Fundamentals of Tooth

Preparation for Amalgam

Restorations

-Radhika Verma
MDS Ist yr

1
 Contents
Introduction
Definition of tooth preparation
Fundamentals of Tooth Preparation
The Need for Tooth Preparation
Objectives of Tooth Preparation
Factors Affecting Tooth Preparation
Why Amalgam for restoration
Indications and Contraindications of Amalgam restoration
Terminology
Carious lesions
Noncarious lesions
Tooth preparation
Classification
Steps in Tooth preparation For Amalgam Restoration
A) Initial Steps
Outline Form
Resistance Form
2
 Contents cont.

Retention Form
Convenience Form
B) Final Steps
Removal of Remaining Carious Dentin
Pulp Protection if indicated
Secondary Resistance and Retention Form
Procedures for finishing external walls
Cleaning, Inspecting, Sealing
Tooth Preparation for Unconventional Amalgam
Restoration
Tunnel preparation for Amalgam
Bonded Amalgam
Box only cavity
3 References
 Why Amalgam Restorations?
Dental Amalgam:

Excellent longevity- Upto 20 years

Low Failure rate i.e. 0.3-6.9% at one year
Condensable, easily carved, burnished, polished
Wears at a rate similar to the tooth.
Still the best plastic restorative for most class I
class II and all multi surface restorations
Low cost

4
 Where?
Indications Contraindications

Moderate to large
restorations.
Esthetically prominent
Restorations not in highly areas.
esthetic areas of mouth.
Small to moderate
Restorations with heavy class I and II
occlusal contacts. restorations that can
Restorations that can be be well isolated.
moderately isolated.
Restorations extending
onto the root surface.
Abutment teeth for P.D.
5
 Primary Caries
Primary caries is the original carious
lesion of the tooth.
Morphologically it can be
Pit and fissure caries
Smooth surface caries
Root caries

Secondary Caries[recurrent]
Occuring at the junction of a restoration
May progress under the restoration.

6
 Pit and Fissure Smooth Surface
Caries Caries

Pits and fissured

Smooth area of
defects of enamel
exposed to caries enamel surface that is
conducive conditions habitually unclean
and is usually covered
Pattern of caries is
with plaque.
base to base
Pattern of carious
lesion is base to
apex

7
 Senile/ Root Caries
Occurs post gingival recession

Root caries is usually more

rapid than other forms of
Caries and thus should be
detected and treated early.

Residual Caries
Caries that remains in a completed
tooth preparation, whether by intention or by accident.
Caries left at the DEJ is not acceptable.
8
 Forward Caries Backward Caries

When the spread of
caries along the DEJ
Caries cone in
exceeds the caries in
enamel is larger or the contiguous enamel,
at least the same caries extends into this
size as that in dentin enamel from the
junction

9
 Acute, Rampant caries Chronic
caries
Advancing front has mainly acid Advancing front
has bacteria
Usually lighter colored Darker due to
extrinsic staining
Reparative dentine Not present +
Sensitvity + Usually not

10
 Non Carious Lesions Requiring Restoration
1. Abrasion 1

2. Abfraction
3. Erosion
4. Attrition
3
5. Fractures
6. Non Hereditary Enamel Hypoplasia
7. Hereditary Enamel Hypoplasia
[Amelogenesis Imperfacta, Dentinogenesis
Imperfecta]
4
6 7a

7b

11
 Simple .

Compound.

Complex .

12
 Direction of Enamel Rods

90

13[2from the
perpendicular to
tangent]
13
 Strong Vs Strongest Enamel Margins

(1)Strong enamel margin: it

is formed by full-length
enamel rods whose inner
ends are on sound dentin

(2)Strongest enamel
margin: If these full
length enamel rods are
also buttressed on the
preparation side by
progressively shorter
rods whose outer ends
14
have been cut off but
whose inner ends are on
 Initial Tooth Preparation Stage
Initial tooth preparation is the extension and initial
design of the external walls of the preparation at
a specified, limited depth so as to provide
Access to the caries or defect,
Reach sound tooth structure (except for later
removal of infected dentin on the pulpal or axial
walls),
Resist fracture of the tooth or restorative
material from masticatory forces principally
directed with the long axis of the tooth and
Retain the restorative material in the tooth

15
 Initial steps
Step I: Outline Form And Initial Depth

Step 2: Primary Resistance Form

Step 3: Primary Retention Form

Step 4: Convenience Form

16
 OUTLINE FORM

Establishing the outline form means:

(1) Placing the preparation margins in the

positions they will occupy in the final preparation,
except for finishing enamel walls and margins

(2) Preparing an initial depth of 0.2 to 0.8 mm

pulpally of the DEJ position or normal root-surface
position (no deeper initially whether in tooth
structure, air, old restorative material or caries
unless the occlusal enamel thickness is minimal
and greater dimension is necessary for strength of
the restorative material).
17
 Two outline forms can be
appreciated

External outline form - which

dictates the external perimeter
of the outline form.

Internal outline form - which

dictates the inner dimension
and detail of the cavity.

18
 Principles
All friable and/or weakened enamel should be
removed:
All surface involvement of enamel from the stage of
decalcification to the stage of enamel penetration.
Include all enamel that has been undermined by
caries.
All faults should be included

Extend far enough on tooth surface so that the margins

of the preparation will be located on finishable, self
cleansable areas.

Extend pulpally or axially to include the DEJ and

penetrate to an average depth of 0.5mm into the
dentin.
19
 Features
1. Preserving cuspal strength,

2. Preserving marginal ridge strength,

3. Minimizing faciolingual extensions,

4. Using Enameloplasty,

5. Connecting two close (less than 0.5 mm

apart) faults or tooth preparations

6. Restricting the depth of the preparation

20
into dentin
 Factors
The extent of caries involvement

Extent of potential threats (enamel cracks,

deep non carious fissures, decalcifications,
defects)

Conservation of as much structurally sound

tooth as possible.
Enameloplasty

21
 Enameloplasty

A, Developmental fault at terminal end of fissure. B, Fine-grit

diamond stone in position to remove fault. C, Smooth surface
after enameloplasty. D, Cavosurface angle should not exceed 100
degrees, and marginal-amalgam angle should not be less than 80
degrees
22
 Depth restriction
Keeping the depth 0.2-.5mm, into DEJ to take
advantage of resiliency of dentin.

Avoid termination at DEJ because

Sensitive area
Thin layer of enamel may crack
under force.

23
 The finish margin
should be in a self cleansing, finishable area
Restoration however well adapted, is
usually surrounded by a gap zone of
microleakage(20-120 microns)
Should not terminate on eminences or
occlusal contacts

24
 Esthetics
Placing margins where they are masked
II to periphery of tooth
Imitation of Biological contours

Patient factors: Age, deblitation, handicap,

other treatments required

25
 Pit And Fissure Cavities

The following additional factors are to be

considered:

Avoid terminating the margin on extreme

eminences such as cusp heights and ridge
crests.

Circumventing of cusps should be followed

resulting in a smooth free flowing outline form.

26
 In case of conservative cavity preparation
shallow supplemental grooves and fissure
crossing lingual or facial ridge can be
eliminated by enameloplasty.

When two pit and fissure cavities have been

separated by less than 0.5 mm of sound tooth
structure, they should be joined to eliminate a
weak enamel wall between them.

27
 To Cap or not to Cap

2/
3 1/2

Depends upon the extension from a primary

groove toward the cusp tip

Ideally the isthmus should be as narrow as

possible from to 1/3 of the intercuspal
28
distance.
 Outline Form Of Proximal Smooth
Surface Preparation

All enamel directly attacked by caries & all undermined

enamel.

Sufficient enamel and dentin to locate pulpal and axial

walls upto the depth of 0.5mm from DEJ.

Margins should extend to self-cleansable area facially

and lingually, including contact areas and end in
embrasure area.

Extend the outline form to provide sufficient access for

proper tooth preparation, restoration placement and
finishing procedures.
29
 Proximal Smooth Surface Preparation
--Gingival margins
Older concept [GV
Black] Newer concept [Dr.
John McCall ]

The gingival margin

should be placed 0.5 to To place the margin
1.0 mm apical to the occlusal to or just clear
crest of healthy free of the margin of the
gingiva. gingival crest.
Due to the natural As gingival
alkalinity of crevicular inflammation can
fluid and less chances change the crevicular
of food impaction in fluid to an acidic form.
this area.
30
 Proximal Smooth Surface Preparation
Facial &Lingual margins
Flare and mesiodistal width of embrasures.
Wider and more flared the faciolingual
embrasures are, less are the chances of food
accumulation and therefore requires less
extension facially and lingually.

Occlusal and masticatory forces.

The more ideal the relationship between the
adjacent and opposing teeth is, the better is the
cleansability of the facial and lingual
embrasures. Therefore, less extension is
required.
31
 Age of patient and tooth structure and attrition of
contact areas.
An older tooth has higher mineral content, is
more resistant to caries and therefore requires
less extension.

Creation of a more convex restoration.

More convex restorations lead to wider
embrasures and therefore less extension and
better self cleansable areas.

Caries index and oral hygiene.

Faciolingual extension of the cavity in the
corresponding embrasure is directly proportional
to the caries index.
32
 Cuspal lesions

The preparation walls may need to diverge

occlusally to ensure a 90-degree cavosurface
margin.

A depth of 1.5 mm is sufficient to provide bulk of

material for strength but extension of the
preparation depth to 0.2 mm into sound dentin
may require deeper invasion into the cusp.

Retention of the restoration is ensured by the

creation of small undercuts along the internal line
33 angles.
 Smooth Surface Preparations For Anterior Teeth

In Class III preparations, the incisal margin may

be placed in the area of contact.

Axial wall dentinal depths in class III: crown,

0.5-0.6 mm ; root, 0.75-0.8 mm

Anatomically curved outline from the incisal to

the gingival margin results in a less visible
margin

34
 The lingual outline blends with the incisal and
gingival margins in a smooth curve, creating a
preparation with little or no lingual wall.

The outline form of Class V tooth preparations

is governed ordinarily only by the extent of the
lesion, except pulpally.

Extension mesially, gingivally, distally, and

occlusally (incisally) is limited to reaching
sound tooth structure.

35
 The axial wall should be uniformly deep into
dentin and follow the faciolingual contour of
the external tooth surface

A limited initial axial depth of 0.5 mm inside

the DEJ translates into usually 1 to 1.25 mm
total axial depth incisogingival location.

The axial depth is approximately 0.75-0.8 mm

on the root surface preparation

36
 RESISTANCE FORM

Primary resistance form may be defined as that

shape and placement of the preparation walls that
best enable both the restoration and the tooth to
withstand, without fracture, masticatory forces
delivered principally along the long axis of the tooth.

The fundamental concept of resistance form is

based on the development of internal stress within
the restoration and remaining tooth structure to
occlusal loading.

When the internal stress developed exceeds certain

limits, structural failure will result.

37
 Features
Relatively flat floors, straight walls box like cavity
To prevent restoration movement.
(rounded pulpal floor restoration rocking action
wedging force shearing fracture of tooth
structure.)

Rounded internal line angles.

The tensile stress in the restoration is least for the
sloping axial wall in combination with the flat
38 pulpal wall.
 Adequate depth of cavity [1.5 mm] to ensure
thickness of restorative material

Reduction of cusps for capping when indicated

Termination of the preparation in an area of

predictable enamel rod direction

Inclusion of weakened tooth structure

Circumvention of cusps and marginal ridges

39
 RETENTION FORM
Primary retention form is that shape or form of
the conventional preparation that resists
displacement or removal of the restoration
from tipping or lifting forces.

Amalgam is not inherently adhesive to enamel

and dentine, the cavity must be designed to
retain the filling.

40
 Obtaining Retention Form for Amalgam
1. The material is retained in tooth by developing
external cavity walls that converge occlusally.
Facial and lingual walls of both- occlusal and
proximal portion of preparation for amalgam
converge towards occlusal surface.

2. Inverted truncated cones or undercuts: improve

retention.

3. Dove tail: purposeful modification which

prevents tipping of restoration.

41
 CONVENIENCE FORM

It is the shape given to tooth preparation or

modifications added to preparation and
instrumentation, which enable adequate
observation, accessibility & ease of operation in
preparing and restoring the cavity.

42
 Obtaining Convenience Form
A. Modification in tooth preparation

1. Flaring some walls

2. Extending proximal preparations beyond
proximal contacts is another convenience
form procedure.

B. Instrument modification
3. Contra-angling or addition of several angles
to shank of instrument facilitates access and
force
application in proper direction.

43
 C. Separation-
1. Wedging teeth away from each other to
make inter-proximal instrumentation
convenient.

44
 FINAL TOOTH PREPARATION STAGES
Step 5: Removal of any remaining infected
dentin and/ or old restorative material, if
indicated

Step 6: Pulp protection, if indicated

Step 7: Secondary resistance and retention

forms

Step 8: Procedures for finishing external walls

Step 9: Final procedures: cleaning, inspecting,

45
sealing
 REMOVAL OF REMAINING INFECTED
DENTIN OR OLD RESTORATIVE
MATERIAL, IF INDICATED
In cases of deep caries normal depth of
preparation does not involve entire lesion and
remaining carious dentin has to be additionally
removed.

Soft debris need only manual excavation by

spoon excavator. [from periphery to centre.]

Disclosing agents are used :0.2- 0.5% of basic

fushin which stains area of irreparable decay.

If decay is hard- slow speed round bur is used in

46
brushing strokes with minimal axial or pulpal
pressure and with lot of water content.
 Any remaining old restorative material should be
removed if
(1)The old material may affect esthetics
negatively.

(2) The old material may compromise retention .

(3) Radiographic evidence of secondary caries.

(4) The tooth pulp was symptomatic

preoperatively.

(5) The periphery of the remaining old restorative

48
material is not intact
 Ideally there should be at least three seats,
tripodally distributed, for the amalgam on
sound dentin at the prescribed level of the
pulpal wall in initial tooth preparation

49
 PULP PROTECTION, WHERE INDICATED

As a general rule, it is desirable to have

approximately a 2-mm dimension of bulk
between the pulp and a metallic restorative
material. This bulk may include remaining
dentin, liner, and/or base.

50
 The Need
Cut dentinal odontoblastic fibrils when exposed
to irritating material may result in
degeneration of affected odontoblasts

Exothermic reaction of some restorative

material

Good thermal conductivity of restorative

material

Galvanic currents due to filling of dissimilar

metals

Microleakage
51
 Liners:
volatile or aqueous suspensions or dispersions
of zinc oxide or calcium hydroxide that can be
applied to a tooth surface in a relatively thin
films' and are used to affect a particular pulpal
response

As medicament.

A barrier to protect remaining dentin and

pulp.

Provide chemical and galvanic insulation and

limited thermal protection.
52
 Thin film liners (1 to 50 m)

solution liners (varnishes, 2 to 5 m)

Any liner based on nonaqueous solvents that
rely on evaporation for hardening
suspension liners (typically 20 to 25 m)
Liners based on water have many of the
constituents suspended instead of dissolved

Thick liners (200 to 1000 m = 0.2 to 1 mm) AKA

cement liners,
selected primarily for pulpal medication and
thermal protection
53
 Solution liners[Varnish ]

Most commonly used Cavity varnish[copalite] is a

mixture of 10% copal resin and organic solvents
and on application, the solvents evaporate,
leaving a resin layer over dentin.

For shallow cavities, can be applied on walls

especially in silver amalgam and cast gold
restorations.

80-90% sealing off effect is seen after double coat

application.

Decreases microleakage and reduces post

operative sensitivity.
Chemical and galvanic protection.
54
 Protection Afforded

Dimension between restoration and pulp = a

combination of natural dentin, liner, and
base.
55
 Bases:
are cements used on pulpal and axial walls in
thickness of about 0.2mm beneath permanent
restoration.

Provide thermal, galvanic, chemical and

mechanical protection to pulp.

Commonly used base materials are zinc

phosphate, glass ionomer, polycarboxylate,
zinc oxide eugenol and calcium hydroxide.

56
57
 SECONDARY RESISTANCE AND
RETENTION FORM
These are of two types:
1. Mechanical features
2. Cavity wall conditioning features

Mechanical features include mechanical

alterations of the prepared cavity.
The retentive features should be as
conservative as possible and should not
undermine the enamel. i.e. should be made
into sound dentin at least 0.5 mm below the
DEJ.

58
 Mechanical features include
1. Retention locks, & coves
2. Pin, slots, steps & amalgam pins
3. Grooves
4. Amalgam bonding agents
5. Skirts, Groove extention
6. Beveled enamel margin
7. Etching

59
 Locks
Are prepared mostly for large amalgam class II
restoration

The No. 1/4 or 169 bur can be used to prepare locks

bisecting the into the mesioaxial and distoaxial line
angles

The depth of the locks at the gingival floor is one half

the diameter of the No. 1/4 bur=.25mm and width
=.5mm

The locks should diminish in depth toward the occlusal

60 surface, terminating midway along the axial wall .
 The 4 characteristics of locks are
Position axiofacial and axiolingual line
angles of initial tooth preparation (0.2 mm
axial to DEJ).
Translation direction of movement of the
axis of the bur.
Depthextent of translation (i.e., 0.5 mm at
gingival floor level).
Occlusogingival orientationtilt of the No.
169L bur, which dictates the occlusal height
of the lock, given a constant depth.

61
 Proximal Locks

62
 Slots
These are used for retention of complex
restorations.

Horizontally oriented retention groove prepared

in dentin to increase surface area.

These are prepared in occlusal box, bucco-

axial, linguo-axial and gingival walls

Slots are particularly indicated in short clinical

crowns and in cusps that have been reduced2
to 3 mm for amalgam

63
 33 inverted cone bur is used to prepare a
slot with undercuts and round bur can be
used to prepare a slot without undercuts.

The dimensions of the slot are dependant on

the bur dimensions. 0.5 mm x0.5x0.6 mm.

64
 Grooves
They are prepared in wall of proximal surfaces at
the axio-buccal and axio-lingual line angles in a
vertical orientation. They are not extended to cavo
surface margins for amalgam restoration.

In a large Class V amalgam preparation, extending

the retention groove circumferentially around all the
internal line
angles of the tooth preparation enhances retention
form

65
 Prepare retention grooves with a No. 1/4, bur into
the occlusoaxial and gingivoaxial line angles, 0.2
mm inside the DEJ or 0.3 to 0.5 mm inside the
cemental cavosurface margin

The depth of these grooves =0.25 mm.

the bur is directed to bisect the angle formed by

the junction of occlusal (or gingival) and axial walls.

Ideally the direction of the occlusal groove is

slightly more occlusal than axial, and the direction
of an gingival groove would be slightly more
gingival than axial

66
 Class V

67
 Coves

Retention coves are appropriately placed undercuts or

small conical depression in healthy dentin

For the incisal retention of Class III amalgams, occlusal

portion of some amalgam restorations and some Class V
amalgams

If extension of a facial occlusal fissure has required a

slight occlusal divergence to conserve support of the
facial ridge then coves can be provided

If occlusal convergence of the mesial and distal walls of

the occlusal portion is absent or inadequate

68
 In a Class III preparation if less retention form is
needed, two gingival coves may be used, as opposed
to a continuous groove.

One each may be placed in the axiogingivofacial and

axiogingivolingual point angles.

The No. 33 , round bur may be used to prepare

a retention cove

The tip of the No. 245 bur held parallel to the long
axis of the tooth crown also might be used taking
care not to undermine the occlusal enamel.
69
 Alternatively, If greater retention is needed
four retention coves may be prepared, one in
each of the four axial point angles of the
preparation

Conserves dentin near the pulp, reducing the

possibility of a mechanical pulp exposure.

70
 Amalgam pins:
For larger amalgam restoration.
Compromised tooth structure

May be
Threaded
Friction retained or
Cemented

71
 Amalgam Bonding :
The primary advantages for amalgam bonding
agents in most clinical situations are the dentin
sealing and improved resistance form, but the
increase in retention form is not significant.

The attachment mechanism between the

adhesive and the amalgam is not fully
understood, but it may be
micromechanical entanglement of the uncured
adhesive material with the setting amalgam
mix during condensation . A
m
A
d R

72
 Bonding may depend on the type of amalgam
used. E.g, spherical amalgam

When using dual cure additional curing after

amalgam condensation from tooth surface walls
has been recommended.

Contradictory results

Mahler and Engle[2000] have reported no

reduction in sensitivity or superiority of strength
.

Tiget al[2005] reported in favor of using

bonding agents.
73
 FINISHING THE EXTERNAL WALL
OF PREPARATION

It is the further development of specific

cavosurface design and smoothness that
produces the maximum adaptation of restoration
to walls and margins and maximum effectiveness
of restoration.

74
 Objectives

1. To create best marginal seal between

restorative material and tooth structure.

2. Afford a smooth marginal junction.

3. Provide maximum strength of both tooth and

restorative material at and near the margins.

75
 Factors and Features
Type of the restorative material to be used

Design of the cavosurface angle and direction

of enamel rods

Degree of smoothness or roughness required

Previous restorative material used, if any

76
 Finishing
Finishing of enamel margins is carried out
almost in every restorative material.

In case of silver amalgam, butt end of the

cavosurface margins are preferred because of
poor edge strength of amalgam.

The gingival wall is slightly bevelled, thereby

removing the unsupported enamel rods.

77
 CLEANING , DISINFECTING AND
INSPECTING

Debridement of the cavity.

Leads to proper adaptation of the restorative

material.

Decreases microleakage.

Increases bulk .

Eliminates stress points .

78
 Procedure
Free the preparation of visible debris with water from syringe

and remove the visible moisture with air syringe gently.

Planing the cavity walls with hand instruments like chisels or

explorer also loosens the debris

After which the preparation is wiped with a wet cotton pellet.

Also cavity cleansers and conditioners may be used [ascorbic

acid ,acetic acid, 10% EDTA]

Use of alcohol to attempt to sterilize the preparation is

contraindicated instead H2 O2 , chloramine or saline may be

used for gross disinfection of the cavity.

79
 UNCONVENTIONAL TOOTH PREPARATIONS
-AMALGAM RESTORATIONS

Amalgam tunnel preparations

Relatively small interproximal lesions.
It conserves the proximalmarginal enamel by using
only the occlusal or a buccal / lingual approach
Angulating either mesially or distally until the
external tooth enamel is perforated.
Tooth cavity is then packed from the access
dimension.
Both effectiveness of caries removal and marginal
ridge strength are reduced in tunnel restorations
compared to conventional class II.

80
Bonded Amalgam preparations

More conservative cavity preparation can be

achieved when amalgam is bonded to a tooth.

The resultant retention with amalgam bonding is

equal to or superior to the traditional means of
mechanical retention.

81 Unbonded (left) and bonded (right)amalgam fillings

 Amalgam Box only Preparations

Only the proximal box is made and the

retention form is enhanced.

Include no occlusal dovetail or extension for prevention.

Analysis of mean failure loads by J Gorucu et al [1997],

indicated that proximal slot preparations with retention
grooves or occlusal extensions were statistically equivalent
but significantly greater than proximal slots without
grooves. The addition of an adhesive system improved
fracture values for all three types of preparations.

30% failure rate was reported by Nordbro et al[1998]

82
 References
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Aleighth Edition 2003,OXFORD UNIVERSITY PRESS
F. Khan,w. G.Young,s. Shahabi.Dental Cervical Lesions
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 Dorothy McComb, Systematic Review of Conservative Operative
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paper7.pdf
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Cells and Materials Vol. 10. Suppl. 1, 2005 (page 34)
http://www.ecmjournal.org/journal/supplements/vol010supp01/p
df/vol010supp01a34.pdf
JaleGrc, MeserretTiritoglu, GlOzgnaltay, Effects of
preparation designs and adhesive systems on retention of class II
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84
 Thank You
85