COMPLEX AMALGAM RESTORATION

DEFINITION

 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
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

o 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
o Role of the tooth in overall treatment plan

Rx. Choice for tooth is influenced by its role in overall Rx. Plan
Remember: in the clinic do not just look at the tooth but
consider its role and function

o Occlusion
Interim restorations for teeth that require occlusal alterations

o Esthetics
Metallic appearance

o Economics
Less expensive and less time consuming than cast restoration
 CONTRAINDICATIONS
 Patient has significant occlusal problems
 Tooth cannot be restored with direct
restoration
because of
anatomic/functional considerations

 Esthetics

 ADVANTAGES
 -Conserves tooth structure
 -Appointment time: one
appointment (most)
 -Resistance and retention forms
increased
 -Cost
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
CLINICAL TECHNIQUE

There are three types of complex amalgam restoration:

1. Pin-Retained Amalgam Restorations
2. Slot-Retained Amalgam Restorations
3. Amalgam Foundations
 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
o (distoincisal corner) of canine when restored with amalgam

 Alternative to pin: Lingual dovetail

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
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

 Remove infected carious dentin

 CaOH liner and resin-modified glass
ionomer base can be applied
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
 FACTORS AFFECTING RETENTION OF THE PIN
INDENTIN AND AMALGAM
 1.Type: Self threading pin is the most retentive
 2.Surface Characteristics: Number and depth of threads on the pin influence its
retention
 3.Orientation, Number, and Diameter: Placing pins in a non-parallel manner
increases their retention
 •
 Avoid bending, bends may interfere with adequate condensation of amalgam around the
pin
 •
 Pins should be bent only to provide for an adequate amount of amalgam (approximately
1 mm) between the pin and the external surface of the finished restoration

 increasing the number of pins increases their retention in dentin and amalgam
 •
 As the number of pins increases, (1) crazing of dentin and the potential
for fracture increase, (2) amount of available dentin between the pins decreases,
and (3) strength of the amalgam restoration decreases
 •
 Diameter of the pin increases, retention in dentin and amalgam generally
increases4. Extension into Dentin and Amalgam :Extension into dentin and
amalgam should be approximately 1.5 to 2 mm to preserve the strength of dentin
and amalgam

 Pin Size :Two determining factors for selecting the appropriate-sized pin are the
amount of dentin available to retention desired
 •
 Number of Pins: Factors to consider (1) the amount of missing tooth structure, (2)
the amount of dentin available to receive the pins safely, (3) the amount of
retention required, and (4) the size of the pins.

 As a rule, one pin per missing axial line angle should be used

 Pins not required if only 2 to 3 mm of the occluso gingival height of a cusp has
been removed

 Location :Factors aid in determining the pinhole locations (1)knowledge of
normal pulp anatomy and external tooth contours, (2) a current radiograph of
the tooth, (3) a periodontal probe, (4) the patient’s age
 Pinholes should be located near the line angles of the tooth, pinhole should be
positioned no closer than 0.5 to 1 mm to the DEJ or no closer than 1 to 1.5 mm
to the external surface of the tooth
 First prepare a recess in the vertical wall with the No. 245 bur to permit proper
pinhole preparation and to provide a minimum of 0.5mm clearance around the
circumference of the pin
 Pinholes should be prepared on a flat surface
 The minimal inter-pin distance is 3 mm for the Minikin pin and 5 mm for the
Minim pin
 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
 o Prepared with 33 ½ or ¼ round bur
 May be used as an alternative to pin-
 retained or in conjunction with pin-
 retained
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 ½ 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
Prepared with 33 ½ or ¼ 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
Retention differences between pins and slots
are not significant
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
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
Amalgam foundations
Tooth preparation depends on type of retention selected—pin
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 ½ 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
oThis 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
oThere is an extension into root canal space
2-4 mm (when pulp
chamber height is 2 mm or less;
anything great greater gives no advantage)