Amalgam Restoration

Introduction
Types Low copper: generally inferior High copper
Compressive strength is similar to tooth The tensile is lower than tooth Exhibit no clinically relevant creep or flow Spherical
Greater leakage Greater postoperative sensitivity More easily condensed than admixed: but some prefer admixed handling type

Admix (lathe-cut)

Properties
Linear coefficient of thermal expansion (LCTE) is greater than tooth. Brittle and have low edge strength High thermal conductor Clinical performance:
Marginal fracture, bulk fracture, secondary caries

Handling: Operator preference regarding using admix or spherical alloys

Amalgam
Advantages Wear resistance. History of use Less technique-sensitive. Inexpensive Strong, long longevity Ease of procedure and isolation needs Eventual seal of margins Easy to develop contours, contacts, occlusion Disadvantages

Not esthetic Conductivity Tooth preparation more demanding, less conservative.

Amalgam Concerns
Mercury content, mercury disposal. Esthetics. Removal of tooth structure weakening a tooth Unless bonded, no bonding benefits: bonding may not be indicated. Recurrent caries: reduces life expectancy Marginal leakage until corrosion: several months

Mercury Controversy
Lack of scientific evidence that amalgam poses health risks to humans except for rare allergic reactions.
True allergies are rare Estimate of human uptake of mercury vapor from amalgam is 5 g/m3

No evidence ensuring that alternative materials pose a lesser health hazard.

Amalgam Use
Nonesthetic cervical lesions. Large Classes 1 and 2 where heavy occlusion exist Classes I and II when isolation problems exist for bonding. Temporary/caries control restorations. Foundations Patient sensitivity to other materials Where cost is a factor Inability to do a good composite

Factors For A Successful Restoration

Appropriately indicated clinical situation. High-copper material. Tooth preparation. 90-degree cavosurface margins. Thickness of amalgam (1-2 mm). Mechanical retention form. Seal tubules. Good condensation (including lateral condensation). Appropriate development of contours and contacts.

Clinical Technique

Initial Clinical Procedures

1. Local anesthesia. 2. Isolation of the operating site: rubber dam/cotton rolls, with or without a retraction cord. 3. Other preoperative consideration:
1. Placing wedge in the gingival embrasure when restoring a posterior proximal surface separates adjacent tooth and protect the rubber dam and the interdental papilla. Make preoperative occlusion assessment before rubber dam For smaller amalgam restorations, the projected facial and lingual extensions of a proximal box should be visualized before preparing the occlusal portion of the tooth, thereby reducing the chance of over preparing the cuspal area while maintaining a butt joint form of the facial and/or lingual proximal margins.

2.
3.

Tooth Preparations Requirements

Appropriate tooth preparation is dependent on both tooth and material:
90-degree or greater amalgam margin (butt joint). Adequate amalgam thickness: 0.7 - 2 mm for adequate compressive strength. Adequate mechanical retention form (undercut form) amalgam has lack of bonding to the tooth, must be mechanically retained.

Principles of Tooth Prep

Initial stage: Provide initial form that retains amalgam
Extend preparation into sound tooth structure at the marginal areas (Mesial-distally). Extend the depth (pulpally and/or axially) to a prescribed, uniform dimension. Establish margins that results in a 90-degree amalgam margin once the amalgam is inserted.

Final stage:
Removes any remaining defect (caries or old restoration) Incorporate any additional preparation features: slots, pins, steps, or amalgam pins:
To achieve appropriate retention and resistance form.

Initial Stage
All initial prep relate to the DEJ, except in two instances:
Occlusal enamel has been significantly worn thinner. Preparation extends onto the root surface.

Initial depth: 0.2 0.5 mm pulpally the DEJ or 1.5 mm as measured from the depth of the central groove
0.2 mm inside when retention locks are not used 0.5 when retention locks are used allows placement without undermining enamel margin.

Axial depths on the root should be 0.75 - 1 mm for retention groove or cove while providing for adequate thickness of the amalgam (Fig. 2-21) Depth of the axial wall in smooth surface lesions shouldn't exceed 0.2 to 0.8mm deep into dentin.

Outline Form
Visualized preoperatively to prevent fracture by estimating:
Extent of defect, preparation form requirements Need for adequate access to place the amalgam

Marginal enamel rods should be supported by sound dentin:

Preserve the strength of cusps and marginal ridges Outline form should be extended around cusps and avoid undermining the dentinal support of the marginal ridge enamel.

Facial and lingual proximal cavosurface margins should be 90: if <90 , fracture because both enamel and amalgam are brittle Facial and lingual proximal walls should be extended just into the facial or lingual embrasure. Extension provides:
Adequate access for performing the preparation (with decreased potential to mar the adjacent tooth), Easier placement of the matrix band, Easier condensation and carving of the amalgam. Clearance between the cavosurface margin and the adjacent tooth.

 Factors dictating outline form:

Caries, old restorative material, Inclusion of all the defect, the proximal and/or occlusal contact relationship, Need for convenience form.

Primary Retention Form

Retention form features locks or ability to retain the restorative material in the tooth.
Composite: micromechanical bonding provides most retention Nonbonded and bonded amalgam: must be mechanically locked

Amalgam retention form is provided by:

Mechanical locking by surface irregularities of the preparation Vertical walls (especially facial and lingual walls) that converge occlusally. Locks, grooves primary retention form Coves, slots, pins, steps, or amalgam pins that are placed during the final stage of tooth preparation coves are secondary retention form

Primary Resistance Form

Resistance form help restoration and tooth resist fracturing from occlusal forces.
Preventing Tooth Fracture
Conserve tooth structure: preserve cusps and marginal ridges. Prepare pulpal and gingival walls perpendicular to occlusal forces Rounded internal preparation angles. Removing unsupported or weakened tooth structure. Placing pins into the tooth as part of the final stage of tooth preparation secondary resistance form

Preventing Amalgam Fracture

Adequate thickness of amalgam (.5-2 mm in occlusal contact and 0.75 mm in axial areas). Marginal amalgam of 90 or greater. Boxlike preparation form, which provides uniform amalgam thickness. Rounded axiopulpal line angles in Class II tooth preparations. Many of these resistance features can be achieved using the No. 245 bur, which is an inverted cone design with rounded corners.

Convenience Form
Preparation features are those that make the procedure easier or the area more accessible. Include arbitrary extension of the outline form so marginal form can be established
Caries can be accessed for removal Matrix can be placed, and/or amalgam can be inserted, carved, and finished

May include extending proximal margins to provide clearance from adjacent tooth and extension of other walls to provide greater access for caries excavation.

Removing Remaining Fault and Protecting Pulp

If caries or old restoration remains after the initial preparation, it should only be located in the axial or pulpal walls. For most nonbonded amalgam restorations, a sealer is placed on the prepared dentin before amalgam insertion.

Secondary Resistance and Retention

Used if insufficient retention or resistance forms. Many features that enhance retention form also enhance resistance form:
Placement of grooves, locks, coves, pins, slots, or amalgam pins. Usually, the larger the tooth preparation, the greater the need for secondary resistance and retention forms (Figs. 2-23 and 2-24).

Restorative Techniques

Restorative Techniques
If amalgam is not to be bonded: Place sealer on prepared dentin: either a coating material or a polymerized resin adhesive.
May occur before or after the matrix application.

If amalgam is to be bonded: apply matrix, etch, prime, and bond

Important that bonding adhesive be fluid and unset when the amalgam condensation occurs. Some adhesives also achieve chemical adhesion with the amalgam.

Matrix Placement
Objectives of a matrix are to:
Provide proper contact. Provide proper contour. Confine the restorative material. Reduce the amount of excess material. Easy to apply and remove. Extend below the gingival margin. Extend above the marginal ridge height. Resist deformation during material insertion. It should be noted that when bonding an amalgam restoration, it might be necessary to coat the internal aspect of the matrix before its placement to prevent the bonded material from sticking to the matrix material (Fig. 2-25).

For a matrix to be effective, it should:

 Mixing (triturating) the amalgam material. The manufacturer's directions should be followed when mixing the amalgam material. Both the speed and time of mix are factors in the setting reaction of the material. Alterations in either may cause changes in the properties of the inserted amalgam.

Inserting the Amalgam

Lateral condensation (facially and lingually directed) is very important in the proximal box portions of the preparation to ensure confluence of the amalgam with the margins. Both high and low types are easily inserted As a general rule, smaller amalgam condensers are used first. Subsequently, larger condensers are used.
Allows amalgam to be properly condensed into the internal line angles and secondary retention features Very important that amalgam condensation occur before adhesive polymerizes.

When amalgam is placed to slight excess with condensers should be precarve burnished with a large, egg-shaped burnisher to finalize the condensation remove excess mercury and initiate the carving process.

Carving the Amalgam

Performed after precarve burnishing has been done, the remainder of the accessible restoration must be contoured to achieve proper form and function. Nonbonded amalgam is relatively easy to carve. Bonded amalgam is more difficult because the excess polymerized adhesive resin accumulates at the margins and is harder to remove. Be careful not to break off chunks

Occlusal areas Use discoid-cleoid to carve occlusal surface of an amalgam restoration.

Discoid (rounded) is positioned adjacent to the amalgam margin and pulled parallel to the margin. To smooth out anatomic form. Use cleoid to form pit and groove anatomy

Carving pits and grooves: to provide pathways for food to escape from the occlusal table.
Carve mesial and distal pits inferior to the marginal ridge height. Carve definite but rounded occlusal anatomy.

For large Class II or foundation restorations, the initial carving of the occlusal surface should be rapid, concentrating primarily on the marginal ridge height and occlusal embrasure areas.
Created embrasure form should be identical to that of the adjacent tooth, assuming the adjacent tooth has appropriate contour.

Height of the amalgam marginal ridge should be same as adjacent tooth to reduce potential fracture of ridge area of restoration.

Facial/Lingual Areas Most facial and lingual areas are accessible and can be carved directly. Hallenbeck carver is useful in carving these areas. The base of the amalgam knife (scaler 34/35) is also appropriate. Contour should be convex; therefore, care in carving this area is necessary.
Develop convexity by using unprepared tooth structure above and below preparation as guides for initiating the carving. The marginal areas are then blended, resulting in the desired convexity and providing the physiologic contour that promotes good gingival health.

Proximal Embrasure Areas Amalgam knife (or scaler) is an excellent for removing proximal excess and refining proximal contours and gingival embrasure form. Position knife below gingival margin, and carefully shave excess by drawing it occlusally. Knifes sharp tip can be used to develop facial and lingual embrasure forms. If the amalgam is hardening, a shaving motion must be used. A cutting motion can chip or break the amalgam Use visual assessment and floss to evaluate proximal embrasure area .
Be careful when using If dental floss to prevent contact area from being removed. Wrap the floss and exert force around the adjacent tooth first, then move floss up and down after floss passes through contact area.

Finishing Amalgam Restoration

Articulating paper. After the occlusion is adjusted, use discoid-cleoid to smooth amalgam.
Can also use a lightly moistened cotton pellet held in the operative pliers

If the carving and smoothing are done properly, no subsequent polishing of the restoration is needed good long-term result

Repairing Amalgam Restoration

If an amalgam restoration fractures during insertion, the defective area must be reprepared as if it were a small restoration. Appropriate depth and retention form must be generated, sometimes entirely within the existing amalgam restoration. A new mix of amalgam can be condensed directly into the defect and will adhere to the amalgam already present if no intermediary material (sealers) has been placed in between If the amalgam has been bonded, carefully condition and apply adhesive to the exposed tooth structure

Common Problems
Postoperative Sensitivity Marginal Void

Causes include: Lack of adequate condensation, especially lateral condensation in the proximal boxes. Lack of proper dentinal sealing with sealer or bonding system.

Causes include: Inadequate condensation. Material pulling away or breaking from the marginal area when carving bonded amalgam.

Marginal Ridge Fractures Causes Axiopulpal line angle not rounded in Class II tooth preparations. Marginal ridge left too high. Occlusal embrasure form incorrect. Improper removal of matrix. Overzealous carving.

Amalgam Scrap and Mercury Collection And Disposal.

Causes Careless handling. Inappropriate collection technique. Potential solutions include: Careful attention to proper collection and disposal. Following the Best Management Practices for Amalgam Waste as presented by the American Dental Association

Controversial Issues

Amalgam Restoration Safety.

Amalgam restorations are safe. The U.S. Public Health Service (USPHS) has reported the safety of amalgam restorations. Even recognizing these assessments, the mercury contained in current amalgam restorations still causes concerns, both legitimate and otherwise. Proper handling of mercury in mixing the amalgam mass, removal of old amalgam restorations, and amalgam scrap disposal are very important, physiologic, and economic manner.

Spherical or Admixed Amalgam

Spherical materials have advantages in providing higher earlier strength and permitting the use of less pressure. Admixed materials permit easier proximal contact development because of higher condensation forces.

Bonded Amalgam Restorations

Bonded amalgam are no longer recommended, even though some operators may select them for large restorations. Use of typical secondary retention form preparation features (e.g., grooves, locks, pins, slots) are still required if bonding an amalgam Small-tomoderate amalgam restorations should not be bonded its actually better to just use composite.

Proximal Retention Locks

Proximal retention locks for large amalgam restorations may be beneficial, although their use for smaller restorations is not deemed necessary. Correct placement of proximal retention locks is difficult.