Chapter 19: Complex Amalgam Restorations S So Complex Posterior Restorations Complex posterior 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 o 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 (See his PowerPoint. This is best summarized in his lecture.) o 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) Protects pulp from oral cavity and insults 2) Provides anatomic contour 3) Facilitates control of caries and plaque 4) 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

Chapter 19: Complex Amalgam Restorations S So Tooth cannot be restored with direct restoration because of anatomic/functional considerations Esthetics DISADVANTAGES -Pinholes 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

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

CLINICAL TECHNIQUES 1. 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 o Pins have greater retention Pins for Class IV restorations rare: small size of anterior teeth o However, can be considered for Class IV on the distal surface (distoincisal corner) of canine when restored with amalgam Alternative to pin: Lingual dovetail 2. Slot-retained amalgam restorations = retention groove in dentin whose length is in horizontal plane o Prepared with 33 or round bur May be used as an alternative to pin-retained or in conjunction with pin-retained 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

Retention differences between pins and slots are not significant

Chapter 19: Complex Amalgam Restorations S So 3. 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 (See his PowerPoint lecture as well) 1. 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 o Carbide fissure bur o Depth of cuts should be a minimum of 2 mm deep for functional cusps and 1.5 mm deep for nonfunctional cusps (p 814) o If unreduced cusp is at less than correct height, then cuts will be less. o 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. o Rounded internal angles o Opposing vertical walls should converge occlusally to enhance retention form o Gingival seat (See powerpoint) Remove infected carious dentin CaOH liner and resin-modified glass ionomer base can be applied o It should not extend closer than 1 mm to slot or pin Pin types o 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 o Pin hole: 0.0015 to 0.004 in. smaller than diameter of pin o Pin drilled into dentin; may generate stress when inserted o See powerpoint for factors affecting retention of pin in dentin and amalgam Problems and failures of pin-retained restorations o Failure can occur within the restoration o At the interface between pin and restorative material o Within the pin o At the interface between pin and dentin o Within the dentin o 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 o Loose pin (example: as in self-threading pins sometimes do not engage in dentin; during preparation)

Chapter 19: Complex Amalgam Restorations S So o Penetration into pulp and perforation of external tooth surface

2. 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 3. Amalgam foundations Tooth preparation depends on type of retention selectedpin retention; slot retention or chamber retention (endodontic therapy) Pin retention o For broken down teeth with few or no vertical walls o 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 o Placed in gingival floor of preparation with No. 33 bur o Placed farther inside DEJ than for conventional amalgam preparations o Depth is usually 0.5-1.0 mm and 2.0 4.0 mm long Chamber retention o 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 o 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)