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Complex Amalgam

Restoration

Complex Amalgam Restoration

Complex amalgam restorations


involve replacement of missing tooth
structure because of teeth have been
fractured or involved with caries or
existing restorations. It involves
replacement of one or more missing
cusps, and often requires bonding
techniques.

INDICATIONS

Large amounts of tooth structure are missing


One or more cusps need capping
Increased resistance and retention forms are needed

Pins, slots, grooves and boxlike forms provide


resistance form
Used as control restorations in teeth with pulpal or
periodontal prognosis
Used as control restorations in teeth with caries
Used as definitive restorations
Used as build up or foundation

FACTORS

Resistance and retention forms


Status and prognosis of tooth
Role of the tooth in overall
treatment plan
Occlusion
Esthetics
Economics

Resistance and retention forms

Retention features depend on amount of


remaining tooth structure and the tooth
being restored
More tooth structure is lost = more
auxiliary retention is needed

Status and prognosis of tooth

Caries activity, endodontic therapy

Control restoration:

1)
2)
3)
4)

Protects pulp from oral cavity and insults


Provides anatomic contour
Facilitates control of caries and plaque
Provides resistance against fracture

Role of the tooth in overall


treatment plan

Tx. Choice for tooth is influenced by its


role in overall tx. Plan
Remember: in the clinic do not just look
at the tooth but consider its role and
function

Occlusion

Interim restorations for teeth that


require occlusal alterations

Esthetics

Metallic appearance

Economics

Less expensive and less time


consuming than cast restoration

CONTRAINDICATIONS

Patient has significant occlusal


problems
Tooth cannot be restored with direct
restoration because of
anatomic/functional considerations
Esthetics

ADVANTAGES
-Conserves
tooth structure
-Appointment time:
one appointment
-Resistance and
retention forms
increased
-Cost

DISADVANTAGESPinholes and pin


placement: Dentinal
microfractures
-Microleakage (from
cavity varnish)
-Decreased strength
-Resistance form is
harder to achieve
-Penetration into pulp
and perforation into
external tooth
structure
-Anatomy

CLINICAL TECHNIQUES
Pin-retained amalgam restorations

=any restoration requiring placement of one or more


pins in the dentin for resistance and retention forms

Pins are used when resistance and retention forms


cannot be achieved with slots/locks/or undercuts

Pins for Class IV restorations rare: small size of


anterior teeth

Pins have greater retention

However, can be considered for Class IV on the distal


surface (distoincisal corner) of canine when restored
with amalgam

Alternative to pin: Lingual dovetail

Slot-retained amalgam restorations

= retention groove in dentin whose


length is in horizontal plane

Prepared with 33 or round bur

May be used as an alternative to pinretained or in conjunction with pinretained

Retention differences between pins and slots are not significant

Pin

-Pin is usually used in


preparations with few
or no vertical walls

Slot

-Slots are usually


indicated in short
clinical crowns and
cusps that have been
reduced 2-3 mm for
amalgam

-More tooth structure


is removed

-Less likely to create


microfractures in
dentin

-Less likely to
perforate/penetrate

Amaglam foundations

=an initial restoration of severely


involved tooth; tooth is restored so
restorative material serves in lieu of
tooth structure to provide retention
and resistance during final cast
restoration

TOOTH PREPARATION

Pin-retained amalgam
restorations

Development of resistance form depth cuts Cusp reduction


Final restoration
If the cusp to be capped is located at correct occlusal height
before preparation, depth cuts should be made on existing
occlusal surface of cusp to be capped

Carbide fissure bur


Depth of cuts should be a minimum of 2 mm deep for functional cusps
and 1.5 mm deep for nonfunctional cusps (p 814)
If unreduced cusp is at less than correct height, then cuts will be less.
The goal is to have at least 2 mm of amalgam thickness for functional
cusps and 1.5 mm of amalgam for nonfunctional cusps during final
restoration.
Rounded internal angles
Opposing vertical walls should converge occlusally to enhance retention
form

Gingival seat

Remove infected carious dentin


CaOH liner and resin-modified glass ionomer base can
be applied

It should not extend closer than 1 mm to slot or pin

Pin types

Self threading pin is most commonly used pin and most


retentive of the three types of pins (self-threadings,
cemented pins, friction locked pins)

Cemented pin is the least retentive

Pin hole: 0.0015 to 0.004 in. smaller than diameter of


pin
Pin drilled into dentin; may generate stress when
inserted
See powerpoint for factors affecting retention of pin in
dentin and amalgam

Problems and failures of pinretained restorations

Failure can occur within the restoration


At the interface between pin and restorative material
Within the pin
At the interface between pin and dentin
Within the dentin
Pin may break during bending if not careful

Choose an alternate location at least 1.5 mm remote


from broken pin to prepare another hole
Removal is difficult

Loose pin (example: as in self-threading pins


sometimes do not engage in dentin; during
preparation)
Penetration into pulp and perforation of external
tooth surface

Slot-retained amalgam
restorations

Slots are usually placed on facial/lingual/mesial/distal


aspects of preparation
They may be continuous or segmented
It depends on amount of missing tooth structure and
where pins are used
Shorter slots = more resistance to horizontal forces
No. 33 bur used to place slot in gingival floor and
No. 169L bur
0.5 mm axial of DEJ
Depth is at least 0.5 mm
Length is at least 1 mm or more

Amalgam foundations

Tooth preparation depends on type of


retention selectedpin retention; slot
retention or chamber retention
(endodontic therapy)

Pin retention

For broken down teeth with few or no


vertical walls
For foundations, pinholes are further
distance from external surface of tooth;
this is the main difference between use
of pins for foundation and use of pins for
definitive restorations

Slot retention

Placed in gingival floor of preparation


with No. 33 bur
Placed farther inside DEJ than for
conventional amalgam preparations
Depth is usually 0.5-1.0 mm and 2.0
4.0 mm long

Chamber retention

This is recommended when:

Dimension to pulp chamber is sufficient to


give retention and bulk amalgam
Dentin thickness in region of pulp chamber
is enough to provide rigidity and strength

There is an extension into root canal


space 2-4 mm (when pulp chamber
height is 2 mm or less; anything greater
gives no advantage)

The end