College of Dentistry

Operative Dentistry VI

Management of Mutilated Vital Teeth - 2

Dr. Hazem El Ajrami

 Line of Treatment:
Adhesives.
Complex restorations (Pin and pinless
restorations).
Intracoronal and extracoronal restoration
(Inlays, onlays, pinlays, laminates, crowns).
 Complex restorations
(Pin and pin less restorations)
Indications:
1. Control restoration in questionable pulpal
&/or periodontal prognosis.
2. Auxiliary retentive means. In the form of pins
are often required for restoration of mutilated
and badly broken down teeth, especially in
restoration of:
Large cervical lesions.
Fractured cusps of posterior teeth.
Extensive proximal lesions with inadequate box
form and or occlusal locks i.e. with inadequate
retention form.
Large complex multiple surface lesion
combining occlusal, proximal, and cervical
areas.
Incisal corners (Class IV) with translucent tooth
colored restorative materials.
Seriously undermined buccal cusps of lower
molars.
Hypoplastic teeth.
Teeth subjected to additional stresses.
3. Reciprocal retention mode for preparation
containing principal retention modes which
are insufficient to prevent restoration
displacement in a given direction.
I. Pin-Retained Direct Restorations:
Pins provide retention & resistance form.
Pins do not strengthen either the tooth or the
restoration (actually weaken both).
Therefore, limit use to minimum as
necessary. It is just mechanical interlocking
of amalgam with undercuts in the pin. Pin
retention depends on resiliency and firmness
of dentin so, place only in healthy dentin.
 Advantages:

1. Cavity preparation is more conservative

than that for cast restoration.
2. The restoration can be concluded in one
session.
3. These restorations are of lower cost than
casting ones.
 Disadvantages:
1. More interfaces with more tendencies for
microleakage.
2. Affect the tensile strength of final restoration.
3. Crazing or internal dentin pressure could be
formed during drilling pin channel or pin
insertion.
4. Risk of perforating pulp or external tooth
structure.
Tooth preparation:
Through excavation of carious dentin and
removal of all undermined enamel. The
dentin floor must be sound and solid.
A ledge or shelf is then prepared inside the
dentino-enamel junction for pin placement.
The rim of the preparation in the damaged
areas is then squared to resemble a shoulder
finishing line. This squaring is perforated to
create a room in dentin for pin placement and
to facilitate placing the amalgam matrix.
 Additional undercut can be made in the cavity
walls to look and assist the retention provided
by pins.
The cavity depth is detected to determine the
type or base and intermediate base that should
be utilized. The cement base is placed at the
bottom and flattened, so that it will allow
sufficient amalgam thickness in the occluso-
cervical direction and around the pins. Care
should be taken that the basing procedure
should not interfere with the condensation of
amalgam around the pins.
 Pin design:
A. Number: It depends on amount of dentin
receiving pin, amount of retention required,
size of pins, amount of missing tooth
structure. One pin /missing cusp /missing line
angle /missing proximal surface /missing
axial wall. When several pins are used: They
should be placed at different levels to
decrease stresses resulting from pin
placement in the same horizontal plane.
 Inter-pin distance dependent of pin diameter.
Each pin must be opposed by another retention
feature: retention groove, amalgapin,
segmental circumferential slot or another pin.
B. Location: The pins must be located in areas
where greater stresses occur in the
restoration. These areas are located under
marginal ridges, cusp tips and line angles of
the tooth. The pinholes should be placed
midway between the root surface and dental
pulp. By this way, it is approximately 0.5
mm apart from DEJ into dentin. The pins
usually are not parallel to each other and this
provides more retention.
 For easy determination of the exact direction
of pinholes, it should be parallel to the external
surface of the tooth, or root rather than to the
long axis. This can be achieved by holding flat
bladed instrument tangentially to the external
surface of the tooth or root and the pinhole
direction is made parallel to this blade.
C. Diameter: The chosen size depends on
amount of dentin receiving pin and the
amount of retention required. They have
different sizes according to their types:
I. Cemented pins.
II. Frictional grip or friction lock pins.
III. Threaded pins (T.M.S).
I. Cemented pins:
For this type, the pin hole is larger in
diameter than the pin. These come in three
sizes.
II. Frictional grip or friction lock. pins:
In this type, the channel is slightly
narrower in diameter than the pin. These
come in one size only.
III. Threaded pins (T.M.S):
In this type, the pin channel is in diameter
is narrower than that of the pin.
These come in four sizes.
Pinhole drilling:
Starting-point was made with small round bur
in the above mentioned predetermined
location to a depth of 1.2 mm to avoid twist
drill movement.
The drill must be run at a very slow
continuous speed not stopping until the drill
is completely withdrawn from the pinhole.
The drill should be air cooled and the flutes
kept unclogged to prevent friction, heat
damage and breakage.
 The depth of the pinhole should be from 1 to 4
mm depending on the type of pin technique
and available tooth structure. The deeper the
hole the more secure the pin providing
increase in retention and resistance to
displacement.
The pinhole should be placed entirely in
dentin. Placement of pins at various depths is
desirable to distribute stresses at different
levels and to minimize a possible fracture line
in the root.
 Pin placement techniques:

A. Cementing technique.

B. Self threading technique (thread-mate

system TMS or screw pins ).

C. Friction-locked or tapping technique.

A. Cementing technique:
The pinhole in the cementing technique
should be coated with cavity varnish using an
endodontic paper point. This was achieved to
minimize the irritational effects of the
cementing material employed. Unfortunately,
coating the pinhole with cavity varnish was
found to decrease the retention property of the
cemented pins in their corresponding holes.
The desired length of the pin (in pinhole and
that projecting in amalgam) is measured, cut,
bent, and trial fitted before cementation.
 The pin must be covered with a 2 mm
thickness of amalgam on top and side of the
pin in the final restoration.
 Pin cementation: The cement mix should be of a
thin consistency mix (inlay mix). By the aid of
lentulo spiral the cement is transferred into
pinholes in a low-speed contra-angle, with the
help of plier, the pins were dipped into the
cement and inserted into their corresponding
holes, held steady until no floating tendency is
observed. The little ring of hardened cement
around each pin should be removed with sharp
explorer to allow amalgam to contact the entire
pin protruding out of the cavity.
 Advantages:
1) No pressure on dentin crazing.
2) Used in teeth with little dentin thickness.
3) Used in endodontically teeth.
Disadvantages:
a) Weakest type of pins.
b) Irritational quality of zinc phosphate cement
can not be ignored even when using cavity
varnish.
B. Self threading technique (thread-mate
system TMS or Screw Pins):
The pin retention relies on the mechanical
grasp of the threads into dentin and of the
visco-elastic properties of dentin.
This technique offers an advantage of
providing a self-shearing pin which shear or
break itself when the pin has reached the
bottom of the hole and has the advantage of
preventing excessive pressure during
screwing, and the twoin-one of 8 mm length
and breaks into 4 mm after full seating.
 Advantages over cementing technique:

1. No cementation complications.

2. No change for pulp irritation.

3. The strongest individual pin retention.

 Disadvantages:
1) Internal stresses to the tooth, which may lead
to fracture.
2) Pre-insertion bending and trial fitting is
impossible.
3) Post-insertion bending is possible, but gives
additional risk for fracture.
4) Not recommended for non vital teeth.
C. Friction-locked or tapping technique :
The pin is inserted in the end of pin-setter
and driven to the base of the hole with a pin-
setter and mallet in the path of withdrawal of
the twist drill.
 Advantages:
a) Eliminate the pin cementation procedure.
b) Quickest and easiest method where access
permits pin placement.
c) Strong individual pin retention.
d) Provided in a variety of precut lengths.
 Disadvantages:
1) Internal stresses on the tooth structure
resulting from pin insertion forces which
may cause fracture of lateral walls.
2) Pre-insertion, bending and trial fitting is
impossible while post insertion bending runs
the additional risk of tooth fracture.
3) It is not recommended for use in non-vital
teeth because of loss of dentin resiliency.
 Restoration procedures:
A thin copper band is selected as a matrix to
encircle the tooth or automatrix can be used.
The band is then placed on the tooth stump
and all dimensions are then checked. Then
the band is stabilized by wooden wedges and
green stick compound. This method produces
a good adaptation of the copper band to tooth
surface.
 Numerous mixes of amalgam will be required
for filling large mutilated cavity. Every, effort
is performed not to interrupt condensation.
Special condensers of 0.5 or 1 mm diameter
are helpful in beginning condensation and
adaptation of alloy around the pins.
After the alloy has been adapted around and
over the tops of the pins, condensation is
achieved by larger condensers to compress
amalgam on the top of the pins. An overpack
of 1 mm is performed to pull up the residual
mercury, so that it can be removed during
carving.
 The copper band is then removed after
condensation.
Carving can be started after initial setting to
produce the functional anatomy and contour and
the occlusion is checked for removal of
premature contact areas. The polishing can be
done after 3 days.
Thank You