:

COMPLEX RESTORATIONS
 Introduction
❖Complex posterior restorations are used to replace
missing tooth structure of teeth that have fractured or
are severely involved with caries or existing restorative
material.

❖These restorations usually involve the replacement of

one or more missing cusps, and often, utilize a
bonding technique.
 Introduction
❖Amalgam is easy to use , has high compressive
strength, excellent wear resistance, and a
proven long-term clinical performance.

❖However, it is metallic (unesthetic), requires a

retentive tooth preparation, and does not seal or
strengthen the tooth.
 Indications
◦ 1.Large amounts of tooth structure are missing.
◦ 2.When one or more cusps need capping.
◦ 3.Increased resistance and retention forms are needed.
❖They may be used :
1. To control restorations in teeth that have a questionable pulpal
and/or periodontal prognosis.
2. To control restorations in teeth with acute and
severe caries.
3. Definitive final restorations.
4. Foundations
 Resistance and Retention Forms.

Status and Prognosis of the Tooth

Role of the Tooth in the Overall

Treatment Plan.
Factors To
Be Occlusion.

Considered: Esthetics.

Economics.

Age and Health of the Patient.

 1.Resistance And Retention Forms:

❖In a tooth severely involved with caries or existing restorative

material any undermined enamel or weak tooth structure
subjected to fracture must be removed and restored.

❖When conventional retention features are not adequate

because of insufficient remaining tooth structure,
pins, slots, and amalgam bonding techniques may be used to
enhance the retention form.
❖The retention features needed depend on the amount of tooth
structure remaining and the tooth being restored. As more
tooth structure is lost, more auxiliary retention is required.
Pins, slots, and bonding also provide additional resistance
form to the restoration.

❖Note :
Usually, a weakened tooth is best restored with a properly
designed indirect (usually cast) restoration that will prevent
tooth fracture caused by mastication force
 2. Status And Prognosis Of The Tooth:

❖The status and prognosis of the tooth will determine the size, number,
and placement of retention features.

❖Larger restorations generally require more retention.

❖However, the size, number, and location of retention features demand

greater care in smaller teeth, in teeth that have been significantly
excavated, and in symptomatic teeth.

❖ Carelessness can risk the pulp causing irritation or exposure.

 3.Role Of The Tooth In The Overall
Treatment Plan:

◦ Complex amalgam restorations are used occasionally as an

alternative to indirect restorations, they are often
indicated for other purposes:
1. Abutment teeth for fixed prostheses may utilize a
complex restoration as a foundation.

2.For periodontal and orthodontic patients, the complex

restoration may be the restoration of choice until the final
phase of treatment when cast restorations may be preferred.
 4.Occlusion:

❖Complex amalgam restorations are

sometimes indicated as interim
restorations for teeth that require elaborate
occlusal alterations ranging from vertical
dimension changes to correcting occlusal
plane discrepancies.
 5. Esthetics:

❖When esthetics is a primary

consideration, a complex amalgam
restoration may not be the treatment of
choice because of the display of metal.
 6. Economics:

❖When cost of indirect restorations is a major

factor for the patient, the complex direct
amalgam restoration may be an appropriate
treatment option, provided that adequate
resistance and retention forms are included.
 7.Age And Health Of The Patient :

❖For some geriatric and debilitated patients, the

complex amalgam restoration may be the
treatment of choice over the more expensive
and time-consuming cast restoration.
 Contraindications

❖The complex amalgam restoration may be contraindicated:

1.If the patient has significant occlusal problems.

2.If the tooth cannot be properly restored with a direct restoration

because of anatomic and/or functional considerations.

3.If the area to be restored is esthetically important for the patient

 Advantages:

1. Conserves Tooth Structure: the preparation for a complex amalgam

restoration is usually more conservative than the preparation for an
indirect restoration or a crown.

2. Appointment Time: the complex restoration can be completed in one

appointment. The cast restoration requires at least two appointments.

3. Resistance and Retention Forms: resistance and retention forms may be

significantly increased by the use of pins, slots, and bonding .

4. Economics: compared to an indirect restoration, the amalgam restoration

is a relatively inexpensive restorative procedure.
 Disadvantages:

❖Most of the disadvantages related to complex

amalgam restorations refer to the use of pins used to
provide retention for these restorations.
 Disadvantages:

1-Dentinal Micro-fractures.
Preparing pinholes and placing pins may create craze
lines or fractures, as well as internal stresses in the
dentin.
2-Micro leakage.
In amalgam restorations using cavity varnish,
microleakage around all types of pins has been
demonstrated .
 Disadvantages:
3-Decreased Strength of Amalgam.
The tensile strength and horizontal strength of pin-
retained amalgam restorations are significantly
decreased .
4-Resistance Form.
Resistance form is more difficult to develop than
when preparing a tooth for a cusp capping onlay or
a full crown.
The complex amalgam restoration does not protect
the tooth from fracture as well as an extra-coronal
restoration.
 Disadvantages:

5-Penetration and Perforation.

Pin retention increases the risk of penetrating into the
pulp or perforating the external tooth surface.
6-Tooth Anatomy.
Proper contours and occlusal contacts, and/or
anatomy, are sometimes difficult to achieve with large
complex restorations.
Types Of Complex Amalgam Restoration :

◦1. Slot-retained amalgam restorations.

◦2.Pin-retained amalgam restoration.
 1. Slot Retained Amalgam
Restorations:
❖A slot is a retention groove in dentin whose
length is in a horizontal plane.

❖Slot retention may be used in conjunction

with pin retention, or as an alternative to it.

❖Slots are particularly indicated in short

clinical crowns and in cusps that have
been reduced 2 to 3 mm for amalgam.
 1. Slot Retained Amalgam
Restorations:
❖Compared with pin placement, more tooth structure is
removed for preparing slots.

❖However, slots are less likely to create micro-

fractures in the dentin and to perforate the tooth or
penetrate into the pulp.

❖Coves and locks can be used to provide additional

retention.
1. Slot Retained Amalgam
Restorations:
Locks (A), slots (8), and coves (C).
Tooth Preparation For Slot Retained
Amalgam Restoration:

◦ Slot length depends on the extent of the tooth preparation.

◦ The slot is at least 0.5 mm in depth and 1 mm or more in

length, depending on the distance between the vertical walls.
2. Pin Retained Amalgam Restoration
 2. Pin Retained Amalgam
Restoration:
❖A pin retained restoration may be defined as any
restoration requiring the placement of one or more
pins in the dentin to provide adequate resistance
and retention forms.

❖Pins are used whenever adequate resistance and

retention forms cannot be established with slots,
locks, or undercuts only.
 2. Pin Retained Amalgam
Restoration:

❖Pins are rarely used in anterior teeth, except in some

cases where a proportionally large class IV is located on
the distal surface of a canine, and is involving the disto-
incisal angle.

❖The use of pins may be considered for a tooth that has

insufficient enamel present for acid-etching, and/or
insufficient remaining tooth structure for adequate
retention features.
Tooth Preparation For Pin Retained
Amalgam Restoration:
❖The general initial form is the same as any deep cavity
preparation.

◦ When caries is extensive, reduction of one or more of the

cusps for capping may be indicated (capping cusps) for the
development of adequate resistance form.

❖Ensure that the final restoration has restored cusps with a

minimal thickness of 2 mm of amalgam for functional
cusps and 1.5 mm of amalgam for non functional cusps.
Tooth Preparation For Pin Retained
Amalgam Restoration:

❖A liner can be applied, if needed, and, if used, should

not extend closer than 1 mm to a slot or a pin.

❖Pins placed into prepared pinholes (also referred to as

pin channels) provide auxiliary resistance and retention
forms.

❖Coves, locks, groves and slots might be used to increase

retention.
 Types of pins

1) Self threading pins: (Most retentive and

the most frequently used pin type, But
generates vertical and horizontal stress on
dentine, pinhole diameter is smaller than
that of the pin).

2) Friction locked pins: ( hole diameter is

0.025mm smaller than that of the pin) ,
The pins are tapped into place, retained by
the resiliency of the dentin .

3) Cemented pins: ( preparation diameter is

0.025-0.05mm wider than the pin used) .
Factors Affecting Retention Of Pin In Dentine And
Amalgam:

1. Type:
Self threaded> friction locked> cemented.

2. Surface Characteristics:
number of and depth of the elevations (serrations or
threads) on the pin influence retention of the pin in the
amalgam restoration.
Factors Affecting Retention Of Pin In Dentine And
Amalgam:

3. Orientation:

❖ Placing pins in a nonparallel manner increases their retention.

❖Bending pins to improve retention in amalgam is not desirable because

bends may interfere with adequate condensation of amalgam around the pin
and thereby decrease amalgam retention.

❖Bending also may weaken the pin and risk fracturing the dentin.

❖Pins should be bent only to provide an adequate amount of amalgam

(approximately 1 mm) between the pin and the external surface of the
finished restoration (both on the tip of the pin and on its lateral surface).
Factors Affecting Retention Of Pin In Dentine And
Amalgam:

4. Number:
❖In general, increasing the number of pins increases the
retention in dentin and amalgam. However, the benefits of
increasing the number of pins must be compared to the potential
problems created.
❖Which are:
(1) the crazing of the dentin and the potential for fracture
increase.
(2) the amount of available dentin between the pins decreases.
(3) the strength of the amalgam restoration decreases.
Factors Affecting Retention Of Pin In Dentine And
Amalgam:
5. Diameter:
❖Also generally, as the diameter of the pin increases, the retention in
dentin and amalgam increases.
❖However, as the number, depth, and diameter of pins increase, the
danger of perforating into the pulp or the external tooth surface
increases.

❖6. Extension into dentin and amalgam:

❖For self threading pins, retention is not increased
significantly when the depth of the pin into dentin exceeds
2 mm to preserve the strength of the dentin and the
amalgam.
 Pin Placement Factors And Techniques:

1. Pin size:
❖Four sizes of pins are available, each with a
corresponding color-coded drill.

❖Two determining factors for selecting the appropriate

size pin are: 1.the amount of dentin available to
safely receive the pin and 2.the amount of retention
desired.
A, Regular [0.78 mm]).
B, Minim [0.61mm]).
C, Minikin [0.48 mm]).
D, Minuta [0.38 mm]).
 Pin Placement Factors And
Techniques:
2.Number of pins:
❖Several factors must be considered when deciding
how many pins are required:
1) The amount of missing tooth structure.
2) The amount of dentin available to receive pins safely.
3) The amount of retention required.
4) The size of the pins.

❖As a rule, one pin per missing axial line angle should be
used.
 Pin Placement Factors And Techniques:

3. Location:
❖Several factors aid in determining the pinhole locations::
(1) Knowledge of normal pulp anatomy and the external tooth contours.
(2) A current radiograph of the tooth.
(3) A periodontal probe.
(4) The patient's age.

❖Areas of occlusal contacts on the restoration must be anticipated because a

pin oriented vertically and positioned directly below an occlusal load
weakens the amalgam significantly, occlusal clearance should be sufficient to
provide 2 mm of amalgam over the pin.
❖Considerations that should take place on
pins insertion:

◦ 1.Pin placement should provide at least 1 mm of remaining

dentin thickness from the pulp.
◦
◦ 2. The pinhole should be positioned no closer than 0.5 to 1 mm to the
DEJ or no closer than 1 to 1.5 mm to the external surface of the tooth,
whichever distance is greater.

◦ 3.The pinhole should be parallel to the adjacent external surface of the

tooth.
❖4. Pinholes should be prepared on a flat surface that is
perpendicular to the proposed direction of the pinhole.

❖5.Whenever three or more pinholes are placed, they should be

located at different vertical levels on the tooth, if possible. This
will reduce stresses resulting from pin placement in the same
horizontal plane of the tooth.

❖6.Minimal interpin distance is 3mm and maximum is 5mm.

 Pinhole Preparation:
❖The Kodex drill (a twist drill) should be used for preparing pinholes.
◦
❖The drill is made of a high-speed tool steel that is swaged into an
aluminum shank.
◦
❖The aluminum shank, which acts as a heat absorber, is color coded so
that it can be easily matched with the appropriate pin size.
Pinhole Preparation:

Determining the angulations for twist drill

 Pinhole Preparation:

❖N.B: Certain clinical locations require extra care in determining pinhole

angulation. The distal of mandibular molars and the lingual of maxillary
molars have been considered as areas of potential problems because of
the abrupt flaring of the roots just apical to the CEJ.

❖Apply pressure to the drill, and prepare the pinhole in one or two
movements until the depth-limiting portion of the drill is reached, and
remove the drill from the pinhole.
❖Two instruments for insertion of threaded pins are
available:

1. Conventional latch-type contra-angle handpiece.

2. TMS (thread mate system )hand wrenches.
❖When using the handpiece activate the handpiece at low speed until
the plastic sleeve shears from the pin. Then, remove the sleeve and
discard it.

❖When using TMS hand wrench a standard design pin is placed in the
appropriate wrench and slowly threaded clockwise into the pinhole
until a definite resistance is felt when the pin reaches the bottom of
the hole.

❖The pin should then be rotated one-quarter to one-half turn

counterclockwise to reduce the dentinal stress created by the end of
the pin pressing the dentin. then carefully remove the hand wrench
from the pin.
❖Once the pins are placed, evaluate their length. Any
length of pin greater than 2 mm should be removed.

❖To remove the excess pin a special bur at high speed

is used, it must be perpendicular to the pin or it might
loosen it.

❖After placement, the pin should be tight, immobile,

and not easily withdrawn.
 Possible Problems With Pin
Placement:
◦ Failure of pin retained restorations:
1. Fractured drills or fractured pin.
2. Loose pins.
3. Penetration into the pulp or external wall
perforation.
 Amalgam Foundation
❖A foundation is an initial restoration of a
severely involved tooth. The tooth is restored so
that the restorative material (amalgam,
composite, or other) will serve in lieu of tooth
structure to provide retention and resistance
forms during the development of the subsequent
final cast restoration.
❖Types of foundation retention:
1- Pin retention.
2- Slot retention.
3- Chamber retention.
◦

❖Chamber Retention. For developing foundations in

multi rooted endodontically treated teeth, an alternative
has been described by Nayyar.
Restorative Technique:

Case : Mandibular first molar with

fractured
disto-lingual cusp.
B, Insert wedges.
C, Initial tooth preparation.
D and E, Excavate any infected dentin; if indicated, remove any remaining
old restorative materials.
F, Apply liner and base (if necessary).
either a dentin desensitizer or a dentin bonding system is used as varnish.
G, Prepare pilot holes.
H, Align twist drill with external surface of tooth.
I, Prepare pinholes.
J, Insert Link pins with slow-speed handpiece.
K, Note depth-limiting shoulder (arrow) of inserted Link Plus pin.
L, Use No. '/, bur to shorten pins.
M, Bend pins (if necessary) with bending tool.
N, Final tooth preparation.
O,Tofflemire retainer and matrix band applied to prepared tooth.
P, Reflect light to evaluate proximal area of matrix band.
O, Preparation overfilled.
R, Restoration carved.
S, Reflect light to evaluate adequacy of proximal
contact and contour.
T, Restoration polished.
Thank you