Compound and complex cavities

on posterior teeth
Cons lec 6 5.11.08
Today we will talk about the non classical class I and class II cavities. We
already know that :
Class I : occlusal surface or part of it is missing .
OD : distal and occlusal surfaces are missing .
OM : mesial and occlusal surfaces are missing.
MOD : mesial, distal and occlusal surfaces are missing .
But, if we have two adjacent surfaces that are missing (one corner missing),
e.g : buccal and distal surfaces are missing, this what we called “compound and
complex cavities” . The problem here is how can we retain the restoration
(amalgam) in these cavities ?

In this picture, you can see a conventional class II cavity (topical class II) and
the matrix band is there, so here we can use amalgam without any problems.
But we have different faces and variations of class II cavity, and they are :
1- Minimal class II cavity: when you have minimal caries on the
occlusal surface and caries in one of the proximal surfaces (either the
mesial or distal), here we don’t need to drill the occlusal surface (only we
drill the box).
2- Conventional approach: in this case, the marginal ridge is week
and the solution is to drill the caries and break the marginal ridge and
restore it with amalgam.
3- Complex class II: in this case we drill all the occlusal surface with
the proximal box .

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 Now we will talk about the approximal slot preparations :
This means is how can I access to lesion on the proximal surface ?
1- A preparation where accessed from the buccal or the lingual
surfaces.
2- Tunneling through the occlusal surface to the proximal surface
underneath the marginal ridge.

What is tunnel restoration ?

It’s a restoration where we are tunneling from the occlusal surface to the
proximal with intact marginal ridge.

Note : in tunnel restoration we end with undermined marginal ridge which is

week (no dentine underneath it), and the solution for this problem is to remove
the marginal ridge.
In minimal class II restoration, we may use resin for restoration which
doesn’t need any mechanical retention components, but if we decided to use
amalgam instead, we need to create retention, one of these retentive
components is a “retentive grooves” in the box which we drill in the line angels
between the axial and buccal walls, and axial and lingual walls. If the amalgam
pulled upward it’s retained by mean of conversion, and if it’s pulled to the side,
it’s retained by the mean of the grooves.

In the picture you can see the caries on the proximal surface from the buccal
side, so you don’t need to go through the occlusal surface, you just drill from
the buccal side and remove all the caries, then restore from the buccal surface
(this is an example of the first way in removing proximal surface) .

What is the concept of tunnel preparation ??

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 1- small proximal caries .
2- sound marginal ridge .
3- occlusal pits and fissure are either carious or very deep and
vulnerable to caries attack .

The figure here will show you the area where we are going to initiate the
tunnel preparation.

This picture show u the tunnel that we started to drill, from that hole where
the arrows indicating we see intact marginal ridge and we are tunneling from
the occlusal surface underneath the marginal ridge, we remove all the caries
then you apply the matrix band then u either fill it with amalgam or composite.

This is how to prepare tunnel restoration, but we should know the

disadvantages of this preparation, and they are :
1- removal of caries isn’t certain: that’s means that u can’t a 100%
guarantee that you removed all the caries on the proximal surface .
2- difficult to prepare and fill .

Now, what is the advantages of the tunnel preparation ??

1. Conservative: marginal ridge remains intact and cusps not weakened.
2. Conventional cavity can still be prepared if modified restoration fails.

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 This picture describes the outlines of tunnel restoration, you can see that
the distance between the opening of the tunnel and the edge of the marginal
ridge is “2mm” , also we can notice that the outline of the preparation on the
occlusal is “T” in shape . Simply, in tunnel preparation we have “O” access
and “T” access .
Why you made it not exactly like a hole ?
Because we want a room to manoeuvre.

Now we will start talking about different subject which is the MOD cavity.
It’s a cavity where the mesial and distal as well as the occlusal pits and fissures
of a posterior tooth are carious, a mesio – occluso – distal restoration may have
to be placed.
If in the maxillary molar the oblique ridge is intact then two separate class II
cavities are prepared.

Another different subject which is the cuspal restoration and pin retention.
When two adjacent walls are missing, in other words there in a corner missing
then we solve this problem by amalgam build up .

You can see a beautiful amalgam filling and how it carved according to
tooth morphology and here you can see how all the cusps were build up (cusp
built).

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Here we can see an example of amalgam filling which has to be replaced

An example of how extensive caries was and attempt of amalgam restoration

resulted afterward by fracture of the cusp . so how can we restore such a
tooth ??
Assuming that this tooth is still vital and u don’t want to do RCT for the it,
so we do “cusp build up”, but how I’m going to retain the amalgam there??
In this case we can’t make conversion or diversion, so we must use pins or
additional retention features.

Weakened cusp can result from :

1. Extensive caries (Gross caries).
2. Repeated amalgam replacement because every time you renew amalgam you
are cutting from the surfaces from the cavity and weakening the walls .

Note : when more than one cusp is to be replaced, additional retention must
be sought.

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Intracoronal retentive features:
1- Amalgapins:
 Chambers cut parallel to the corresponding tooth surface and filled
with amalgam
 The margins of chambers are bevelled
 0.5-1mm from Amelodentinal junction
 Depth 1.5-2.0 mm
 Diameter 0.8 mm Place with #330 (0.8mm diameter).

In this picture you can see amalgam pins, there is no crown at all and you
prepare it by drilling several holes corresponding to the corners of the tooth
(under every cusp there is a hole) then we use a matrix band and condense the
amalgam, this amalgam will enter the holes and act as a pin made of amalgam.

2- Slots (grooves) :
 They are essentially troughs cut in the sound tooth tissue on the
floor of a complex cavity.
 .5-1 mm from ADJ, 1-1.5mm deep and wide enough for
convenience.
 It may be segmented or continuous and its length depends on tooth
tissue available.

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A: A round bur is being used to groove the cervical floor of the box.
B: A number 1 round bur has been used in the lingual cusp
** Grooves should be sufficiently deep to offer some resistance to bur
withdrawal .

3- Box preparation :
 Box in Buccal or palatal extension on molars of posterior teeth
(class II).
 Design the boxes to be retentive by making them occlusally
convergent.

4- Cleat holes :
 Are located in the bulbous part of the lingual cusp of a premolar.
 0.5 – 1 mm from amelodentinal junction.
 They are usually round or ovoid with a flat floor and about 0.75 to 1 mm
deep.

5- occlusal steps.

Now, when we have to remove lateral caries??

1. a wall might fracture .
2. undermined that you have to fracture it (when the walls are very
thin, they can’t resist the condensation forces of the amalgam) .
3. the patient comes with a fractured wall already .

So what do I do for the walls ??

 If it is supported with enough dentine the we keep it.
 If it is thin then we remove it
 If it is supported with some dentine the we reduce it about 2 mm’s.

Now we will shift to the assessment before inserting the Pins, always we
must have a good x-ray to make a good assessment,

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 1- to assess the angulations of the tooth .
2- To assess the size of the pulp and PDL .

Note: x-rays can sometime be misleading for example, 1) when we have

amalgam filling in buccal pit, you will see it in the x-ray is sitting in the pulp
because of superimposition . 2) also on the x-ray a buccal lesion will be seen
in the pulp and interpreted as a pulp exposure, so you have to look clinically
and trust your clinical judgment more than trusting the x-rays .

We will talk a little bit about pins that we use to retain the amalgam inside
the cavity and we have 3 types:
1- cemented pins : by making a hole in the tooth which is larger than
the diameter of the pin and fix it by mean of the cement in the hole, if
you fit it during condensation it may not resist these forces .
2- frictional locked pins : they are actually pieces of wires that are
laterally attached inside the dentine and they are retained by mean of
frictional locking (in this case we make hole that are narrower in
diameter than the pin so we will have retention 2-3 times more than what
we get from cemented pins ) .
3- self threaded pins : also here the diameter of the hole is narrower
than the pin and offer retention 5-6 times more than cemented pins, so it
gives retention more than frictional locked pins also .

Note : frictional locked pins and self threaded pins are contraindicated in
non-vital teeth, but cemented pins may be used in non-vital teeth because
they don’t induce stress in dentine .

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 In this picture you can see two pins, notice on the right pin we have two
arrows, we insert the pin by a handpiece inside the hole that we drill, when it
reaches the bottom it will fracture from the point that is pointed by the upper
arrow, so we will have part inside the hole (below the lower arrow) and one
above (between the lower and upper arrows) that will catch the amalgam and
retain it with the remaining part of the tooth .

In this picture you can see on the left side amalgam filling which was
retained by several pins (self threaded pins), on the right side you can see that
there is no way to retain an amalgam filling in this tooth, so what do I have to
use here ??
I have to use additional forces which are pins .

All the time we talked about pins, so where do I place the pins ??
 Never in enamel .
 Never in amelodentinal junction .
 Never in the pulp .
 Never in the ligament .
 Always in dentine with specific features :
* 1 mm away from ADJ .
* 1 pin at each corner of the tooth .
* A maximum of 4 pins .

Disadvantage of the pins is that they can easily perforate the periodontium
in areas of root concavity of molars and
premolars .

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 ** Copper Rings :
Comes in a thin plate, you just fix it around the tooth and condense the
amalgam inside it and carve the tooth, then trim the ring with a bur to prevent
interfering with the occlusion and after 24 hours cut the ring and remove it
then continue the finishing and polishing.

** Core build up :
If you want a core then you can build it up by amalgam pins and then crown
preparation .

** Non-vital teeth :
How do I utilize the pulp space ?
by mean of posts, and we have two types :
1- custom made post .
2- prefabricated post : like parapost and charlton post .

Where do I use them (posts) ??

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  Root canals of anterior teeth .
 The distal canal of lower first molar .
 The palatal canal of the upper first molar .

Uses of posts :
1- retain restoration .
2- retain crowns .
3- make cores .

This is an example of a parapost in a non-vital tooth with RCT, and the

post is inserted inside the gutta percha, but we must maintain the seal of the
apex in this case, so there should be no communication between the root
canal and the apex.
It’s very important to keep in mind that post will never make a seal with the
canal walls, so we never use posts in non obturated canals .

The End
Done by :
Abdulla T. Halhouli .
Ta7ye kbere XXL l3bdalla 3wadi 3la 6eba3et almo7adra o
mbrok ka2s dawre alkolyat . o ta7ye ll3’ale eyas
"sadekeee". O as7ab aldrb mo3ad’ abo “hadye”, anas reb7e
(jam3a qwye m3 shwayet mshakel), 3mo mo7sen. O ma
bnnsa alshbab al6aybe: m7mad alshamare,anwar,5aled
7rbe, 7sen, sale7 alyaf3e ,zain"abu 3oday"

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montaser, qadi, ferri, 3zam, basel o amen, m7ajne, abo sh3eb, adham, 3bd alr7man, swal7a,
m7md sh3ban.
Ta7ye llsadeqat ele sa3ado balnotes: shahd, fara7, sokayna, lena O aked la maram z3’olo
jomanah. O a5r ta7ye kbere lkol aldof3a la7lwe ……

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