_________________________________________________________________________________________________________________________________ Complex Amalgam Preparation & Restoration Alex Chen Dent 430 ePortfolio Faculty of Dentistry University of British Columbia Page 1 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Complex Amalgam Preparation critical reuirements Tooth: 46 MODB Critical requirements of this procedure Rationale of requirements and supporting literature New skills accomplished in this excercise, problems encountered, and breakthrough moments id m! product meet these requirements" Class ## Amalgam$ Reerse ! 1" The reerse ! shape# is nee#e# #$e to the %i#ening of the preparation of the proximal &ox" The ! shape allo%s the proximal &ox to maintain '( o )aos$rfa)e an# opening &$))al*ling$al )onta)ts %hile presering so$n# tooth str$)t$re at the same time +!)h%art, et al- .((6/" ." 0t sho$l# &e note# that the 1reerse !2 is not al%a3s nee#e# an# sometimes een &e)omes a 1!2 shape #epen#ing on the lo)ation of the )onta)t %ith the a#4a)ent tooth" To a)hiee a reerse 1!2 +%hen nee#e#/- 0 learne# to )$t the proximal &ox part an# o))l$sal part of the preparation separatel3 an# finall3 4oin them together" This ens$re a #istin)t 1!2 shape# preparation is forme#" 5es %pen interproximal contact 1" Allo%s is$al erifi)ation that all )aos$rfa)e margins are pla)e# in so$n# tooth str$)t$re +Ro&ertson et al"- .((6/" ." Conenien)e of a))ess for finishing an# polishing" 6" Allo% self7)leansing of the )aos$rfa)e margin to #e)rease ris8 of pla9$e a))$m$lation an# se)on#ar3 )aries +:athi an# Morta,ai- .((4/" ;The a#antage of not &rea8ing the )onta)t is the The proximal )onta)t %as #iffi)$lt to open as it $s$all3 en# $p too %i#e" M3 sol$tion %as opening the )onta)t slightl3 %ith a fine nee#le nose# &$r" 5es Page . of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ )onseration of tooth str$)t$re an# &etter ens$re of proximal )onta)t" <en)e- %e m$st &e )aref$l not to ex)essiel3 an# $nne)essaril3 remoe ex)ess so$n# tooth str$)t$re %hen &rea8ing the )onta)t +A8er&oom et al"- .((6/" &'( to ca)osurface The '(= to )aos$rfa)e ma8es s$re that there>s no $n#ermine# enamel ro#s" Also- it ma8es s$re the amalgam is of s$ffi)ient &$l8 than if the angle is too a)$te" This #e)reases the )han)e of the enamel or amalgam fra)t$res +Ro&erson- .((6/" This %as fairl3 eas3 to a)hiee &3 )he)8ing the preparation from o))l$sal ie%" 5es *alls con)ergent occlusall! O))l$sal )onergen)e resists restoration #islo#gement o))l$sall3 &3 me)hani)al retention +!$mmit et al"- .((6/" 0 ha# no tro$&le %ith this re9$irement" 5es + shelf$ 1" Parallel to o))l$sal plane ." ?$st into #entin 6" :lat an# e9$al %i#th thro$gho$t 1" The parallelism of &$))al shelf to o))l$sal plane gies it the most resistan)e to%ar#s o))l$sal loa# &3 eliminating the ramp effe)t that %o$l# o))$r if the shelf an# o))l$sal plane are not parallel" The parallelism also ens$res that the res$lting amalgam restoration %ill &e e9$al in thi)8ness tho$gho$t the o))l$sal plane- %hi)h helps resist fra)t$re" ." The shelf is 4$st into #entin to ens$re s$ffi)ient &$l8 for the amalgam restoration to resist fra)t$re"
6" The shelf is flat to ens$re that the res$lting amalgam restoration %ill &e e9$al in thi)8ness #is)$sse# in point 1" 0 learne# to $se the 66( &$r length as a g$i#e for #epth" Also- 0 smoothen an# flatten the shelf &3 r$nning a &$r a)ross it at @.(A spee#" 5es Page 6 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Pulpal slot$ 1" 0n area of )entral grooe ." At least 1mm in #epth 6" A))ommo#ates smallest )on#enser 1" P$lpal slot is pla)e# in the area of )entral grooe &e)a$se that>s %here the p$lp is f$rtherst a%a3 from the o))l$sal plane" <en)e- a p$lpal slot at this lo)ation has the least )han)e of p$lpal expos$re +M4or et al"- .((6/" ." The 1mm #epth is to gie the amalgam restoration s$ffi)ient &$l8 to resist #islo#gement" +M)Daniel et al"- .(((/ 6" The a))ommo#ation of the smallest )on#enser is for proper )on#ensation of amalgam #$ring restoration" 0 $se 66( &$r +.mm length/ as a g$i#e for length an# al%a3s )he)8 to see if the a small )on#enser )an fit in m3 preparation" B*A Proximal trough: 1" B$tts $p against axial %all ." At least 1mm in #epth 6" A))epts smallest )on#enser 4" ("5mm into #entin 1" The proximal tro$gh )onta)ts the axial %all ." At least 1mm in #epth proi#es the amalgam restoration %ith &$l8 to proi#e resistan)e to #islo#gement an# fra)t$re" +M)Daniel et al"- .(((/ 6" The a))ommo#ation of the smallest )on#enser is for proper )on#ensation of amalgam #$ring restoration" 4" The tro$gh nee#s to &e at least ("5mm into #entin to preent the o$ter %all of the tro$gh from fra)t$ring #$e to thin remaining tooth str$)t$re" 0 learne# to ma8e s$re m3 tro$gh &$tts $p against the axial %all &3 onl3 lightl3 mar8 the position of m3 tro$gh an# )he)8 to see if 0>m satisfie# %ith the positioning &efore 0 start )$tting #o%n more aggressiel3" 5es Pin$ 1" Parallel to )aos$rfa)e ." ?$st into #entin 6" Clearan)e of 1" The pin parallels the )aos$rfa)e to preent perforating the tooth as the tooth tapers to%ar#s )eri)al" ." The pin is 4$st into #entin to #e)rease the ris8 of 0 #i# not hae pro&lem %ith pla)ing the pin" B*A Page 4 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ smallest )on#enser perforation an# stress pla)e# on the tooth that ma3 )a$se mi)rofra)t$re of #entin or gross fra)t$re of the )ro%n" +B$rgess et al"- 1''C/ 6" The a))ommo#ation of the smallest )on#enser is for proper )on#ensation of amalgam #$ring restoration" Retention groo)es$ 1" a))ommo#ates smallest )on#enser 1" The a))ommo#ation of the smallest )on#enser is for proper )on#ensation of amalgam #$ring restoration" The retention grooes are fairl3 eas3 to pla)e" 0 $se the 66( &$r to ens$re the %all )onergen)e is maintaine#" B*A Page 5 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Complex Amalgam Preparation pictures Complex Amalgam Preparation !iscussion 0n a)hieing this &rea87thro$ghs- ho% %ill this help 3o$ in #efining 3o$rself as a #entistD The &iggest pro&lem 0 ha# %ith the )omplex amalgam preparation is the proximal tro$gh retentie feat$re" Preparing this feat$re is har# for me &e)a$se 0 )annot is$ali,e the area as 0 )$t as m3 ision +&oth #ire)t an# in#ire)t/ is &lo)8e# &3 m3 han#pie)e" This )a$se# me to hae less )ontrol oer m3 preparation an# m3 tro$ghs %o$l# t$rn o$t either too #eep or too %i#e" 0 trie# to sole the pro&lem &3 tr3ing to fin# the optimal pla)ement of m3 mirror an# the mani8in hea# position to is$ali,e the area 0>m )$tting- &$t ha# no s$))ess" Eent$all3- 0 learne# to #epen# on m3 ta)tile sense to estimate the #epth of m3 &$r an# )$t slo%l3" 0 %o$l# also )he)8 m3 #epth fre9$entl3 %ith in#ire)t ision $ntil the re9$ire# #epth an# %i#th is met" This &rea87thro$gh ta$ght me that Page 6 of 15 aaa %pen interproximal contact Re)erse , &'( to ca)osurface +uccal shelf$ 1" Parallel to o))l$sal plane ." ?$st into #entin 6" :lat an# e9$al %i#th thro$gho$t Proximal trough: 1" B$tts $p against axial %all ." At least 1mm in #epth 6" ("5mm into #entin *alls con)ergent occlusall! Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ sometimes a %e )annot al%a3s see %here %e are %or8ing an# some g$essing %or8 is inole#" 0n these )ases- patien)e is extremel3 important" For8ing slo%ing an# )he)8ing o$r o%n %or8 )onstantl3 is the %a3 to pro#$)e the optimal res$lt" 0 also felt that the )omplex amalgam preparation reall3 re9$ires $s to reall3 hae a #eep $n#erstan#ing of the tooth str$)t$re an# retention me)hani)s" Compare# to the other )lasses of preparations %e learne# &efore %here the shape an# feat$res of the preparations are 9$ite similar in the same )lass of lesions- there are great aria&ilit3 in the #esign of the preparation in )omplex amalgam preparation as %e hae man3 #ifferent feat$re options %e )an )hoose from" The operators nee# to hae a firm $n#erstan#ing of the anatom3 of the tooth an# the retention me)hanism to &alan)e the remoal of so$n# tooth str$)t$re that %ea8ens the tooth an# the retention nee#e# for the restoration" This is an ex)ellent example of ho% #entists nee# to )onstantl3 appl3 their 8no%le#ge an# 4$stif3 their %or8 instea# of follo%ing a fixe# re)ipe" Complex Amalgam "estoration critical reuirements Tooth: 46 MODB Critical requirements of this procedure Purpose of critical requirements and supporting literature New skills accomplished in this excercise, problems encountered, and breakthrough moments id m! product meet these requirements" Close Contact -. Pre)ent food impaction. /. 0aintaining health of interproximal soft tissue 1Roberson et al., /''23. # had a lot of trouble with this requirement. 4he most important step in ensuring a closed contact # find is to laterall! condense the amalgam )er! well towards the 5es Page C of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ 6. Pre)ent tooth migration 10amoun and Ahmed, /''23. ad7acent tooth in the contact area to close the contact. + height of contour -3 #n proper alignment /3 #n proper arch contour + cups -3 #n proper alignment Central groo)e -3 #n proper arch alignment 1" proper alignment an# )onto$r of )$sps proi#e optim$m integrit3 of the )$sps" ." Properl3 repro#$)e# )entral grooe gies i#eal o))l$sion %hen arti)$late# %ith the opposing )$sps as o))l$sal relationship is repro#$)e# +Taernier an# Colon- 1'G'/" " 0 al%a3s follo% a s3stemi) se9$en)e %hen )aring the in#ii#$al feat$res" M3 pro)ess is #es)ri&e# in the follo%ing #is)$ssions se)tion" Another pro&lem 0 str$ggle# %ith is the ten#en)3 to oer)are the )$spal ri#ges" 0 fin# that %hen 0 )are the ling$al )$spal ri#ge- the tip of m3 <ollen&a)8 %o$l# exten# an# ta8e off parts of the &$))al )$spal ri#ge- an# i)e ersa" Eent$all3- 0 %o$l# en# $p %ith &oth &$))al an# ling$al )$spal ri#ges oer)are#" 0 sole# this pro&lem m3 pa3ing attention to the tip of m3 <ollen&a)8 an# ma8e s$re it #oes not exten# past the )entral grooe" 5es 4rue anatom! -3 Not o)er8 or under8 car)ed /3 4rue cusp positioning and contour 63 m9d pits in proper Properl3 #efine# pits gie the marginal ri#ge a prominent in)line %hi)h %o$l# allo% foo# to es)ape from interproximal area to preent impa)tion" +!)h%art, et al- .((6/ Please see #is)$ssions se)tion" 5es Page G of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ position Properl! shaped marginal ridge -3 Not o)erl! bulk! /3 4rue position le)el with ad7acent ridges An ex)essiel3 high restoration %o$l# ta8e other teeth o$t of o))l$sion" A))or#ing to !$mmitt et al" +.((6/- )onta)ts #$ring o))l$sion sho$l# neer o))$r on restoration alone" 0f this happens- the restoration sho$l# &e ta8en o$t of o))l$sion an# ens$re )onta)t is on restoration as %ell as tooth str$)t$re sim$ltaneo$sl3 +!$mmitt et al"- .((6/" 0 ma8e s$re the marginal ri#ges are leel %ith a#4a)ent ri#ges &3 leeling it %ith the flat en# of the &ea)h )arer" N% #n occlusion -3 proper cusp9fossae relationship An ex)essiel3 high restoration %o$l# ta8e other teeth o$t of o))l$sion" A))or#ing to !$mmitt et al" +.((6/- )onta)ts #$ring o))l$sion sho$l# neer o))$r on restoration alone" 0f this happens- the restoration sho$l# &e ta8en o$t of o))l$sion an# ens$re )onta)t is on restoration as %ell as tooth str$)t$re sim$ltaneo$sl3" 0 %o$l# al%a3s )he)8 the o))l$sion %ith an arti)$lating paper to ens$re none or onl3 minimal )onta)t on m3 restoration" 5es Proper cusp height$ 0+ cusp higher than + cusp, higher than cusp The )$sps nee# to &e in proper positions to o&tain )orre)t o))l$sion" 0f )$sps are too high- hea3 o))l$sal for)es )an lea# to fra)t$re of the restoration +!$mmitt et al"- .((6/" 0 fin# it helps a lot to loo8 at a irgin 46 as a example %hile )aring to get a is$al i#ea of the height relationships of the )$sps" 5es No marginal )oids 0arginal )oids or o)erhangs accumulates food debris and plaque. 4his ma! lead to recurrent caries. epending on location, marginal )oid could also make the restoration susceptible to fracture 10ahler and 0arant:, -&;'3. 0arginal )oids are a)oided b! condensing the amalgam with a lot of force. <oading amalgam in small increments is also essential in remo)ing the )oids. 5es Page ' of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ ,mooth no scratches 1" !)rat)hes on restoration ma3 feel $npleasant to the patient" ." !)rat)hes also proi#es a pla)e for &a)teria a))$m$lation an# gro%th +Paarmann an# Be)8man- .((5/" 6" !)rat)hes ma3 a)t as )enters for )orrosion" +A8er&oom et al"- .((6/ 0 smoothen m3 restoration %ith a )otton roll at the en#" 5es Complex Amalgam "estoration pictures Page 1( of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Complex Amalgam "estoration !iscussion Page 11 of 15 Close Contact Properl! shaped marginal ridge 1/ Bot oerl3 &$l83 ./ Tr$e position leel %ith a#4a)ent ri#ges Reerse ! ;Distal ri#ge is too &$l83 Proper cusp height MB )$sp higher than B )$sp- higher than D )$sp Reerse ! Central groo)e 0n proper ar)h alignment +uccal height of contour 1/ 0n proper alignment ./ 0n proper ar)h )onto$r +uccal cups 0n proper alignment No marginal )oids ,mooth no scratches Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ 0n a)hieing this &rea87thro$gh- ho% %ill this help 3o$ in #efining 3o$rself as a #entistD 0 ha# a har# time )aring the anatom3 of the molar at first" Fith pra)ti)e- 0 got a lot faster an# m3 restoration &e)ame more anatomi)all3 )orre)t" Fhat 0 fo$n# helpe# is haing a s3stemati) approa)h %hile )aring the tooth feat$res" 0 learne# to %or8 in a fixe# or#er an# al%a3s $se the same instr$ment for a parti)$lar feat$re" :or example- 0 %o$l# al%a3s start &3 #efining the o))l$sal ta&le %ith an explorer" Then 0 %o$l# )are a ro$gh o$tline of the )$sps an# grooes %ith the same explorer" 0 %o$l# then moe on to #efine the )$sps %ith a hollen&a)8 an# &ea)h )arer" This is follo%e# &3 #efining the pits an# marginal grooes %ith a #is)oi#7)leoi#" Hastl3- 0 %o$l# finish off %ith shaping the &$))al or ling$al )onto$r %ith a hollen&a)8" 0 fo$n# this s3stemi) approa)h ma#e s$re all the feat$res of the restoration is present an# nothing is misse#" Also- repeate# pra)ti)e %ith the same instr$ment on the same anatomi)al feat$re greatl3 improes m3 spee# an# 9$alit3 of %or8 then if 0 )are# the str$)t$re %ith #ifferent instr$ment ea)h time" This experien)e )learl3 signifie# the importan)e of a#opting a s3stemi) approa)h in o$r #ail3 pro)e#$res" :rom a ro$tine patient exam to )ompli)ate# #ental pro)e#$res- haing a s3stemi) approa)h %ill greatl3 improe the effi)ien)3 an# ma8e s$re eer3thing is )oere#" Referen)es: Page 1. of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ A8er&oom- <"- A#o8aat" ?"- Amerongen I"- Borgmei4er- P" +.((6/" Hong7term eal$ation an# rerestoration of amalgam restorations- Community Dentistry an! #ral $pi!emiology% .1+1/: 4574G B$rgess- O"- Alare,- A"- !$mmitt B" +1''C/" :ra)t$re resistan)e of )omplex amalgam restorations" &ournal of #perative Dentistry- ..+6/:1.G716." :athi M"- Morta,ai- I"- +.((4/" A Reie% on Dental Amalgam Corrosion an# 0ts Conse9$en)es- &ournal of "esearch in 'e!ical (ciences- '+1/: 4.751 Mahler" B"- Marant,- H" +1'G(/" Marginal fra)t$re of amalgam: effe)t of t3pe of tooth an# restoration )lass an# si,e" &ournal of !ental restorations) 5'+'/: 14'C715(( M)Daniel- R"- Dais- R"- M$r)hison- D"- Cohen- R" +.(((/" Ca$ses of fail$re among )$spal7)oerage amalgam restorations" &ournal of American Dental Association% 161+./: 1C671CC" Retriee# ?an .6- .(1(- from http:**4a#a7pl$s")om*)gi*reprint*161*.*1C6" M4or- 0"- Hars- B"- :errar- M"- <e3eraas- J" +.((6/" Pulp*!entin biology in restorative !entistry) Chi)ago: K$intessen)e P$&" Paarmann- C"- Be)8man- T" +.((5/" Polishing amalgam restoration) Department of !ental hygiene% +!aho (tate University) Retriee# ?an .1- .(1(- from http:**%%%")si"e#$* %e&Tools*sites*Bo%)$t5G*)o$rses*6.(*DentalPolishingAmalgamRestorations"p#f K$altro$gh- A"- !atterth%aite- ?"- Morro%- H" +.((5/" Principles of operative !entistry" Ames- 0o%a: Bla)8%ell P$&" Kist- I"- ?ohanessen- H"- & Br$$n- M" +1''1/" Progression of approximal )aries in relation to iatrageni) preparation #amage" &ournal of Dental "esearch% C1+6/: 16C(7C6" Ro&erson- T" <e3mann- <" O"- !%ift- E" ? "+.((6/" (tu!evant,s Art an! (cience of #perative Dentistry" !t" Ho$is- Misso$ri: Mos&3 P$&" Page 16 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Rosenstiel- :"- A3a#- :"- Maghra&i- A" +.((5/" Assessment of Conergen)e angles of tooth preparations) &ournal of Dentistry- 66+G/: 6667G" !)h%art,- R"- !$mmitt- ?"- Ro&&ins- F" +.((6/" Fun!amentals of operative !entistry - a contemporary approach +6 r# e#"/ Chi)ago: K$intessen)e P$&" Taernier- B"- Colon- P" +1'G'/" :$n)tional #ental anatom3 an# amalgam- "ev #!ontostomatol .Paris/) 1G+1/: .17.' Page 14 of 15 Alex Chen Complex amalgam preparation & restoration _________________________________________________________________________________________________________________________________ Page 15 of 15