A m alga m restorations: cavity preparation,
condensing and finishing
Rafael N adal,* D .D .S., M .S .D ., San Juan, Puerto R ico
Clinical studies and laboratory investiga­
tions support a conservative approach to
cavity preparation. M odifications in the
amalgam cavity design aimed at increas­
ing bulk— such as grooving, excessive
slanting or rounding the pulpal floor or
the axiopulpal wall— are superfluous pro­
cedures. A n extreme traumatic occlusion
is the predominant factor influencing the
moss isthmus fracture of Class I I amal-
gam restorations. A buccolingual reduc­
tion of the occlusal outline will reduce
significantly the incidence of marginal
failure. T h e margin o f safety of amal­
gam is even greater than thought in the
past, and certain laborious and exacting
technics may be unrealistic. However,
amalgam is more susceptible to human
variables than any other dental restora­
tive material.
Amalgam is the most frequently used re­
storative material today. This preference
for amalgam does not seem to be new;
there is evidence to indicate that even
during its early controversial days, as far
back as 1844, the material was already
widely used in this country.1 A survey
by Brekhus and Armstrong2 in 1936 not
only demonstrated that amalgam was the
most frequently used restorative material
but, more important, it showed that the
incidence of failure o f amalgam restora­
tions was lower than that of any other
type. This, as well as more recent clinical
observations,3 5 indicates that amalgam
possesses a generously wide range o f tol­
erance. Today, as a result of greater un­
derstanding o f the material, along with
the superior alloys and improved instru­
mentation available, it is apparent that
this latitude o f safety o f amalgam is be­
coming increasingly wider. Obviously, the
dental profession is aware o f this fact.
Unfortunately, however, in the light of
the rather large number o f failures seen
every day, it seems obvious that this ver­
satility o f amalgam sometimes inspires
haphazard technics.
Amalgam demands a meticulous se­
quence o f procedures, and failure to ob­
serve any of the principles involved will
most certainly jeopardize the integrity of
the restoration.
Amalgam has been the subject o f much
speculation and research but, although in
many respects the evidence and opinions
appear to be in agreement, the literature
reveals that there is a lack o f unanimity
on many aspects o f the subject. Some o f
the outstanding controversial points will
be discussed in this paper with the hope
that it may provide a background for a

profitable discussion.
Generally the failure of an amalgam
restoration may be attributed either to
(1) improper cavity preparation or (2)
incorrect manipulation.
C A VITY PRE PAR ATIO N
Since Black’s classic work was published
in 1895,® it has been universally agreed
that correct cavity preparation is an in­
dispensable requirement for the success
of any restoration. Recently, several clin­
ical investigations have shown that im­
proper cavity preparation is the pre­
dominant factor causing the failure of
amalgam, accounting for over 60 per cent
of the amalgam failures observed.7 9
The importance of producing a sound
cavity preparation is unquestioned. How­
ever, although the fundamental principles
established by Black are still enunciated
by all, the opinions of the best-qualified
men differ widely as to which is the most
effective combination of mechanical prin­
ciples for the amalgam cavity. This di­
versity of opinion is greatest when the
Glass II cavity is considered. Inasmuch as
the same basic principles involved in a
simple occlusal cavity are contained in
the Glass II design, it seems logical for the
discussion to center on this type of cavity.
Class 11 C a vity Prep a ra tion • A great
variety of designs has been suggested for
the Class II cavity preparation; however,
all the existing designs stem from two
origins: first, Black’s original design,6 and
second, the design originated by Bronner
in 192910'11 (Fig. 1). The buccal and
lingual walls of the proximal box in Bron-
ner’s design converge toward the occlusal
surface producing a self-retentive form.
In Black’s cavity these walls are approxi­
mately parallel to each other. The cervi­
cal divergence of the proximal outline in
Bronner’s cavity is supposed to bring the
gingival aspect of the lingual and buccal
margins farther out into more immune
areas; its occlusal convergence produces a
NADAL . . . VOLUME 65, JULY 1962 • 81/67
Fig. I • The two basic designs for C lass II cavity
preparation for am algam
more narrow occlusal step which will re­
sult in less area of restorative material
exposed to the stresses of mastication,
increased resistance properties of the re­
maining tooth structure and less danger
of encroachment on the pulp. In contrast,
Black’s proximal outline diverges slightly
toward the occlusal aspect, which results
in a relatively wide step; this divergence
is the result of a slight flare of the oc­
clusal third of the lingual and buccal
wall.
Most of the amalgam failures observed
occur among the Class II restorations;
among these, fracture is the most fre­
quent.7 Gross fracture across the isthmus
is not frequent12 but there is accurate
clinical evidence to show that when this
type of failure occurs it is generally due
to a lack of bulk in this region.9
The importance of providing adequate
bulk at the isthmus has long been em­
phasized. However, the means by which
this bulk is obtained is perhaps the most
controversial aspect of the Class II cavity
preparation for amalgam. Black once
stated that the isthmus should include
the middle third of the distance between
the buccal and lingual cusp tips and indi­
cated that the depth should be deter­
mined by an initial cut just below the
enamel.13 These procedures result in a
cavity with a fairly wide isthmus on a
relatively shallow step. Today, although
some men emphasize greater width,14'16
others stress the importance of both in­
creased width and depth;17"19 the latter
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workers advocate a V-shaped pulpal wall
which slopes against a rather vertical
axiopulpal wall at the proximal aspect.
Another group stresses the conservation
of tooth structure. In this group are some
who, although favoring a narrow isthmus,
still stress the importance of increased
depth.20'21 Others, on the extreme side of
the conservative approach, recommend
both a narrow isthmus and a shallow oc­
clusal step.22
In recent years, with the introduction
of the photoelastic stress analysis technic,
several laboratory investigations have
contributed greatly to our understanding
of the problem of cavity design.23'25 How­
ever, even the data from these investiga­
tions are conflicting, and although these
earlier works suggested the use of a wide
as well as deep isthmus, a more recent
photoelastic analysis strongly favors a
conservative approach.26 A greater sig-
Fig. 2 • A b o v e : R ou n d in g of axiopulpal line angle
(view above left) will increase bulk of am algam
at that region. This procedure supposedly will
obviate w e d gin g action of a sharp angle at that
critical region (view ab ove right). Below: A x io ­
pulpal line angle located in region well below line
of d a m a gin g tensile stress
nificance of this last research conducted
by Mahler lies in the fact that, in contrast
with the earlier investigations which con­
sidered only the distribution of stresses
induced in the restoration, his conclusions
were based on a correlation of the distri­
bution of stresses both in the restoration
and within the remaining tooth structure
itself. Mather’s approach would seem to
be more realistic, and a recent clinical in­
vestigation strongly supports his conclu­
sions.27
The rounding of the axiopulpal line
angle is a procedure recommended by
many,14'19’21,28,29 not only because of the
resulting increase in bulk but also to obvi­
ate the wedging action of a sharp angle
at this critical area (Fig. 2, above). How­
ever, research has shown that this pro­
cedure is of little clinical importance.
Haskins and co-workers24 using the pho­
toelastic method, observed that the shape
of the axiopulpal line angle did not influ­
ence significantly the concentration of
stresses at the area. This observation has
been later corroborated by Mahler,26 who
found that tensile stresses are the most
important factor influencing gross isthmus
fracture. He observed that these stresses
act in a predominantly horizontal direc­
tion within the restoration and that they
remain close to the occlusal surface (Fig.
2, below). He points out that this latter
fact may be the reason for Haskins’ obser­
vations regarding the unimportance of
the shape of the axiopulpal line angle.
Opinions on the cervical retention
groove also are well divided; however, it
is generally agreed that this groove is not
an important factor influencing the re­
sistance and retention potentials of the
Class II design (Fig. 3, left).24'26 Thus,
the secondary importance attached to the
factor obviates the need for any further
discussion.
Consideration now will be given to the
proximal buccal and lingual retention
grooves (Fig. 3, right). Black13 objected
to any undercut in the proximal walls,
and Blackwell in his latest revision of

Black’s text30 still follows this same view,
although he points out that in certain in­
stances undercutting may be a desirable
procedure. Data are available, though, to
indicate that this may be an important
factor in preventing the clinical fracture
of Class II amalgams,17'26 and today, un­
dercutting seems to be a universally ac­
cepted procedure. The only differences of
opinion in this respect are concerned with
the shape of the undercut grooves and
the instrumentation necessary to produce
them. Obviously, the importance of shape
and instrumentation may be considered
academic and, therefore, a matter of per­
sonal preference.
Briefly, I have just covered most of
the evidence available in the subject of
cavity preparation. Up to this point all
the existing views have been based either
on laboratory data or on casual clinical
observations. However, the findings of a
recent clinical study27’31 at Indiana Uni­
versity have provided evidence to sup­
port very interesting conclusions. First of
all, it was found in this work that a
narrow as well as shallow occlusal portion
of the Class II cavity for amalgam is
definitely desirable and that the bulk fac­
tor at the isthmus is not important as long
as excessive trauma from opposing cusps
is avoided. These findings are in agree­
ment with Mahler’s photoelastic analy­
sis.26
It was observed in this clinical work
that the gross isthmus fracture of Class II
amalgams is the result of a combination
of factors, mainly a severe traumatic in-
tercuspal relation in the presence of in­
adequate bulk. In other words, it was
found that, whenever a small and narrow
restoration fractured across the isthmus,
the fracture invariably was due to the
excessive trauma resulting from a sharp
and elongated opposing cusp. After this
abnormal relation was corrected and a
new restoration was placed in the same
conservative cavity, the failure did not
recur.
Thus, the importance of adjusting the
NADAL . . . VOLUME 65, JULY 1962 • 83/49
Fig. 3 • Left: C e rvica l retention gro ove in prox­
imal box is not a critical facto r influencing resist­
ance and retention. Right: There is evidence to
indicate that proximal retention gro ove on buccal
and lingual axial walls m ay be im portant factor
in preventing gross isthmus fracture of C lass II
am algam
occlusion in amalgam work is now more
evident than ever. Miller32 is of the opin­
ion that the intercuspal relation should
be studied carefully by observation and
the use of carbon paper even before the
tooth is restored with amalgam. In the
light of the previously mentioned evi­
dence this certainly would be a commend­
able practice.
Further evidence from the mentioned
clinical study supporting a buccolingual
reduction of the occlusal outline lies in
the fact that a significant reduction in
the incidence of marginal failure was ob­
served when a conservative cavity was
used.
Two main schools of thought exist in
regard to the direction of the axial walls
in occlusal cavities.18 Some workers, in
accordance with Black, advocate parallel
and perpendicular walls (Fig. 4, above
left). Others believe that these walls
should follow the direction of the enamel
rods and therefore should converge oc-
clusally (Fig. 4, above right). The advo­
cates of parallel walls feel that an occlusal
convergence of the axial walls will leave
a weak enamel margin, whereas the ad­
vocates of occlusally convergent walls
claim that parallel axial walls may result
in a weak margin of amalgam. Whether
we accept one view or the other is not as
important as it is to understand that an
exaggerated occlusal divergence may re-
84/70 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
W EA K F E A T H E R W EAK CWAHEL
EDGE OF MARGIN
Fig. 4 • A b o v e left: Parallel and perpendicular
axial walls of occlusal cavity. A b o v e right: Axial
walls o f occlusal cavity converge occlusally as they
follow direction of enamel rods. Below left: W e a k
featheredge m argin of am algam caused b y ex­
ag ge ra te d occlusal divergence. Below right: W e a k
enamel at m argins caused by extreme occlusal
convergence
suit in a weak featheredge margin of
amalgam (Fig. 4, below left) and that by
the same token, an extreme occlusal con­
vergence may leave weak enamel at the
margins (Fig. 4, below right).
On the basis of the evidence at hand
it may be concluded that a Glass II
cavity preparation for amalgam should
contain a narrow occlusal outline to in­
clude the isthmus area, a flat and rather
shallow pulpal floor, a slightly sloping
axiopulpal wall, a sharp axiopulpal line
angle and proximal lateral undercut
grooves.
Class V C a vity Prep a ra tion• The litera­
ture indicates that the differences of opin­
ion on Class V cavity preparation are few
and that most of these deal with lesser
details that do not merit discussion. How­
ever, as in the case of the Class II design,
both an old and a new form exist. The
old form, as proposed by Black, has the
conventional kidney-shaped outline. In
contrast is the modern form, the Ferrier
Fig. 5 • Left: C o rre c t restoration of contour
in C lass V restoration where little or no gingival
recession has occurred. Right: Properly reposi­
tioned contour in C lass V restoration where con­
siderable gingival recesson has occurred
type of preparation, containing straight
lines and sharp angles.33 It is claimed that
this new form of cavity results in a less
conspicuous restoration and that it will
allow a better restoration of contour.
Again, a choice between these two pro­
cedures would seem to be a matter of per­
sonal preference.
A cited clinical survey of amalgam
failures7 has shown that, aside from con­
tamination, inadequate flaring of the
mesial, distal and cervical walls is the
most common cause for failure among the
Class V restorations. There is a rather
drastic change of direction of the enamel
rods at these areas as they radiate with
the anatomy. It is imperative that the
enamel walls be flared in accordance with
the direction of the rods.
Proper contour is another aspect of this
type of restoration that is often neglected
(Fig. 5, left). This is particularly true in
instances in which there has been consid­
erable gingival recession. In these in­
stances, not only should contour be re­
stored, but perhaps more important, it
should be repositioned in order to safe­
guard the health of the adjacent perio­
dontium (Fig. 5, right).
COND ENSATIO N
As previously mentioned, the factors af­
fecting the amalgam restoration are in­
numerable. From the moment the con­
stituent metals are put together by the

manufacturer, to the last step of the pol­
ishing technic, practically every factor
involved may, in one way or the other,
influence the behavior of the restoration.
But little doubt remains that the most
influential variables, directly under the
dentist’s control, are contained in the
trituration and condensation procedures.
First of all, maintaining an accurate
mercury-alloy ratio is extremely impor­
tant. The greater the amount of mercury
in the original mix, the higher will be the
percentage of mercury retained in the
finished restoration.34 This will be true
regardless of how much packing pressure
or which condensing method is used.
Some kind of proportioning device should
be employed. Although some of the alloy
and mercury dispensers available in the
market are fairly accurate, a device
which measures by weight rather than
volume is usually more dependable.
Even slight underamalgamation will
result in a weak and rough restoration.
In fact, clinical research35 has shown that
a slight overtrituration beyond the man­
ufacturer’s recommendations is desirable
in order to minimize the chance of un­
dertrituration and its undesirable results.
Although it has been proved that me­
chanical amalgamation is not necessarily
superior to a carefully controlled hand
technic,38 this method has two definite
Fig. 6 * Use of a steel ball (L. D. C au lk C o .)
instead of conventional cylindrical pestle aids in
m aintaining cleanliness of capsule
N ADAL . . . VOLUME 65, JULY 1962 • 85/71
advantages: first, it eliminates the human
element, particularly if the procedure is
in the hands of the assistant, and second,
the speed of trituration allows the prepa­
ration of multiple mixes for the conden­
sation of extensive restorations. If me­
chanical trituration is used, the capsule
and pestle should be thoroughly cleaned
immediately after trituration is com­
pleted. A simple procedure that will keep
the capsule clean is to retriturate the mix
for two or three seconds after the pestle
has been removed. For this purpose the
use of a steel ball has been recommended
instead of the conventional cylindrical
pestle; a device of this type is already
available commercially (Fig. 6).
Heavy condensation pressures are nec­
essary in order to produce a dense restora­
tion as well as to maintain the residual
mercury content at a minimum. Research
has also shown that mechanical conden­
sation will produce superior physical
properties;36 however, the differences are
not clinically significant when compared
to a good hand technic. Therefore, the
use of automatic condensation is optional.
Despite the multiplicity of variables
associated with amalgam, residual mer-
Fig. 7 • Extreme deterioration of restoration in
first m olar shows effects of excessive am ount of
residual mercury in am algam restoration. Note
contrast to restoration in second bicuspid which
has adequate mercury content
86/72 • THE JOURNAL OF THE AM ERICAN DENTAL ASSOCIATION
Fig. 8 • Left: Am algam aster. Right: Presto A m a lga m a to r
cury is probably the greatest single fac­
tor influencing its clinical behavior. An
already cited clinical investigation has
shown the detrimental effects of an ex­
cessive amount of residual mercury in the
restoration.27’31 It was found that ex­
cessive residual mercury will invariably
result in surface and marginal deteriora­
tion (Fig. 7).
Recently, considerable efforts have
been directed toward the standardization
of trituration and condensation pro­
cedures, and emphasis has been given to
the problem of residual mercury. As a
result, a variety of technics and instru­
ments have been designed in an attempt
to minimize residual mercury. It may be
useful to review briefly some of the more
commonly used condensation methods.
Generally there are four basic conden­
sation technics.37
1. The oldest and probably the most
widely used method is the so-called “in­
creasing dryness” technic in which pro­
gressively drier increments of material are
condensed after an initial fairly wet por­
tion.
2. In a second method all the excess
mercury is squeezed from each increment
just before it is condensed.
3. A third technic indicates that all
the mercury should be eliminated from
the entire mass immediately after tritura­
tion and that the remaining portion
should be mulled in a piece of rubber
dam until the cavity is properly packed.
4. As a variation of this last technic
some men recommend elimination of all
the excess mercury from the entire mass
immediately after trituration but object
to the mulling procedure.
Research has shown that it makes little
difference which method is used as long
as a sound condensation procedure is fol­
lowed.37 It is thus evident that all argu­
ments in favor of any particular method
would be superfluous. Obviously, efforts
should be directed toward the standard­
ization of a more simple and universal
technic.
For those who prefer to start conden­
sation with a rather wet portion of amal­
gam and then remove the excess with the
use of a squeeze cloth, two centrifugal
machines have been recently introduced.
The Amalgamaster (Fig. 8, left) (Torit
Manufacturing Co., St. Paul) has an
interval timer similar to that on the
Crescent Wig-L-Bug and a capsule with
a funnel-shaped trap for the elimination

of excess mercury by centrifugal force.
Another centrifuge machine, designed by
M r. E. O. H all of Los Angeles, has been
introduced recently. Its main advantage
is that it does not require a special cap­
sule for the elimination o f mercury. T h e
mix is dropped down into a chute and
then is delivered into a tray at the bottom
o f the machine after the excess mercury
has been eliminated.
Both o f these machines work on the
same basic principle, as they remove ex­
cess mercury by centrifugal force. M e r­
cury analysis as well as a series of tests
on physical properties has shown that
both machines w ill standardize nicely the
residual mercury content. Also, the re­
sulting physical properties compared very
favorably with a well-standardized hand
condensation technic.38 For those who
delegate the removal o f mercury to their
assistant, the use o f either one o f these
machines may be o f some value, as it w ill
eliminate the human element involved
in the procedure.
T h e Presto Amalgamator (McShirley
Products, Glendale, C alif.) is another re­
cent attempt toward simplicity and stand­
ardization in amalgam work (Fig. 8,
rig h t). This is a simple device consisting
o f three basic parts: a cylinder and its
mating part, a piston and an activating
lever. T h e mercury is first placed in the
cylinder after it has been screwed on the
mating part and the alloy then is placed
on top o f the mercury. T h e piston then is
engaged in the cylinder and pressure is
applied. T h e pressure exerted may be
controlled with the calibrated scale at­
tached to the lever system. I t is claimed
that the pressures created w ill produce
amalgamation and that the excess mer­
cury is eliminated simultaneously. U n for­
tunately, certain preliminary studies in­
dicate that, although its use certainly will
standardize the residual mercury, amal­
gamation remains incomplete.39
Increased efforts now are being made
to solve this problem of incomplete amal­
gamation. I f this problem is ever solved,
NADAL . . . VOLUME 65, JULY 1762 • 87/73
the resulting instrument would be the
greatest advance toward a more simple
and universal amalgam technic. O f con­
siderable interest along these lines is the
new trituration method recently proposed
by Eames.40 This method makes use of
original mercury-alloy ratios o f less than
50:50, and its main objective is to stand­
ardize the final mercury content of the
restoration by starting with the minimal
amount that would be compatible with
manipulation and physical properties.
But the amount of mercury necessary to
obtain a properly triturated and workable
mass varies with the different alloys and
ranges from 45 to 50 per cent. These ex­
treme ratios are possible only with the
use o f the now available fine-cut alloys
that amalgamate more readily.41,42 R e ­
search has already shown that this technic
will produce specimens with adequate
physical properties.43 This method de­
mands speed and exactness, and consider­
able practice is required before it can be
perfected and routinely used.
M A T R IX T E C H N IC
Research has demonstrated that a prop­
erly contoured and wedged matrix is
indispensable for the adequate reproduc­
tion o f proximal contour and the preven­
tion o f cervical overhang o f amalgam.44
Both improper proximal anatomic form
and cervical excess o f material may
easily lead to periodontal disease (Fig. 9,
l e f t ) . This is another aspect of the Class
I I amalgam restoration which unfortu­
nately is often neglected. A great number
o f matrix retainers are available in the
market, but certain observations from the
previously mentioned investigation indi­
cate that there is no retainer or technic
available that will perfectly reproduce
normal contour (Fig. 9, right). It has
been suggested by this work that the type
o f retainer or technic used is not impor­
tant as long as the band is properly con­
toured and wedged. A soft-tempered
band material that w ill lend itself to
88/74 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION

Fig. 9 • Left: Restoration on second bicuspid shows gross cervical excess of

am algam which will lead to periodontal disturbances. Right: Encircled areas in
bitewing roentgenogram show prope r restoration of proximal contour in three
C lass II am algam restorations

contouring is indicated. The band mate­
rial should also be thin as well as strong.
Bands as thin as .015 inch are now avail­
able.
Particular care should be taken to use
a wedge of the proper size and shape in
order to avoid interfering with the proxi­
mal contour (Fig. 10, left). The wedge
should be triangular, and it should hold
the matrix firmly just below the cervical
margin (Fig. 10, right). It should be in­
serted with sufficient pressure in order
that the resulting separation may com­
pensate for the thickness of the band and
thereby obtain adequate contact. Me­
chanical separation is not necessary.
The stabilization of the matrix with
compound may be useful for the conden­
sation of extensive restorations; however,
in the average Class II restoration its use
is optional. Aside from the ability to re­
produce contour, a good guide for de­
termining the need for a compound
reinforcement is to test the band for adap­
tation with an explorer at the buccal and
lingual margins.
CARVING
The carving of amalgam should not be
started until the material is hard enough
to offer some resistance to the instru­
ment. The carving instruments must be
kept very sharp in order to avoid the
burnishing effect of a dull edge. Any
burnishing will draw excess mercury to
the surface and the margins of the res­
toration.

Fig. 10 * Left: Im p roper size and shape of w edge will interfere with proximal
contour. Right: C o rre c t size and shape will allow an adequate reproduction of
proximal contour

All efforts should be made to repro­
duce, as nearly as possible, the original
anatomic form of the tooth except in
those instances in which certain modifica­
tions might be demanded by the occlu­
sion. Another exception to this rule is
made at the occlusal aspect where the
depth of the grooves is not extended to
the original position and is kept reason­
ably shallow. Secondary grooves should
not be reproduced.
The importance of studying and ad­
justing the intercuspal relations at this
time cannot be overemphasized.
F IN IS H IN G
The importance of properly finishing and
polishing the amalgam restoration has
been well established.3’4,34 Esthetics aside,
a well-polished amalgam will be less sus­
ceptible to recurrent caries, tarnish and
corrosion. Moreover, it will be better tol­
erated by the soft tissues. This is of par­
ticular importance in the Class V resto­
ration.
Of course, amalgam should not be
polished until at least 24 hours after in­
sertion of the restoration. Readjusting
occlusion and reshaping the occlusal anat­
omy may be done at this time with the
use of plug finishing burs. The use of
mounted stones for this purpose is to be
avoided inasmuch as these instruments
will tend to scratch the enamel. Finishing
burs cannot cut enamel and will leave
a smoother surface of amalgam.
Although the rubber abrasive wheels
are helpful in eliminating the larger sur­
face scratches, they should be used with
care in order to avoid the creation of
heat, which will draw undesirable mer­
cury to the surface of the restoration. For
this reason it may even be advisable to
avoid the use of these wheels. Even
though it may take a little longer, the
more prominent surface scratches may
be removed with the use of a cone-shaped
bristle prophylaxis brush with fine pum­
ice. The surface then may be worked to
NADAL . . . VOLUME 65, JULY 1962 • 89/75
Fig. I I • Properly carved and polished am algam
restoration
a high degree of smoothness using a
prophylaxis rubber cup and flour of pum­
ice. The same cup with whiting or tin
oxide will provide a high luster.
If a sound matrix technic is followed,
the proximal surface of a Class II resto­
ration which has been packed against a
perfectly smooth surface will require little
polishing. This may be accomplished
easily with the use of smooth, wide, amal­
gam finishing strips with flour of pumice
and tin oxide. Separation is not neces­
sary; if the finishing strips are used with
care, the contact will not be lost.
The surface must be kept moist at all
times, and the polishing instruments
should be applied with intermittent mo­
tion to avoid the creation of heat (Fig.
11 ).
SUM M ARY
In the light of the available evidence, it
may be concluded that a conservative ap­
proach to cavity preparation is indicated.
All modifications in the amalgam cavity
design aimed at increasing bulk, such as
grooving, excessive slanting or rounding
the pulpal floor or the axiopulpal wall,
are superfluous procedures.
An extreme traumatic occlusion is the
90/76 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
predominant factor influencing the gross
isthmus fracture o f Class I I amalgam res­
torations. T h e importance o f the bulk
factor in this region w ill remain secondary
until extreme traumatic intercuspal rela­
tions are present. Thus, the importance
of carefully studying and adjusting the
occlusion in amalgam work cannot be
overemphasized.
Further support fo r a conservative ap­
proach in the cavity preparation for
amalgam lies in the fact that a bucco-
lingual reduction o f the occlusal outline
will reduce significantly the incidence of
marginal failure.
A ll the new evidence indicates that the
inherent amplitude o f safety o f amalgam
is even greater than thought in the past.
Everything tends to suggest that certain
laborious and highly exacting technics
often proposed in the literature, which
seem to defy the skill o f the average oper­
ator, may be unrealistic and that perhaps
a less strict but nonetheless adequate tech­
nic could be designed for amalgam work.
However, until such a technic is designed
or a superior material is developed, the
adherence to high standards is the only
relative assurance o f success that the den­
tist has. Success with amalgam, for the
most part, remains the dentist’s responsi­
bility. Amalgam, despite its ample range
o f tolerance and all the advancements
made in this field, remains more suscep­
tible to human variables than any other
dental restorative material available
today.
*Associate professor and chairman, department of
operative dentistry, University of Puerto Rico, School of
Dentistry.
1. Westcott, Am os. Report of the O nondaga County
Medical Society, on mineral paste. Am. J. D. Sc. 1st
series 4:175 1843-1844.
2. Brekhus, P. J., and Arm strong, W . D. Civilization—
a disease. J.A.D.A. 23:1459 A u g . 1936.
3. Phillips, R. W., and others. Clinical observations
on am algam s with known physical properties. J. D.
Res. 22:167 June 1943.
4. Phillips, R. W., and others. Clinical observations
on am algam with known physical properties— final re­
port. J.A.D.A. 32:325 March 1945.
5. Sweeney, J. T. A m algam manipulation: manual
vs. mechanical aids. Part II. Com parison of clinical
applications. 27:1940 Dec. 1940.
6. Black, G. V. Investigation of the physical charac­
ters of the human teeth in relation to their diseases,
and to practical dental operations, together with the
physical characters of filling-materials. D. Cosmos
37:553 July; 37:637 A ug.; 37:737 Sept. 1895.
7. Healey, H. J.t and Phillips, R. W. Clinical study
of am algam failures. J. D. Res. 28:439 Oct. 1949.
8. Roper, L. H. Restorations with amalqam in the
army: an evaluation and analysis. J.A.D.A. 34:443 April
1, 1947.
9. Moss. R. P. A m algam failures. U .S . Arm ed Forces
M . J. 4:735 M a y 1953.
10. Bronner, F. J. Engineering principles applied to
Class 2 cavities. (Abst.) J. D. Res. 10:115 Feb. 1929.
11. Bronner, F. J. Mechanical, physiological and
pathological aspects of operative procedures. D. C o s­
mos 73:577 June 1931.
12. Easton, G. S. Causes and prevention of am algam
failures. J.A.D.A. 28:392 March 1941.
13. Black, G. V. W ork on operative dentistry, vol.
2, ed. 3. Chicago, Medico-Dental Publishing Co., 1917.
p. 150, 152.
14. Brown, W . E., Jr. Mechanical basis for the prepa­
ration of Class II cavities for am algam fillings in
deciduous molars. J.A.D.A. 38:417 A p ril 1949.
15. Ketsten, L. B. A m algam restorations for the pri­
mary dentition. J. New Jersey D. Soc. 23:33 Jan. 1952.
16. Ingraham, Rex. Application ^ of sound biom e­
chanical principles in the design of inlay, amalgam and
gold foil restorations. J.A.D.A. 40:402 A p ril 1950.
17. Lampshire, E. L. Relation^ o f cavity form to
failure of sllver am algam restorations In primary molar
teeth. M.S. thesis, University of Nebraska Library, 1950.
18. Simon, W. J., editor. Clinical operative dentistry.
Philadelphia, W . B. Saunders Co., 1956, p. 21.
19. Sweet, C . A . Cavity preparation in deciduous
teeth. J.A.D.A. 38:423 A p ril 1949.
20. McGehee, W . H. O.; True, H. A., and Inskipp,
E. F. Textbook of operative dentistry, ed. 3. Philadel­
phia, The Blakiston Co., 1950, p. 329.
2!. Gabel,, A . B., editor. American textbook of> o p ­
erative dentistry, ed. 9. Philadelphia, Lea & Febiger.
1954, p . 287.
22. Markleyt> M . R. Conserving tooth structure with
improved cavity preparation. Paper read at Indiana
University School of Dentistry symposium on amalqam,
A p ril 9, 1958.
23. Noonan, M . A . Use of photoelasticity in a study
of cavity preparations. J. Den. Children 16:24 4th quart.
1949.
24. Haskins, R. C.; Haack, D. C., and Ireland, R. L.
Study of stress pattern variations in Class II cavity
restorations as a result of different cavity designs.
J. D. Res. 33:757 Dec. 1954.
25. Guard, W . F. Study of stress pattern variations
In buccal-lingual sections of C lass II cavity restorations
as a result of different cavity forms. M.S. thesis, Uni­
versity of Nebraska Library, 1956.
26. Mahler, D. B. Analysis of stresses in a dental
am algam restoration. J. D. Res. 37:516 June 1958.
27. Nadal, Rafael. Clinical investigation on the rela­
tion of mercury to the am algam restoration: II.
J.A.D.A. 63:488 Oct. 1961.
28. Simon, W . J., editor. Clinical operative dentistry.
Philadelphia, W . B. Saunders Co., 1956, p. ¡9.
29. McGehee, W . H. O.; True, H. A., and Inskip,
F. E. Textbook of operative dentistry, ed. 3. Philadel­
phia, The Blakiston Co., 1950, p. 328.
30. Blackwell, R. E. G. V. Black's Operative dentistry,
ed. 9. S. Milwaukee, Medico-Dental Publishing Co.,
1955, p . 183.
31. Nadal, Rafael. Clinical investigation on the rela­
tion of mercury to the am algam restoration: I. J.A.D.A.
63:8 July 1961.
32. Miller, E. C . Technical suggestions in the use
of am algam . Pennsylvania D. J. 17:183 June 1950.
33. Markley, M. R. Am algam restorations for Class V
cavities. J.A.D.A. 50:301 March 1955.
34. Phillips, R. W ., and Boyd, D. A . Importance of
the mercury-alloy ratio to the am algam filling.
J.A.D.A. 34:451 A p ril I, 1947.

35. M cDonald, R. E., and Phillips, R. W . Clinical o b ­
servations on a contracting am algam alloy. J. D. Res.
29:482 A u g . 1950.
36. Phillips, R. W . Physical properties of am algam
influenced by the mechanical am algam ator and pneu­
matic condenser. J.A.D.A. 31:1308 Oct. 1944,
37. Swartz, M. L., and Phillips, R. W . Study of
am algam condensation procedures with emphasis on
the residual mercury content of the increments. I.
Strength, flow, and dimensional change. J. D. Res.
33:12 Feb. 1954.
38. Mosteller, J. H.; Nadal, Rafael, and Phillips,
R. W . Preliminary study of the characteristics of two
centrifuge machines for removal of mercury from
amalgam. J. South. California D. A. 28:161 M ay 1960.
39. Nadal, Rafael, and Phillips, R. W . Unpublished
data.
Review of services
for fifty-nine dental patients
Charles M . Stebner, D .D .S., Laram ie, Wyo.
T h e dental services rendered 59 small­
town patients during the last 20 to 27
years were evaluated. A ll had been seen
in one continuous practice. T h e average
patient’s total cost was $556, or about $23
a year. T h e average patient received 23
restorations, of which 28 per cent were
gold foil. Teaching programs should em­
phasize operative dentistry procedures. I t
is satisfying to help the patient conserve
his natural dentition with regular prophy­
lactic programs, sound operative proce­
dures and use of the best available tools.
W e have all heard that experience is the
best teacher, and records in a dental office
can be a valuable history of such experi­
ence. An examination o f the records in
this office may help others in planning
the care o f patients.
It is well to observe the patients in a
practice by looking over the shoulder of
STEBNER . . . VOLUME 65, JULY 1962 • 91/77
40. Eames, W . B. Preparation and# condensation of
am algam with a low mercury-alloy ratio. J.A.D.A. 58:78
A p ril 1959.
41. Crowell, W . S., and Phillips, R. W . Physical prop­
erties of am algam as influenced by variation in surface
area of alloy particles. J. D. Res. 30:845 Dec. 1951.
42. Mosteller, J. H. Evaluation of the fine cut silver
alloys. Bui. A labam a D. A . 33:11 Oct. 1949.
43. Skinner, E. W., and Mlzera, S . T. Evaluation of
the Eames am algam condensation technic. (Abst.) J. D.
Res. 38:750 July-Aug. 1959.
44. Castatdi, C . R.; Phillips, R. W., and Clark, R. J.
Further studies on the contour of Class II restorations
with various matrix technics. J. D. Res. 36:462 June
1957.
the operator at work and observing some
o f those experiences. In the first five years
o f one’s practice, the conscientious, well-
educated young man w ill see very few
o f his failures, but perhaps the man
across the street w ill see more of them.
As the years pass by the number o f oper­
ative failures steadily increases— -the fail­
ures become more apparent at the end
o f 15 years.
M ETH O D
W ith this thought in mind, I have chosen
to evaluate patients who have been in one
continuous practice during the last 20 to
27 years. T h e records o f 59 patients who
are still active in the practice were avail­
able. N o records or patients that were
available were eliminated. I t was desired
to study patients of the 40 to 60 year age
group; all 59 fit into this category with
the exception o f a few that perhaps are
over 60 years old. I wanted to find out