Operative Dentistry 2004

OPERATIVE
Legend
Major Topic Abbreviation
Amalgam Arnat
Bases I Liners I Cements B/LIC
Caries Caries
Composites Comp
Gold - Direct and Indirect Gotd
Instruments I Burs Instr I Burs
Miscellaneous Misc.
Pins Pins
Rubber Dam ROam
Sealants I Fluoride S I FI
Terms Terms Copyright © 2004 - DENTAL DECKS

OPERATIVE

BILle

After the initial setting period, which of the following cements is the least soluble?

• Zinc phosphate cement

• Zinc polycarboxylate cement

• Glass ionomer cement

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• Glass lonomer cement

***Zlnc polycarboxylate is the most soluble (it is slightly more soluble than zinc phosphate).

Glass lonomer cements are hybrids of silicate and polycarboxylate cements designed to combine the fluoride releasing properties of silicate particles with the chemically adhesive and more biocompatible characteristics of the polyacryllc acid matrix compared to the extremely acidic matrix of silicate cement.

Advantageous physical properties of glass ionomer cements:

• Release of fluoride ~ anticariogenic

• Chemical adhesion to the prepared tooth and certain metals. Mlcromechanlcal bond to composite resins.

• Blocompatlbility Is high, thus with enough dentin remaining (0.5-1 mm) no pupal pro-

tective agent (calcium hydroxide) is required.

• Good thermal Insulators ~ equal to that of natural dentin

• Thermal expansion is similar to that of tooth structure

• After Initial setting. they have low solubility In the mouth

Note: Its disadvantage as a cement is that it has a higher cement film thickness than zinc phosphate cement.

OPERATIVE

BILle

'Mlich cement, when set, has the potential to Inhibit the development of recurrent carles at its margin as a result of fluoride release from its surface?


• Zinc oxide-eugenol



Copyright e 2004 - DENTAL DECKS

• Glass Ionomer cement

In addition, glass ionomer cements have the potential to absorb fluoride when local ionic concentrations are high and then release the fluoride slowly when the environmental concentration decreases, thus acting as a fluoride sponge.

Glass lonomer cements are mixed powder-liquid component systems. The powder consists of a calcium-aluminofluoroslilcate glass that reacts with a liquid which is polyacryllc acid to form a cement of glass particles surrounded by a matrix of fluoride elements.

CIUllflcaUon of Glan lonomer Cements

1. Conyentlonal -+ used as a luting agent. Example: Ketac-Cem

2. Llght-cured -+ used as a base or liner. Note: liquid has HEMA added to it.

Advantages Include: an extended working time, short on-demand setting times, a set mass that is stronger, more adhesive, and more resistant to desiccation than selfcured glass ionomers. Examples include Vitrebond and XR lonomer

3. Resln-modlfled (Hybrid) IIght-cured ~ can be used for any application where glass ionomers are good choices. Note: liquid has HEMA added to it. Example: Fuji-II lC

OPERATIVE

BILle

In zinc oxide-eugenol (ZOE) cements, the powder is zinc oxide and the liquid is:

• Phosphoric acid

• Eugenol

• Zinc polyacrylic acid

• Saline solution

Coovriaht e 2004 - DENTAL DECKS

• Eugenol

Zinc oxide-eugenol cement is a soft, sedative - type cement. It is used as a sedative or temporary filling material, as an insulative base, and in interim caries treatment. Eugenol has a palliative effect upon the dental pulp, and this is one of the main advantages of using this type of cement.

A conventional mixture of zinc oxide and eugenol is relatively weak. In recent years nreinforced" or "improved" zinc oxide-eugenol cements have been Introduced (called reinforced ZOE or ZOE-EBA). The particles of the zinc oxide powder are surface treated to produce better bonding of the particle to the matrix.

Contraindication. to the use of ZOE include:

1. On dentin or enamel prior to bonding ~ compromises bonding.

2. As a base or liner for composite resins ~ eugenol interferes with polymerization.

3. Patients who are allergic to eugenol (or oil of cloves) ~ this is somewhat common.

4. Direct pulp capping ~ eugenol is a pulpal irritant when in direct pulpal contact.

Remember: ZOE is soluble in oral fluids and is difficult to remove from cavity preparations.

OPERATIVE

BILle

Match the following four types of ZOE material with their indications for use:

Types of ZOE Materials Indications for use
Type I ZOE Cavity liner
Type II ZOE Temporary cement
Type III ZOE Permanent cement
Type IV ZOE Temporary filling or base Copyright © 2004 - DENTAL DECKS

Four b'pu of ZOE Matedal.

• Type I ZOE -+ Temporary cement

• Type II ZOE -+ Pennanent cement

• Type III ZOE -+ Temporary filling material and thennal insulating base

• Type IV ZOE -+ Cavity liner

The basic composition of all of these materials (whether it be a cementing medium, surgical dressing, temporary filling material, or impression paste) is the same: mainly zinc oxide, eugenOl; and resin. Plasticizers, fillers, accelerators, and other additives are incorporated as necessary to provide the desired properties for the particular use of the product.

Reinforced ZOE (Type 11/) -+ the powder is composed of zinc oxide and finely divided polymer particles (polymethyl-methacrylate) in the amount of 20 to 40% by weight. In addition, the zinc oxide powder is surface treated by an aliphatic monocarboxylic acid, such as propionic. The liquid is eugenol. Note: This combination of surface treatment and polymer reinforcement results in a material that has good strength and toughness which markedly improves abrasion resistance.

Reinforced ZOE is fine for basing large and complex cavities. This material is able to withstand the pressure of amalgam condensation and it has minimal effect on the pulp.

OPERATIVE

BILle

V\lhich cement is the oldest of the luting cements and thus is the one that has the longest "track record" and serves as the standard to which newer systems can be compared?




·ZOE

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It is a powder-liquid system; the powder is mostly zinc oxide and the liquid is orthophosphorlc acid. The primary use of zinc phosphate cement is as a luting agent for the cementation of cast restorations. It can also be used as a base material when a high compressive strength is needed. The initial mixture of this cement is very addic (3.5) and can cause irreversible pulpal damage if a cavity vamish (2 coats) is not placed on the tooth prior to cementation of the crown.

It has superior strength compared to other cements, and its retention is dependent upon mechanical Interlocking (as opposed to glass ionomer and po/yearlJoxy/ate cements whieh adhere to tooth structure by virtue of the po/yaery/le aeld in the liquid).

Notes:

1. Zinc phosphate cement liquid that has lost some of its water content will cause the setting time of the mix to be lengthened.

2. Mixing zinc phosphate cement very rapidly will decrease the final compressive strength of the cement.

3. Zinc phosphate cement will shrink slightly upon setting.

OPERATIVE

BILle

When mixing zinc phosphate cement. a cool glass slab is used to:

• Accelerate the setting time

• Create more free zinc oxide in the set cement

• Increase the powder-liquid ratio

• Increase expansion of the set cement


• Increase the powder-liquid ratio

Mixing procedure for zinc phosphate cements:

• A cool mixing slab should be used. Caution: The temperature of the slab should not be below the dew point of the room.

• Mixing should be started with the addition of a small amount of powder to the liquid.

This procedure, along with the cool slab, Increases the working time.

• Small increments of powder are added approximately every 20 seconds with vigorous mixing until a creamy consistency is achieved. This will promote a high powder-liquid ratio and a superior cementation medium by providing the following:

-+ a lower viscosity of the mix

-+ a stronger final set

-+ a lower solubility of the set cement

***Important point: The advantages of USing the cool slab method are a substantial increase in the working time of the mix on the slab and a shorter setting time of the mix after placement in the mouth.

[OPERATIVE

BILle

All of the following statements are true regarding glass ionomer restorations, except:

• Glass ionomer is often the ideal material of choice for restoring root surface caries in patients with high caries activity

• The best surface finish for a glass ionomer restoration is that obtained against a surface matrix

• Glass ionomer adheres to mineralized tooth tissue

• Glass ionomers are somewhat esthetic and polish much better than composites

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• Gla .. lonome ... are somewhat esthetic and polish much better th.n composites

-It is true that glass ionomers are somewhat esthetic, however, they do not polish as well as composites.

Both self-cured and light-cured versions of glass ionomers are available. Light-cured glass ionomers are preferred because of both the extended working time and their improved physical properties. Because of their limited strength and wear .... I.tanc., glass ionomers are indicated generally for the restoration of low stress areas where caries activity potential is of significant concern.

Compared to composites, gla .. lonomers:

• Have a lower compressive strength, tensile strength, and hardness.

• Are generally very technique sensitive because of their high solubility when first mixed.

Note: With the newer hybrid or light-cured resin-modified glass ionomers, the above properties have been Improved.

GI.sa lonomers are generally considered the nearty ideal base I liner material because of the following properties:

• Adhnlv. bond to tooth structure

• Snap set in the light-cured form (for example, Vitrebond)

• Antlcarlogenlc -+ due to fluoride release

• Bond to composite -+ makes for excellent liners for Class V root caries restorations.

Sometimes called the "sandwich technique". This technique achieves all the benefits of the glass ionomer cements plus the high polishabillty, surface hardness, and strong bond to enamel of the composite resin.

OPERATIVE

BILle

Which cement (luting agent) is also used as a permanent restorative agent?

• Zinc polycarboxylate

• Zinc phosphate

• Glass lonomer



• GI ••• lonomer

- Only gla .. lonomer is used as a cement (luting agent) and a pennanent restorative materIal. Glass ionomer cements are often used for root surface carious lesions because of the potential advantage of fluoride release in helping to control the spread of caries.

Commonly Uaed Dental Cementa
Cement U ...
Zinc phosphate As a luting agent for gold restorations
and orthodontic appliances
Also used as a base under certain restorations
Zinc oxide-eugenol As a base, as a temporary restoration, and lUI a
luting agent
Zinc polycarboxylate As a luting agent
Gfasa !anomer As a luting agent and In CIIUl8V restorations
with oomposile ("HndWlch technique") Note: ZOE, reinforced ZOE, ZOE-EBA, siUcate, and zinc silicophosphate cements are no longer routinely used to pennanently cement restorations. Zinc phosphate cement has been extensively replaced by polycarboxylate or glass ionomer cements. These cements are based on ioncrosslinked polyacryllc acid matrices that have the potential to react chemically with residual powder particles and the surface of tooth structure.

OPERATIVE

BILle

The first cement system developed with a potential for adhesion to tooth structure was:




. Copyright e 2004 - DENTAL DECKS


Zinc polycarboxylate cement was the first system developed with a potential for adhesion to tooth structure. The polycarboxylate cements are powder I liquid systems. The liquid is an aqueous solution of polyacryllc acid and copolymers. The powder is zinc oxide and magnesium oxide.

Zinc polycarboxylate cements have a compressive strength slightly lower than that of zinc phosphate while the tensile strength Is higher. Its final strength is dependent on the powder I liquid ratio, with more powder giving greater strength. The strength of the set material is sufficient for amalgam condensation and its effect on the pulp is mild enough to eilminate the need for sublining. Thermal conductivity is low and thus the material gives good protection against thermal stimuli applied to metallic restorations.

An advantage of zinc polycarboxylate cement is that it can bond to tooth structure -t This is attributed to the ability of the carboxylate groups in the polymer molecule to chelate to calcium in the tooth. A disadvantage is that the working time is extremely short.

Remember: 'lv'hen cementing a cast restoration, always apply cement to both restoration and the tooth.

OPERATIVE

BILle

If a zinc phosphate cement base is used when restoring a tooth, when should the varnish be applied?

• Prior to placement of the base

• After placement of the base

• Makes no difference when the vamish is applied

• Vamish should not be used in conjunction with zinc phosphate cement


• Prior to placement of the base

It should be emphasized that the use of a base in conjunction with amalgam or gold foil does not alleviate the need for a varnish as an aid in sealing the cavity margins against leakage. However, the type of base governs the respective order of application of the varnish and the base. If a zinc phosphate cement base is to be used, then the cavity varnish should be applied to the cavity walls prior to placement of the base. On the other hand, if a biocompatible agent,e.g., a calcium hydroxide, zinc oxide-eugenol, or polycarboxyfate cement base is employed, then these should be placed against the dentin, and the varnish should not be applied until the base material has hardened. Note: The varnish will reduce the initial microleakage of an amalgam restoration.

Zinc phosphate cements provide good pulpal protection from thermal, electrical, and pressure stimuli, but may damage the pulp as a result of an Initial low pH. This, however, can be of benefit as it provides an antibacterial effect which reduces the number of viable microorganisms in the cavity floor and thus decreases pulpal irritation.

Important: Cements used for bases should be mechanically stronger than when used as luting agents and are mixed with the maximum powder content that is possible. A low powder-to-lIquld ratio produces a low viscosity cement that Is needed for luting agents.

OPERATIVE

BILle

The selection of a base to be used under a permanent restoration is governed by:

• The design of the cavity

• The type of permanent restorative material used

• The proximity of the pulp in relation to the cavity wall

• All of the above



The most important consideration for pulp protection in restorative techniques is the thlcknan of the remaining dentin.

In general, cements that are thicker than 2 mm are tenned bases and as such function to replace lost dentin structure beneath restorations. A base may be used to provide thennal protection under metallic restorations, to increase the resistance to the forces of condensation of amalgam, or to block out undercuts when taking impressions for cast restorations.

Important A base should not be used unnecessarily.

Ramamber: Calcium hydroxide is very effective in promoting the fonnation of secondary dentin, which is an important aid in the repair of the pulp.

-The only distinction between a base, a cement, and a cavity liner is their final application thickness.

1. Cements for luting have a desired final film thickness of 15 to 25 microns.

2. Cavity line... (either solution or suspension liners) have a desired final film thickness of 5 microns.

3. Baa .. have a final application thickness of 1-2 mm (they may be thicker depending on the amount of dentin that has been destroyed).

Note: The selection of appropriate bases and liners to restore the axial wall of a Class II restorations dependent upon the biological effect required and the thickness of tha remainIng dentin.

OPERATIVE

Bases are materials that function:

• As barriers against pulpally irritating agents

• To provide thermal insulation below a restoration

• To provide adequate resistance to the compressive forces of mastication



BILle

- All of the above

*** Ba ... in essence serve as a replacement or substitute for the protective dentin that has been destroyed by caries and I or cavity preparation.

Materials that have been employed as bases:

- Zinc phosphate cement -+ remember to seal dentinal tubules with vamish prior to application

- Zinc polycarboxylate cement -+ provides adhesion

-ZOE

• Glass ionomer cement -+ provides fluoride release and adhesion

• "Hard setting" calcium hydroxide materials -+ thicker than when used as a liner ***Baaea are typically 1-2 mm thick

Remember: All of the above are suitable as a base under amalgam restorations, however, for composites, ZOE cannot be used because the eugenol will inhibit the composite setting reaction.

Baaes are classified as either primary or secondary:

• Primary bases are placed on the dentin in close proximity to the pulp primarily to provide protection from toxic and thermal irritants. Under amalgam and tooth-colored restorations, the primary base is usually calcium hydroxide, whereas, under gold restorations, the primary base is usually zinc phosphate cement or zinc polycarboxylate cement. Glass ionomers are commonly used today as well.

• The most common use of a .. conary ba .. is the placement of zinc phosphate cement over a calcium hydroxide base which has been placed over a pulpal exposure (dil8Ct pulp cap).

Nota: A primary base is not needed under zinc polycarboxylate cements that are used to base to ideal form since these cements are non-irrltatlng to the pulp.

OPERATIVE

BILle

Cavity liners are used to:

• Help retain the restorative material

• Protect the pulp

• Add strength to the restorative material

• Decrease the setting expansion of amalgam

COpyright © 2004 - DENTAL DECKS

• Protect the pulp

Cavity liners are materials that are placed as thin coatings over exposed dentin. Their main purpose is to protect the pulp by creating a barrier between the dentin and pulpally irritating agents (i.e., acids from etchants or cements, restorative materials, etc.) by .eallng the dentinal tubules.

Cavtty liners are usually classified into two main groups:

1. The typical cavity vamlsh (also called solution liner) is principally a natural gum, such as copal, rosin, or a synthetic resin dissolved in an organic solvent such as acetone, chlorofonn, or an ether. Copallte is the most commonly used.

2. The typical auapenalon liner is a liquid in which calcium hydroxide, and occasionally zinc oxide, is suspended in a solution of natural or synthetic resins. Dycal (calc/um hydroxide) is most commonly used.

Notes:

1. Suspension lin .... are thicker (15 microns) than solution liners (1 w5 microns).

2. Solution liners (Copafite) have been shown to reduce the Initial mlcroJeakage of a restoraw tion. Important: This type of liner should not be used under a composite, they will Inhibit the polymerization of the resin.

*""These liners (both solution and suspension) are being replaced by the new dentin bonding agents. Remember: Zinc phosphate cement may also be used 8S a liner when 8 particularly strong one is needed. It should always be preceded by at least two coats of cavity varnish to prevent pulpal irritation. When using polycarboxylate cement as a liner, this is not necessary since this cement is non-irritating to the pulp -+ apply varnish after placing the polycarboxylate cement liner.

OPERATIVE

BILle

V\lhich cavity lining agent does not provide thermal protection?

• Calcium hydroxide

• Zinc oxide eugenol

• Copalite



• Copallte

The three most commonly used cavity lining agents are:

1. Cavity varnish (solution liner) -+ seals dentinal tubules without adding bulk

• Reduces marginal leakage -+ improves the marginal seal for the short term

• Helps prevent penetration of acid

• Protects pulpal tissue from the phosphoric acid in zinc phosphate cements

• Prevents mercury penetration into the dentinal tubules from amalgam restorations -+ pre-

vents discoloration of dentin

Note: Cavity varnish does not act as a thermal barrier. It should not be used with composite restorations since in will inhibit polymerization.

2. ZInc oxide eugenol (suspension liner)

• Prevents penetration of acids

• Prevents thermal shock

• Has adequate strength so that it can be used under permanent restorations

Note: ZOE is a particularly good liner due to the fact that it is palliative (soothing) to the pulp. Commonly used for temporary fillings.

3. Calcium hydroxide (suspension liner)

• Prevents thermal shOCk

• Prevents passage of acid from restorative materials

• Has enough strength to resist forces used in placing restorations

Note: Calcium hydroxide has the ability to stimulate the formation of secondary dentin when placed near or in direct contact with the pulp. Also, when viewed radiographically, calcium hydroxide can be easily confused with caries -+ both are radiolucent.

OPERATIVE

Caries

Zone II of carious dentin is also referred to as: • Normal dentin

- Sub-transparent dentin

- Transparent dentin

- Turbid dentin

-Infected dentin

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• Sub.transparent dentin

Zones of carious dentin --+ from innermost to outermost:

• Zone 1 (normal dentin) --+ totally normal dentin with no bacteria in the tubules.

• Zone 2 (sub-transparent dentin) --+ zone of demineralization created by the acid from caries. Damage to the odontoblastic process is evident, however, no bacteria are found in this zone. Capable of remlnerallzatlon.

• Zone 3 (transparent dentin) --+ softer than normal dentin, shows further demineralization. No bacteria are present. Capable of remlnerallzatlon.

• Zone 4 (turbid dentin) --+ is the zone of bacterial Invasion , tubules are filled with bacteria. Zone is not capable of remlnerallzatlon and must be removed prior to restoretion.

• Zone 5 (infected dentin) -+ the outermost zone, consists of decomposed dentin that is filled with bacteria. Must be totally removed prior to restoration.

Four zones of an Incipient lesion In enamel:

1. Translucent zone --+ the deepest zone, represents the advancing front of the ensmel lesion.

2.The dark zone --+ does not transmit polarized light. Areas of demineralization and reminerallzation.

3.The body of the lesion --+ the largest portion of the incipient lesion. Area ofdemineralizatlDn.

4.The surface zone --+ relatively unaffected by the caries attack.

OPERATIVE

Caries

Caries that is often found in older patients and attacks the cementum and radicular (root) dentin is called?

• Residual caries

• Secondary (recurrent) caries

• Root surface (senile) caries

• None of the above


• Root surface (senile) carles

-Root surface caries are sometimes referred to as senile carles.

The rising incidence of root surface caries can be attributed to the aging of populations and the fact that most adults are retaining more teeth. In this population, there is Increased gingival recession with exposure of root surfaces, leading to the development of root surface caries. Root surface carles generally spreads more on the surface, rather than in depth. In older patients, rampant caries can be caused by poor oral hygiene, decreased salivary flow, and side effects of medications.

Notes:

1. Residual carles is caries that remain in a completed cavity preparation, whether by dentist intention or by accident.

2. Secondary (recurrent) carles is decay appearing at the margins of a restoration and under it.

3. The etiology of root surface carles is now-a-days believed to be the same as for coronal caries -+ S. mutans, S. sanguis, A. viscosus, A. naeslundii, Lactobacillus, and Veillonella.

OPERATIVE

Caries

Acute caries is characterized by all of the following, except:

• Most frequently found in children

• Often multiple, soft-to-the.-touch lesions

• Slowly progressing

• Little or no staining

CopyrIght e 2004 - DENTAL DECKS

• Slowly progressing

""Acute caries, which is sometimes referred to as rampant carlee, is characterized by prog. resslng rapidly.

Other characteristics of acute cari .. :

• The entrance to the lesion is small

• The lesion is deep and narrow (large lesion)

• Pain may be a feature

Chronic caries is sometimes referred to as slow or arrested caries. It is characterized by:

• Common in adults • Oaric pigmentation with leathery dentin

• Progresses slowly • The lesion is shallow (small/asion)

• The entrance to the lesion is wide - Pain is uncommon

-"Chronic caries should be completely removed when found in enamel and close to the

OEJ.

Note: Changes of the pulp and dentin depend on the rate of the carious progression. The response of the pulp to carious attack or the trauma of operative procedures depends on the blood supply of the pulp and its cellular activity.

Defense mechanisms of the pulp (to protect it from irritation):

- Sclerotic dentin (peritubulaf dentin formation) ~ initial defense

- Reparative dentin (irritation dentin formation) ~ second line of defense

- Its vascularity (innsmmation)

OPERATIVE

Caries

The most susceptible area of a tooth for the retention of dental plaque is:

• The cusp tips

• The proximal surfaces

• The developmental pits and fissures

• The buccal and lingual surfaces

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• The developmental pitt and fissures

Pit and fissure caries has the highest prevalence of all dental caries. Smooth surface areas, especially the proximal enamel surfaces immediately gingival to the contact area are the second most susceptible areas to caries. Streptococci and lactobacilli species are common in this area. The facial and lingual root surfaces may have plaque containing filamentous actinomyces species which can cause root surface caries.

Flourlde treabnenta will dramatically reduce smooth surface carles though they are not as effective in preventing pit and fissure caries. Sealing the pits and fissures just after tooth eruption may be the single most important procedure to help protect these areas from caries destruction.

Remember: Dental caries is Inltlatad at the tooth surface as a result of the growth of streptococci, specifically S. mutans, S. mitis, S. sanguis (which is the most frequently isolated Streptococcus in the oral cavity), and S. salivarius. These bacteria produce dextran sucrase (also called glucosy/transferase), which catalyzes the formation of extracellular glucans from dietary sucrose. Glucan production contributes to the formation of dental plaque. This dental plaque holds the lactic acid which is produced by these Streptococci against the tooth. This acid eats through the enamel of the tooth, creating caries.

Important: Predominant bacteria found In dental plaque:

• Streptococcus sanguis (found the earliest)

• Actinomyces viscosus and naeslundii

• Streptococcus mutans, mitis, and salivarius

• Veillonella, LactObacilli, and Fusobacterium

OPERATIVE

Caries

V\lhich of the following Is not an essential factor needed for the initiation of a carious lesion?

• Susceptible host (tooth)

• MicrotJora with cariogenic potential (plaque)

• Saliva

• Suitable substrate (dietary carbohydrates)


• Saliva

Dental carles is an infectious microbiological disease that results in the localized dissolution of tooth structure. For caries to occur, a susceptible host (a tooth), microflora with cariogenic petential (plaque), and a suitable substrate (dietary carbohydrates), all interact to promote the seven. ty of the disease.

The greatest percentage of tooth loss in the first two decades of life (except from the natural loss of deciduous teeth) is due to untreated dental carles. The rate at which the carious destruction of dentin progresses tends to be slower in older adults than in young persons due to generalized dentinal ,cleroels which occurs with aging.

Notes:

1. Flouride and occlusal sealants modify the susceptible host (tooth).

2. Saliva helps prevent carles by diluting acid and acting as a reservoir for Ca, PO .. , fluoride and other ions for remineraJization and hypermineralization of the enamel. It also affects caries through its antimicrobial properties.

3. Enamel demineralization occurs at pH 5.5. Remlnerallzatlon of the damaged tooth structure occurs as the pH rises above 5.5.

4. The prevalence of cartn has been dedining in children. A decline in adult caries is not as evident. Fluoridation has received the most credit for the dedine in the development of caries.

5. Pregnant patients, compared with similar non-pregnant patients, are likely to have the same degree of dental caries, but more inflamed gingival tissues.

OPERATIVE

Caries

There is abundant evidence that the Initiation of dental carles requires a high proportion of:

• Staphylococcus au reus within saliva

• Streptococcus mutans within dental plaque

• Streptococcus mutans within food

• Staphylococcus aureus within dental plaque


• Streptococcus mutl.,. within dental plaque

The first event in the development of caries is the deposit of plaque on the teeth. Dental plaque Is a highly organized gelatinous mass of bacteria that adheres to the tooth surface. Streptococcus m .... .,. pr0.duce great amounts of lactic acid (acicIogenic), are tolerant of acidic environments (aciduric), are vigorously stimulated by sucrose, and appear to be the prima" organlaml associated with dental caries however, they are not the only organisms required for caries initiation. Other mutans streptococci species in humans can do this as well (for example, S. sobrlnus).

Factors to which the tooth surface Is directly exposed, and which contribute to the development of dental caries:

FACTOR HIGH RISK
AmoI.Int of plaque large amount of plaque on teeth, meaning many bacteria
that can produce acids Oow DH demineralization)
Type Of b8cteI1a urge proportion Of canogenic" types or Daclelia, reSUlting In
loWer pH and sticky plaque and also prolonged acid production
Type of diet High in car:oonyorates, in particular sucrose; "StICky' diet laading
to low pH for a longer lime
Frequency of carbohydrates High sugar frequency resulting in longer lime per day with low pH
Saliva secretion Reduced saliva flow leadl~ to prolorlged sugar clearance lime
and to a reduced amount other saliva protective systems
Saliva bu1l'er capacity low bufl'er capacity resulting in prolonged tima with low pH
Flourides Absent: reduced reminerallzatkm OPERATIVE

Caries

All of the following are true concerning dental caries, except:

• Dental caries is an infectious microbiological disease of the teeth that results in localize dissolution and destruction of the calcified tissues

• The evidence for the role of bacteria in the genesis of dental caries is overwhelming

• Streptococcus sanguis is considered to be a principal etiological agent in dental caries

• Organisms which cause caries are called "cariogenic·

• Lactic acid produced by acidogenic bacteria is the main cause of enamel decalcification


• Streptococcus sanguis Is considered to be a principal etiological agent In dental carin

.... A1though S. sanguis is etiologically related to dental caries, It Is not considered to be a principal etiological agent in dental caries.

Carlopnic Bactarla

• Mu1aos streptococci, of which Streptococcus mutans and Streptococcus sobrinus are the two most

commonly found in man.

• Lactobacilli casel

Nota: Most current research suggests that the microbial etiology of root caries is very similar to c0ronal caries ~ in the past it was thought that Actinomyces species (viscosus and naeslundii) were most commonly associated with root surface caries.

Eu'nUal Propertjta of Cadog.nlc Bacteria

• Acidog.nlc (produce acid) and aciduric (being able to tolerate an acid environment)

-Note: lactic acid is formed in large quantities following the degradation of sucrose by mutBns streptocOCCi.

• The ability to attach to the tooth surface. Nota: Streptococci species have special receptors for adhesion to the surface and also produce a sticky matrix that aUows them to cohere to each other.

• The ability to fonn a protective matrix. Nota: Streptococci species produce an extracellular insoluble dextran, which protects them from being removed from the teeth by saliva, liquids, foods, and masticato'Y forces. Remember: Glucans occur as dextrans or mu1ane. They are synthesized from sucrose by plaque bacteria as extracellular polymers of glucose. L.evans are polymers of fructose.

Dental plaque describes the soft white film of organized bacterial colonies (main component), salivary glycoproteins, and inorganic material that readily forms on the surface of teeth. Note: The strong correlation between the pre .. nce of dental plaque and the appearance of dental carin and periodontal disea .. has been recognized for many yea".

OPERATIVE

Comp

V\lhich of the following are advantages of the visible light curing systems compared to the old ultraviolet light curing systems?

• A greater depth of resin can be cured by visible light

• The resin can be polymerized through enamel, which is particularly advantageous in Class III restorations

• The intensity of visible lights remains relatively constant until the bulb fails completely




Visible light curing systems have totally displaced the UV light systems. Also, visible light curing systems are much more widely used than the chemically activated ones (self cured). An advantage of light curing systems as a whole is that the dentist has complete control over the working lime and is not confined to the built-in curing cycle of the selfcure. This is particularly beneficial when large restorations are placed.

Note: To deal with problems of incomplete curing with VlC due to the thickness of restorations and filler particles scattering light, manufacturers have developed composite resins that are dual-cured which combines self-curing and visible light-curing. Another polymerization method is staged curing which is a two-staged cure. However, VLC composites are still the most popular today.

Remember: Visible light cured composites are single component pastes, and the polymerization process is adlvated by an external energy source. The alpha-dlketone Initiator (generally camphor quinone) absorbs energy from a visible (470 nm - blue light) light source. The ketone absorbs energy and reacts with an amine (added to the system to enhance the effect of the light-sensitive catalyst) to produce free radicals.

OPERATIVE

Comp

VVhich of the following statements are true conceming posterior composite restorations?

• Posterior composite restorations are frequently Indicated in the treatment of occlusal lesions which allow censervatlve preparations

• Posterior composite restorations are contraindicated in a patient with heavy occlusion (bruxism)

• Posterior composite restorations may be Indicated for the restoration of Class II cavities in premolar teeth where the appearance is very important, the cavity margins are in the enamel, and the occlusal contacts are on the enamel

• All of the above statements are true

Copyrtght e 2004 - DENTAL DECKS

• All of the above slatementB are tRle

Although the ADA does not endorse composite resins as a substitute for amalgam in posterior teeth, composite restorations can be excellent If strict guidelines are followed for tooth selection and if the restorations are done properly. But remember, composite resin .... loradon. are inferior to amalgam in terms of compressive strength and abrasion resistance (occlusal wear). Also, current composite resins have no capability to provide an anticariogenic effect as do freshly placed glass ionomer or resin modified glass ionomers, for example.

The most serious limitation of the visible light-cured posterior composite restoration is the polymerization shrinkage, which can cause internal stresses and gap fonnations at butt-joint interfaces, which are seen at the gingival ftoor of Class II and V restorations.

Note: The major Indication for the use of posterior composites is the demand for esthetics by the dentist and patient. Other criteria are noninvolvement of cusps, minimal occlusal contact, no excessive wear, and the isthmus must be no wider than one-third of the intercuspal distance.

Remember: Composite is the material of choice if the patient has a documented allergy to mercury.

Important: In the past, posterior composite restorations were contraindicated in a patient with a caries-active mouth. New concepts stress that you should manage the disease (i.e., dental caries) before or at the same time as you are treating the consequence of the disease (i.e., by placing restorationS). Therefore, the current literature does not see a special problem for these restorations in caries-active patients. They have as bad a prognOSis as any other restorative treatment if the disease is not managed simultaneously.

OPERATIVE

Comp

Vllhich property of filled resins is primarily to blame for the failure of Class II composite restorations?

• Low flexural strength

• Low compressive strength

• Low tensile strength

• Low wear resistance

Coovrioht e 2004 _ n~IIITAI n~('I(<<:l

• Low wear .... I.tanee

Ideally, composite resins should be used only to restore minimal cavltle. In poaterlor teeth. Its use should be restricted to those instances where it will not be subjected to excessive occlusal forces and where, when teeth are in occlusion, there is cusp-to-cusp contact and not cusp to restoration.

For Cia •• III preparations using resins, the rule of extension for prevention into embrasures is disregarded for Class III esthetic restorations. This compromise is for esthetic reasons, as well as the unnecessary removal of tooth structure which will often involve the incisal edge. If possible, the outline form should place the gingival margin incisally from the crest of the gingiva.

VVhen placing the composite resin in a Cia •• III preparation, the wooden wedge is placed in order to provide some separation of the teeth (for contact), to stabilize the mylar strip, and to avoid creation of excess gingival flash. Important Restoring the contact area must be done property and diligently.

Remember: For Class III composite preparations the retentive grooves are placed along the glnglvo-axlal and Inc!eo-axlal line angles (entil'9ly in dentin). These grooves will provide for mechanical lock in the preparation. Small, rounded retentive areas are preferred, as contrasted to sharp angles, since It is difficult to insert viscous composite material into the sharp angles.

Note: Once proper finishing has been completed, a thin layer of unfilled resin can be applied as a glaze (this seals the margins and smooths the surface). The difficulty in finishing composite resin restorations is due primarily to the softness of the resin matrix and hardness of the filler particles. The most desirable finished surface for composites is obtained with aluminum oxide disks.

OPERATIVE

Comp

Small size filler particles in composite resins:

• Results in a composite resin that has beHer finishing characteristics but a lesser resistance to wear

• Results in a composite resin that has a greater resistance to wear but doesn't finish well

• Results in a composite resin that has beHer finishing characteristics and a greater resistance to wear

• Results in a composite resin that has a lesser resistance to wear and also doesn't finish well

COpyright it' 2004 - DENTAL DECKS

• Resulta In a composite resin that has better finishing characteristic. and a greater

resistance to wear

The first composite resins that were developed contained large filler particles (10-100 microns in diameter) and became known as macroflll materials. However, large .Ize filler particles reduce the degree of surface smoothness that can be achieved and also reduce the resistance to wear. In response to this problem. manufacturers have produced and continue to produce smaller and smaller particles that result In better finishing characteristic. and a greater resl.tance to wear. Note: The newer microfilled and hybrid resins are about 40-60% filler by weight as compared to 70- 80% filler that is characteristic of the macrofill materials.

Claulflcatlon of ComPQIital

1. Based on fU.Im particle size (diameter in microns)

• MIIcrofill (traditional composites) -+ 10-100

• Mldifill (small partic18 composites) -+ 1-10

• Minlflll -+ 0.1-1

• Microflll (fine particle composites) -+ 0.01..Q.1 ***develop smoothe.t finish

• Hybrid -+ mixture of particles, usually midifill or minifill with microfill

2. Based on polymertzaUon method

Composite resins are dimethaaylate monomers and polymerize by the eddition mechanism that is initiated by free radicals. These free radicals can be generated by chemical activation or external energy (heat, light).

• Chemically activated (self-cured) -+ two paste system, one contains the benzoyl peroxide initiator, the other a tertiary amine activator.

• Light-actlvated -+ visible light has replaced UV light One paste system which contains a photolnltlator molecu Ie (generally camphor quinone) and an amine activator.

OPERATIVE

Composite filler particles function to do all of the following, except: - Increase the coefficient of thermal expansion

-Increase the tensile strength and compressive strength

- Reduce the polymerization shrinkage

-Increase the hardness

- Improve the wear resistance

Comp

Incre ... the coefficient of thennal expansion

*"'*This Is fa ... ; fillers reduce the coefficient of thermal expansion.

Remember: As the overall filler content increases, the physical, chemical, and mechanical properties generally improve. Obviously, there is a limit to the amount of filler that can be added to a resin because as the filler level is Increased, the fluidity decreases. Note: Restorative composites have a high filler content while flowable composites have a low filler content.

ComposlUQn of Co"",,"",s (filled resins.1

• Filler particles ~ colloidal silica, crystalline silica (quartz) or silicate glasses (non-aystBlIine)

• Mabix ~ difunctional monomers BIS-GMA or recently UDM (urethane dimethacrylate). Both of these monomers are diluted with another difunctional monomer TEGDMA to reduce the viscosity.

• Coupling agent ~ silane which acts as an adhesive between the inert filler and the organic

matrix.

--Recently, ions have been added to the filler to produce desirable physical changes. Lithium and aluminum ions make the glass easier to crush to generate small partides. Barium, zinc, boron, zirconium, and yttrium ions produce radiopacity in the filler particle.

Notas:

1.The normal wear mechanism of the composite resins is best explained by the following events: abrasion of the matrix, followed by exposure of filler particles and subsequent dislodgement of these filler particleS.

2. Wth any of the restorative resins, cavity varnish or zinc oxide eugenol should not be used as they might Inhibit polymerization. The use of a cavity vamish might prevent direct contact between the composite and the tooth structure, preventing bonding.

OPERATIVE

Comp

VVhen comparing the physical properties of filled resins to unfilled resins, all of the following are true, except:

• Filled resins are harder

• Unfilled resins have a lower coefficient of thermal expansion

• Filled resins have a higher compressive strength

• Unfilled resins have a lower modulus of elasticity

• Filled resins have a higher tensile strength

• Unfilled resina have a lower coefficient of the"".1 expansion

-Th18 Is false; unfilled resins have a higher coefficient of thermal expansion.

The most common classification method for composite resins is based on filler content, filler particle size, and the method of filler addition. Almost all Important properties of composite resins are Improved by using higher filler levels. However, as the filler level is increased, the fluidity decreases.

Highly filled resina typically contain large filler particleS but this composition results In a rough finished surface. Smaller ftller particles are used to produce a resin that has a relatively smooth ftnlshed surface.

Resin filler particles are called:

• Macronlle ... -+ 10-100 microns in diameter

• Mldlflilers -+ 1-10 microns in diameter

• Mlnlflilers -+ 0.1-1 micron in diameter

• Microfillers -+ 0.01-0.1 micron in diameter

"*Hybrid resina contain a mixture of particles with different diameters which allows higher filler levels and still permits good finishing. The principal particle size is in the 0.1 to 1 micron range.

Note: Hybrid and mlcroflll resins utilize colloidal silica fllle ... which are useful for increasing the hardness and wear resistance of the base resin material while maintaining high polishability and overall esthetic qualities.

-New resins with nanoftllers that range in size from .005 to 0.01 miaon are in the process of being developed. These particles are so small that very high filler levels can be achieved while still maintaining workable consistencies.

OPERATIVE

Comp

Today the most popular way to polymerize matrix monomers is:

• Self~cured

• Chemically cured

• Ultraviolet Ught-cured

• Visible light~cured

Copyright II:) 2004 - DENTAL DECKS

• Visible IIght-cured

Important points to remember when using a visible light~curing unit:

• Hold the light as close to the resin as possible ~ within 2 mm to be effective.

• Place a shield between the light tip and the operator's eyes. Patients who have had recent cataract removal should have protection also. Note: Studies have shown that the visible light used in polymerization of phot~activated materials can cause retinal damage ~ always use a shield and eyeglasses for protection.

• For deep restorations, you have to cure the composite in increments ~ if you don't, the deeper areas will not be cured.

• Make sure the bulb In the light is still powerful enough ~ they have commercially available products to test the bUlb.

• WIth darker resin shades. cure a little longer.

Remember:

• For large restorations (those that are wider than the diameter of the light tip),cure each area for the full required time. Do not back off light tip until it lights up entire surface of restoration.

• VIsible Jlght-curlng involves light energy in the range of 410-500 nm with a peak intensity of about 470 nm.

OPERATIVE

Comp

Filled resins (composite rosins):

• Are harder and stronger than unfilled resins

• Have a lower coefficient of thermal expansion than unfined resins

• Are more resistant to abrasion than unfilled resins




The first materials that were used as esthetic materials were based on silicate cements. Due to solubility problems the silicate cements were replaced by unfilled acrylic resins. Unfilled acrylic resins contracted excessively during polymerization permitting subsequent marginal leakage and were not strong enough to support occlusal loads.

These unfilled aaylic resins have been replaced by filled resins (also called composite resins). A filled resin is one in which an Inorganic Inert filler (usually silica orquartz) has been added to the resin matrix.

Most of the present composite resins are based on BIS-GMA as the primary monomer. BIS-GMA is a difunctional monomer. Another very similar difunctional monomer, UDMA (urethane dimethacrylate) is also used. Because BIS-GMA and UDMA are both very viscous, they are diluled with another difunctional monomer, TEGDMA, to reduce the overall viscosity.

Important: The high filler content and the BIS-GMA resin matrix drastically reduce the coefficient of thermal expansion (as compared to the unfilled acrylic resins). The filler also reduces polymerization shrinkage and increases hardness.

OPERATIVE

Comp

Unfilled resin (acrylic) temporaries fabricated for inlays and onlays should have which of the following properties?

• Restore and maintain proximal contacts

• Restore and maintain the occlusion

• Restore and maintain tooth contours

• The margins should be closed and flush with the tooth




-*Most Importantly. methyl methaaylate maintains the occlusal and Interproximal contact relationships.

For both inlays and onlays, plastic (acrylic) provisional restorations are fabricated prior to the final restoration being cemented. Their physical properties enable them to withstand occlusal forces and the adverse oral environment for short periods of time.

Methyl methacrylate, ethyl methaaylate, and ethylene imine resins have been employed to produce provisional restorations. However, methyl methacrylate (MMA) is by far the most common. It is the liquid monomer that is mixed with the polymer polymethyl methacrylate (the powderj. The monomer partially dissolves the polymer to form a plastic dough. Note: The monomer Is polymerized by the action of an Initiator (benzoyl peroxide).

Remember: Polymerization should not go to completion in the mouth for fear that the provisional will not be able to be removed from the tooth. These provisionals are usually cemented in with a ZOE cement.

The main disadvantages to using methyl methacrylate as a permanent restorative material are its low resistance to abrasion and a high coefficient of thennal expansion.

OPERATIVE

Comp

\Nhich restorative material has the lowest thermal conductivity and dlffuslvlty? -Amalgam

- Gold

- Unfilled resin

- Filled resin

Copyright It> 2004 - DENTAL DECKS

• Unfilled resin

This characteristic probably offsets to some degree the undesirable effects of the relatively high coefficient of thermal expansion, which is 7 to 8 times that of the tooth. Due to this low thermal conductivity and diffusivity, the unfilled resin restoration changes temperature quite slowly. Therefore, it takes considerably longer for the unfilled resin restoration to become hot or cold, as compared to metallic restorations, which have a high thermal conductivity and diffusivity.

Notes:

1. The compressive strength of the unfilled resin is low; the yield strength and tensile strength are even lower.

2. Unfilled resins are the softest of all restorative materials.

3. Compared with amalgam, filled resin, direct gold and silicates; unfilled resins show the greatest extent of marginal leakage related to temperature change.

Remember: A low coefficient of thennal conductivity is most characteristic of currently available cement bases.

OPERATIVE

Comp

A properly acld-etched enamel surface appears:

• Somewhat yellow in color

• Identical to unetched enamel

• Dull white and chalky

• Slightly gray with a shine

Copyr1ght e 2004 - DENTAL DECKS

Dull white and chalky

One of the most effective ways of Improving the marginal seal and mechanical bonding of composite resins to tooth structure Is to condition or pretreat the enamel with acid prior to insertion of the resin. This procedure is referred to as "acld-etch" technique.

The acid cleanses the surface of debris left after cavity preparation, thus providing an opportunity for better wetting of the enamel by the resin. Even more important though, is that a selective dissolution of the enamel occurs during etching. Wlile enamel is normally porous, the acid removes calcium salts, increasing both the size and number of microspaces present. This "acld-etch technique" conserves tooth structure, reduces microleakage, improves esthetics, and provides micro-mechanical retention.

Note: Studies indicate that acid-etched composite resin restorations have the best Initial seal (mk:ro/eakage), however, over time this weakens (amalgam has the best seal overtime).

OPERATIVE

Enamel is etched with:

• Boric acid

• Phosphoric acid

• Acetic acid

• Nitric acid

Comp

COpyrIght 10 2004 - DENTAL DECKS

• Phosphoric acid

Teeth are normally treated with a 37% solution of phosphoric acid to roughen the surface of the enamel. This forms little tags approximately 10-25 micrometers in length, providing mechanical retention. Enamel rods are most effectively etched at the enamel rod ends. V\lhen using the acid etch technique all enamel cavosurface margins should be chamfered (this process forms obtuse angles). This chamfer or bevel affords more . surface area for etching to enhance the seal and retention (reduces microleakage). Also, this bevel improves esthetics and exposes enamel rod ends for acid attack.

Remember: Once you etch the tooth, it cannot be contaminated with saliva. If it does, you must complete the entire etching procedure again.

OPERATIVE

Comp

The outlIne tonn of a Class V composite preparation resembles that of a Class Vamalgam preparation except for what important feature?

• No retentive grooves are necessary

• The intemalline angles are much more rounded

• Pulp protection is not required

• None of the above

COevnaht e 2004 - DENTAL. DECKS

• The Internal line angles are much more rounded

"*VVhen restoring teeth with composite resin, it is much easier to compress the material into rounded line angles.

The outline form of a Class V restoration is not always uniform, as it win vary depending on the location and amount of caries or decalcification -+ the size and location of the carious lesion determines the outline form of the cavity preparation. When the carious tissue has been removed and the margins are on reliable enamel or dentin, the outline win usually be rectangular with the corners round, ovoid, or kidney-shaped, very much resembling the amalgam Class V preparation except that the intemal line angles are much more rounded.

The cavosurface margin is chamfered wherever it is placed on enamel -+ this is a major difference between composite and amalgam preps. This chamfer is etched and provides retention for the restorative material as well as Improving the marginal seal and maintaining the strength of the resin with sufficient bulk. Retentive grooves supplement the etched enamel retention (these grooves are placed in both incisal and gingival axial line angles).

Whenever poSSible, use a composite syringe to place the composite resin in the restoration, this wil1 minimize the possibility of trapping air in the final restoration.

OPERATIVE

Comp

VVhich component of a dentin bonding system functions primarily to remove the smear layer of the dentin?

- Etchant

- Conditioner

- Primer

-Adhesive


• Conditioner

Dentin bonding systems are complex and multi-step systems. The etchant is used to roughen the surface of the enamel which helps to provide mechanical retention. Once the enamel is etched, a dentin conditioner is then used. Typically these conditioners remove the smear layer and etch the intertubular dentin. This produces microspaces within the dentinal surface.

Following conditioning, the primer is applied. This wetting agent provides micromechanical and chemical bonding to the microspaces created by the conditioner.

Finally, the unfilled resin adhesive (which is also known as a bonding agent) is applied. The resin is then cured (light-, self-, ordua/-cured). This layer can now bond to composite or amalgam.

Note: third generation dentin bonding agents are capable of generating bond strengths almost comparable to that of resin to etched enamel. These depend on dlfunctlonal coupling agents being able to bond to either the inorganic or the organic components in dentin.

OPERATIVE

With respect to onlay preparations, "shoeing" of a functional cusp is:

• Sometimes indicated

• Atways indicated

• Never indicated


Gold

• Never indicated

***Important: "Shoeing" is never Indicated on functional cusps.

Onlay preparations:

• Resistance form ~ two types of cuspal protection

1. "Cap" ~ refers to the complete coverage of the cusp.

2. "Shoe" ~ refers to the minimal or partial coverage of the cusp by means of a finishing bevel on the crest of the cusp.

Except in situations demanding a minimal display of gold (primarily the facial cusps of maxillary molars and premo/ars), capping is always preferred over shoeing.

OPERATIVE

Gold

Rapid cooling by immersion in water, of a dental casting from the high temperature at which it has been shaped is referred to as:

• Annealing

-Tempering

- Quenching

- None of the above


• Quenching

This usually is undertaken to maintain mechanical properties associated with a crystalline structure or phase distribution that would be lost upon slow cooling.

Two advantages gained in quenching:

1. The noble metal alloy is left in an annealed condition for bumishing, polishing, and sim liar procedures -+ it maintains its malleability and ductility.

2. \Ntien the water contacts the hot investment, a violent reaction ensues. The investment becomes soft and granular, and the casting is more easily cleaned.

Remember: Annealing is the softening of a metal by controlled heating and cooling to make its manipulation easier. It makes the metal tougher and less brittle.

OPERATIVE

Gold

All of the following are advantages or Indications for a Class II gold inlay, except:

• The desire for permanency

• A low caries index

• Less expensive

• Moderate size lesions with conservative outlines


• Less expensive

Other advantages or Indications for a Class II gold inlay:

• Esthetics -+ posteriorly where amalgam staining is to be avoided

• Tooth contours -+ where optimum contour and surface finish is desired to maintain periodontal health

• Rest seat retainers on abutment teeth

Disadvantages and contralndlcatlons for a Class II gold inlay:

• Expense -+ gold is 6 to 7 times more expensive than amalgam

• Time -+ at least two visits is necessary

• Minimal lesions -+ best restored with gold foil

• Large lesions -+ if cavity width exceeds one-third the intercuspal width, the tooth should receive cuspal coverage

OPERATIVE

Gold

Surrounding the wax pattem with a material which can accurately duplicate its shape and anatomical features is referred to as:

.Investing

• Burnout

• Casting

• Pickling


-Investing

Gypsum bonded investments are used with Type I,ll, and III gold alloys. Gold alloys used for cast gold restorations shrink upon solldification. Therefore, it is necessary to compensate for the solidification shrinkage of the specific alloy used by expanding the mold enough to equal the shrinkage.

The dimensional compensation necessary is accomplished by two methods of expansion:

1. Setting expansion --+ occurs as a result of normal crystal growth but can be enhanced by allowing the investment to set in the presence of water, producing hygroscopic expansion.

2. Thermal expansion --+ is achieved through the normal expansion that occurs upon heating the silica (quartz or cristobalite). Note: The amount of expansion depends on the particular refractory material used (cristobalile produces grealerexpansion than does quarlz). **"Thermal expansion is the principal cause for mold expansion.

Variables that influence expansion:

- The older the investment is --+ the less it will expand

- If the water I powder ratio is increased --+ the expansion is reduced

- The longer the spatulation time --+ the greater the expansion

• The longer the time between mixing and immersion in a water bath --+ the less it will expand

Note: During solidification of an alloy, the number of grains forming depends on the rate of cooling and the presence of nucleating agents.

OPERATIVE

Gold

A diagonal cut across the cavosurface margin that is flat in one dimension only and curved in its other dimensions is called a:

• Plane

• Bevel

• Chamfer


• Bevel

Cavosurface angle configurations that are used when preparing a tooth for a cast gold restoration:

• A bevel is a diagonal cut across the cavosurface margin which is nat In one dimension only and curved in its other dimensions. It involves the extemal ends of enamel prisms and follows a continuous curved outline. It can be either a short bevel which cuts only the external one-third of the enamel prisms, a full bevel Involving the entire thickness of enamel, or a wide bevel involving not only enamel but some dentin as well.

• A plane is a diagonal cut across the cavosurface margin which is flat In all dimensions. A plane may Involve the entire thickness of enamel (which it usually does) or most of it but cannot be cUlVed In any direction.

Note: A chamfer is essentially a hollow ground bevel. Instead of a flat diagonal cut across the cavosurface margin, the chamfer is "scooped out" creating more bulk of restorative material near the margin and providing a greater cavosurface angle.

OPERATIVE

Gold

The one characteristic that is common to all Class II gold Inlay preparations is:

• The unifonn depth of the pulpal floor

• The lack of undercuts

• The placement of a base



• The lack of undercuts

***The restoration will not seat if there are undercuts. Actually this holds true for all cast metal restorations.

When designing a Class" preparation for an inlay, an occlusal lock or dovetail should be established to prevent proximal dislodgement. Also, the marginal ridges of posterior teeth that are restored with cast gold should be rounded to help form the occlusal embrasures and be in contact with the cusps of the opposing teeth. Marginal ridges should be the same height as the adjacent tooth's marginal ridge (or else you can CI&ate an interference in retrusive movement).

Note: When removing a Class " inlay, the method of choice is to cut through the Isthmus to remove the occlusal and proximal pieces one at a time.

OPERATIVE

Gold

AU of the following are disadvantages of cast gold restorations, except:

• Esthetics

• Cost

• Time-consuming

• Difficulty of technique

• Gold has a low thermal conductivity

• The need to use cement, which is the weakest point in the cast gold restoration


• Gold has a low thermal conductivity

"·Thls Is false; another disadvantage of gold is that it has a high thermal conductivity.

Advantages of cast gold restorations:

• They are very strong and able to withstand the forces of mastication

• They are ideal for occlusal rehabilitation

• They are kind to the gingival tissue

Important: For maximum retention of cast gold restorations, the axial waUs should be as parallel as possible and as long as possible. Retention is directly proportional to the area of the axial walls and their parallelism. The axial walls should converge slightly from the gingival walls to the pulpal wall.

Note: The cement's main function in a cast gold restoration is to seal the cavity, not for retention. Retention is designed within the preparation and results from friction between the cavity wall and the casting.

OPERATIVE

Gold

All of the following statements concerning the use of base metal casting alloys compared to using noble metal casting alloys for cast restorations are true, except:

• Base metal alloys are harder to cast and finish

• Base metal alloys are less dense

• Base metal alloys are stronger

• Base metal alloys are more resistant to corrosion


• Ba.e metal alloy. are more resistant to corrosion

***This Is false; base metals (also called non-precious metals) are I ... resistant to corrosion. Base metal alloy advantages are principally found only in their strength and low density.

An alloy is a mixture of two or more materials that are mutually soluble in the liquid state. A pure metal solidifies at a constant temperature, whereas alloys solidify through a range of temperature.

Ba .. metal aUoys are based on active metallic elements that corrode, but which develop corrosion resistance via surface oxidation that produces a thin, tightly adherent film, which inhibits further corrosion. Example: Cobalt-chromium alloys form a Cr203 oxide film, which passivates the surface.

Types of alloy .ystems (classified on the basis of the type of structure that fonns as they solidify)

• Solid solution alloys -+ the metals freeze without segregation of the individual constituents.

Note: Are generally used in dentiStry because they have a very homogenous structure and provide maximum strength.

• Eutectic alloy. -+ separate into individual grains of the respective constituents. Exhibit com-

plete liquid solubility but limited solid solubility. Example is the .Ilver-copper .ystem.

Remember: Noble metal. (also called precious metals) are very resistant to corrosion and do not oxidize on casting. Noble systems for dental use are based on the noble or precious metal elements gold, .lIver, palladium, and platinum.

OPERATIVE

Gold

Silver's major effect on a gold casting alloy is:

• Corrosion resistance

• To increase the hardness

• To offset the color contributions of copper

• To elevate the melting range


• To offset the color contributions of copper

Componenl Major Effect on Gold Cullng Alloy
Gold (Au) Corrosion resistance
Copper (eu) Solution hardening, orange color
Silver (Ag) Offsets the color contributions of copper
Zinc (Zn) Scavenger of oxygen during processing
Palladium (Pel) Increases hardness, elevates melting range, strong
whitening effect on the color
Platinum (Pt) Elevates melting range OPERATIVE

Gold

High-goid alloys used for cast restorations are:

• Greater than 20% gold or other noble metals




Copyright © 2004 - DENTAL DeCKS


Four IYPU of Hlgb-Gold Alloys

1. ADA type I -+ highest gold content, 83% noble metals. Intended for small inlays.

Easily bumished due to high ductility.

2. ADA type II -+ greater than 78% noble metals. Intended for larger inlays and onlays.

Can also be burnished.

3. ADA type III -+ greater than 75% noble metals. Intended for on lays and crowns.

Capable of being heat-treated.

4. ADA type IV -+ greater than 75% noble metals. Intended for bridges and removable

partial dentures. Also capable of being heat-treated. Hardest of high-gold alloys.

Medlum-gold alloys are 25-75% gold or other noble metals. Low-gold alloys are less than 25% gold or other noble metals.

Gold substitute alloys are alloys not containing gold. These alloys are called passive because they form some type of protective layer (surface oxide film) that offers maximum resistance to corrosion. Examples Include: Palladium-silver alloys and Cobalt-chromium alloys.

Remember: The karat of a gold alloy is the number of parts that are pure gold, on the basis of 24 parts as a unit (thus, 24 kaf8t is 100 % gold, while 18 kSf8t is 75% gold). Fineness is measured on the basis of parts of pure gold per 1,000 (1,000 fineness is 100% gold, while 500 fineness is 50% gold). Pure gold 18 only used In the foil reatoradon.

OPERATIVE

Gold

A cavosurface bevel is used when preparing a tooth for a cast gold Inlay or onlay. VVhat is the principal reason for its use?

• To allow room for the cement

• To improve the marginal adaptation

• To compensate for shrinkage of the casting gold alloy

• To provide resistance form to the preparation


• To Improve the marginal adaptation

The bevel on the cavosurface margin permits closer adaptation of the gold margin because the thinner margin of gold overlying the bevel Is more ductile and is able to be burnished. Note: During cementation, the finishing (burnishing) of the margins of a cast gold restoration should be started as soon as the restoration is well~seated Into the preparation.

VVhile preparing a tooth to receive an inlay or onlay, a gingival bevel is used to remove unsupported enamel and to compensate for casting Inaccuracies. Gingival margin trimmers, carbide finishing burs or fine, tapered diamonds are used to place this bevel.

Note: This margin is always placed gingival to the contact area.

Remember:

• VVhen preparing teeth with short clinical crowns, the facial and lingual walls should have a minimal gingival to occlusal divergence angle for maximum retention.

• From facial to lingual, the axiopulpailine angle of an onlay preparation is longer than the axloglngivailine angle (if it wem not, the pmparatlon would be undercut and the onlay would not seat). For an MOD onlay prep, the axial walls must converge from the gingival walls to the pulpal wall (for the same mason, the on/sy would not seat if they diverged).

OPERATIVE

Gold

Frequently the surface of a gold casting is dark due to the formation of a surface oxide film. This surface film is removed by:

• Quenching

• Age Hardening

• Pickling

• Fusion


• Pickling

This process consists of careful healing of the casting which is placed in an acidic solution to reduce the surface oxides. The most effective pickling solution is 50% hydrochloric acid solution. Note: The fumes are very corrosive and will damage metal objects in the office. It is recommended to use commercially available pickling agents, which are solutions of acid salts. They act more slowly but will produce acceptable results.

Two methods of pickling:

1. Place casting in pickling solution and gently heat the solution. This will produce a clean, gold-colored casting.

2. Heat the casting until it barely emits a dull glow and then drop it in the pickling solution. Note: VVith this method, there is a risk of distorting delicate margins.

Note: Whichever method is used, always wear safety glasses.

OPERATIVE

Gold

Annealing is the process of heating and cooling a metal to make it:

• Weaker and more brittle

• Tougher and less brittle

• More tarnish resistant

• Easier to cast and finish


,. Tougher and less brittle

Annealing, in general, comprises three stages: recovery, recrystallization, and grain growth. The higher the melting point of the metal, the higher the temperature needed for annealing. Note: During this process the stresses in the metal are relieved.

Important: Gold foil is annealed (also called degassing) to remove volatile surface impurities prior to its placement in the cavity preparation.

Remember:

,. Cold work (also called strain hardening or worlc hardening) is the deformation of a metal at room temperature, in contrast to the effect of working at a higher temperature, such as in forging. An example of cold work would be the bending of a wire back and forth rapidly between the fingers.

• Burnishing is somewhat related to polishing in that the surface is drawn or moved.

However, instead of using many tiny particles, only one large point is employed. If a round steel point is rubbed over the margin of a gold inlay (made from a Type I or /I gold alloy), the metal may be moved so that any small discrepancy between the inlay and the tooth can be closed.

OPERATIVE

Gold

Essential properties of a Class V cavity prepared for direct filling gold include:

• Sharp internal line angles

• Small retentive undercuts placed in the axio-occlusal and axio-gingival line angles

• Mesial and distal walls that flair and meet the cavosurface at a 90° angle

• An axial wall that is convex and follows the external contour of the tooth .5 mm into dentin




Class V cavity preparation for direct filling gold:

• The outline fonn is usually either trapezoidal (most popular) or kldney-shaped. The axial wall is placed .5 mm into dentin (this will make the occlusal wall slightly deeper than the gingival wall because there is a thicker layer of enamel making up the occlusal wail). The mesial and distal walls are placed at the line angles of the tooth.

Remember: For any Class V prep (whether for amalgam, composite ordirecl filling gold), the outline form is determined by the extension of the carious lesion.

• The retention fonn is attained by sharp intemalline and point angles (axio-gingival and axio-occlusa/).

• The resistance fonn is provided by flat mesial and distal walls and a convex axial wall which parallels the extemal surface of the tooth.

Note: The axial wall is convex in a mesiodistal direction in order to conserve tooth structure and minimize pulpal irritation.

Important: The rubber dam Is essential to prevent contamination of the gold with sali~ va. A cervical clamp usually is necessary to retract the gingiva (#212 ivory clamp). The hole that is to be punched in the rubber dam for the tooth that Is being restored should be located facial to the normal alignment with the adjacent teeth.

OPERATIVE

All of the following statements conceming direct gold are true, except:

• It is the most nearly permanent of all restorative materials

• It provides good adaptation to the cavity walls

• Its coefficient of thermal expansion is close to that of tooth structure

• It has a low tensile strength (edge stmngth)

• It will not corrode


Gold

Operative Dentistry 2004

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