CONTENTS

Introduction Definition History Rationale Indications / Contraindications Advantages / Disadvantages Classification Pin Materials Mechanical Aspects of Pin Retained Restorations A) Pins and Tooth Structure Stressing Capability - Retention in Dentin - Microcracking and Crazing B) Pins & Restorative Materials - Effect on Strength - Retention of Pin to Material

 ANATOMICAL ASPECTS OF PIN RETAINED RESTORATIONS

TECHNIQUES FOR INSERTING PINS COMPLICATIONS DURING PIN PLACEMENT FAILURES OF PIN RESTORATION BIOLOGICAL CONSEQUENCES OTHER APPLICATIONS

INTRODUCTION
The operative dentist is confronted with restoration

of extensively damaged teeth in routine. Many a times, the damage, which may be because of caries or fracture, involves half or more than half of the tooth structure and the remaining tooth structure is not sufficient enough to retain the restoration. Use of Pins has been tried to achieve required retention in such teeth.

DEFINITION
Pin retained restoration :-Any restoration requiring

the placement of one or more Pins in the dentin to provide adequate resistance and retention forms.

Pins :- A small rod that fits into a channel drilled into

dentin away from the pulp space.

Other names Dentinal Pin / Parapulpal Pin

HISTORY
Burgess first to consider Pin retention in 1915

RATIONALE
Support the restorative material ( Retention form )
Resist their dislodgement in teeth that have been

severely damaged ( Resistance form )

Cavity preparation can also be limited to only damaged

surfaces thereby preserving Esthetics and Contours

INDICATIONS
Mutilated teeth Join two bulk Endo / Ortho RD Auxillary Prognosis

Anti rotation Post

Foundation Economical

CONTRAINDICATIONS
Large Pulp ( Young )
Occlusion problems Esthetics

ADVANTAGES
Conservative
Time Economical Retention

DISADVANTAGES Micro cracks

Micro leakage Perforation Reduces the material properties Micro fractures Crazing

CLASSIFICATION
Direct Pins / Non Parallel Pins

Types : Cemented Pins Friction Lock Pins Threaded Pins ( Most popular )
Indirect Pins / Parallel Pins

Types : Cast Gold Pins ( Smooth ) Wrought Precious Metal Pins ( Knurled / Wrought )

 CEMENTED PINS Late 1950s Markley

Pin hole diameter 0.001 to 0.002 larger than pin diameter Pin hole Pin diameter 0.027 0.025 0.021 0.020 Cemented using ZnPO4, Polycarboxylate, GIC (LC) Least retentive Least Crazing & Stress Hole depth 3 to 4mm Indications : i)Most ideal for all rest. ( least crazing and stress ) ii)Endodontically treated teeth iii)Available location of pin very close to DEJ iv)D bulk limited v)U or L shaped pins in Cl.IV rest and foundations. vi)Ideal for sclerosed , tertiary , calcific barrier or highly mineralized or dehydrated D. vii)For cross-linkage of 2 parts of same tooth.

 Advantages :

Passive retention (no stress) Less Micro leakage (cement seal) Can be cut / bent before fixing

Disadvantages

Less retention Difficult cement insertion Easily dislodged Greater time

 FRICTION LOCK PINS 1966 Goldstein

Pin hole diameter is 0.001 smaller than pin diameter Pin hole diameter Pin diameter 0.021 0.22 Tapped in place retained by elasticity of dentin Retention 2-3 times > Cemented Pins Indications : i)Vital teeth only ii)Very bulky dentin ( at least 4mm in 3 D ) iii)At least 2.5mm from DEJ iv)Use only in accessible areas ( as seating force should be parallel to pin axis) Advantages : Better retention Acquires stability immediately after insertion Disadvantages : Greater stress & Micro leakage May not reach full channel depth (gauging) Bending/contouring Increases stress Pin length judged by trial & error

 SELF THREADED PINS

1966 Going Pin hole diameter is 0.001 smaller than pin diameter Pin hole diameter Pin diameter 0.027 0.031 Regular 0.021 0.024 Minim 0.018 0.019 Minikin 0.013 0.015 Minuta Active engagement by threads + Elasticity of dentin Retention 3 6 times > Cemented pins Moderate Crazing & Stress

Indications : i)Vital teeth ii)Primary or secondary D properly hydrated iii)Pin location at least 1.5mm from DEJ iv)Minimum number of pins located v)Maximum retention

Types Standard design, 7mm length, shortened after seating Self shearing design (4mm) Twin stage (2 in 1) design Pins with a disposable latch head Advantages : Ease of insertion Maximum retention Disadvantages : Excessive stress May need Bending / Cutting May fail to seat completely Higher Micro leakage

A. Standard B. Self Shearing C. Two in one D. Link series E. Link plus

PIN MATERIALS

Used in Direct technique Stainless steel Titanium Silver Used in Indirect technique Cast Gold alloys Platinum Palladium } Prefabricated Platinum Iridium Used with Temporary Restorations Plastic Pins Aluminium Pins Acrylic Pins

MECHANICAL ASPECTS OF PIN RETAINED

RESTORATIONS

PINS AND TOOTH STRUCTURES 1) STRESSING CAPABILITIES

Type of pins Diameter of pins

Pin depth & dentinal engagement

Bulk of dentin
Loose pins

 Type of dentin

Inter pin distance

Non coinciding eccentricity in pins

or pin channel circumferences

Wedge, chisel, or irregularly shaped dentinal end of pins

 Ratio of depth of pin in dentin

to that protruding into the cavity

Number of pins in one tooth Twist drill variability Overthreading or Overriding of pins into pin channel Stress induced during shortening pins inside cavity preparation

Bending or aligning pins after dentinal engagement

Retentive features in the remaining portion of the cavity preparation

Inserting pins in stress concentration area of a tooth

2) RETENTION Type of Pins IN DENTIN

Type of involved of Dentin

Depth of engagement in

Surface roughness of Pins

Ratio of dentinal engagement

dentin

Pin channel circumference

of pins to their protruding lengths in the cavity after insertion

shape relative to that of Pin

Number of Pins Type of Cement

Mode of shortening the pins Bulk of dentin around Pin

3) MICROCRACKING AND CRAZING

Type of Pins Proximity of Pins to DEJ Induced stress in involved Dentin Thickness of adjacent Enamel Type of dentin between Pin and adjacent Enamel

PINS AND RESTORATIVE MATERIALS

EFFECT OF PINS ON THE STRENGTH OF AMALGAM & COMPOSITE RESINS

Decreases both -

Compressive strength & Tensile strength

RETENTION OF PINS TO RESTORATIVE MATERIALS Type of Pin

Pin length in restorative material Pin diameter Inter Pin distance Proximity of restorative material to Pin surface Surface material of Pins Bending of Pins

ANATOMICAL ASPECTS OF PIN-RETAINED RESTORATIONS Knowledge of Anatomy

Radiographs

Outer surface of tooth

Amount of Dentin

 Anatomical features

Tooth alignment

Cavity extent

Age or relative age

TECHNIQUES FOR INSERTING PINS

2 steps: preparation of pin channel and placement of pins.

I.Pin channel preparation :- Three basic instruments are used : A. Twist drill :Description : End cutting, bi beveled, revolving instrument made of steel. Four basic designs: 1) Regular twist drills without limiting shoulder / stop 2) Limited depth twist drills which have stop / shoulder either prefixed or adjustable to limit the depth of cutting. 3) Miniature twist drills(overall length short 17mm) which are regular or limited depth type. 4) Twist drill with parallelometer attachment

 Rules : 1) Ultra low speed ( 300 to 500 rpm ) 2) Should be revolving while inside the pin channel 3) Do not use pumping strokes 4) Never use in enamel causes drill fracture Used in direct cutting strokes
B. Number 1, 2, or 3 round burs Used to establish

the lead / pilot holes in enamel

C. Measuring probes or depth gauge

 II. Pin placement

Cemented Pin technique: Procedure: Pin channel is prepared. A piece of wire of smaller

diameter is cut using cutter to the desired length and placed in the channel with the help of lock in tweezer or hemostat for try in. The desired cement is placed in the channel using an explorer tip or lentulo-spiral at slow speed and the pin is seated.

Threaded Pin Technique: Most applicable and feasible Procedure: Pin channel is prepared. The pin has a wrench

attachment portion. Wrench can be reusable, disposable or hand piece wrench used in gear down hand piece. The pin is threaded continuously until it offers the resistance initiated by touching the channel floor. This resistance may lead to self shearing or disengagement of the driving device.

Hand Wrenches for TMS Pins

 Friction Grip Pin Technique

(Least used follow strict requirements) Procedure: Pin channel is prepared to the desired

depth and a counter sink of 0.5 mm depth is prepared at the orifice using a 168 bur. The correct length of pin is cut, held by a hemostat and seated at the orifice and a specially made seater with a concave head is firmly applied on the pin head. With a hammer, light strokes are applied to the seater head

COMPLICATIONS DURING PIN PLACEMENT PROCEDURES

Drill breakage Lateral stress

Pin breakage Loose pins Pin shears off before having reached its full depth Twist drill dulling Pin fails to bind and shear, but keeps rotating within its channel Heat generation Micro leakage Dentinal cracks Perforation into the pulp space Perforation onto external tooth surface

- Dull drills - Stop rotating while entering or exiting

FAILURES Tooth fractures

Pin fractures Restoration fractures Failure at Dentin-Pin interface Failure at Pin-Restoration interface

BIOLOGICAL CONSEQUENCES Irritating Factors 1) Cracks - Increased Permeability 2) Vibrations 3) Cements - Zinc phosphate and Copper phosphate 4) Stress produced 5) Thermal & Galvanic irritation 6) Irritants from Restorative materials Pulp Reaction 1) Healthy reparative when no cracks, stress 2) Reparative reaction cracks, stress present 3) Destructive reaction pulp exposure, microorganism contamination

OTHER APPLICATIONS Cast restoration - In extensive preparations - Short or excessively tapered prep.

Post and Core

For Anti rotation

Reattachment treatment procedures

 Universally accepted and less technique sensitive

Controlled & predictable clinical performance Inexpensive Self sealing margins Less amount of training & skill required Ease of use

 Adhesive systems designed to bond amalgam to

enamel to dentin introduced to overcome certain disadvantages :

MICROLEAKAGE

LACK OF ADHESION

NEED FOR

ADDITIONA L RETENTION

 One of the first attempts to improve retention & seal

of amalgam
Painting the cavity walls with a thin coat of zinc

phosphate
condensing wet amalgam immediately .

Advocated in 1920s Baldwern technique

 Zardiackas 1976

POLYCARBOXYL ATE CEMENT

SELECTIVE INTERFACIAL AMALGAMATION LINER

AMALGAM ALLOY PARTICLES

This liner tensile bond strength 3.5 Mpa

Shear bond strength 15 MPa

 Major development in amalgam bonding-

development of metal adhesive resins - originally for bonding FPDs in Maryland bridge technique . Adhesive resin cements with special resin monomers enhance bonding to metal surfaces ( air abraded ) .

Monomers have both hydrophobic and hydrophillic groups

SUN Medicals SUPERBOND 4 META TBB adhesive monomer

KURARAYs PANAVIA MDP monomer

 Researchers Japan & US testing these for amalgam

bonding . Varga et al Panavia & Superbond bond amalgam to etched surfaces inhibit microleakage . Bond strength 17.7 Mpa Superbond Statinec & Holt Panavia Bond strengths : 9.7 1.6 Mpa etched enamel 3.2 0.4 Mpa etched dentin
Microleakage was less cavity varnish

CURRENT ADHESIVES USED TO BOND AMALGAM

Most products for composites
Few products specifically for amalgam bonding : ALL BOND 2 (BISCO ) AMALGABOND PLUS with HPA Powder . OPTIBOND 2 (KERR) PANAVIA EX PANAVIA 21

 Strength of composites to enamel ( 20-25 Mpa ) best

restorative bond strength .

ELIMINATE MICROLEAKAGE

COUNTERACT DIMENSIONAL CHANGE CAUSED BY POLYMERIZATION SHRINKAGE & TEMP

Amalgams dimensionally stable requirement

Various studies - 3 10 Mpa

20 Mpa

Recent studies upto 13 Mpa for ALL BOND 2 ( Silva et al)

In Vitro Studies
FRACTURE RESISTANCE
Greater for teeth restored with bonded amalgams

compared to non bonded . ( Eakle & others 1992) Greater for bonded amalgam as compared to restorations mechanically retained with pin in case of single cusp capping ( Rauvola , Broome , Simon 1997 )

 MICROLEAKAGE STUDIES

Bonded amalgam less than varnish lined restorations

( Yu , Wei & Xu , 1987 )

CLINICAL STUDIES
Low incidence of secondary caries around bonded as

compared to non bonded 2 years . At three and 12 months, teeth with bonded restorations exhibited less sensitivity than those with nonbonded restorations ( Davis and Overton study ) .
Bonded restorations survived better than non bonded

in teeth with no delibrate retention ( Setcos et al 1998 )

Indications

Large compound restorations: In extensive cavities with gross tooth loss. Repair of restorations (to bond new to old amalgam and to seal cavity margins in the old restorations). Preparations without retention. Repeated fracture of amalgam restorations.

Geriatric and debilitated patients Bonded amalgam is preferred over more expensive and time consuming cast restorations.
Repairing marginal defects.

Amalgam sealants

ADVANTAGES
It is a treatment option for extensively carious posterior teeth, with a

lower cost than either cast metal restorations / metal ceramic crowns.
It allows the use of amalgam in teeth with low gingival- occlusal height

(unlike conventional amalgam with pins amalgapin, inlays; onlays) etc.

It permits more conservative cavity preparations - does not always

require additional mechanical retention (unlike amalgam with pins; etc).

It eliminates the use of retentive pins and their inherent risks e.g.:

periodontal perforation and pulpal exposure.

It reduces marginal leakage to minimum.

 It reinforces tooth structure weakened by caries and cavity

preparation .

It reduces the incidence of postoperative sensitivity commonly

observed with amalgam restorations.

It reduces the incidence of marginal fracture. It reduces the incidence of recurrent caries. It allows definitive restorations of a tooth with a badly broken

down crown in one clinical session ( compared to cast restorations ).

It allows the biologic sealing of pulpodentinal complex

DISADVANTAGES
Increases the time to perform a conventional

amalgam and may be technique sensitive. It requires practitioners to adapt to the new technique. It increases the cost of amalgam restoration. It makes the use of amalgam seem feasible in situations where it would not be indicated such for large restorations involving functional cusps. It has not been in use long enough to allow a proper evaluation of its clinical performance.

Clinical Technique
Enamel & vital Vital mandibular dentin etched molar large 10% phosphoric carious lesion acid 15 sec

Caries excavation Enamel & dentin done dried

Conditioned enamel dull white appearance

Three coats of adhesive primer ( Primer A + Primer B ) have been applied

The dentin enamel bonding agent is applied with a disposable brush ( All Bond Liner F )

Amalgam is condensed into the cavity before the auto curing bonding agent is polymerized

Restoration is carved

Finished and polished restoration

BONDING MECHANISM
Between adhesive resin & dentin hybrid layer

B/w resin & amalgam :Due to the method of condensing amalgam onto unset adhesive resin liner, there is an intimate mechanical interlocking created.

The mechanism responsible for bonding amalgam to resin is predominantly MECHANICAL in nature. It is produced by condensing the plastic amalgam mass into a plastic resin layer, producing MACRO RETENTIVE areas within the resin after the resin has polymerized .

 AMALGAM BOND:
It is based on a dentinal bonding system developed in

JAPAN by NAKABAYASHI.
It uses a solution of 10% CITRIC ACID and 3% FERRIC

CHLORIDE to remove the smear layer and demineralize the dentine surface.
A primer is applied after the dentine is conditioned. Finally, a self-curing methacrylate resin is applied to

impregnate the primed dentine. The resin contains an adhesive monomer called 4-META. (4methacryloxyethyl trimellitic anhydride)

 Panavia - marketed in 1980s Contained bi- functional monomer 10 MDP Powder liquid system Bond strength to etched metal greater than tooth . In 1994 Panavia modified to include primer HEMA improves

bond strength to dentin 2 paste system marketed as Panavia 21 Polymerization requires exclusion of O2 covering gel was provided .

 Current product available is Panavia F dual cure ,

self etching & self adhesive & Flouride releasing . Conclusion from studies .

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