Operative Study Guide Summer 2016

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Operative Introduction
Isolation of the operative field
Class V Composite Resin
Class III Composite Resin
Class I and II Composite Resin
Class I Amalgam
Class V Amalgam
Amalgam Condensing and Carving
Dental Caries

Operative Introduction

Operative Dentistry: Restoring damaged areas of teeth

o Damage may be due to caries, erosion, abrasion, attrition, fracture, or
developmental defects
o Not all lesions require restorations
Early caries lesions are treated through risk management strategies and
remineralizaiton therapy
Specific indication are needed for operative intervention for abrasion,
attrition, or erosion
Dental Restoration
o Step 1: preparation (prepared cavity)
o Step 2: Restorative materials
Preparation: Cutting tooth structure with the goal of shaping the cavity to receive the
restorative material
o Considered surgery since its cutting into human tissue
Purpose of Dental restorations
o Restore form, function, and esthetics
o Protect the pulp, periodontium, and remaining tooth structure
Restorative materials
o Provisional (temporary)
o Definitive (permanent)
o Direct (composite and amalgam)
o Indirect (inlays and onlays)
G.V. Black Classification of cavities
o Class I: pits and fissure
Normally the occlusal, but also in places like the buccal pit on mn molars
o Class II: Proximal contact of posterior teeth
o Class III: proximal contact of anterior teeth
o Class IV: incisal edge fracture
o Class V: cervical enamel lesion
Facial and lingual
o Class VI: Cusp ridges
Cavity naming
o
o
o

M = mesial
O = occlusal
D = distal

B/F =
buccal/facial

L = lingual

Cavity walls
o Class I
B, L, M, and D walls
Pulpal floor (perpendicular to long axis)
o Class V
M, D, O/I, and gingival walls
Axial wall (parallel to long axis)
o Class II
Buccal occlusal, lingual occlusal, either distal or mesial wall, and pulpal floor
in the center of the tooth
Proximal Box: area on the proximal end that is removed
Walls
o Buccal proximal wall
o lingual proximal wall
o gingival seat/wall (flat part on the bottom)
o axial wall
Line-angles: lines where surfaces come together
o Axio-buccal line angle
o Axio-pulpal line angle
o Axio-lingual line angle
o Axio-gingival line angle
o Buccal-gingival line angle
o Lingual-gingival line angle
Point angles: point where 3 surfaces all meet
o Axio-bucco-gingival point angle
o Bucco-gingivo-cavosurface point angle
o Axio-linguo-gingival point angle
o Linguo-gingivo-cavosurface point angle
Cavosurface: area where prepared surface meets original tooth
structure (only a few examples listed below)
o Buccal proximal cavosurface margin
o Gingival cavosurface margin
o Lingual proximal cavosurface margin
Outline form: the extent and configuration of the cut faces of the cavity preparation
o External outline form: perimeter configuration of the enamel cavosurface margin
o Internal outline form: inner dimension and detail
Resistance form: form of the cavity prep which aid in prevention of fracture of either tooth
or restorative material during function
Retention form: form of the cavity preparation which protect the restoration against
displacement
Convenience form: form of the cavity that allows adequate vision and access for
instrumentation of the preparation and insertion of the restorative material

Isolation of the Operative Field

Isolation of the operative field involves

o Protecting the lips, cheeks, and tongue
o Preventing obscuring of view by lips, cheek, and tongue
o Preventing aerosols of patients oral microorganisms
o Keeping saliva & tissue fluids from obscuring view
o Preventing swallowing/aspiration of materials and instruments
o Preventing moisture contamination by patients breath

o Enhancing visibility due to high contrast

Methods of isolation
o Driangles: place over the buccal mucosa/parotid papilla and let them soak up saliva
o Hygroformic: bendable wire that can keep the cheek and tongue away from the area
while still sucking up saliva through the slow speed
o Low speed suction
o High speed suction
o Cotton roll holders
o Svedoptor: more rigid than hygroformic. Also keeps the tongue and cheek away
while sucking up saliva
o Dental Dam
Placing the Dental Dam
o Armamentarium
Retainers
Retainer forcepts
6x6 heavy non-latex dam
Youngs frame
Rubber dam napkin
Waxed floss
Scissors
o Check the proximal contacts to determine if the dam will retain
o Trace the template
The holes should not be centered. Maxillary arch holes should be close to the
top, and mandibular arch holes should be near the bottom
o Punch the template
Hole sizes
Smallest: mn incisors and max lateral incisiors
2nd smallest: mx central incisors, canines, and premolars
3rd size: molars
Largest size: tooth with retainer on it
o Ligate the retainer: wrapping flow through the holes and around the bow in order to
prevent it from breaking and being swallowed/aspirated
Retainers
Parts
o Bow
o Jaw
o Forcep hole
o Beaks
Ivory set
o W3 goes on first molars
o W2 goes on premolars
o W8A goes on second molars
o 212 is used for retraction
Brinker Set
o B1 goes on lower molars
o B2: upper left molars
o B3: upper right molars
o Place with the retainer forceps around the desired tooth
Usually on one of the back molars
Wedjets stabilizing cord: can be used instead of the retainers, hold the dam
down by being stretched, placed between the teeth, then let go so it expands
o Lubricate the dam

 Facilitates placement of the dental dam

Placing the Dam
Place large hole over the retainer and the tooth its on.
Place the hole over the furthest away tooth (should be at least the canine on
the other side)
Fill in over all the other teeth using floss to slide the septum in-between the
teeth down to the gingival papilla
Place Youngs frame around the area with the arch down at the mandible
Make sure theres slack between the holder pins, if its pulled tight if
knocks the retainer of
o Apply the Napkin
Simply for patient comfort
o Position Frame
Allow the upper posts to engage the top of the dam, and the lower ones to
engage the bottom ones
o Floss the Dam through contacts
Interdental Septum: the piece of material in-between the teeth holes
Thread the floss on one side of the tooth and pull the dam down with it. Dont
just floss directly down the proximal area or it bunches up
o Invert the dam
Inverting: process of turning down the edges of the hole around each tooth so
that the top side of the dam sits against the tooth neck rather than the
bottom of the dam (prevents leakage)
Removing the dam
o Pull the dam tight so the septum is tight and pulled out so you can see the soft
tissue underneath.
o Cut the septum with scissors, and do this for each tooth
o Check afterward to make sure you got all the rubber dam material

Class V Composite Resin

Class V lesion characteristics

o Wide M-D
o Short Incisal-Gingival
o Undermine the enamel around them
Prone to caries in this area because
o Portion of the enamel is thing
o The area is cervical to the height of contour, representing an area of stagnation and
pooling
Caries lesion position, extension, shape, and dimension of final prepared cavity
o Tend to be narrow, crescent shaped and paralleling the free-gingival margin
o Extend mesially to distal, but range of sizes
o Locate lesion visually and with an explorer
o Simply remove caries and then fill the cavity for composite
Need rounded internal form since composite wont flow into corners
No need for retentive features like amalgams, strength comes from bonding
to dentin

Shade match before you begin prepping

Caries removal and prep
o Remove all softened dentin & stain at the DEJ with a straight bur (probably a 170L)
o Use a slowspeed and round bur (most likely a #2 round bur) to remove carious
dentin
o No sharp internal line angles in the prep
o Place a 20 to 45 bevel on the facial of the prep to improve marginal adaption
(retention) and give a better visual transition. Bevel should be 0.5 to 1.0 mm
Bevel should be done with a 7902 finishing bur
Materials
o Composite resin: When isolation, access, and visibility are optimum, and margins
are on enamel
o Resin-Modified Glass Ionomer: when isolation, access, and visibility are optimum,
but the margins are on root surface
o Amalgam: If it is difficult isolation, access, or visibility
Retracting gingiva
o 212 retainer retracts the facial gingiva
Even more retraction if you bend of the lingual teeth
o Use a cord packer to retract gingiva with opposite hand
Adding composite resin material
o Perform an acid etch (35% phosphoric acid)
o Rinse and blot dry with cotton (not bone dry though)
o Apply two coats for 15 seconds of single bond.
Lightly air dry between applications to smooth out
Cure for 10-15 seconds after application
o Add composite to cavity
Directly fill, keeping the nozzle tip in the composite and then cutting it of
with the margin edge
Place on a designated sheet and add as needed
o Contour and smear the composite around the margins
Working time is finite due to ambient light, but pretty long
o Cure
Ramp curing: cure for the first 5 seconds 5 mm away, then as close as
possible for 30 seconds. Helps to lighten the stress caused by polymerization
shrinkage
Cure for 30 seconds on normal shades, cure for 40 seconds on more intense
shades
Curing depth is about 2.5 mm
o Refine the margins and contours with a #12 scalpel or an IPC 1
o Smooth the prep and margins with a soflex disc, always moving it so it wont sit in
one place
Avoid the delicate enamel gingival line, we dont want to take of
cementum/enamel and expose dentin
Could also use Enhance/Pogo disks as well
Rinse and dry in between abrading steps to prevent

Class III Composite

Class III Caries Lesion

o Proximal contact area of anterior teeth
o Begins on the gingival edge of the contact area

Requires a higher caries risk than pit and fissure caries

Lesion is broader Fa-Li, found gingival to the contact
Detected with
Bitewing radiographs
Visual inspection
transillumination
Preparation features
o Can do labial or lingual access
Lingual access is commonly done on maxillary anteriors for esthetic purpose
Often done labially on mandibular anteriors for better access
Ultimately the choice can be base on which side has more protruding carious
tissue
o Outline form is lesion-specific (simply remove the lesion)
o Cavity is extended with the incisal wall still in contact (take out part of the cervical
contact though)
For amalgams, the entire contact needs to be removed in order to try and
prevent recurrent caries
o Walls should be smooth
o Internal line angle should be rounded, no retentive features
o Cavosurface margin is crisp, smooth, and free of loose enamel
o Cavosurface bevel is added on toward the lingual side and blends into the incisal
and gingival edges
o Cavity is accessed through the labial embrasure at an angle perpendicular to the
tooth and that spot (not parallel to the proximal plane)
Extend the cavity until the gingival part of the proximal contact is broken
o Use hand tools to flatten the edges of the prep
111 hoe for a labial approach
Jefery 7 for a lingual approach
o Bevel with the 7902 finish bur on slowspeed
Class III restoration features
o Esthetics match as before
o Surface is smooth, dense, porous free, and shiny
o Margins are undetectable and restored to preparation margins
Over-contoured/overhang is when composite is bulged out
Under-contoured/step is when the composites too low
Over-extended/flash is when the composite goes past the margin
Under-extended/open is when theres a gap between the margin and tooth
o Proximal contact is visual closed but admits floss
o Proximal contour matches original tooth contours and the adjacent tooth is
unaltered
o Labial and ling contours have proximal line angles and marginal ridges that are
restored
o Function: occlusion is in harmony with the rest of the dentition
Restoration technique
o Etch the prep
o Place a Mylar strip in the embrasure, then firmly place a wood wedge in there so
that the Mylar strip is held, but the teeth are not spread further apart.
o Place 2 coats of single bond for 15 seconds, air drying in-between. Then light cure
for 10 seconds
o Squirt composite onto a pad only, do not direct inject for this prep
o Place composite on the cavity so that it seats all the way
o butter the composite along the edges
o
o
o

Wrap the Mylar strip around the tooth so that the contour is recreated. Dont pull all
the way tight, or it will be undercontoured
o Ramp Cure for 30 seconds for normal composited, or 40 seconds for more intense
composites
o Remove excess with Bard Parker #12
o Re-contour if necessary and polish with soflex discs of finishing burs.
o If the contact is too tight, then use a finishing strip to smooth it down
Consequences of Inadequate light curing
o Restoration will be physically weak, prone to fracture, and wear rapidly
o Inadequate bonding to tooth can result in leakage, recurrent decay, pulpal
pathology, and restoration loss
o Unreacted monomer has potential for adverse health consequences
Essentials of light-curing
o Instruments must be regularly checked, power decreases over time
o Keep wand clean and free of resin/bonding agent (contamination will reduce light
strength getting through)
o Keep the end of the wand 90 to the surface being cured. A 45 reduces light
energy by 56%
o Keep the tip of the wand in contact or as close as possible with the material. At a
distance of 6 mm the intensity is decreased by 50%
o Keep wand steady and optimally position throughout the process
o Cure for 30 seconds on standard shades, and 40 seconds for intense shades
o Composite will only cure 2.5 mm (2.0 mm for intense shade), so if the prep is bigger
do it in stages
Light curing safety
o Chronic exposure (7 times a day for 1 second) will lead to macular degeneration
o Always use the orange protective shield when viewing the light
o Heat intense light and exothermic polymerization can damage the pulp. If the cavity
is close to the pulp, use a continuous stream of air to keep the material cool
Avoid flowable because it has a higher exothermic reaction
o Avoid directing the light at patient soft tissue, this can cause burns. When necessary
use the dental dam or wet squares
o

Class I and II Composite Restorations

Class I: pits and fissures

Class II: proximal surfaces of posterior teeth
Types of direct restorations
o Amalgam or composite
o Material Specific Restorations: cavity form is based on the physical properties and
the technique used for placing the material
Usually amalgam restorations
o Lesion-Specific Restorations: Cavity form is based on the location and size of the
lesion
Usually composites
Contraindications of composite restorations
o Unable to establish absolute isolation
o Challenging proximal contacts/ difficult to establish
o Location of caries/defect is out of reach of the curing light
o Cavosurface margins that are not all in the enamel
o Occlusal contacts for the tooth are solely on the restoration; wide isthmus width

Advantages of composites
o Conservation of tooth structure (overall a stronger restored tooth)
o More esthetic
Disadvantages of composites
o Cost
o Extremely technique sensitive
Need to follow each step in order and exactly, otherwise the restoration is
significantly weaker. Amalgams are more forgiving
Lesion-Specific Restoration Cavity Preparation Principles
o Outline form should be dictated by the size and location of the lesion
Conservation of tooth structure
o Cavosurface margin and all internal surfaces are smooth
Viscous composite materials will not adapt well into rough or irregular
surfaces
o No sharp internal line angles
Sharp internal line angles serve as stress concentration areas
o All loose enamel at the cavosurface margin should be removed
Prevent breaking of enamel during polymerization and shrinkage
o All aspects of prep should be accessible to the curing light
Direct light contact is required for polymerization of the resin
o Prep should be free of foreign debris
Allows for optimal bonding
Histopathology of Pits and fissures Caries lesions
o The fissure/pit is intact while the lesion spread laterally at the DEJ
o Surgical treatment decision is based on our ability to assess the histopathological
condition of the dentin at the DEJ
Class I steps
o Locate lesion (diagnosis)
Visual assessment is the primary diagnostic tool
Also use explorer, but limited because the tip getting caught in the grooves
can be perceived as carious tissue (wedging efect)
Radiographs are limited usefulness except for deep lesions
Procedure
Use an explorer to remove plaque and food debris from fissure orfice
Under good lighting and isolation (dry), visually inspect for any
damage to the enamel
Look for any subtle color changes around the pits and fissures
Enamel is low in opacity, thus any changes in color in the underlying dentin
will show through the enamel.
Look for a gray shadow or opaque area around the pits and fissures (halo)
Ignore the color change within the pits and fissures
o Use an appropriate bur (about the size of the lesion) to gain access through the
groove/pit
Usually 245 or #2 round bur
Create initial access to the lesion, and then extend as needed to remove all
the carious dentin
Remove all loose enamel
Class II
o Diagnosis of proximal caries
Primary tool is bitewing radiographs

Secondary tool is visual (looking for changes in the optical properties of the
marginal ridge under bright light)
Preparation steps
Locate lesion
Approach lesion from the marginal ridge, usually slightly lingual and gingival
to the contact area
Using a 245 bur penetrate at an angle parallel to the long axis of the tooth
until you have a visual of the lesion
Extend buccal-lingually and/or gingival until you have a full access to the
lesion
Initially leave a thin wall of enamel between the teeth to prevent
adjacent damage
Remove the remaining lesion using a round bur on a slow speed handpiece
Remove loose enamel with a hatchet (probably of-angle)
Examine buccal and lingual proximal walls to ensure complete removal of
caries
Filling Cavity
Matrix band
Use 0.001 thickness band for composite fillings
0.0015-0.002 thickness bands for amalgam fillings
Burnish the inside of the matrix band with an egg burnisher
o gives a more convex proximal surface
Place around tooth and tighten
Place wooden wedge into the contact area
o Controls excess material at the gingiva
o Dont separate the teeth, as this will cause excess to go onto the
buccal surface
Placement techniques
Etch the prep
Fill with multiple increments.
o First should be around to 1 mm thick
o Following increments should be 1 mm thick
Using the supper plugger, apply light pressure and adapt the resin into
the prep
Remove excess resin before curing
Cure for 20-40 seconds
Build to slightly overcontoured
Establish the occlusal embrasures
Remove the tofflemire band
Finishing and Polishing techniques
Finishing bur
o Needle shaped 7902 for the bulk removal of excess composite at
the embrasure (buccal, lingual, and occlusal)
o Egg shaped 7404 for creating occlusal anatomy and adjusting
occlusal contact
#12 Bard-Parker for removing gingival overhang and excess at the
buccal and lingual embrasures
o Could also use gold foil knife or composite carver
Soflex disks for final finishing and polishing at the embrasures
Enhance/PoGo for the occlusal surfaces

Class I Amalgams

Amalgams vs. Composites

o Amalgams
Retention form is macro-mechanical (opposing walls, grooves, mortise-form)
Resistance of the restorative material is due to
right angle butt joints
adequate bulk
Smooth and flat walls
Resistance form of the tooth is due to
Right angle butt joints
Removal of all unsupported enamel
Proximal clearance requires breaking contact with the adjacent tooth
o Composite Resins
Retention form is micro-mechanical (bonding)
Resistance form of the material is due to
Bevel enamel
Feather edges are acceptable
Resistance form of the tooth is due to
Lesion dictates form
Preserve unsupported enamel
Proximal clearance does not require breaking contact with the adjacent tooth
Visually looking is the accepted way to look for these lesions
Terminology
o Preparing a cavity, cavity preparation, prepared cavity
o Extend, extension, or incorporate for increasing prep size
Preparation characteristics
o Outline form
Smooth flowing, gentle curves
Angular contours can chip during condensation
Angular contours can concentrate stresses and lead to restoration
fractures
Easier to find when carving back fresh amalgam
Invaginations are susceptible to fracture during condensation
Evaginaitons are difficult to condense into
o Extensions
Encompasses carious tissue
Eliminates unsupported enamel
Eliminates weakened tooth structure
Encompasses contiguous fissures
Reduces the risk of secondary caries and increases life-span
Encompasses contiguous restorations
Maximizes restoration lifespan
o Bucco-Lingual Extensions
Extend far enough up the Buccal and Lingual grooves to terminate on gentle
contours
Margins in sharp anatomy are difficult to finish and keep clean
Extend minimally in area of triangular ridges (width is less than 1/3
intercuspal distance)
Provides convenience form while preserving cusp strength
o Mesio-Distal Extensions

Stop short of marginal ridge crests

Preserves the strength of the marginal ridge (resistance form)
Groove extensions kept narrow
Preserve strength of cusps (resistance form)
Occlusal Depth
0.5mm into dentin, about 2 mm measured at the triangular ridges
Sufficient bulk of amalgams to prevent fracture
Maximum thickness of dentin protecting the pulp
Pulpal Floor
Smooth and flat
Uniform bulk of the amalgam prevents fractures
Parallel to occlusal table
Best resistance to occlusal stresses and forces of condensations
Buccal and Lingual Walls
Smooth, curved mesio-distally, straight pulpo-occlusally
Optimize adaption of amalgam to walls
Elimination of weak tooth structure
Convergent 6 pulpo-occlusally under triangular ridges
Helps lock restoration in tooth (retention)
Preserves strength of cuspal ridge (resistance form)
Divergent 6 pulpo-occlusally in groove extensions
Keeps amalgam from being too thin at margins (resistance)
Mesial and Distal walls
Smooth
Optimize adaption of amalgam to walls
Straight and divergent 6 pulpo-occlusally
Elimination of weak tooth structure
Preserves strength of marginal ridge (resistance form)
Cavity Refinement
Internal line angles are well-defined but not sharp
Use a 245 rounded fissure bur to obtain this
Maximizes amalgam resistance to dislodgement
Reduces stress concentration and risk of subsequent tooth fracture
Cavosurface margins are regular, well-defined, and well supported
Easier to visualize and carve following condensation
Optimize adaption of amalgam to margins
Eliminates weak tooth structure
Maximizes marginal integrity (get bad marginal adaption otherwise)
Cleanliness
Cavity is free of debris and moisture for better adaption and elimination of
voids from foreign materials

Class V Amalgams

Found on the Cervical 1/3 of the facial or lingual surface for any tooth. Below the height of
contour to gingival margin usually
Outline Form
o Rounded trapezoid in the gingival third
o Gingival and Occlusal outline straight & parallel to occlusal table
Extensions
o Encompasses carious tissues

o Eliminates unsupported enamel

o Encompasses contiguous restorations
occluso-Gingival Extension
o Occlusally to height of contour or extent of lesion
o Gingivally to extent of lesion (frequently subgingival)
Mesial-Distal Extensions
o To the line angles of tooth or extent of lesion
Axial Depth
o Depth 0.5mm into the dentin (1-1.25 mm gingivally, 1.5-1.75 mm occlusally)
Axial Wall
o Smooth
o Curved M-D
o Straight O-G
o Parallel surfaces
Mesial and Distal walls
o Smooth
o Diverges, creating 90 cavosurface angle
Occlusal wall
o Smooth
o Straight mesiodistally
o 90 cavosurface angle
o If the cavity is extended too far occlusally, then the O and G-walls are now
divergent. Need to place a retention groove 0.5 mm deep into the DEJ to create
retention
Gingival wall
o Smooth
o Straight mesiodistally
o 90 cavosurface angle
o Retention groove 0.5 mm deep placed in gingival wall 0.5 mm deep to the DEJ
Gingival wall is slightly divergent due to the angle of the enamel rods. Need
to add the groove to so the cavity can keep in line with the enamel rods and
stay strong, but still have retention
Cavity Refinement
o Internal line angles well defined but not sharp (#245 bur)
o Angles between the surfaces are rounded
o Cavosurface margins regular, well defined, well supported
o Cavity is free of debris and moisture
o If the prep is spherical instead of box like, diferential forces at the margins will
cause the amalgam to rotate and come out
Most common fractures with class Vs is a cusp breaking. This is because usually theres
another class I or class II, and so the cusp is isolated between two diferent restorations

Amalgam Condensing and Carving

Mercury Hygiene
o Salvage all amalgam scraps and store dry in a closed container
o Avoid heating amalgams
o Use water spray and suction when cutting dental amalgams
o Avoid direct contact with freshly mixed amalgams (use gloves and rubber dams)
Dental Amalgams
o Type
Dispersed phase (Dispersalloy)

Speed
Slow set (6 minute working time)
Regular set (4.5 minute working time)
Fast set (3 minute working time)
o Size
1 spill (0.8 g)
Enough to fill a class I
2 spill (1.2 g)
Enough to fill 2 surfaces (MO for example)
3 spill (1.6 g)
Enough to fill 3 surfaces (MOD)
Armaterium
o Amalgam capsules (dispersalloy)
o Amalgam well
o Amalgam carrier
o Amalgam condensers
Minn 2
o Burnishers
Egg burnisher
Ball burnisher
PKT 3
o Carvers
Walls 3
Hollenbeck
Discoid-cleoid
Compaction Steps
o Pretest the condenser to make sure the size fits in the cavity
o Triturate according to the manufacturers specks
Amalgam mixer, amalgamator, or triturator are names for the mixer
Mixing time for our capsules is 8 seconds on medium (turtle)
o Working time starts as soon as the mixing ends
Our capsules are 4.5 minutes of working time:
3.5 minutes for condensation
1 minute for initial carving
o Express plastic amalgam into the cavity preparation and condense
Objectives of condensation
Adapting amalgam intimately to walls, angles, and margins
Eliminating air voids and porosities
Brings mercury-rich material which has inferior physical properties to
the surface and can then be removed
Technique
Organize: spread the amalgam out evenly over the entire preparation
Expressing and condensing should be done in layers (3 to 4) so that
the amalgam will properly adapt into the corners and walls (instead of
absorbing some of the compressing energy and not fully adapting)
Condense the amalgam in a stepwise pattern
o Apply approximately 3-4 pounds of pressure
o

Mixed lathe cut and spherical, high copper

Spherical (Tytin)
Spherical, high copper

Begin condensing in one end of the cavity prep and move to the
other end
o Near vertical walls, include lateral components to the
condensation force for proper adaption
o Each successive push should overlap the previous site
o Continue in this stepwise pattern until the entire surface is
covered.
o Do this quickly to stay within working time
Last layer should be overfilled by 1 mm and condensed with the large
end of the condenser.
o This allows the removal of the high mercury amalgam
o Angling the condenser face to match the tooth contours at the
margins creates the initial anatomy and condenses the material
at the height of contour
o Pre-carving burnish with the egg burnisher
Place the pointy side in the central groove but dont cross over it. This will
place the central groove in the wrong place
Begins the establish the contours of the amalgam, allowing the contours of
the tooth establish the contours of the amalgam
o Carving
Initial carve
Be gentle so as not to dig into the amalgam
The Walls 3 rounded end is good since its so big
Gently go around the outside and remove flash as well as bring the
amalgam down to the margins of the prep
Anatomy
Carve the grooves and anatomy into the amalgam
Use a Hollenbeck, cleoid end, or triangular edge of the Walls 3
carver
o Post-carving burnish
Wait 20-30 minutes after the trituration. If you dont wait long enough, the
amalgam will be compressed or altered
Use a PKT 3 or a ball burnisher.
Burnish decently hard until the amalgam shines. This helps reduce the
amount of plaque that can stick
Occlusal Anatomy for #30
o Central groove rises and falls from M-D, its not linear
o Deep anatomy is created by carving without guidance from adjacent tooth slopes or
burnishing too early
This leads to a weakened amalgam, and the margins will probably recede or
crumble away, leaving exposed tooth structure
Facial cavity for # 30
o Condense carefully to avoid pushing large portions of the mass out of the
preparation mesially & distally
o Near the peripheral walls, include lateral component forces
o Create a restoration surface that is curved M-D and O-G
Gently carve back only the margins resting the instrument on the tooth,
leaving the middle alone
Be careful to maintain O-G convexity of the surface when carving back the
excess
Setting of Amalgam Restorations
o

At 1 hour, its at 60% of its final strength

At 24 hours its at 90% of its final strength
Burnish with discs and greenie/brownie after 2 days
o Corrosion seal of margins takes 6-24 months (due to expansion from corrosion)
Stages of amalgam plasticity
o Stage 1: maximum plasticity
The amalgam appears to be semi-fluid. It ofers no resistance when slicing it
o Stage 2: medium plasticity
Amalgam mass holds its form. It slices easily into thin slices, may curl on the
blade, and it carves easily
o Stage 3: Insufficient plasticity
Amalgam feels brittle. Requires heavy force to carve. Difficult to slice and
sections tend to fracture
o Stage 4: No plasticity
Amalgam is very brittle and non-carvable. It fractures into small pieces rather
than slices
o
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Dental Caries

Dental Caries: It is a disease, and a singular noun. You cant find multiple caries, but you
can find multiple caries lesions
Definitions
o Caries lesion: changes in the teeth caused by disease creating decay
o Incipient caries: the earliest stages of a caries lesion. Earliest visible detection of
caries
White, cloudy looking demineralization
This is not treated with surgical intervention, lesion is still only in the enamel
o Cavitated lesion: lesion that has reached the dentin and has resulted in substantial
structure loss.
Have opaque white halos around them showing the undermining and
demineralization of the enamel covering it
When active they are more pale white, and the more inactive they are the
darker they become due to the de-remineralization processes
Go from pale white, to yellow, to brown, to black
This needs to be treated with surgical intervention
o Coronal Caries: caries that is localized to the crown of the tooth
o Cervical enamel caries: caries that are only in the enamel, but close to the CEJ
o Root caries: caries in the root. Begin in the dentin (cant detect when its in the
cementum) and spread aggressively
o Primary caries: initial carious lesion of a tooth
o Secondary caries: a secondary carious lesion of a tooth
Residual caries: caries accidently left behind or purposefully left behind to
hopefully allow the pulp to survive (should not ever be done)
Recurrent caries: caries that begin at the surface of a restoration
o Early childhood/baby bottle caries: aggressive caries that completely destroy the
teeth and found in children
Often due to drinking sugary formula or other sugary drinks
o Rampant Caries: caries that rapidly destroy teeth
Basically the adult equivalent of early childhood caries
o Older terms

Senile caries: aggressive caries in the elderly due to a reduction in saliva.

Saliva reduction is due in part to aging salivary glands, as well as from
medication
Cemental Caries: older name for root caries
Radiation caries: aggressive caries resulting from radiation exposure or
treatment. Initially thought to be caused directly by radiation, but now known
its due to destruction of salivary glands.
Incipient Caries Lesions
o Active (currently undergoing decay) or inactive (decay process has been halted)
Active: more dull and chalky feeling due to lack of covering enamel
Inactive: more glassy and hard due to remineralization of surface enamel.
Tactically, dont feel any diferent
o Usually seen at the cervical region (class V)
o Parallel to the free gingival margin
o Other similar condition
Hypoplasia: improper development of the hard tissues.
Demineralization can be anywhere and is not parallel to the free
gingival margin (parallel to the incisal edge for instance)
fluorosis: staining and unevenness in the teeth due to overexposure to
fluoride during development
Stains are not parallel to the free gingival margin
More resistant to caries, but if bad enough the brown areas will flake
of and leave dentin exposed
Ortho treatment can take of enamel from the teeth
o Formation process
Enamel first demineralizes into the tooth
The outer surface will remineralize if the bacteria are stopped and the
pH balance shifts toward remineralization
The porosity continues to grow deep until it reaches the DEJ, which at that
point becomes a cavitated lesion
o Enamel lesion naming system
E1: lesion is confined to the outer of the enamel
E2: lesion reaches the inner of the enamel
Seen on bitewing radiographs
Cavitated Lesions
o Dentin lesion naming system
D1: Outer 1/3 of the dentin
D2: Middle 1/3 of the dentin
D3: inner 1/3 of dentin, near the pulp
o Class V
Once the lesion reaches the dentin, the enamel becomes undermined and will
eventually crumble away
Tend to go M-D than migrate incisally
Diagnose visually primarily. Can use an explorer as a secondary means
o Class I
Dark stains in pits and fissures is often diet related, not necessarily caries
lesions
Very quickly reach the dentin since its so close, and very difficult to diagnose
early
Cant pick up incipient caries in pits and fissures

Class

Explorers dont help much since they get stuck in the fissure or pit before it
reaches the lesion
Primary diagnosis is visually. Look for white halos in the enamel after cleaning
pits and fissures
Hidden lesions: deeper caries that are spread much more widely than
expected after the initial diagnosis
Enamel is much harder to demineralize. Once it reaches the dentin, it
spreads much more rapidly
II and III
Primary diagnosis is with Bitewing radiographs
Usually start forming cervical and lingual to the contact
Can also visually be detected for class IIs by seeing opaque white areas at
the marginal ridges

Root caries
o Root Caries Severity Index of Billings
Grade 1: Incipient caries, no surface defect. Softening of just the surface
tissue
Basically undetectable to us
Grade 2: Shallow surface defect, less than 0.5 mm
Treated by scaling away the defect
Grade 3: Cavitated lesion reaching the dentin
Needs to be treated with a restoration
Grade 4: Lesion reached the pulp (doesnt take very long to reach the pulp)
o Often start at the CEJ and progress.
They can spread and undermine the enamel as well
o Similar conditions
Cervical Abrasion/ Abfraction: flexure of the teeth from parafunctional habits
leads to loss of tooth structure in the cervical area
Flexure in the cervical area causes cracking, which is then brushed
away and leaves open tooth structure
Erosion: Acid removal of tooth structure
Found globally in the mouth and will also reduce the contacts of the
teeth
Can be caused from stomach acid or acid foods/beverages
External Resorption: Body resorbing minerals from an area of the body,
usually after trauma
Has distinct/defined borders, while root caries would have difuse
borders
Starts subgingival instead of supragingival, and it also fills up with soft
tissue.
Will be exposed eventually if the PDL migrates far enough apically
Cervical Burnout: a radiographic artifact produced by a localized, relative
radiolucency. Radiopaque components generating the artifact will surround
the area
Usually is bounded by CEJ, crest of alveolar bone, lip line, or calculus
Inspect the teeth clinically to back up the radiographic interpretation
o Distinguishing active vs. inactive
Active
Yellow to brown
Surface defect possible

Tacky and leathery

Inactive
Dark brown to black
Surface defect possible
Hard and glassy

Notes from the Book

The specific plaque hypothesis for dental caries formation is more favored than the nonspecific
Dental caries is a transmissible disease that can be spread tooth to tooth and person to
person due to caries pathogens
Caries Pathogens
o Mutans streptococci: chief pathogen in dental caries initiation
Reside almost exclusively on non-shedding teeth
Acidogenic (tend to lower pH, make acid)
Acidouric (can thrive in a low pH environment)
Produce intracellular and exctracellular polysaccharides. The extracellular
polysaccharides initiate dental caries
o Lactobacilli: Involved in the propagation of caries. Take over after strep mutans
Primary habitat is dorsum of the tongue
Acidogenic and acidouric beyond that of strep mutans
Doesnt produce extracellular polysaccharides, so it cant initiate caries
o Actinomyces: may be involved in root caries
Acidogenic but not acidouric
Cariogenic diet
o Frequency and consistency of sugar consumption are more important that quantity
Eating more sugar during 3 meals did not increase caries, eating it more
often did.
Stephan Curves: describes the pH at the interface of the dental plaque and the tooth
o Initial fall: due to conversion if sugars into acidic compound
o Acid plateau: between pH 5-5.5, it holds steady
Inadequate bufering or continuous intracellular polysaccharide production
will lead to 30-60 minutes of low pH
o Gradual return: slow return up to pH around 7.0
Host factors
o Saliva
Dilutes
Bufers
Immunological function
Remineralization
Lubrication of oral tissues
o Acquired enamel pellicle
0.1 to 3 m thick
Contains receptors for initial colonization of bacteria
o Tooth factors
Occlusal pits/fissure, proximal contact, and interfaces with restorations are
main areas for colonization
Much harder to grow on a smooth surfaces
Only need 3,000 colony forming units/mL (cfu/mL) for pits/fissures
Need 45,000 cfu/mL for smooth surfaces like on the lingual wall

Malocclusion, poor access for home care, and non-functional teeth are more
susceptible
o General Health
Anything reducing ability to perform home care increases caries risk
Caries may be increased by certain medications containing sugars
o Fluoride increases caries resistance
Natural history of Dental Caries
o It is a reversible disease until it reaches the dentin (cavitation/tissue morbidity)
Subclinical phase is early, clinical phase is once theyre visibly detectable
o Evidence of an active lesion
Increase in size over time
Soft texture
Bacterial sampling identifies high levels of pathogens
o Inactive lesion
Remineralized
Can be white, yellow, brown, or black due to dentin color
o Rampant caries tends to show up in people who are
Addicted to cafeine-containing soft drinks
Head-and-neck radiation patients
Early childhood caries
Root caries
o Lesions generally do not develop in the gingival sulcus. However, they do retain
more plaque, which leads to marginal gingivitis
o Usually asymptomatic until it reaches the pulp
Comprehensive caries control involves
o Caries risk assessment: estimating how prone someone is to caries
Saliva output
Fluoride exposure
Frequency of fermentable carbs
History of caries lesions
o Caries risk testing
Determining saliva flow rate
Chair side culture test for causative microorganisms
Dietary analysis
Caries risk status
Caries Frees: patient does not and has never had caries
Caries Active: patient has developed frank caries lesions in the past
year
Caries prone: patients has had no frank lesions in the past year, but
has incipient lesions or other caries risk factors are present
Caries inactive: theres a history of caries activity, but nothing new in
the past year and no new caries risks have arisen
o Specific control measures
Diet modification
Fluoride treatment
Xylitol chewing gum
Xylitol is a sugar substitute that the bacteria cant process, and then
waste energy trying to digest it.
Chlorohexidine mouth wash
Exogenous calcium phosphate

Milk-derive protein called casein-phosphopeptide amorphous calciumphosphate (recaldent)

Beneficial to any caries active patient
Restorative treatment
Pit and fissure sealants