of the tooth and the width occluso-gingivally should approximate
one-third the height of the crown from the gingival. Adequate facial, lingual, gingival
and occlusal embrasures must be present to prevent food impaction and periodontal
problems.

191
 The two parallel strands should not be more Relationship of ideal interdental papilla to
than 1.5-2mm apart (approx one-third tooth molar contact area (from Sturdevant et al)
width and height)

Occlusal assessment. With the crown accurately seated the patient is asked to close
the teeth and the position of the crown during maximum cuspal position is assessed.
Use of a mirror in the buccal sulcus will show if there is any significant occlusal
discrepancy. Significant occlusal opening will require the use of coloured fine
articulating paper to determine the areas requiring adjustment areas. If there are no
visible signs of significant occlusal discrepancy using a mouth mirror, shimstock should
be used to assess for the presence of perfect occlusal contact in the areas of normal
centric stops.

For a posterior crown the shimstock is placed on the occlusal surface of those teeth
immediately adjacent and on either side of the crown and for anterior crowns on the
nearest posterior teeth. “Tug-back” should be present. If “tug-back” is not present on
appropriate adjacent teeth, the crown is judged “high” in occlusion and will require
identification of high spots using fine coloured articulating paper and adjustment until
“tug-back” is present. Articulating paper will mark a dry crown better than a wet crown
but sometimes the highly polished surface is resistant to marking. Use of the working
model and opposing model is often helpful to identify the areas most likely to be
“high”. Slight adjustment in these areas can be followed by confirmation with
posteriors articulating paper intra-orally which is more likely to produce a mark on a slightly
canines = roughened surface. If “tug-back” is present on appropriate adjacent teeth using
shimstock in centric, the shimstock is then moved onto the crown itself, to ensure the
tug back crown is itself in occlusion. For posterior crowns and canines, “tug-back” should also be
- incisors present on the crown. For incisor crowns, the shimstock should just slip through the
lingual surface.
= slip thru lingual
Once centric occlusion is satisfactory lateral movements – any gross discrepancies
(working or non-working interferences) should be adjusted. The patient is asked to bite
and then guided laterally from one side to the other keeping the teeth in contact. Final
192
lateral = post cementation
assessment of lateral movements is safer when carried out post-cementation –
particularly where group function is present.

Once the occlusion is considered perfect, any areas that have been adjusted will
require smoothening. Final polish is best left until the crown occlusion has been finally
assessed as satisfactory after cementation.

Esthetic assessment. The final crown should provide appropriate shape and if
applicable, optimal colour matching (hue, value, chroma). The patient must be given
the opportunity to look at the final crown and approve the esthetics prior
cementation.

2. Cementation Process
The internal surface should be clean and dry.

During cementation a layer of the chosen cement is placed inside the casting and the
crown is seated firmly on the tooth. The objective is to provide optimal permanent
seating of the finished crown (i.e. to the same marginal seating as that which was
produced at the try-in) resulting in the minimum possible cement line. The luting
cement fills the microscopic gap, seals the margin and secures the crown. All cements
should be mixed according to the manufacturer’s directions to provide a smooth mix
and used without delay. Delayed use allows initiation of the setting process causing
reduced cement flow, incomplete seating, increased thickness of the marginal cement
line and crown elevation requiring occlusal adjustment.21

Isolation from saliva during the luting process is essential, using a saliva ejector on the
floor of the mouth and appropriately placed cotton wool rolls. The latter are placed in
the adjacent buccal sulcus for all maxillary crowns and mandibular anterior crowns. To
control salivary flow adequately for mandibular posterior crowns, rolls are necessary
both in the maxillary and mandibular buccal sulcae, as well as the lingual sulcus.

The crown should be coated evenly with cement over the internal surface avoiding
trapping air bubbles and be no more than half filled. The crown is immediately seated
firmly on the clean, isolated and dry tooth providing significant force and steady
pressure to express the excess cement and ensure complete seating. The marginal
adaptation should be quickly checked at this point with an explorer (to ensure the
situation is exactly as prior to the introduction of cement) and firm pressure
maintained until the cement has set. Many practitioners find that steady pressure can
be better maintained by having the patient bite down on a cotton roll however, it is
essential that the crown not be displaced by eccentric movements. Use of patient
biting pressure is therefore only advised on posterior teeth in arches with well aligned
occlusal planes to avoid tipping or rotational forces that might result in inaccurate
seating. For the same reason the technique is contraindicated for anterior teeth. Very
firm steady axial finger pressure is advised.

193
All cements are sensitive to early moisture contamination which results in a cement
with inferior properties that is more prone to leakage and/or dissolution. A dry field is
therefore essential to allow development of optimal physical and mechanical
properties. If the required seating pressure is to be performed by the patient, it is
necessary to maintain cotton rolls in the lingual sulcus to prevent salivary
contamination and early cement dissolution.

Once the cement has set, the excess cement is fractured away from the margins with
hand instruments and the interproximal areas cleared with floss. Attempting to clear
excess cement prior to setting will disturb the marginal integrity. Cement removal is
best achieved immediately the cement is “chippable”. Waiting for further maturation
of high strength cements will make them extremely difficult to remove. It is essential
that all excess marginal and intra-sulcular cement be totally removed as the presence
of cement will cause gingival irritation and potential periodontal problems. Floss
should be passed through the proximal contacts to check that there is no residual
cement in the proximal contact regions (keep one finger on the occlusal surface to
prevent crown movement), and a knotted floss can be passed in buccolingual direction
below the contact areas to remove excess proximal-gingival cement.

3. Post-Cementation Assessment
A final check of the occlusion is necessary prior to dismissing the patient as it is
possible that, if seating pressure is inadequate or if the cement film thickness is
unsatisfactory, the crown will be elevated. Any occlusal adjustments required at this
point however should be minor. The initial use of shimstock, in the same way as above
on adjacent teeth, will immediately indicate whether the occlusion is satisfactory or
not. If tug-back is not present then marking of the crown with articulating paper and
appropriate adjustment should be carried out. Occlusion during lateral movements is
now assessed carefully for the presence of working side or non-working side
interferences which must be corrected. They can be the cause of porcelain fracture
and/or patient pain during function and/or tooth mobility.

When the occlusion is finalized, the occlusal surface should be polished. A specific
metal polishing kit and porcelain polishing kit are available in our clinics for this
purpose. After a final check that all cement remnants have been removed the patient
can be reminded of the need for and care of the crown over the long term.

At future comprehensive recall appointments crown margins should be checked

carefully for signs of plaque build-up or recurrent caries. A well-placed crown can be an
excellent long-term restoration if is maintained optimally by the patient.

194
References

1. Schwartz NL, Whitsett LD, Berry TG, Stewart JL. Unserviceable crowns and fixed
partial dentures: life-span and causes for loss of serviceability. J Am Dent Assoc.
1986;81:1395-1401.
2. Walton JN, Gardner FM, Agar JR. A survey of crown and fixed partial denture
failures: length of service and reasons for replacement. J Prosthet Dent 1986;
56:416-421.
3. Valderhaug J, Jokstad A, Ambjornsen E, Norheim PW. Assessment of the
periapical and clinical status of crowned teeth over 25 years. J. Dent 1997;
25:97-105.
4. Wilson PR. Effect of increasing cement space on cementation of artificial
crowns. J Prosthet Dent. 1994;71:560-564.
5. Rosenstiel SF, Land MF, Crispin BJ. Dental luting agents: a review of the current
literature. J Prosthet Dent 1998; 80:280-301.
6. Diaz-Arnold AM, Vargas MA, Haselton DR. Current status of luting agents for
fixed prosthodontics. J Prosthet Dent 1999; 81:135-141.
7. Smith, DC; Ruse, ND. Acidity of glass ionomer cements during setting and its
relation to pulp sensitivity. J Am Dent Assoc. 1986;112:654-657.
8. Brackett WW, Metz JE. Performance of a glass ionomer luting cement over 5
years in a general practice. J Prosthet Dent 1992;67:59-61.
9. Attar N, Tam LE, McComb D. Mechanical and physical properties of
contemporary dental luting agents. J Prosthet Dent 2003;89:127-134.
10. Groten M, Probster L. The influence of different cementation modes on the
fracture resistance of feldspathic ceramic crowns. Int J Prosthod 1887; 10:169-
177.
11. El-Mowafy OM, Fenton AH, Forrester N, Milenkovic M. Retention of metal
ceramic crowns cemented with resin cements: Effects of preparation taper and
height. J Prosthet Dent 1996;76:524-529.
12. Zidan O, Ferguson GC. The retention of complete crowns prepared with three
differenta tapers and luted with four different cements. J Prosthet Dent 2003;
89:565-571.
13. Christensen GJ. Seating non-metal crowns or fixed partial dentures with resin
cement. J Am Dent Assoc. 1998; 129:239-241.
14. Saskalauskaite E, Tam LE, McComb D. Flexural strength, elastic modulus and pH
profile of self-etch resin luting cements. J Prosthod. 2008;17:262-268.
15. Richardson D, Tao L and Pashley DH. Dentine permeability: effects of crown
preparation. Int J Prosthodont. 1991;4:219-225.
16. Pashley DH. Clinical considerations of microleakage. J Endod 1990;16: 70-77.
17. Land MF, Rosenstiel SG, Sandrik JL. Disturbance of the dentinal smear layer by
acidic hemostatic agents. J Prosthet Dent 1994;72:4-7.
18. Johnson GH, Hazelton LR, bales DJ and Lepe X. The effect of a resin-based
sealer on crown retention for three types of cement. J Prosthet Dent. 2004;
91:428-435.

195
19. Ganss C, Jung M. Effect of eugenol-containing temporary cements on bond
strength of composite to dentin. Oper Dent 1998;23:55-62.
20. Rouse JS. Anterior ceramic crowns. Chapter 17 in Fundamentals of Operative
Dentistry. A contemporary approach. Third Edition. Edit Summitt JB et al. Quint
Pub Co. 2006.
21. Wilson PR, Stankiewicz NR. Effect of cement space and delayed placement on
the seating of crowns luted with Vitremer, Fuji Duet and Dyract Cem. Am J
Dent. 1998;11:240-244.

196
CLINICAL USAGE OF LUTING CEMENTS in Faculty
Clinics

197
RMGI Rely X Plus (RMGI)
- PFM, FGC
LUTING AGENTS

Resin-modified Glass Ionomer Cement (Rely X Luting Plus)

Available in a universal white shade only.

CLINICAL USAGE: routine FGC and PFM crown cementation

 Rely X Luting Plus is available as both a powder and liquid or base and catalyst pastes in
“Clicker” dispenser. Cement chemistry includes a GI acid-base reaction and is essentially
the same as that of the RMGI restorative materials. Working time is 2.5 minutes and
excess cement can be removed after 2 minutes in the mouth (should be “chippable” but
not “rock” hard). RelyX Luting Plus is available in a white shade only.

1. Thoroughly clean the cementing surface of restoration.

2. Thoroughly remove all remnants of temporary cement and clean tooth structure (optional:
gently pumice crown preparation). Leave tooth surface moist, do not overdry.
3. Following instructions from manufacturer, mix for 20 seconds prior to insertion
4. Apply a thin layer of cement to internal surface of crown and seat crown with firm finger
pressure. Maintain pressure for 2 minutes, during which time gross excess can be initially
removed using a dry brush or blunt hand instrument.
5. Light exposure is not usually necessary.
6. After 2 minutes, remove excess cement from margins with a suitable hand instrument (eg.
scaler, explorer) and from interproximal areas with a knotted dental floss passed from the
occlusal and in a buccal-lingual direction, being careful not to displace the crown during
the 5 minute auto curing period.
7. Final set is 5 minutes after insertion in mouth (keep area isolated from moisture and
continue with moderate consistent pressure).
8. Ensure complete removal of excess cement.

Dual-Cure Resin Cements

Retention, tooth vitality, technique sensitivity and the need for porcelain reinforcement are
factors that should be considered for each individual case.
 For crowns to be retentive, proper design of the original preparation is required.
When other techniques (e.g. optimized cylinder of parallelism, sub-gingival extension,
axial grooves, crown lengthening etc.) are either not possible or have not provided
adequate retention/resistance form, then resin cements may help in the adhesion of
the crown to the remaining tooth structure. However, adhesive resin luting cements
should not be regarded as substitutes for mechanical retention.
 For low-strength all-ceramic crowns, inlays, onlays and veneers, a conventional resin
cement in combination with a dentin bonding agent is mandatory.

198
low strength ACCs, inlays, onlays, veneers = conv. resin cement + bonding
UNICEM (self etch resin)
- posts
- emax on vitala) RelyX Unicem: A self-etch resin cement. Available in shade A2 only.
- pfm fmc (non- retentive) 
 CLINICAL USAGE: Cementation of Posts, E.max CADCAM or E.max pressed crowns on
vital teeth, Non-retentive PFM or FMC Crowns on vital or non-vital teeth.

 Rely-X Unicem self-etch adhesive resin cement is generally the preferred resin cement
for posts, all e.max crowns on vital teeth, non-retentive PFMs, and non-retentive FMCs.
Unicem is easier to use than the conventional resin cement (Calibra). No separate
dentin bonding procedures are needed for this self-etch adhesive resin cement.
Avoidance of the separate etch step is beneficial for vital teeth because the loss of the
protective smear layer over a large area of vital dentin is avoided.

Calibra b) Calibra: A conventional resin cement. Available in light, medium,

translucent and opaque shades.
(conv. resin) 
- Emax (nonvit) CLINICAL USAGE: Cementation of E.max crowns or E.max pressed crowns on non-vital
teeth, Non-retentive posts, Non-retentive PFM or FMC Crowns on non-vital teeth,
- non-retentive ceramic inlays and onlays, veneers.
posts, PFM, FMC (non vital)
 As a conventional resin cement, Calibra is used in combination with a dentin bonding
- in/onlays, agent for superior bonding, strength and reinforcing properties for the overlying e.max
restoration while the concern about etching a large area of vital dentin is not applicable
VENEERS in non-vital teeth.
 The dentin bonding agent to be used with Calibra is Prime&Bond NT (separate
phosphoric acid etch, combined primer/adhesive component). A combined
primer/adhesive component has a thinner film thickness than separate primer and
adhesive materials that together, may prevent full seating of the crown after
polymerization.
veneer  For veneers, avoid using the catalyst component that is used to achieve a dual-cure (ie.
= light cure only the conventional resin cement should be light-cure only) because dual-cure resin
cements are more prone to discolouration, a quality to be avoid in esthetic veneer
DONT USE CATALYST
situations. A try-in paste is available within the Calibra kit.
 Silane is available within the Calibra kit for ceramic restorations that have not been pre-
silanated (e.max pressed crowns, inlays, onlays, veneers) or for ceramic restorations
that need re-silanation.
 RelyX Unicem is available in shade A2 only. silane for ceramic pretx
Panavia (self etch resin + MDP)
- zirconia c) Panavia SA: A self-etch resin cement containing MDP. Available in
shade A2 only.

 CLINICAL USAGE: Cementation of Zr (or Procera) bilayer or monolithic crowns on vital
or non-vital teeth.

199
 zirconia cant be etched with HFl unlike Emax
 Panavia is a self-etch adhesive resin cement that contains MDP (Methacryloyloxydecyl
dihydrogen phosphate) for bonding to zirconia. Unlike E.max, zirconia cannot be etched
with hydrofluoric acid and lacks hydroxyl groups for bonding to silane. MDP has a
phosphate monomer that can chemically bond to zirconia and might play an important
role in enhancing the resin cement bond to zirconia. No separate dentin bonding
procedures are needed for this self-etch adhesive resin cement. Avoidance of the
separate etch step is beneficial for vital teeth because the loss of the protective smear
layer over a large area of vital dentin is avoided.

Clinical technique for crown cementation using Dual-Cure Resin Cements

1. Thoroughly clean the cementing surface of restoration. Ensure appropriate laboratory

pretreatments have been done (eg. microetching, hydrofluoric acid etching, silane
application)
2. Thoroughly remove all remnants of temporary cement and clean tooth structure
(optional: gently pumice crown preparation).
3. Step #3 for Calibra cement only: Apply phosphoric acid etchant to any enamel margins
(15 seconds) then onto dentin (15 seconds). Rinse thoroughly 15-20 seconds and gently
CAN LIGHT CURE dry to a moist but not visibly wet surface. Dispense 2-3 drops of Prime & Bond NT
primer/adhesive. Apply sparingly with a brush to thoroughly wet dentinal surface for 30
BUT LEC SAYS
seconds. Gently but thoroughly air dry until surface has a uniform ‘dry’ shiny surface.
DONT HAVE TO (Care: maintain minimum film thickness) Light cure for 10 seconds.
4. Dispense and mix cement. The working time is 2.5 minutes.
5. Apply a thin layer of cement to internal surface of crown (or veneer), and seat crown or
veneer with firm finger pressure. For inlays and onlays, it may be helpful to also place a
thin layer of cement directly onto the preparation to minimize voids. Maintain pressure
during which time excess cement should be removed from margins with a dry brush or
blunt probe and from interproximal areas with a knotted dental floss passed from the
occlusal and in a buccal-lingual direction, being careful not to displace the crown during
the 6 minute auto curing period. Tip: a 10 second total light application can pre-set the
excess cement to a gel consistency for easier removal.
6. Once excess cement is removed, light cure all margin areas from buccal, lingual and
interproximal- 20 seconds each.
7. Final auto-cure set is 6 minutes after insertion in mouth (keep area isolated from
moisture and continue with moderate consistent pressure if there are areas which are
inaccessible to light).
8. Ensure complete removal of excess cement. Fully set resin cement is very difficult to
remove.

200
ALL-CERAMIC SYSTEMS

201
 ALL-CERAMIC MATERIAL SYSTEMS

Ceramic restorations offer excellent biocompatibility and esthetics. Disadvantages of

all-ceramic crowns compared to traditional PFM crowns, however, include increased
tooth reduction, increased fracture risk, inadequate marginal fit, excessive wear of
opposing teeth, technique sensitivity and limitations with respect to case selection.

Ceramic materials can be categorized in several ways eg. by fusion temperature, by

fabrication technique (eg. sintered, heat-pressed, machined), or by chemical and
crystalline composition. An understanding of ceramic type and the surface
treatment/bonding/luting procedures appropriate for each ceramic type is essential
for clinical success.

GLASS CERAMIC (“traditional” dental feldspathic porcelain, eg Vitadur Alpha, Vita Mark
II)
 Predominantly glass (silicon) and feldspar minerals
 High esthetics, relatively translucent feldspathic porcelain
high esthetics, TL
 Low strength- must be bonded to increase its fracture resistance
low strength
 Used as a veneering material over metal and ceramic copings, also inlays,
onlays, veneers
 Luting: Etchable by hydrofluoric acid. 5-10% HF for 1 minute, silane, followed by
adhesive plus resin cement (ideally) or a self-etch adhesive resin cement.

REINFORCED GLASS CERAMIC lithium disilicate

 Glass ceramic with leucite (eg. IPS Empress) or lithium disilicate (eg.IPS
inc'd strength Empress2, IPS e.max Press, IPS e.max CAD) particles.
reduces esthetics & TL
 Increased strength but reduced esthetics and translucency.
1. leucite -low strength  Leucite-reinforced glass ceramics are still low strength, so used as inlays,
2. lithium disilicate onlays, veneers and low stress single crowns (monolithic).
- intermediate stregth
 Lithium disilicate -reinforced glass ceramics have intermediate strength, so
used as inlays, onlays, veneers, single crowns (monolithic) and copings (for
bilayered crowns).
 Luting: Etchable by hydrofluoric acid. Leucite: 10% HF for 1 minute; Lithium
disilicate: 5% HF for 20 seconds. Silane, followed by adhesive plus resin cement
(ideally) or self-etch adhesive resin cement

GLASS-INFILTRATED CERAMIC In-Ceram (AlO core + molten glass)

 Sintered aluminum oxide core infiltrated with molten glass. Eg. In-Ceram
Alumina, In-Ceram Spinell
 High strength- Therefore, bonding (to decrease fracture risk) is not mandatory
high strength and anyways, difficult because it is not readily etchable by hydrofluoric acid.
mod-low esthetics  Moderate (in-Ceram Alumina) or low (In-Ceram Spinell) esthetics. Relatively
NOT etched by HFl opaque.
not etched by HF
202
  Generally used as a coping and then veneered with a feldspathic porcelain
(bilayered crown), for short anterior FPD frameworks.
 Luting: Conventional non-adhesive cements can be used.

HIGH STRENGTH POLYCRYSTALLINE OXIDE CERAMIC not etched by HF

highest strength  Polycrystalline aluminum oxide (eg. Procera Alumina) or zirconium oxide (eg.
resistant to crack propagation Lava Zirconia, IPS e.max ZirCAD), Stabilizing oxides eg. yttria.
not etchable by HFl  Highest strength. Resistant to crack propagation. Therefore, bonding (to
low-mod esthetics
decrease fracture risk) is not mandatory and anyways, difficult because it is not
relatively opaque
etchable by hydrofluoric acid.
 Low to moderate esthetics. Relatively opaque.
 May be used as a coping and then veneered with a feldspathic porcelain
(bilayered crown), for FPD frameworks, implant abutments, or as monolithic (Zr
only) crowns.
 Luting: Adhesive resin cements are generally recommended but non-adhesive
non-resin cements can be used also. Many investigations are being conducted
to improve its bonding, eg. using MDP for chemical bonding, sandblasting.
 Structure and properties of zirconia (ZrO2):
White crystalline powder
Melting point: 2,715 oC
High hardness
Low thermal conductivity
High fracture toughness (6.5-8 MPa m1/2)
High density

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 ALL-CERAMIC CROWNS

At the present time utilization of porcelain crowns by dentists is on the rise. There are
a number of reasons for this trend. Firstly, they can offer superior esthetics compared
to PFM crowns as they eliminate the metallic core component that results in excessive
opacity. Secondly, through elimination of metallic content, the risk of undesirable
allergic responses or discoloration of the gingiva is avoided. Thirdly, new and improved
manufacturing technology (CAD-CAM) along with the availability of reliable porcelain
blocks to be milled with machines utilizing the CAD-CAM technology have made it
easier and faster to produce porcelain crowns with a high degree of marginal and
internal fit. This technology is swiftly gaining popularity within the dental profession as
it continues to improve and develop.

anterior
= bilayered ACC
Maxillary left central incisor with PFM crown that caused gingival discoloration

In the anterior region where demand for optimum esthetics is high, bi-layered all-
ceramic crowns are typically recommended. These are made with a thin (approx
0.6mm) and strong zirconia core that is subsequently veneered with an overlying .4-
.6mm thick feldspathic porcelain. The feldspathic porcelain veneer material is more
translucent than the zirconia core material and it can be applied by a lab technician
anterior using different shades, depth and characterization for a better esthetic result.
= emax press
In the anterior region where demand for optimum esthetics is not as high, an e.max
(esthetics Press crown can be recommended as an alternative to bi-layered all-ceramic crown.
not as high)This is a monolithic lithium disilicate crown that is pressed to full contour. A superficial
stain is generally added to the top of the monolithic material, and for greater esthetics,
the incisal aspect of the facial surface can be cut back for a thicker veneer of esthetic
porcelain addition. Because it is a relatively translucent material, the underlying shade
of the prepared tooth will usually affect the overall shade result. Therefore, 2 shades

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 emax press stump/die shade + vita shade

must be selected for the fabrication of the e.max Press crown: 1) “stump” or “die”
shade, and 2) final desired Vita shade.

posterior = In the posterior region, where occlusal forces are considerably higher and esthetic
considerations are less, monolithic porcelain crowns are the only all-ceramic crowns
monolithic used at the Faculty. The monolithic crown design is composed of a single porcelain for
= lith dis both the core and veneer. This design eliminates a major reason for the failure of
bilayered crowns in the posterior area: weakness in the joint between the core and
(emax CAD)veneering porcelain. Monolithic crowns have adequate strength to resist forces of
mastication in the molar area. At the Faculty, the monolithic all-ceramic materials for
zirconia posterior crowns lithium dilisicate or zirconia.

Lithium disilicate (commercially named e.max CAD) blocks are provided by the
manufacturer partially-crystalized to enable the milling machine to mill them into
crowns. The design (CAD) of the crown and the milling (CAM) of the crown are usually
done by our own Technical Services Lab. Once milled, they are placed into a furnace
with a special program to achieve full crystallization and glazing. Once crystallized, the
crowns are strong enough for function in the posterior area. lith dis emax cad = milled, furnace
for full crystallization & glazing
Zirconia crowns are made at an outside commercial lab using CADCAM technology. At
the present time, they are the strongest but most opaque all-ceramic crowns available.
Zirconia forms naturally and is found in abundance in certain areas. Zirconia was first
used in dentistry for fabrication of cores for crowns and bridges due to its white
opaque colour. Colouring techniques were later developed and this led to the
development of full-contour zirconia crowns and bridges. The crown is milled out of a
large partially-sintered zirconia disc. Milled crowns are then dipped in a dye solution
for a brief colouring stage before they are placed in the furnace for complete sintering.
Sintered crowns are then subjected to a surface staining process to optimize esthetics.
Zr = milled out of partially sintered then dyed then completely sintered
- surface staining on sintered crowns
Contra-indications for all-ceramic crowns

 Short teeth. Narrow teeth or teeth with minimal bulk*

 Less than regular crown preparations, eg. grooves, irregular margins
 High caries risk
 Deep subgingival margins
 Bruxism/ excessive occlusal loading
 Future extensive occlusal adjustment or endo access needed
 Bruxism, excessive occlusal loading
 Inadequate bonding/ support for ceramic*
 RPD abutments

*Not as applicable to Zr crowns.

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Failure of a bilayered porcelain molar crown.

Delamination of veneering porcelain of a bilayered crown on maxillary second

premolar.

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ANTERIOR ACC
Bilayer emax press is monolithic lith dis
1.2 facial
All-ceramic anterior crown preparation design
1 prox ling
2 incisal - 1.2 mm minimum facial shoulder margin (bilayer) or 1.0 mm minimum
facial shoulder margin (monolithic)
. - 1 mm proximal and lingual shoulder margins
- 2 mm incisal reduction for bilayer, 1.5 m incisal reduction for e.max Press.
Monlithic - Rounded line angles.
1 facial - Smooth, regular, clear margins essential.
- Ideally, prep margins at or slightly below gingival margin.
1 prox ling
1.5 incisal
+ emaxpress

Porcelain crown prep on maxillary central incisor.

Maxillary lateral incisor prepared to receive porcelain crown.

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ACC = shoulder
emax CAD is lith disil
POSTERIOR
- 1 mm
- 1.5-2 occlusal
emax CAD
- 1.5 for Zr

Porcelain crown cemented on maxillary lateral incisor. Notice ideal color match.

All-ceramic posterior crown preparation design

- 1 mm shoulder margins.
- 1.5-2 mm occlusal reduction for e.max CAD, 1.5 mm occlusal reduction for
Zr
- Rounded line angles.
- Smooth, regular, clear margins essential.
- Ideally, prep margins at gingival margin.

Preparation for porcelain crown on mandibular second molar. Notice the uniform 1
mm shoulder finish line that wraps around the whole preparation. Notice also the
rounded occluso-axial line angles.

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PVS impressions
emax press = stump and final shade needed
Impression for all-ceramic crowns

Take impression in custom tray using PVS as usual.

Bite registration (if necessary) and shade selection must be made at this stage.
For e.max Press only, both a “stump” and final shade are needed.

All-ceramic crown fabrication

 Technical services lab will pour impression, trim die and seek quality assurance
approval.
 Approved die will proceed to articulator mounting by student.
 The die is scanned with a scanner to create a virtual model (digital impression).
A crown is then designed on the created virtual model. The designed crown file
is then sent to a milling unit where crowns are milled.
 For e.max CAD, arrange with lab staff (Victoria) for digital impression of die,
crown design, milling, glazing and crystallization.
 For zirconia, the commercial lab will take the digital impression of die, design,
mill and sinter the crown.

Zirconia crown that has been

E.max CAD crown that has been
sintered, stained and glazed.
crystallized, stained and glazed.

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Emax Press (HF and silane (student))
Emax CAD (HF and silane)
Zirconia - N/A Try-in of all-ceramic crowns

Premolar and molar zirconia crowns ready for cementation.

 Check that the intaglio surface of crown has been appropriately treated by the
lab prior to clinic delivery.
E.max Press. Hydrofluoric acid and silane pretreatment required. At this time,
the commercial lab will do the hydrofluoric acid etch step. Student will need to
apply silane (from Calibra resin cement kit).
E.max CAD. Hydrofluoric acid and silane pretreatment required. At this time,
the Faculty Technical Services lab will do the hydrofluoric acid etch step and
silane application.
Zirconia. No specific pretreatment required. Intaglio surface of zirconia crowns
CANNOT be etched with hydrofluoric acid or chemically bonded to silane. Grit-
blasting with aluminum-oxide powder is optional. A special resin cement with
MDP that can bonding chemically to zirconia must be used.
 Remove all visible traces of temporary cement. Wash (optional: gently pumice
crown preparation) and gently dry tooth preparation.
 Try-in crown for fit, contacts, and centric occlusion only (gently). Adjust if
needed using fine diamonds or course aluminum oxide disk and polish using
intraoral porcelain polishing system. If significant adjustments were done,
resubmit to lab for polish and glaze.
 If the internal aspect of the crown is dry after try-in: proceed to cementation.
 If the internal aspect of the crown is wet from saliva after try-in:
a) Wash and dry the internal aspect of crown (can optionally etch internal
surface with phosphoric acid for 15 seconds prior to the wash and dry step)
b) Apply silane (available from Calibra resin luting cement kit) to the inner

210

silane = dry surface with air, DO NOT RINSE

 surface of the veneer and leave to react for 60 seconds. Subsequently dry the
surface with air. Do not rinse.
c) Avoid application of silane to the external surface of the restoration as this
will complicate clean-up of excess cement.
 The application of additional silane is generally advised when in doubt.

Cementation of porcelain crowns

 See previous section regarding cement materials and techniques.

 Porcelain is stronger when bonded to an underlying resilient material such as
metal (ie. PFM crown) or dentin. Therefore, the complete and final check of
occlusion, including excursions, should be done after ceramic crown
cementation.
if e-max crowns,
check excursions
AFTER cementation

Cemented e.max crown on mandibular first molar.

A full-contour zirconia crown has been cemented on maxillary first premolar.

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 Trimming and Polishing Systems Available in Faculty Clinics

For polishing composites:

Green and white wheels/cones (in regular bur block),
Multifluted carbide burs for high-speed drill (in regular bur block): football 7406,
bullet 7801, flame 7901, round 7006
Fine diamonds (diamond bur block)
Enhance polishing cones and cups (outside dispensary).
Esthetic trimming carbides bur block (from dispensary): ET6 (small football), ET9
(large football), OS1 (flame tip), OS2 (rounded tip)

For polishing porcelain, metal (dispensary):

Fine diamonds (diamond bur block and Laminate Veneer system [Brasseler] bur
block)
Brasseler polishing kit for zirconia
Shofu polishing kit for porcelain
Shofu polishing kit for metal

For polishing amalgam (dispensary):

Multifluted carbide burs block for slow-speed drill

Occlusal adjustment of zirconia crowns

Use medium-grit football diamond in high speed handpiece with copious water
cooling. Sparks at contact points with crowns are common, however, with adequate
air/water spray cooling there is no need for concern.
Polish adjusted areas with porcelain polishing points in low-speed handpiece.

This specially-made zirconia kit for occlusal adjustment and fininshing and polishing
is available at Clinic 1 dispensary.

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Full-contour zirconia crown made for maxillary second molar.

Full-contour zirconia crown cemented on maxillary second molar after

occlusal adjustment, finishing and polishing.

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 CERAMIC INLAYS and ONLAYS
Ceramic Inlays and Onlays can be alternatives to direct posterior composite
restorations and crowns. Ceramic inlays and onlays are indirect restorations that
are bonded to the tooth using resin cement. Bonding mechanism is through:

a) Etching and bonding to the tooth structure.

b) Bonding to porcelain; achieved through hydrofluoric acid etching and the
use of silane coupling agent.

Ceramic inlays and onlays procedures are rarely done in the Faculty clinics.
Inlays preparations are wedge-shaped and despite bonding, an inlay will not
provide significant long-term cusp reinforcement. There is no body of evidence
to indicate that there is reduced microleakage or increased longevity with the
use of the indirect technique compared with the direct composite resin
technique. The significantly higher cost and the increased technique-sensitivity
of the indirect technique are difficult to justify, particularly for smaller and non-
complex (non-cusp-capped) preparations. Because direct composite restorations
have less longevity in large complex cases and it is more difficult to create ideal
anatomy and contacts directly in large complex cases, a ceramic onlay
(CAD/CAM e-max) may be considered in select cases for vital teeth in the
Faculty. The cement is a dual-cured resin cement (Calibra). The student should
speak to the Course Coordinator prior to proceeding with ceramic onlay
procedures.
emax onlays = dual cured resin cement (calibra)
Indications

1. MOD preparations with wide isthmuses and need for cuspal coverage.
2. Low caries risk patients.
3. Esthetic needs.
4. When more conservative restoration is required than a ceramic crown.

Contraindications

1. Small and moderate-sized preparations.

2. Poor oral hygiene.
3. Para-functional occlusion.
4. Patient with excessive occlusal loading.

Advantages (compared to direct composite complex restoration) vs direct composite

1. May optimize esthetics, anatomy, contacts using indirect technique
2. Can use materials with optimized properties eg. wear resistance.

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 3. Reduced amount of material subject to polymerization shrinkage (only
small amount of resin cement will shrink compared to a bulk of
composite resin).

Disadvantages (compared to direct composite complex restoration)

1. Difficult tooth preparation. Obtaining adequate retention is challenging.

May require greater amount of tooth structure removal.
2. Multiple appointments needed.
3. Try-in, bonding and cementation procedures are technique sensitive.
4. Occlusal adjustment can only be done when cemented.
5. Margins finishing is difficult.
6. Wear of luting cement can lead to marginal gaps on occlusal surface.
7. Risk of porcelain fracture.
8. Long term clinical history is lacking.
9. High cost

Advantages (compared to all-ceramic crown) vs ACC

1. Conservation of tooth material.

Disadvantages (compared to all-ceramic crown)

1. Difficult tooth preparation. Obtaining adequate retention is challenging.

2. Less cuspal extracoronal reinforcement.
3. Wear of luting cement can lead to marginal gaps on occlusal surface.

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 PORCELAIN VENEERS

Introduction
• Introduced to the profession by Dr. Calamia of New York University in 1985.
• They rely in their retention on bonding to enamel.
• Minimal tooth reduction is required (0.3 mm on average).
• Veneers are typically made of feldspathic porcelain, however, other
porcelain/ceramics have been used.
• Intaglio surfaces of veneers are etched with hydrofluoric acid to provide micro-
roughness.
• A light-polymerized resin cement is used for their bonding. Dual-polymerized
resin cements should be avoided as they limit working time and cause
discoloration as the veneers age.
light poly
Indications not dual poly for veneers
• Color: Discolored anterior teeth that do not respond well to vital bleaching.
• Spacing: Moderate spacing between anterior teeth that need to be closed by
means other than orthodontics or diastema closures.
• Shape: When there is need to modify shape of anterior teeth within limits
(lengthening for example).

Contraindications
• Inadequate enamel.
• Teeth structurally compromised (endo-treated).
• Teeth in severe labial position. (veneers will make teeth look even more labial)
• End-to-end incisal relationship or Class 3.
• Lack of posterior support.
• Poor oral hygiene. Dental neglect.
• Presence of para-functional activity (bruxism).
• Posterior teeth.

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El-Badrawy WA, El-Mowafy O. Porcelain veneers vs. crowns when resolving esthetic
problems – two case reports. J Can Dent Assoc. 2009 Dec;75(10):701-4.
PMID:20030026

The following case was first reported in the above publication as being ideal for
treatment with porcelain veneers.

Facial aspect of a case indicated for treatment with porcelain veneers showing spacing,
rotation and dark anterior teeth.

Lingual aspect of the above.

217
Maxillary stone model of the case above.

Diagnostic wax-up of the above case. Spaces were closed, rotation corrected and
tooth alignment improved.

218
Lingual aspect of diagnostic wax-up.

Uses of diagnostic wax-up

• Share with patient expected treatment outcome.
• Fabricate matrix for provisional veneers if it was necessary.
• Share with lab patient’s needs and expectations.
• Establish new incisal height.
• Fabricate incisal reduction guide.

Treatment objectives of the above case

• Lighten color of teeth.
• Close diastemas and recreate incisal embrasures.
• Realign maxillary central incisor.
• Lengthen central incisors to create optimum smile.

Treatment plan of above case

• Bleaching of lower teeth to degree desired by patient.
• Prepare maxillary anterior teeth for veneer restorations
• Six maxillary feldspathic porcelain veneers.

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 Incisal reduction guide made based on the diagnostic wax-up.

a b c

a/b porcelain is in fxn

C if not
lengthening

Three possible preparation designs depending on the case.

A thin layer of enamel ranging from .3 - .5 mm is removed with diamond burs. It is very
important to ensure that prep remains in enamel to optimize bonding and retention.
If incisal lengthening is not indicated, preparation “c” is most conservative of enamel
and the final result is least prone to porcelain fracture (if keep protrusion away from

220
porcelain incisal edge). Preparations “a” and “b” are less conservative and expose the
porcelain veneer to function and greater fracture risk. Preparation “a” (and
occasionally “b”) must provide for a path of insertion from the incisal aspect.

Diamond guide groove burs are provided in two sizes, .3 and .5 mm. These are used to
make grooves to guide dentist during enamel reduction. Care must be used to avoid
excessive enamel removal, especially in the gingival third where enamel is thin.

221
Example of horizontal depth grooves made on ivorine teeth. Preparation is then
completed using chamfer diamond burs.

Completed veneer preparation on maxillary right central incisor.

222
Completed veneer preps on all upper six anterior of earlier case.

Intaglio surfaces of porcelain veneers are etched with hydrofluoric acid. (Verify that
this was done in the Lab).

223
SEM image of an etched porcelain surface. Note the created roughness necessary for
bonding.

Etched porcelain surfaces are coated with a layer of silane coupling agent to enhance
their bonding to the resin cement used for their cementation. This may or may not
have been done by the Lab.

224
 Six porcelain veneers are tried-in.

At try-in stage
- Recline seat so that patient is almost in a horizontal position.
- Remove provisional (if applicable) and clean teeth with pumice slurry in a
try in stage: rubber cup.
- Carefully seat the veneers on the teeth using try-in pastes. Available shades are
proximal Translucent, Light, Medium, Dark, Opaque.
esthetics - Provide patient with hand mirror to view veneers. Final shade will be influenced
by the shade of resin cement selected.
not occlusion Proximal contacts and esthetics can be verified during the try-in stage. Do not
-
check occlusion at this stage.

Porcelain veneer cementation (Calibra).

 Use water-spray to wash the try-in paste and dry with moisture/oil-free air.
calibra Rinse and dry.
 Apply silane to the inner surfaces of the veneer and leave to react for 60
veneers seconds. Subsequently dry the surface with air. Do not rinse. Avoid application
of silane to the external surface of the restoration as this will complicate clean-
up of excess cement.
 Discuss sequence of cementation if several veneers are to be cemented.
 Apply mylar strips to prevent inadvertent bonding to adjacent teeth.
 Etch enamel with phosphoric acid-etchant for 45-60 sec.
 Apply resin bonding agent on enamel.

225
  Place selected shade of resin cement on veneer and seat veneer. Push chair
light away from operating field to avoid premature setting of resin cement.
 Ensure proper positioning of the veneer(s)! Compared with crowns, it is much
more difficult to ensure if a veneer is completely and properly seated,
especially when there is no incisal stop (preparation “c” above). Remove excess
cement with suitable instrument. If some initial light-curing can be restricted to
the center of the veneer, further excess cement removal can be accomplished
without fear of displacing the veneer.
 Light-cure through the veneer for at least 60 sec and ensure that the entire
surface is adequately exposed to light (light cure gingival third, mesial-incisal
third and disto-incisal third).

Image from above case after cementation of six porcelain veneers.

Finishing of porcelain veneers

- Excess cement at gingival margin is removed with fine-grit needle-shaped
diamonds.
- Excess at interproximal is removed with interproximal finishing strips.

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Occlusal adjustment
- Check occlusion using articulating paper. Centric occlusion should be on the
lingual tooth structure, not on the lingual of the porcelain veneers.
- Ask patient to glide lower jaw forward while maintaining teeth closely together.
This will simulate protrusive jaw movement. For veneers on preparation “c”,
protect the porcelain by adjusting the porcelain to avoid protrusive contacts on
the porcelain incisal edges. For single or few porcelain veneers on preparations
“a” or “b”, similarly try to avoid protrusive contacts on the porcelain by
adjusting the porcelain. If all the incisors are veneered using preparations “a” or
“b”, it is impossible to completely avoid protrusive contacts on the veneers. In
this case, have protrusive contact distributed as evenly as possible.

Lingual aspect of maxillary anterior teeth after six veneers after cementation.

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 MICROABRASION TECHNOLOGY/ REPAIR

a) for cementation of resin bonded bridges, porcelain fracture repair (metal exposed) or
replacement of gold acrylic facings
b) for cementation of non retentive crowns and unetchble all-ceramic crowns (e.g. Procera)

Background:

Microabrasion (mechanical micro-etching) is a form of “sandblasting” which can be used on a

wide range of materials, including metals, composite resins, ceramics and tooth structure to
provide a mechanically retentive (micro-etched) surface for composite resin attachment.
Various studies have demonstrated that aluminum oxide (50 µm) under high pressure (80 - 100
psi) can provide a micro-retentive surface. Extra-oral microetching should be done in the
enclosed cabinet, located in Technical Services, to minimize exposure to air borne particles.
For intraoral applications, a microetcher (Danville Engineering) is available from the Clinic 1
dispensary. The microabrasion unit should be connected to the air-line outlet on the top of the
control box located at the foot of the chair (prior to air-pressure step-down for dental
handpieces). The following precautions should be observed for intraoral applications:

Guidelines for use of mechanical microetcher

1) assure patient’s eyes are well protected

2) isolate area with a well sealed rubber dam
3) mask glazed porcelain with strips of green occlusal indicator wax
4) microetch surface 2-4 seconds for each square centimeter
5) direct assistant to place high volume suction tip as close as possible to the
preparation site.
clearfil = i. Cementation of resin bonded bridges: (Calibra)
self etch primer
1. After fabrication and verification of fit and aesthetics of the resin bonded bridge, the
+ adhesive resin bonded bridge should be etched if possible by the laboratory. The etching
procedure (electrolytic electrochemical or thermochemical etching) creates a rough
surface on the metal frame and increases overall surface area for attachment of the resin
luting cement. If etching is not possible, micro-abrasion can be performed. This will
clean the surface, however will not give as high a bond strength as will standard
electrolytic chemical etching.
2. Apply Clearfil SE2 primer to the metal surface. Air-dry 5 seconds.
3. With the metal prepared, the teeth should be isolated using a rubber dam.
4. The enamel surface to be bonded should first be pumiced with non fluoridated pumice
and rinsed clean with the air water syringe. The enamel surface should then be etched
for sixty seconds, rinsed and dried.

RBB - calibra 228

primer to metal surface (electrolytic electrochem or thermochem etching)
 5. Utilise Calibra resin luting cement as described under Clinical Usage for Calibra/Unicem
Resin Luting Cements.

ii. Bonding to metal: METAL

The repair of a fractured porcelain facing from a PFM, leaving exposed metal, is difficult.
Patients must be advised of the unpredictable nature of this repair. The steps for this
procedure are as follows:

1. Isolate the tooth with a rubber dam.

2. Provide macro-mechanical bur retention whenever possible.

3. Protect the nostrils as well as the eyes of the patient using a drape and protective glasses.

4. Under high volume suction, micro-abrade the exposed metal surface of the crown 2-4
seconds. microabrade
5. Clean off excess aluminum oxide and dry the metal well. phosphoric acid etchant
6. Clean with phosphoric acid etchant. Rinse and dry.
clearfil primer & adhesive
opaquers
7. Apply Clearfil SE2 primer and adhesive.
resin
8. Apply composite resin opaquers to mask the underlying metal, if necessary, and cure for
40 seconds.

9. Apply composite resin free hand to form the veneer, and polish as necessary.

iii. Bonding to porcelain: PORCELAIN

The repair of fractured porcelain with no or limited metal exposure and bonding to porcelain,
is more predictable than bonding to metal only. Still, patients must be advised of the
unpredictable nature of this repair. Hydrofluoric acid selectively dissolves the glass matrix
creating micromechanical retention. Silane is a dual functional monomer consisting of a
silanol group that reacts with the ceramic surface and contains a methacrylate group that co-
polymerizes with the resin matrix of the composite. The success of porcelain repair depends
on the type of porcelain being repaired (feldspathic or leucite-based better than aluminous or
zirconia-based). The steps for this procedure are as follows:

1. Isolate the tooth with a rubber dam.

2. Protect the nostrils as well as the eyes of the patient using a drape and protective
glasses.

229 microabrade
clean off al oxide
HF - only if isolation
silane
optibond primer + adhesive
3. Under high volume suction, micro-abrade the fractured porcelain (and if any, exposed
metal) surface of the crown. Clean off excess aluminum oxide and dry

AND/OR

4. Apply porcelain etch (9.5% Hydrofluoric acid [HF]) to the fractured porcelain surface for
60 sec. Note: HF is extremely caustic to soft tissue surfaces and extreme care must be
used to protect the operator and patient. Use a soft tissue protectant eg. Orabase, if
area is close to gingiva. Do not apply HF to glazed porcelain. Mask glazed porcelain with
strips of green occlusal indicator wax.

5. The intraoral application of HF must be skipped if isolation CANNOT be achieved. Use

light pressure to eject the HF from the syringe and never forcefully eject. Use high
volume suction to grossly remove the hydrofluoric acid gel first, then use the air/water
syringe to wash the surface.

6. Apply silane (from Calibra kit) to fractured porcelain surface and dry.

7. Apply Optibond FL primer and adhesive.

8. Apply composite resin free hand to form the veneer, and polish as necessary.

iv. Replacing gold acrylic crown facings:

Gold acrylic crowns have been a very useful restoration in dentistry in the past. In situations
where the marginal integrity of a gold acrylic crown is adequate but the esthetics are
inadequate (requiring that the acrylic facing be replaced), composite resin can be used.
Follow the following steps.

1. All old acrylic should be removed from the gold acrylic crown.

2. Follow steps Bonding to metal.

remove all acrylic from gold acrylic crown facing

then bond like metal

230
REMOVAL OF A SINGLE PORCELAIN BONDED TO METAL CROWN

1. Cut through the porcelain with a diamond bur in order to expose the underlying metal.

2. Cut through the labial (buccal) metal and over the incisal (occlusal) metal with a metal
cutting bur (# 1958 F.G.).

3. Flex the crown with an instrument (eg. Fenton crown remover available in Clinic 1
dispensary) in the crevice created.

231
4. If there is still resistance, continue to section metal on the lingual so as to separate crown
in two halves.

PROBLEMS - watch for posterior crowns with MOD keyways - you may have to cut this section
away with a bur. If you flex the crown within the MOD keyway, you
may break dentin. Watch for crowns with pins for retention.

REMOVAL OF BRIDGES
In these cases follow the same principles as outlined above, except you must also section one
of the solder joints between any two abutments. Before removing the section with pontic(s)

232
 attached, secure with dental floss around the pontic connector so as to avoid the possibility of
the patient swallowing or aspirating a segment of the bridge.

If a bridge is defective it is contraindicated to attempt to mallet it off without sectioning the

crowns, since this is traumatic to the abutment teeth and results in a high incidence of
postoperative pain and fractured teeth.

THE USE OF DISCS

N E V E R use diamond, Carborundum or any other disc for intra-oral use. These are extremely
dangerous because they can bind and will continue to run against soft tissue. They will
perforate a cheek or section a lip before you can stop the rotation.

NEVER USE DIAMOND, CARBORUNDUM OR OTHER DISC INTRAORALLY.

233
APPENDICES

234
THE SAFETY OF SILVER AMALGAM RESTORATIONS

235
 THE SAFETY OF SILVER AMALGAM RESTORATIONS

Dr. D. McComb.

Treatment planning according to sound basic principles is the key to the provision of rational
and successful patient care. Current treatment planning guidelines in education emphasise
critical-thinking in clinical decisions, the need to base treatment on current evidence and the
ability to recognize appropriate patient care. Treatment planning guidelines include:

 accurate patient evaluation and diagnosis

 careful consideration of the patient’s treatment needs
 full discussion of the benefits and risks of all proposed treatment

Sound amalgam restorations are being replaced because of alleged adverse health effects but
this cannot be condoned on the basis of the evidence. There is no credible evidence in the
scientific literature that the presence of silver amalgam restorations is in any way associated
with, or the cause of, any generalized health problem. Silver amalgam restorations are
considered to be extremely safe and have gone through decades of refinement to produce an
extremely stable, corrosion resistant and long-lasting dental restoration. Current high copper
amalgam formulations are metallurgically superior to previous alloys, are highly refined and
provide a quality restoration. Unfortunately misinformation is all too common regarding this
material and it is important that dentists provide balanced and cogent information to
patients.

In an April, 2002 News Release(1) the ADA provided a statement to clarify that concern about
amalgam’s mercury content is intuitive, but unfounded. The statement re-affirms that “dental
amalgam is the most thoroughly researched and tested restoration material among all those
in use” and that safety questions have been answered satisfactorily by “the major US and
international scientific and health bodies, including the National Institutes of Health, The US
Public Health Service, the Food and Drug Administration, the Centers for Disease Control and
Prevention and the World Health Organization, among others.” The US Public Health Service
review, published in 1993, involved 60 experts (no dentists) and examined 500 scientific
references. It concluded that the health benefits of silver amalgam have probably been
underestimated and if there are any potential undesirable health effects they would be so
minor as to be difficult to detect. Any undesirable health effects would be expected to show
up in dentists and this has not been the case. An update to this review was performed in 1998
and the USPHS found no new evidence to consider any policy changes with regard to silver
amalgam. Similarly, after an extensive review of the literature, an Ad Hoc Working Group of
European Union experts mandated by the European Commission, made no recommendations
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for any special restrictions on the use of silver amalgam. They concluded that there is no
scientific evidence of systemic health problems (other than rare cases of allergy) or toxic
effects arising from amalgam restorations.

The “folk-lore of anti-amalgam” has recently been examined by Wahl (2001) who has provided
two well-referenced (282) publications (2) challenging the “myths and half-truths” that abound
concerning silver amalgam. Examples of the evidence-based conclusions include:

 teeth with amalgam restorations have a low incidence of fractured cusps

 the vast majority of teeth with amalgam restorations do not have recurrent caries

 amalgam restorations last longer than resin composite restorations

 the American Dental Association has stated that amalgam is safe and effective
despite the fact that its research foundation receives financial remuneration for
alternative restorative materials (12 current patents) and no remuneration for
amalgam restorative materials

 dental amalgam has not been banned in any country in the European Union.

 The available scientific evidence does not support that amalgam is associated with
“amalgam illness”, any diseases of the central nervous system, any increase in
antibiotic resistance or any other health concerns.

It has been known for many years that minute amounts of mercury vapour are released from
silver amalgam during chewing and tooth brushing. Recent evidence is showing that all direct
filling materials are not as inert as was once thought. Leached components and degradation
products, including formaldehyde, have also been identified in measurable amounts from
resin composites and salivary enzymes take part in the degradation process. In a 1998 review
of toxicity of non-amalgam materials, Schmalz (3) concluded that “it is not possible to rank
dental filling materials in respect to their biocompatibility and it is evident that
biocompatibility must be considered to the same extent for both amalgams and commonly
used or recommended alternative filling materials.” The safety of any material to be used in
the mouth is of utmost concern to all dentists and most professionals are trying to balance the
use of all materials in a way that will maximize the material advantages and minimize the
(dental) risks. Although tooth-coloured restorative materials have reached a high level of
development they cannot as yet compete with silver amalgam in all clinical situations. To
attempt to do so is bound to cause problems and patient dissatisfaction.

All alternative direct restorative materials have certain limitations. Resin composites are
recognized as an important part of contemporary practice. They are essential for
“preservative-based” approaches to new caries management and for esthetic locations. They
are also a good choice for core restorations where the overlying crown provides optimal
anatomy and contacts, marginal seal and wear resistance. Although composites are entirely

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satisfactory for small to moderate intra-coronal restorations, they are technique-sensitive and
require exacting clinical procedures, are more costly and are indicated only for patients with
good oral hygiene and who are at low caries risk.(4) Clinicians must be aware of the factors
influencing success with posterior composites which include a) careful choice of patient,
location and material, b) use of a suitable matrix system to achieve a tight contact, c) use of a
clinically proven dentin bonding system and d) placement techniques designed to minimize
the detrimental effects of polymerization shrinkage stress. Polymerization problems include
shrinkage, heat generation, strain and physical changes on the teeth and restorations. Strain
relief is evident as white lines at the tooth-resin interface, open margins prone to leakage and
cracks in enamel adjacent to margins. All clinical studies to date reveal that silver amalgam
restorations provide significantly greater longevity than posterior composites. Even a recent
clinical trial of modest size restorations for initial caries(5) utilizing current resin restorative
materials and techniques showed 15% of 90 such restorations had already been replaced after
6 years. For the treatment of primary caries, direct composite can provide many advantages.
When larger sized, or amalgam replacement restorations are involved, composite resins
become far less favourable.

Rationale treatment planning should be patient-centered using the most appropriate

materials with maximum benefit/prognosis for the particular clinical situation. If patients have
a strong material preference they must understand and accept the limitations of alternative
material selection such as additional costs, longer treatment time, greater chance of problems
or failure and increased treatment requirements. Silver amalgam still has an important place
in everyday practice, albeit reduced in comparison to its former use. Amalgam should be used
where it offers clear advantages over other materials and this requirement will continue in the
provision of optimal patient care until true substitutes are developed and evaluated. It is
imperative that dentists practice wisely, and not be pressured into selecting materials that will
cause short-term or long-term problems to the dentition.

References

1. ADA New Release. April, 2002, http://www.ada.org/public/media/newsrel

2. Wahl MJ. Amalgam – Resurrection and redemption. Quint Int. 2001, Part 1: The clinical
and legal mythology of anti-amalgam. 32:525-535. Part 2: The medical mythology of
anti-amalgam. 32;696-710.
3. Schmalz G. 1998. The biocompatibility of non-amalgam dental filling materials. Eur J Oral
Sci:106:696-706
4. Manhart J, Garcia-Godoy F, Hickel R. 2002, Direct posterior restorations: clinical results
and new developments. Dent Clin North Am. 46:303-339
5. Busato AL et al 2001, Clinical evaluation of posterior composite restorations: 6-year
results. Am J Dent 14:304-308.

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Update on the Safety of Silver Amalgam Restorations (2009) D. McComb

FDA White Paper (2006) and Addendum (2009)

The FDA (Food and Drug Administration of the U.S. Department of Health and Human
Services) most recently reviewed the best available scientific evidence to determine
whether the low mercury vapor release levels associated with dental amalgam fillings
(during chewing and brushing) are a cause for concern. This culminated in the
publication of a White Paper in 2006 and an Addendum in 2009. The FDA reviewed
more than 200 valid scientific articles published from 1997-2008, conducted a
literature search for 2008-July 2009, and utilised previously conducted scientific
reviews - including the United States Public Health Service Reviews (1993, 1995) and
the 2004 Life Sciences Research Office (LSRO) Report. The latter examined studies
published from 1996 through 2003 and engaged an independent panel of academic
experts in the fields of immunotoxicology, immunology, and allergy; neurobehavioral
toxicology and neurodevelopment; pediatrics; developmental and reproductive
toxicology; toxicokinetics and modeling; occupational health and epidemiology;
pathology; and general toxicology.

The FDA utilized the following reference values in their deliberations. The U.S. Agency
for Toxic Substance and Disease Registry (ATSDR) has established a Minimal Risk Level
(MRL) for elemental mercury vapor at 0.2 μg/m3. The Environmental Protection Agency
(EPA) has established a Reference Concentration (RfC) for elemental mercury vapor at
0.3 μg/m3. These reference values were derived using a standard risk assessment
approach employing uncertainty factors, including an uncertainty factor to account for
variability in sensitivity of the human population. “They are considered to represent
chronic or lifetime inhalation exposures that are free from adverse health outcomes and
protective of human health for all individuals, including potentially sensitive populations
such as children prenatally or postnatally exposed to mercury vapor”. Further,
“Exceeding these levels does not necessarily mean that any adverse effects will occur.”

Representative FDA Conclusions

With regard to people with amalgam restorations FDA has concluded that “exposures
to mercury vapor from dental amalgam do not put individuals age six and older at risk
for mercury-associated adverse health effects”.

With regard to purported links between dental amalgam and neurological problems
and diseases or the possibility of renal damage FDA concluded that “the existing data
support a finding that exposures to mercury vapor at levels associated with dental
amalgams do not result in neurological deficits, tremors, peripheral neuropathies, or
Alzheimer’s Disease” and “the data from these studies support a finding that exposures

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to mercury vapor at levels associated with dental amalgams do not result in renal
damage” in the population age six and older. The FDA concluded that, “in light of the
air monitoring and biological monitoring evidence --- there is information from which to
determine that general and special controls are sufficient to provide a reasonable
assurance of safety and effectiveness”. It was also noted that these conclusions are
supported by other scientific bodies, including the European Commission’s Scientific
Committee on Emerging and Newly Identified Health Risks (SCENIHR) which stated in
2007 that “no risks of adverse systemic effects exist and the current use of dental
amalgam does not pose a risk of systemic disease”.

With regard to children under six years of age the FDA found that the scientific data
was “not as robust due to the absence of measured urinary mercury concentrations
and limited clinical data”, however FDA concluded: “Based on comparisons between
the expected daily dose in these potentially sensitive subpopulations and the MRL and
RfC, the exposure estimated from breast milk in breastfed infants, and clinical studies,
we would not expect to see any adverse health effects in these subpopulations from
mercury vapors released from dental amalgam”.

With regard to dental professionals occupationally exposed to dental amalgam, FDA

concluded that “existing data indicate that dental professionals are generally not at risk
for mercury toxicity except when dental amalgams are improperly used, stored,
triturated, or handled”.

FDA Special Controls

The FDA determined that “Class II with special controls” is the appropriate
classification for dental amalgam after evaluating the scientific evidence and safety
assessments. The review resulted in the two findings required of FDA by U.S. law when
classifying a device such as dental amalgam:

1) “the probable benefits to health outweigh any probable risks” and

2) “the scientific evidence adequately demonstrates the absence of unreasonable
risk of illness or injury associated with the intended use of amalgam”.

The special controls that have been introduced are:

i. Specific Labeling Recommendation

FDA specifies labeling for the presence of mercury. “The recommended warning about
the presence of mercury in a dental amalgam device and the recommended disclosure
of mercury content by weight will alert dental professionals of the potential for
exposure to mercury vapor and will remind them of the need for protective measures,
such as the use of gloves when handling the device. The recommended precautions
about the need for adequate ventilation and the need to store in a cool, well ventilated
place will encourage professionals to ensure there is adequate ventilation when in

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proximity to the device and to use a vacuum pump and adequate ventilation during
placement of dental amalgams to minimize the amount of mercury vapor that they or
their patients may inhale.”

ii. Information for Use Recommendation

FDA recommends the inclusion of an “information for use” statement in dental
amalgam labeling as a special control. “The purpose of this labeling recommendation is
address potential misunderstandings about the risk of exposure to mercury from the
device and to help dental professionals plan appropriate treatment recommendations
for their patients by providing them with FDA’s assessment of the most current, best
available evidence regarding potential risks to health from mercury vapor released from
dental amalgams.”

iii. Performance Test Recommendation

Additional FDA Considerations

“This final FDA “rule” classifying dental amalgam reflects FDA’s careful consideration of
the valid scientific evidence related to dental amalgam’s benefits, which include its
effectiveness as a restorative material, strength, and durability, and its potential
risks, which include those related to the release of low levels of mercury vapor.”
“As part of its assessment, FDA considered the important public health benefits of
dental amalgam and the advantages it presents as a restorative material. Dental
amalgam may provide benefits over other dental restorative materials because
amalgam fillings offer a broad range of applicability in clinical situations, ease of use
and relative insensitivity to variations in handling technique and oral conditions.”

“FDA also considered the fact that dental amalgam is a commonly used device with a
low frequency of adverse events reported to the Agency. FDA received 141 adverse
event reports related to dental amalgam from 1988 to 2008. It is estimated that over
one billion amalgam restorations were placed during this time period. The majority of
the dental amalgam adverse event reports submitted to FDA were anecdotal, lacked
specific details, and were often reported years after placement of the restoration,
making it difficult for the Agency to perform a causal analysis.”

References
1. FDA Update/Review of Potential Adverse Health Risks Associated with Exposure to
Mercury in Dental Amalgam, National Center for Toxicological Research, Food and Drug
Administration, August 2006. (FDA Draft White Paper)
2. Addendum to FDA Draft White Paper, Addendum Review in Response to Advisory Panel
Comments and Recommendations, July 2009. (The 2006 Draft White Paper and
the 2009 Addendum constitute the final White Paper.)

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3. Dental Amalgam: A Scientific Review and Recommended Public Health Service Strategy for
Research, Education and Regulation; Public Health Service, U.S. Department of Health and
Human Services, January 1993.
4. Update Statement by the U.S. Public Health Service on the Safety of Dental Amalgam,
September 1, 1995.
5. Dental Amalgam and Alternative Restorative Materials: An Update Report to the
Environmental Health Policy Committee, September 1997.
6. Agency for Toxic Substances and Disease Registry (ATSDR) and Research Triangle Institute,
Toxicological profile for mercury, U.S. Dept. of Health and Human Services, Public Health
Service, Atlanta, Georgia, 1999.
7. United States Environmental Protection Agency (EPA), “Integrated Risk Information System
(IRIS) Screening-Level literature Review” – Mercury, elemental, 2002.
8. The Safety of Dental Amalgam and Alternative Dental Restoration Materials for Patients
and Users – Preliminary Report, Scientific Committee on Emerging and Newly Identified
Health Risks (SCENIHR), European Commission, Health and Consumer Protection DG, 2007.
9. Review and Analysis of the Literature on the Potential Adverse Health Effects of Dental
Amalgam, Life Sciences Research Office, July 2004.

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 HEALTH CANADA POSITION STATEMENT ON DENTAL
AMALGAM 1996

Following a thorough review of the Safety of Dental Amalgam

Health Canada issued the following statement:-

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 II. HEALTH CANADA POSITION STATEMENT ON DENTAL AMALGAM

Consideration:

1. Although dental amalgam is the single largest source of mercury exposure for average
Canadians, current evidence does not indicate that dental amalgam is causing illness in the
general population. However, there is a small percentage of the population which is
hypersensitive to mercury and can suffer severe health effects from even a low exposure.

2. A total ban on amalgam is not considered justified. Neither is the removal of sound amalgam
fillings in patients who have no indication of adverse health effects attributable to mercury
exposure.

3. As a general principle, it is advisable to reduce human exposure to heavy metals in our

environment, even if there is no clinical evidence of adverse health effects, provided the
reduction can be achieved at reasonable cost and without introducing other adverse effects.

Recommendations:

Health Canada advises dentists to take the following measures:

1. Non-mercury filling materials should be considered for restoring the primary teeth of children
where the mechanical properties of the material are suitable.

2. Whenever possible, amalgam fillings should not be placed in or removed from the teeth of
pregnant women.
NOT LIVER
3. Amalgam should not be placed in patients with impaired kidney function.

4. In placing or removing amalgam fillings, dentists should use techniques and equipment to
minimize the exposure of the patient and the dentist to mercury vapour, and to prevent amalgam
waste from being flushed into municipal sewage systems.

5. Dentists should advise individuals who may have allergic hypersensitivity to mercury to avoid
the use of amalgam. In patients who have developed hypersensitivity to amalgam, existing
amalgam restorations should be replaced with another material where this is recommended
by a physician.

6. New amalgam fillings should not be placed in contact with existing metal devices in the mouth
such as braces.

7. Dentists should provide their patients with sufficient information to make an informed choice
regarding the material used to fill their teeth, including information on the risks and benefits
of the material and suitable alternatives.

8. Dentists should acknowledge the patient’s right to decline treatment with any dental material.

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