Osce aid.

Content …
1 Classes .. by hana khasawneh

2 Diagnosis of caries .. by mays tayseer

3 Evaluation criteria .. by nada adel

4 Noncarious lesion .. by balqees alsheik theeb

5 Traumatic lesions .. by mays tayseer

6 Root resorption .. by yaman tahaineh

7 Anesthesia .. by hadeel ghassan

8 Matrix sys .. by yaman tahaineh

9 Composite .. by rahaf nawafleh

10 Amalgam .. by rahaf nawafleh

11 Bonding sys .. by taimaa hussien

12 Restorative material selection .. by hana
13 TMJ muscles .. by samah abu-zaideh
14 Mandibular movements .. by samah abu-zaideh
15 Radiographic anatomy .. by nada adel
16 Hazards .. by hana khasawneh

Cons
 PRINCIPLES AND STEPS OF CAVITY PREPARATION
Conventional cavity preparation
Tooth preparation related to amalgam, gold, or ceramic restoration need
specific (walls, depth, marginal form, shape, contour, line angles), to
retain the filling within the cavity.

Modified cavity preparation

Tooth preparations for direct bonded restorations (G.I, Composite) are in
less need for specific (depth, walls, marginal ridges). So we remove the
defect without any special design before filling.
Except in some cases of badly destructed tooth we do some grooves or
retentions to the tooth structure in order to retain the filling.

− Those restorations have adhesion to the tooth structure using acid-

etching technique that helps in the retention of the restoration.
− When we replace an amalgam filling with an esthetic filling, we
follow the same design of the cavity, with modifications (acid-
etching, bonding agent).
Definitions:
Walls: The walls of the prepared cavity take their names from the
tooth surface that the wall is placed on.
Example:

− Wall located on buccal surface of the cavity = buccal wall

 ➢ Pulpal wall (pulpal floor):
The internal wall above the pulp, parallel to the occlusal surface, and
perpendicular to the long axis of the tooth.
We see it in: Class I and II occlusal surfaces.
➢ Axial wall:
An internal wall parallel to the long axis of the tooth.
Class II proximal surfaces (mesial or distal portion of the cavity).
Class III proximal surfaces of anterior teeth.
Class IV proximal surfaces or incisal third fracture (modified cavity for
esthetic filling material).
Class V.
➢ Gingival wall:
Parallel to the pulpal floor, parallel to the occlusal surface, and
perpendicular to the axial wall.
Class II, III, V, IV adjacent to gingiva (common in class II cavity).
➢ Cavosurface angle:
The junction of the prepared cavity wall with the external surface of the
tooth at the margin.
[The angle between the outer
surface and the internal wall of
the cavity]
 G.V BLACK STEPS OF CAVITY PREPARATION
1. Outline form (from mesial to distal include all fissures according to
dental caries)
2. Resistance form
3. Retention form
4. Convenience form (remove more tooth structure to be able to
access dental carries).
5. Removal of remaining caries
6. Finishing of walls and margins
7. Cleansing of the cavity

1. OBTAIN THE OUTLINE FORM:

− The outline form depends on the extension and location of dental
caries.
− The main objective of cavity preparation is to remove dental
caries.
Points to consider:
1) Extend the cavity margin to include all the carious fissures or the
ones able to be.
2) Extend preparation until no unsupported enamel remains.
3) Extend all margins into sound tooth structure.
4) Extend the cavity margins/walls to allow sufficient access to a
proper placement of the restoration.
5) Two separate cavities should not be united unless:
- The separating ridge is less than 0.5mm.
- Undermined.
- Carious.
 So, in maxillary molar if we had caries in both MB, DL fissures
and oblique ridge thickness is less than 0.5 or undermined (caries
extended laterally) or had caries, we do unite the cavities. If not,
we separate them.
6) Depth of the preparation:
- Keep the depth of preparation into dentine to minimum.
- For pit and fissure 0.2-0.5mm in enamel beyond DEJ, and the
total depth of occlusal access for fissures 1.5-2mm.
- For smooth surface 0.2-0.8mm.

Note1: Bur should be rotating during insertion until removing it.

Note2: the shape of cavosurface margin will be assumed after the cavity
has been prepared.
Note3: Enamel thickness is = 0.6mm.
7) Preserve the marginal ridge strength (mesial + distal wall)
(proximal wall):
- The remaining marginal ridge should be greater than 1.6mm
for premolars and 2 mm for molars.
- If the remaining marginal ridge after cavity preparation is less
than 1.6mm it increases the incidence of fracture due to
undermining the marginal ridge.

▪ When the remaining thickness of proximal walls is more than

1.6mm then → proximal walls should be parallel.
▪ When the remaining thickness of proximal walls is less than
1.6mm then → the proximal walls should be divergent. Why?
Ans: Following the divergence of enamel rods to prevent fracture of the
walls.

Parallel Diverge

8) Faciolingual extension (buccolingual extension):

- Minimal extension faciolingually to prevent weakening of the
cusps.
- Commonly for mild cavity it is about 1⁄4 the distance
buccolingually.
- In moderate caries 1-1.5 mm either 1⁄4 or 1/3 of the distance
buccolingually.

9) Gingival margin (class II):

- Extend the gingival margins apically of the contact to provide
clearance between the gingival margin and the adjacent teeth
(0.5mm clearance).

2. RESISTANCE FORM
A cavity has resistance form if it is prepared (shaped) so that the
remaining tooth structure and restoration is protected against fracture
during forces of mastication.
Cavity design should include:
1) Flat and smooth floor to resist occlusal forces. (Equal distribution
of forces on the area)
 2) Cavity walls meeting the cavosurface margins at right angles.
(Relation with enamel rods and prisms)
3) Restrict the extension of the cavity walls (MD) to keep the dentine
support. (Minimal extension).
4) Internal line angles should be rounded to reduce stress
concentration. (Sharp internal line angles do stress concentration).
5) Enough thickness of filling material to prevent its fracture under
load.
Minimum occlusal thickness of restoration:
- 1.5 mm for amalgam.
- 1-2 mm for cast restorations.
- 2 mm for porcelain.
Factors influencing the resistance form:
- Depth of the cavity.
- Width of the cavity.
- Filling material.
Deep and wide cavity →high incidence of fracture.
Shallow and wide cavity → high incidence of fracture (because the
thickness should be 1.5-2mm).

3. RETENTION FORM:
A cavity has retention form if it is shaped or formed to prevent the
displacement or removal of the restorative material.
• The cavity designed for retention form may include:
1) Parallel or slightly convergent walls:
- Buccal and lingual wall converge slightly toward occlusal
portion, so the floor is a little wider than occlusal.
 - Class I or II: The facial and lingual walls of the occlusal and the
proximal walls converge toward the occlusal surface about 10
degree.

2) Retentive groove:
- The retentive grooves are prepared on line angles by small size
round bur in low speed.
- The retention groove is close to the DEJ but must not
undermine the enamel of its dentine support.
- Resistance form and retention form are as a rule obtained
during the same steps of cavity preparations.

▪ Shallow grooves:
− Class I shallow grooves are placed in dentine in the pulpolingual
and pulpobuccal line angles. (not mesiopulpal or distopulpal
because it undermines enamel rods and prisms)
− Class II axiobuccal and axiolingual line angles.
− Class III retention grooves at axiogingival line angle + retention
grooves at insicolabiolingual line angle.
− Class V retention grooves at the axiocclusal and axiogingival line
angles.

3) Dovetails shape:
- Narrow extension
between the cusps. Outside the cusp, wide extension occurs to
prevent lateral displacement of the filling in class II cavity.
- This outline of the cavity is to preserve cusp extension.
- Dovetail provides retention in class II cavity.
 4) Retentive pins (restorative pins):
- Inserted inside dentine in badly destructed tooth and missing
cusps.
- Defined as any restoration which requires the placement of
pin/s in dentine (in midway between DEJ and dentinopulpal
junction) in order to provide
retention and/or resistance form to
the restoration.

✓ When the remaining tooth structure is difficult to have optimal

resistance and retention form achieved, then in such cases dovetail
shape and grooves are prepared.
✓ When dovetail and grooves are not enough to provide desired
retention, then restorative pins are used.
✓ In a severe badly destructed tooth, it is preferable to do RCT and
reinforcement of the tooth structure with endodontic post then we put
the restoration and finally crowning the tooth structure.

➢ Advantages of restorative pins:

− Support the restorative materials.
− Resist their displacement in severely
damaged tooth.
➢ Restorative pin types:
− Cemented pins.
− Friction locked pins.
− Self-threaded pins.
Q: How the retentive groove is achieved in class V cavity (on DEJ)?
Ans: Grooves in Axio-gingival line angle and axio-occlusal line angle.
 Note: the most retentive friction locked and self-threaded.

4. OBTAIN THE CONVENIENCE FORM:

Shape or form of the cavity that provides for:
- Adequate visibility.
- Adequate accessibility.
- Ease of operation in preparing and restoring the cavity.

5. REMOVAL OF REMAINING CARIES:

It is the removal of any remaining infected caries left in the deep area of
the tooth after the initial step of cavity preparation.
- The operator must decide whether to remove or leave the
questionable area (soft or hard area in the dentine).
- If it is hard and no more can be removed with spoon excavators
(hand instruments) or with round low speed bur, it’s advisable to
leave this hard-stained dentine undisturbed → this is called
affected dentine.
Affected dentine: as the caries progress the decalcification precedes the
penetration of microorganisms. (Decalcification then microorganisms
invade)

Affected
Not invaded by microorganisms
Can be remineralized by restorative
means
It is acceptable to allow affected
dentine to remain in prepared tooth.
Infected
Invaded by microorganisms
Can’t be remineralized
Should be removed during cavity
preparation

Hard Soft + removed with spoon excavator

or low speed handpiece
 ➢ When pulpal or axial wall has been established at the proper level
and a small carious area remains, only this area should be removed
leaving a rounded concave area in the floor.
➢ This area will be deeper than the adjacent sound tooth structure
(rocking), it will be corrected by the use of protective base
(calcium hydroxide filling material or G.I) to be equal with the
adjacent tooth structure.
− Calcium hydroxide stimulates the formation of reparative dentine.

6. FINISHING THE CAVITY WALLS:

The purpose of finishing the enamel walls is to achieve the best marginal
seal between the filling material and tooth structure:

− To obtain a smooth marginal junction.

− To provide maximal strength of both cavity walls and the filling
material at the margin.
• Amalgam doesn’t have adhesion with tooth structure, so we should
overcome some weak points of amalgam.
Smooth walls (smooth marginal junction) specially in amalgam:

− Prevent microleakage. (Of fluid and saliva along filling material)

**First indication of microleakage is pain.
 − Prevent post-operative sensitivity.
− Prevent discoloration.
− Prevent secondary caries.
− Increase the strength of restoration.
− Increase the strength of tooth structure.
− Increase the longevity of restoration. (10-12 years).

7. CLEANSING OF THE CAVITY

The cavity should be clean and dry before inserting the final restoration
It is aimed to:
- Remove debris, dentine chips, saliva.
- Improve adaptation of final restoration.
- Prevent microleakage
- Prevent recurrence caries.
This is done using air water spray syringe.
BLACK CARIES CLASSIFICATION (FROM I TO VI)
G.V. Black developed a system to categorize carious lesions based on
the type of the affected tooth (anterior or posterior) and the location of
the lesion.

CLASS I
Involves pits and fissure on occlusal surface of posterior teeth & lingual
surface of anterior teeth. (Most common caries)
Why Class I caries occur? Because the fissure is “V” shaped and it’s
difficult for toothbrush to reach this area, so this encourages bacteria to
live there, and acid formation will happen.
1. Obtain the outline:
− Carious tooth structure should be eliminated.
− Margins should be placed on sound tooth
structure. Marginal ridge thickness should be
around 1.6mm.
− Straight fissure or pear-shaped bur can be used.
− The preparation is widened to give access to all carious dentin and
to remove any unsupported enamel.
− No sharp angles. (Round angle – no stress concentration)
 − Smooth walls and floor
− Conservative (not wide cavity to be proper for direct restoration)
− For conservative class I cavity, faciolingual should be 1-1.5 mm.
When there is a very thin lingual or buccal walls, we should remove
all the cusp and do cuspal-coverage, so we complete it as indirect
restoration.
Case:
In this case with recurrent caries lesion we have to do class I
preparation when replacing a defective restoration, the outline form
will be determined by:
1. The outline form of the old restoration.
2. Additional carious lesion.
3. The resistance form required. Especially if the cavity
becomes very wide.
Outline form of class I on different teeth

Lower 5

Lingual pit → Kidney shaped Central fissure (A)

Central fissure + lingual extension (B)
Lower 4:
(A) caries on the 2 pits of the tooth so we
have 2 separate cavities
(C) Caries on the entire fissure of the
tooth.
The most important thing in lower 1st
PMs: because of the lingual inclination we draw an imaginary line with
the long axis of the tooth and another line touches the lingual area, the
middle of this distance between them is the best orientation to make
class 1 cavity and to protect the pulp from exposure. (If we use the bur
perpendicularly with the tooth structure we will end with perforation)

Upper 6:
This picture about the most common outlines for upper 6:
A: Just at the mesial area
B: Crosses the oblique ridge to the
distal side
C: Crosses the oblique ridge +
lingual extension
Note: with buccal and lingual extensions it is still class1 not class 2.
Buccal pit:
Common area for caries with a triangular
outline, its base gingivally and its apex
occlusally. Circular outline when the caries
are deep.
.
 2. Resistance Form
- Adequate thickness 1.5 mm if less than this the amalgam
restoration will break under occlusal load.
- Cavo-surface should be 90 with amalgam to resist
fracture of both the restoration and the tooth. It is
not important for composite to be 90 degrees.
- Flat pulpal floor.
Roughness in the floor means losing part of the resistance form.

3. Retention Form
- Walls should be parallel to each other or should converge slightly
occlusally.
Parallel walls achieved by → straight fissure
Convergence walls done by → pear shaped or straight fissure
bur.
- Grooves: Bucco-pulpal or lingo-pulpal line angles.
(It is removal of extra tooth structure with a round bur, lock for
the restoration inside the line angles of the cavity).
4. Convenience Form
- Creating sufficient access to the carious lesion to facilitate:
A. Visibility
B. Instrumentation during cavity preparation and restoration.

5. Removal of remaining caries:

- Done for caries which remained in dentine after doing good outline
and convenience form. (Removed from the peripheral DEJ)
- Best removed using spoon excavator or slow speed round bur.
 6. Finishing the walls and margins
- Finishing of the external walls and flares for any roughness.

Reminder: Every two opposing walls should be parallel or slightly

converged (to make the retention form), but when we move toward the
margins mesially and distally (minimal walls) there is change in the
direction of enamel rods, so if we make these walls converge in class I
we will get undermined enamel → we will lose the resistance.

Parallel Divergent Convergent

CLASS II
Class II cavity is done when there is caries in the proximal surfaces
(M&D) in the area beneath (apical to) the contact area between two
posterior teeth.
- Occurs in case of not flossing between teeth especially for people
who suffer from teeth crowding.
- The general outline form is boxlike with an occlusal dove tail like
extension.
Isthmus is a term which refer to the line angle between the pulpal floor
of class I and the axial wall of the class II box.
In the preparation of the isthmus we care about 2 things:
1. To be beveled not sharp.
2. To be as narrow as possible. Which means to NOT extend it more
than one quarter (1/4) of the distance between the buccal and
lingual cusps.
This is very important to guarantee enough supporting of the tooth
structure to support the amalgam restoration.
➔ The wider the isthmus the weaker the amalgam restoration is and
become easier for it to break. (Most common area for amalgam
fracture)
According to G.V Black the cavity is composed of a box in the
proximal area and a normal class I cavity in the occlusal surface
“'extension for prevention”.
Now we don't do complete class I we just create a “Dove Tail” like
shape which is enough for retention. (Minimal Invasive Dentistry)
- The formation of the dove tail area is for amalgam retention, as
amalgam don't bind to the tooth structure chemically, so it needs
mechanical means.

➢ The minimum depth is of 2 mm to gain good bulk of strength for

resistance, so it doesn't break with lateral forces. Also the cavosurface
angle must be 90°.
And occlusally the walls are flaring out and not straight this is done
for two reasons:
1. To create a 90° angle between the surface of
amalgam & enamel. Why? Because if the angle on
the enamel side is less it would be unsupported and
 will break down easily, the same for amalgam, and in both cases
this will lead to micro leakage.
2. The cavity must end out of the contact area with adjacent tooth, as
if this is not done this will lead to have an area that is very hard to
clean and will cause micro leakage.

FEATURES OF THE CAVITY PREPARATION

- The pulpal wall is flat and perpendicular to the long axis.
- The gingival wall is also flat and perpendicular to the long axis of
the tooth.
- The same convergence in class I we also do in class II, but the only
difference is that the buccal wall will be more convergent as it
follows the inclination of the buccal surface (so to look parallel to
it).
And this (following the outer surface outline) would result in the
90° angle we talked about before.
- All the line angles have to look smooth not sharp.
- The axiopulpal line angle (isthmus) should be beveled.
- Establish (ideally) not more than 0.5 mm clearance with
the adjacent proximal surface facially, lingually, and
gingivally. But how to calculate it gingivally? actually
we don’t we just go under the contact area and if the tip
of the explorer passes between the two teeth, then we had achieved
it. (Also if we start to see the red color of the gingiva then we are
done).

- The axial wall is parallel to the long axis of the tooth and curves
slightly to follow the facio-lingual curvature of the tooth (If the wall
is concave then we’re exposing the pulp)
 In class II cavity of posterior teeth, caries are located slightly gingivally
to contact point. So, the gingival floor of class II cavity is extended
slightly sub-gingivally to have clearance from the adjacent contact point
to get 100% removal of dental caries.

Proximal walls in class II cavity:

Extend the buccal and lingual margins into the respective embrasures
(beyond the adjacent teeth) to provide clearance between the prepared
margins and the adjacent tooth.
• Patient with wide contact to the adjacent tooth with a good oral
hygiene → no need to extend buccally and lingually.

- Formation of Retentive grooves:

In the linguo-axial and facio-axial line angles we just pass on them with
round bur to create this groove. These grooves are in dentin only and
follow the facio-lingual curvature of the axial wall.
Notice that they extend from gingival floor to the
isthmus (pulpal floor) without continuing as this
would lead to enamel cutting & weakening.

MEASUREMENTS OF THE PREPARED CAVITY

The isthmus must not be more than 1.5mm,
the gingival floor 3-4 mm (buccolingually),
and the space between the floor & the
curvature of gingiva must be 1mm at least.
The length horizontally not more than 1-2 mm as this in danger the pulp.
- You have to leave a 0.5 to 1 mm between the marginal ridge and the
area at which you start drilling to avoid the destruction or damaging
of the adjacent tooth.
- Make sure that you are directing your forces upon drilling toward
the outside (towards enamel) not toward the inside (dentine) when
you are making the box.
- We usually use straight fissure bur.
We can obtain retention for a restoration in class 2 cavity from:
1) The convergence of the walls
2) Dove tail cavity
3) Retention grooves
And we obtain the resistance by:
1) Making the floor flat, smooth, and perpendicular to the long axis of
the tooth structure.
2) Making the depth of the cavity 2 mm.
3) Making the isthmus narrow & beveled.
4) Rounding the line and point angles.
Mand 1st PM (also in rotated teeth):
The bur is always perpendicular to the occlusal surface of the tooth
because the lingual cusp in this tooth is rudimental, and the occlusal
table is tilted toward the cervical and lingual (this to avoid the exposure
of the pulp).
So the pulpal, gingival, and the occlusal floor should be tilted toward the
cervical and be parallel to the long axis of the
tooth.
Upper 6
In some cases we make two separate cavities (mesial and distal) without
going beyond the oblique ridge (like in A) BUT if the oblique ridge is
weak and narrow, we make one cavity and remove the oblique ridge (B).
Pits?
Sometimes when there is caries on the palatal pit, and if it is very large
you should extend the palatal pit with the occlusal cavity that you have
made. So we call it class 2 with palatal extension. (C)
In small cases there would be large buccal pit so we
should extend it with the occlusal cavity. So we call it
class 2 with buccal extension. (D)

Max 1st and 2nd PMs

When you are working on the mesial side of maxillary first & second
premolars you should not extend the amalgam restoration toward the
buccal side for aesthetic reasons and minimize it as much as you can
(but usually we use composite for these cases).

Sometimes when the caries are deep enough we just do the box without
the occlusal extension. In this case the creation of the grooves will be
extended more than the pulpal floor until reaching occlusal cavosurface.
CLASS III
Cavities or restoration in the proximal surfaces of anterior teeth NOT
involving the incisal angles.

− Tooth preparations for composite materials should be as

conservative as possible.
− Outline of any cavity preparation depends on extension, size, shape
and location of the caries.
− The size of the cavity should be large enough to improve
1. Access
2. Preparation
3. Instrumentation
4. Insertion of filling materials.

INITIAL STEPS OF CAVITY PREPARATIONS:

1) Extra & Intraoral clinical examination
2) Examination of the tooth:
-Inspection, palpation, percussion, sensitivity test, X-ray.
3) Diagnosis
4) Check the articulation points
To help in properly adjusting the restoration’s function and in
determining the tooth design.
5) Anesthesia
6) Cleaning dental plaque (Polishing paste).
7) Shade selection
Determine tooth shade at the start of an appointment.
- Make sure you make good isolation, and the tooth is dry.
- The composite kit contains a shade guide, hold the shade guide
adjacent to the teeth and do a rapid comparison and selection with
no more than 5s because after this period it becomes harder to
distinguish between colors.
- If more time than 30s required then look at a dark area, this will
revitalize and desensitize the color receptors in the eye.
Use Natural Light (day light but not direct sunlight or unit light)
Composite filling material has a special property that you can mix
2 or more shades together to have the most appropriate shade
matching patient’s teeth color.

CONVENTIONAL CLASS III CAVITY PREPARATION

1) Cavity preparation is done using high speed round bur.
2) The bur is oriented perpendicular to thickened area (most affected
area)
3) Initial opening is made close to the adjacent tooth at inciso-
gingival level of caries.
Ex: To enter directly in mesial cavity at upper right central →
direction of the bur should be slightly adjacent for mesial upper left
central.

4) Parallel to enamel rods.

5) Incorrect access overextends the cavity outline and may cause
tooth destruction.
6) The same bur or diamond bur is used to enlarge and remove caries,
while establishing the axial wall depth.
Cavity form:
- Box shape (triangular shape) when the tooth is rotated or the
adjacent is missing, while it’s U-shaped or oval when adjacent is
fully erupted.
- Depth= 1.5mm in axial wall, 0.75mm on root, 0.2 mm
in dentin.
- Extending the cavity cervically = Means less enamel
thickness = so the depth should be less than 1.5mm
- 90 cavosurface margin.
- Retention groove at the axiogingival line and axioincisal line. If the
retentive groove is not enough to obtain adequate retention, we
make a Dovetail extension lingually.
- Bevel:
The width of beveling depends on:
1. The size of the preparation
Larger missing tooth structure = Larger cavity → so to increase
retention we increase width of beveling.
2. Location of the margin
If there is gingival margin in enamel so it’s little enamel= NO
BEVELING because I want to improve composite retention and
bonding with enamel margin.
3. Lingual area where there is high contact point= NO BEVELING
because there are high forces on composite restoration which does
not have wear resistant.
4. Esthetic requirements of the restoration
The width of the bevel should be 0.5-2 mm, Depth of bevel: 0.2 mm in
dentin / 0.1-0.2 mm in enamel, bur-oriented 45 to external tooth surface
(round or flamed shaped bur)
Retention:
1. Micromechanical retention by etching of enamel and dentin.
2. Mechanical undercuts when margin terminate in cementum
(grooves on line angles).

MODIFIED CAVITY
Indication: small and moderate carious lesions or fractured tooth (ex:
fractured incisal edge) surrounded by enamel.
-Cavity form:
▪ Designed to be as conservative as possible
▪ Involve only the defected area
▪ No specific shapes or forms
▪ No retentive grooves (so only micromechanical retention).
Overview: Remove dental caries/fractured structures without any shape
or design → beveling → Then acid etching, wash and dry the area →
After that you apply the bonding agent, then blow the bonding agent
with air (to remove excess) → Light cure the bonding agent → Place the
composite filling material and wait for polymerization → then light
curing again …

Indications for labial access include:

1) The carious lesion is located facially 2) The teeth are irregularly
aligned 3) Carious lesion extends to the labial surface 4) Failed
restoration placed facially
Note: Contact point between two adjacent teeth 2-3mm from incisal to
middle third.
CLASS IV
Cavity that is prepared on the proximal surfaces of anterior teeth
including the incisal edge.
Note: if just the incisal edge of the anterior tooth is missed, it is also
called class 4 cavity.
Indications of doing a class 4 cavity:
A) Caries
B) Trauma ➔ high incidence specially in children & athletes.
C) Non-carious injuries (tooth wearing): attritions & abrasions.
25-30% of the tooth destruction is caused by non-carious injuries.

− When the indication is the caries, the carious lesion starts at the
proximal surface (middle and cervical thirds), then if left untreated, it
will extend and cause an undermined incisal edge that gets fractured
under load of mastication (or the incisal edge may get broken due to
trauma when there is unsupported enamel).

CLASS 4 DUE TO NON-CARIOUS INJURIES:

1. Attrition: mechanical wearing of the incisal edges/occlusal surfaces
caused by direct forces between contacting teeth during functional
(occlusion) & parafunctional movements of mandible (surface tooth
structure becomes loose because of direct frictional forces between
contacting teeth).
− Attrition is common in patients with occlusion disturbances, patients
with high stress and bruxism patients.
Bruxism: excessive teeth grinding during night (sleep).
Treatment of attrition: initially the cause of tooth attrition should be
eliminated to prevent further damage
 A. Then, if the area in the occlusal surface (incisal edge) was
sensitive and complete class 4 cavity can’t be prepared, minimal
restoration is usually done.
B. The treatment of attrition includes using a night-guard, the patient
is instructed to wear this night guard during sleep so that the forces
of mastication will be distributed on this guard rather than on the
teeth themselves.
C. Another possible permanent treatment is done by crowning
(prosthetic replacement) the teeth so that they withstand the forces
of mastication, attrition & grinding caused by stress.

2. Abrasion: abnormal mechanical wear of tooth structure.

Common causes of abrasion:
A. Improper brushing
-The proper way of brushing is brushing in a circular manner from
upper to lower parts of teeth.
-Remember that the DEJ is a thin area near the gingiva (sometimes
it’s completely missed), and upon scaling or brushing
accompanied by applying too much force, this area will be
exposed causing extreme sensitivity.
The area of abrasion is usually very thin, V-shaped, sharp margined
area.
B. Other habits:
Pipe smoking >> causes destructions.
Tobacco chewing >> causes destruction on the occlusal surfaces of
posterior teeth.
 Holding pen or pencil >> common in children.
Holding hair clips or needles (common in sewers)
Nut’s >> specially in the anterior teeth (common).

In class 4, we make a conventional cavity preparation according to the

caries extension including the cervical third, while in the fractured
enamel in both middle third & incisal edge there is no cavitation, we just
make beveling on the labial & lingual surfaces.

Before starting the restoration process, first we have to make occlusal

assessment & adjustment (both before & after restoration) because for
example if I was working on an upper tooth, and there was a high
contact point located lingually with the lower opposing tooth, we don’t
do beveling on this contact point/area because it is subjected to heavy
forces of mastication

In class 4 due to trauma, it is simply restored using composite material,

it is a simple case that needs just beveling (no certain design needed) and
then we continue the restoration process steps...
CLASS V
Cavity located on the cervical 3rd of facial or lingual surfaces including
anteriors and posteriors. (Once it’s on the gingival 3rd it’s called class V
despite ant. /post.)
Clinical technique: (the usual treatment plan as any other class).
1- Anesthesia: for the patient’s comfort and to decrease salivary flow.
2- Shade selection: we can’t rely on the incisal shade as the tooth’s
shade/color cervically is darker than incisally especially in the usage of
composite as it has a variety of shades. (we have materials other than
composite to use in class V)
3- Class V isolation: it’s hard but must be done to improve visibility and
margins exposure.
4- Tooth preparation.
5- Pulp protection: especially if the cavity was too big.
6- Restoration, finishing and polishing.
Methods of isolation:
A. 212 isolation: it’s a gingival retraction by the rubber dam using the
butterfly clamp/retainer but with special requirements.
The RD butterfly retainer is characterized by having 2 beaks at the
same level, to use it for class V we should modify the facial beak
by moving it more cervically than the lingual beak so it will go
deeper (sub-gingivally) eventually retracting the gingiva more
cervically.
B. Retraction cord and cotton: it has different sizes and types, also
used in the impression of crown & bridges.
Q: How to modify the butterfly clamp?
Heat the clamp and tilt the facial beak by plier, facial beak cervically at
the level of the gingiva, lingual beak upward, so when you put the clamp
around the tooth lingual beak will catch the lingual surface.

Conventional design:
A. Flat pulpal floor.
B. Cavosurface margin – angle between outer surface and internal
walls – equals to 90 degrees.
C. Design: butt joint margins.
D. Gingival floor perpendicular to the long axis of the tooth.
Recap: This resembles class I where the gingival floor was
perpendicular to the long axis but the pulpal floor was parallel to
the occlusal surface.
E. Uniform depth.
➔ Preparation guidelines #1
Outline form: Kidney, bean shaped on the cervical 3rd, within mesial
and distal line angles.
Initial depth: 1 mm at occlusal and 0.75 mm at gingival.
Gingivally is shallower than occlusally due to the thinner enamel there,
in addition the proximity to the pulp
Burs: #700, 701, 271/ No.1 or No.2 round bur (high/low). In general we
draw the outline in high-speed burs and for caries removal (cavity
modification we use low speed burs).
➔ Preparation guidelines #2
- Watch axial wall contour and depth of prep.
- Axial wall should follow the original contour of the facial surface
which should be parallel to the outer surface and curved not flat to
avoid pulp exposure
Rule: always follow the enamel rods depending on the anatomy of the
area that you’re preparing.
➔ Preparation guidelines #3
- Mesial / distal walls must flare to the outside following the enamel
rods.
- Watch angulation of bur: keep it perpendicular to the external
surface.
- Rounded internal line angles, smooth prep, clean margins.
➔ Auxiliary retention (retention grooves) is placed at:
A. Cervical & incisal walls (but not mesial/distal walls because they’re
short). In other words at the junction between internal walls and
axial wall.
B. Half the depth of the #1/4 round, smallest bur as we’re not aiming
for more cutting, it’s just grooves.
C. The bur should be oriented in an angle to avoid exposing the pulp
(in 45°).
 D. We drill the 1st groove at the incisoaxial junction to stay away from
the pulp, if more retention is needed cervicoaxial groove is made
with percussion as here you may hit
the pulp, especially if the cavity was
deep.

Modified design:
Indications: small and moderate lesions or faults designed to be as
conservative as possible in the crown.
- Design: No specific shape, doesn’t necessarily include all the
conventional design features with no specific walls and shape, and
no flat pulpal floor.
- Cavosurface margin ≥ 90 ̊
- External walls = no shape.
- Only include caries or defective restoration.
Basically remove the caries resulting in whatever cavity shape and
restoring it, it aims to remove caries and restore.
Most of class V cavities are prepared this way.
 Diagnosis of caries

*factors that affect the diagnosis:

1)age of the patient
2)oral hygiene of the patient
-for example:
1) -patient with bad OH and a small lesion → restore
-patient with good OH and a small lesion→ preventive methods

2) -60 years old patient with discolored teeth → mostly it’s arrested
-teenager with discolored teeth → mostly it’ll become active

*Common case: what to do for discolored occlusal fissures?

Not to be over conservative and not to do over treatment we choose the
worst tooth and we drill it, if we find very minimal caries we don’t drill
others, but if we find extensive caries we operate the tooth and go to the
second worst and so on until we reach a tooth with minimal
discoloration (arrested caries, that we don’t operate except for aesthetic
reasons on demand)
*Requirements for the diagnostic tools:
1-Validity: whether or not an instrument accurately assesses what it sets
out to measure.
2-Reliabilty: reproduction and replication (multiple examination of the
tooth and multiple examiners should all have the same result for the
same tooth)
3- Accuracy: measuring the true amount or the severity of the lesion or
caries.
4- Sensitivity: the ability of the test to correctly identify those with the
disease (true positive).
5- Specificity: the ability of the test to correctly identify those without
the disease (true negative).
6- Potential negative aspect: side effects of the instrument used (ex: x-
ray radiation) so taking this step must be justified.

*The clinical exam for caries:

-how clinicians detect the presence of caries?
-methods that are commonly used in Jordan:
-examination should always be conducted in dry, well
Visual illuminated filed.
-by eyes,mirror and light with air.
-mostly used in class 1 + class 5

*Characteristics:
1)unreliable/subjective
2)low sensitivity
3)high specificity

tactile -be careful not to cavitate an incipient caries with a sharp probe

*characteristics:
1)unreliable/subjective
2)low sensitivity
3)high specificity

Radiographs -lesions are always smaller radiographically than clinically

-tooth needs 30-40% mineral loss to be detected that’s why
radiographs are used in diagnosis only, not for monitoring
-Mostly used for class 2 with good justification such as poor OH
or shadowing on the marginal ridges or when the patient
complains from this area between the teeth.
-are not used with pregnant ladies

It must be an accurate radiograph with the correct angulation. To

avoid problems such as:

1)overlapping: due to an error in the technique or in the

angulation of the radiograph or the beams, we won't be able to
locate caries
2)Too dark or too light: due to a problem in the fixation step or
processing of the x-ray films.
3)Burnout : blackness on the cervical region due to an error in
the angulation of the film
4)Machband : it appears in the radiograph as caries but it is not,
it’s because the enamel in this region is hypermineralized and the
dentine is hypomineralized so it appears more black
*NEW TECHNOLOGY to detect caries

DIAGNOdent -Used mainly in Europe, for all surfaces

-small in size and depends on laser light (655nm red light).
-when the light is applied to caries, products of the bacteria will
produce a fluorescence. It gives a reading from 0 to 99 and
according to it, we determine whether there’s a lesion or not and
it’s extension

*Characteristics:
1)High sensitivity 2) High reliability 3) High validity
4) Low potential negative aspects
5)Has a correlation with the histological depth

-we have to be aware whether the tooth is dried or wet because

the interpretation in the guide differs according to that.
- If we have calculus or hypomineralization it will appear as
caries

Quantitative -A blue light applied to the tooth in specific environment that

light gives a green fluorescence representing the tooth structure
fluorescence except for the demineralized areas which appears black.
(QLF)
*Characteristics:
1)It is better used in the buccal and lingual surfaces
2)needs a good oral hygiene patient
3)used for monitoring as it’s highly sensitive technique. It
captures the small changes in any lesion.
4) no correlation with the histological depth
Digital
imaging fiber Used mainly in Germany and Switzerland, it mimics the QLF
optic trans- but the difference here is that it’s connected with a computer so
illumination any demineralization will appear black.
instrument -no correlation with the histological depth.
(DIFOTI):
Electrical -The oldest one, depends on the electrical conductivity of the
conductance saliva, so when saliva enter the pores that have been made by
measurement carries this device will detect it and correlate it with a lesion.
 Evaluation criteria for a restoration

1-Aesthetic: especially in anteriors teeth.

2-Functional:(the most important one especially in posterior
teeth).
3-biological.
Aesthetic properties:
1- Surface gloss/luster and roughness :
Our aim is to restore the natural appearance and function.
Ideally surface roughness should approximate that of enamel.
-nano-composite has very small filler so it’s more polish-able
unlike micro-composite which produce hard surface.
-evaluate the roughness of the surface by vision or probe
(tactile sensation)
-When assessing these criteria it is recommended that the
operator light be switched off and the evaluation carried out at
a distance of 60-100 cm..
2-Surface and marginal staining:
Slight staining : visible on clinical inspection using mirror
and illumination, while severe staining: is visible at a
speaking distance of 60-100 cm.
-Color change along the restoration margin is an indication
about the sealing properties, it’s prevented by achieving good
isolation.
-Over hanged/overfilled restoration lead to marginal staining
due to accumulation of food, even under-filled cavities should
be filled properly by redoing acid etch then apply composite.
3-Colour match/stability and translucency (not applicable
for metallic inlays, amalgam restorations or restorations not
visible during normal function).
-The size of the restoration is important as color and
translucency usually differ slightly in the incisal, middle and
cervical thirds of the tooth.
4-Anatomic form:
-Aesthetic outcome is partly determined by an acceptable
anatomic form that is essential in both aesthetic and function.
-The anatomic form is the first thing noticed by the patient so
always mimic the shape of patient’s teeth not the standard
form.
-the height of central is more than its width, so if I just widen
centrals in order to close diastema this will result in square
form of central instead of rectangular so we refer the patient
to surgeon to remove part of his gingiva(crown lengthening)
and retrieve normal height /width proportion.
Functional Properties:
1-Fracture of restorative material and restoration
retention
-Good retention and resistance must be achieved to prevent
fracture of restoration and maintain retention, resistance form
can be achieved by:1-Cavo-surface margin = 90. 2-Adequate
thickness 3-Flat pulpal floor.
2-Marginal adaptation
-No gaps between the restoration and the tooth structure
should be present -Importance of wedge: increase the space
between teeth + adaptation of matrix at gingival portion of
cavity. - To detect the presence of gap or overhang the
proximal area of the restoration should be examined with a
blunt explorer with a 50μm tip and dental floss (blunt probe
not sharp in order to prevent destruction of newly placed
restoration)
-Slight overfill → polishing of the surface (after 24 h for
amalgam) -major underfill → repeat restoration
3-Marginal deterioration
Marginal degradation and irregularities due to chemical
degradation.
-slight roughness→ polishing
- Major roughness(probe can pass in it) → change restoration.
-Marginal gaps (diameter of 150 μm and 250 μm ) can be a
parameter for secondary caries development and restoration
failure.
4-Wear
A physical phenomena as a results of occluding with opposing
surfaces, leading to the loss of restorative material, more
hardness of the opposite material → more wear of composite
–Two types of wear:
1- occlusal wear: due to mastication forces on posterior
teeth(more wear than the 2nd type)
2-proximal wear: due to attrition of adjacent teeth while
eating.
5-Proximal contact point and food impaction
- A proximal contact point has physiological strength when
dental floss or a 25μm metal blade can pass through it and is
evaluated for a certain degree of resistance or “snap” effect. -
Metal matrix strips of different thicknesses of 25 μm, 50 μm
and 100μm allow for a more precise determination than dental
floss.
-making class 2 composite need sectional matrix rather than
universal matrix otherwise it’ll result in flat surface not
countered and dental floss pass easily without any resistance -
semi-stock paper (like articulator paper) made from metal
with very minimum thickness, not passing between teeth
confirm good contact point, while passing means no contact.
6-Radiographic examination
Information with regard to gaps, secondary caries, overhangs,
steps/underfilling and the level of alveolar bone. only
performed if clinically indicated. Almost all dental materials
are radiopaque on x-ray.
7-Patient satisfaction with restoration.
A patient`s perception with regard to aesthetics, chewing
comfort, pain/hypersensitivity, ease of ability to clean the
restoration with toothbrush/dental floss, gingival bleeding or
detection of the restoration with the tongue, are items under
this topic. Patient satisfaction is important indicator for the
function of restoration. I don’t evaluate patient satisfaction
after day only, maybe after week, months and years.
Biological properties
1-Postoperative hypersensitivity and tooth vitality
Pain after 1-3 weeks after placement restoration is normal,
month or more then we should re-evaluate the tooth. Tooth
should remain vital, and if died that’s failure of restoration
and RCT is needed.
-According to hydrodynamic theory, improperly sealing
dentinal tubules result in exposure of dentinal tubules so
whenever eating or drinking fluid inside dentinal tubule start
moving leading to mechanical deformation and activation of
sensory nerves then pain will arise.
-Postoperative hypersensitivity is recorded at the time of
restoration placement, at baseline and at all recall visits, and
can include type of pain, discomfort and duration and/or on
stimulus at clinical assessment.
-Transient pain elicited on stimulation is acceptable, persistent
pain renders the restoration unacceptable and requires
intervention to alleviate the problem.
2-Recurrence of initial pathology and/or new pathology at
the restoration margins such as caries, erosion, or abfraction
that cannot be alleviated by a minor intervention is considered
unacceptable.
3-Tooth cracks and fractures due to improper cavity design
or treatment plan, make your treatment plan according to
remaining tooth structure and occlusion of patient to
avoid it.
-Provided no clinical symptoms are present, signs of tooth
enamel cracks are acceptable. If a major intervention such as
repair or replacement is needed to remedy the consequences
of these defects, the restoration is considered unacceptable.
4-Effect of the restoration on the periodontium
No inflammation of the papilla should be present, No
overhangs, No overcountour
5-Localized reactions of soft tissue in direct contact with
the restoration
-If there are signs of allergy caused by the restorative material
and/or there are indications of allergy in the patient’s history,
the restoration should be removed and replaced by a material
non-allergenic for the patient.
-If any adverse reaction with restoration present you should
re-evaluate the restoration and know where’s the problem then
change restoration with appropriate one.
 Non-carious lesions
are defined as loss of enamel and/or dentine caused by means other than caries or trauma.

Mainly in: elderly but prev increasing in young pts and in max post teeth esp premolars due to high occlusal forces

DEFENTION ETIOLOGY
1-Erosion Progressive loss of *intrinsic: GI problems like GERD, Anorexia nervosa, bulimia (appears
tooth structure by on palatal surfaces of upper)
chemical *extrinsic: citrus ingestion, conti exposure to air born acids (on facial
surfaces of anterior teeth)
-characterized by a smooth surface that covers a good portion of
the tooth,if it goes beyond the cervical area (reaches the middle or
incisal region) of the tooth, then it is most likely erosion.
2-Abrasion Loss of tooth structure *incorrect brushing (on cervical margins of B surfaces of PMs and
by mechanical or canines)
frictional forces -appear more wide than deep while Abfraction deep than wide
*Abnormal habits like eating seeds appears as V-notch
*removable appliances as clasps
- Affect more than one tooth in quadrant in any surface except
proximal
3-Abfraction Loss of tooth structure *commonly associated with wear facets; which indicate that the
at cervical areas by tooth is exposed to excessive occlusal load.
tensile and -v-shaped
compressive forces -deep than wide
during tooth flexure -commonly affect single tooth
-on cervical areas
4-Attrition Mechanical loss of *functional movements(Physiologic attrition) which can cause some
tooth structure by sort of wear on proximal surfaces or parafunctional movements of
mastication or mandible (pathological attrition)
occlusion - matching wear facets on both upper and lower teeth
-tooth-tooth contact -saucer shaped facets on cusp tips, flat occlusal surfaces
5-Non- Injury of ameloblasts *Trauma to 1ry teeth, fluorosis, high fever
hereditary during enamel - opaque white or light brown areas with smooth intact hard surface,
enamel formation by trauma or
hypoplasia infection resulting in
defect enamel
formation
pitted or grooved enamel
6-Amelogenesis Defective enamel -localaized areas of pitting and sometimes with very thin shell of
imprefecta enamel
-poor esthetic and more vulnerable to caries and attrition
7-dentogenesis Hereditary cond. Only -pulp chamber obliterated
imperfecta defective dentine, -teeth color brown and roots short and stunted
normal enamel
attached weakly and
lost early
CC: Tooth Sensitivity

EX: severe erosive lesions esp on the palatal surfaces Of upper anterior teeth and incisors are worn down to

almost half their original size

After history taking: Pt suffering from anorexia nervosa

-referred to a medical consultation before starting any dental Tx

matching wear facet on both upper+lower

possible fracture of cusps or restoration is

indication for attrition

-in begging:loss of enamel is gradual and

takes time, once dentine exposed it
becomes faster ( loss of dentine faster
than enamel)

Rx of AI: Dentine and pulp are normal in

form and size but teeth lack of enamel
AI: Localized area of pitting and sometimes
very thin shell of enamel
 MANAGEMENT of non carious lesions
Before any treatment is done, a proper diagnosis and recognition of the causes of the cervical lesion is
important and will influence the long-term success of our treatment.
to restore or NOT to restore? In general, cervical lesions that are carious in nature must be treated,
However, some cases of non-carious lesions can be left untreated and the reason is that many cervical
restorations tend to fail, so case selection is important.
In general, small cavities with no signs and symptoms do not need restorations, usually they only require
preventative measures and eliminating the etiological factors.

Indications for restoring Non-Carious Lesions (NCL):

1)dentine hypersensitivity
We notice this in cases of erosive lesions more than attrition lesions, because usually the progression of
erosion is faster, whereas in attrition secondary dentine forms, so you may have a patient that comes with
severe attrition, but with no hypersensitivity
most of dentine hypersensitivity cases can be treated with simpler stuff than restorations for example:
fluoride gels, desensitizing agents, toothpaste for sensitive teeth. We always try to solve the problem
without doing restoration first, but in severe cases we must put restoration

2)esthetic concern
3) secondery caries
One of the indications that we don’t have options other than restorations

4)large/deep lesions: compromise vitality and integrity of tooth structure or lead to food impaction
5) Loss of occlusal stability and/or function

proper management for tooth surface loss

Immediate Therapy: Long term therapy:

-Relieve sensitivity and -Protection and

pain conservation of remaining
tooth structure
- Identify etiological
factors -Resolution of pulpal
sensitivity
- Protect remaining tooth
tissue - Improvement in aesthetic
 MANAGEMENT OF TSL

PASSIVE TREATMENT ACTIVE TREATMENT

Occlusal DIRECT INDIRECT

Desensitization
adjustment RESTORATION RESTORATION
as in
abfraction,
without it
restoration
tend to fail

The choice of restoration depends on a lot of

things including:

SEVERITY AGE
IF severe: direct If young adult:
than indirect LOCATION crowns or full
mouth rehab
If ant: direct or
indirect
If post:
indirect
 The management of traumatic injury
-most crown fracture occur in young (7-10 years old),caries free
anterior teeth due to falls and accidents.
*general management:
1)Full history
-medical history: if the condition is life-threatening refer the
patient to a physician. Check the bleeding tendency and cardiac
output
-dental history: you have to know when ,where and how the
trauma happened

2)examination
Radiographic imaging is essential for thorough examination,
diagnosis, and management of dentoalveolar trauma. Imaging
may reveal root fractures, subgingival crown fractures, tooth
displacements, bone fractures, root resorptions, and embedded
foreign objects.
Vitality testing is performed. it involves the electric pulp testing
and cold test(the sensibility test)
Important note: the cold test doesn’t actually test for true vitality. False negative
results are common following trauma because the sensory nerves in the tooth may
be disrupted for at least 2-8 weeks following the traumatic event. But, vascular
supply may still be intact

3)follow up May extend from 1-5 years after the trauma

1)Uncomplicated crown fracture

Clinical findings Radiographic Treatment

-fracture involves -3 angulation to rule -if the tooth fragment

enamel or enamel and out displacement or is available → it can
dentine; pulp is not fracture of the root be bonded to the tooth
exposed *90 horizontal angle
*occlusal view -urgent care option is
-sensibility testing *lateral view to cover the exposed
may be negative (mesially or distally) dentine with GI or
initially indicating composite permanent
transient pulpal -radiograph for lip or restoration This
damage (the tooth is cheek laceration is prevents any ingress
in state of shock) recommended to of bacteria into the
search for tooth tubules and reduces
-monitor pulpal fragments of foreign the patient’s
response until a material. discomfort
definitive diagnosis
can be made -definitive treatment
is to restore the tooth
with accepted dental
restorative material.
if the remaining
dentine is less than
0.5mm we apply
calcium hydroxide
layer as a first step.
2)complicated tooth fracture

Clinical findings radiographic Treatment

-involves enamel, -3 angulation -The choice of

dentine and pulp radiographs to rule treatment depends on
out fracture the stage of
-the vitality of the development of the
pulp can be -Radiograph of lip or tooth and the time
visualized; sensibility cheek lacerations is between trauma and
test is not indicated recommended to treatment
search for tooth
-Follow-up control fragments or foreign
visits after initial material
treatment include
sensibility testing to -The stage of root
monitor pulpal status. development can be
determined from the
Radiographs which
affect the choice of
treatment

1) In Young pts with immature apices every effort must be

made to keep the tooth vital, at least until the apex and
cervical root have completed their development .preserve
pulp vitality by pulp capping or partial pulpotomy. This
treatment is also the choice in young patients with
completely formed teeth. Calcium hydroxide and MTA are
suitable materials for such procedures.
2) In older patients, root canal treatment can be the treatment
of choice especially if too much time elapses between
 accident and treatment and the pulp becomes necrotic.
Although pulp capping or partial pulpotomy may also be
selected to preserve the pulp.
3) In extensive crown fractures a decision must be made
whether treatment other than extraction is feasible

3)crown root fracture

Clinical findings Radiographic findings Treatment

-Fracture involves -as in root fractures, -Treatment

enamel, dentin and more than one recommendations are the
root structure; the radiographic angle same as for complicated
pulp may or may not may be necessary to crown fractures
be exposed detect fracture lines in
the root -Restoration depends on
-Additional findings subgingival margin of the
may include loose, tooth. We can either pull
but still attached, the tooth by orthodontic
segments of the treatment to make the
tooth. margin of the fracture on
equigingival/supragingival
-Sensibility testing or we can pull it by
is usually positive. forceps until we can see
the margin and then we do
the restoration

-In addition, attempts at

stabilizing loose segments
of the tooth by bonding
may be advantageous, at
least as a temporary
measure, until a definitive
treatment plan can be
formulated.
4)Root fracture

Clinical findings Radiographic treatment

-The coronal segment -The fracture involves -Reposition, if

may be mobile and the root of the tooth displaced, the coronal
may be displaced and is in a horizontal segment of the tooth as
or diagonal plane. soon as possible.
-The tooth may be
tender to percussion -Fractures that are in -Check position
the horizontal plane radiographically.
-sensibility testing may can usually be detected Stabilize the tooth with
give negative results in the regular 90˚ angle a flexible splint for 4
initially, indicating film with the central weeks
transient or permanent beam through the
pulpal damage; tooth. This is usually -If the root fracture is
the case with fractures near the cervical area of
-Monitoring the status in the cervical third of the tooth, stabilization
of the pulp is the root. is beneficial for a
recommended. longer period of time
Transient crown -If the plane of fracture (up to 4 months). It is
discoloration (red or is more diagonal, advisable to monitor
grey) may occur which is common with healing for at least one
apical third fractures, year to determine
an occlusal view is pulpal status.
more likely to
demonstrate the -if pulp necrosis
fracture including develops ,RCT is
those located in the indicated.
middle third
5)Alveolar fracture

Clinical findings Radiographic Treatment

- The fracture - Fracture in the alveolar - Stabilize the

involves the bone/ injury on the tooth using splints.
alveolar bone and periodontium. We can do
may extend to Panoramic view is helpful in stabilization for the
adjacent bone. this case. tooth or the bone
for 4 weeks
- Movement in the
tooth & we can see -after 8 weeks →
bleeding line on repeat the clinical
cervical margin. examination

- Sensibility testing -after a year →

may or may not be repeat the
positive(Note: we radiographic
don’t depend on it examination
because it can give
negative result for
3months.)
-favorable outcomes: Positive response to pulp testing (false negative
possible up to 3 months) , continue root development in immature teeth ,
signs of repair.
-The unfavorable outcomes: Pulpal necrosis, Apical periodontitis and Root
resorption
 Treatment guidelines for Luxation injuries
1-concussion
-The tooth is tender to percussion and touch.
-Sensibility test could be +ve/ -ve
-We don’t have any radiographic abnormalities.
Management: follow up the patient for about one year.

2-subluxation
-Tender, Bleeding in the gingival margin
-Sensibility test could be +ve/ -ve
-Normal radiograph
-The tooth moves more
- Management: splint for short period not more than 2 weeks,
with keeping an eye on the tooth.
3)extrusive luxation
-The tooth appears elongated and is excessively mobile.
-if the tooth came out of the socket we reposition the tooth to its
place and splint (semi rigid because rigidity will cause root
resorption), and we observe the vitality of the tooth.
-If the tooth becomes necrotic we do RCT But, in cases of open
apex the chance of revascularization is high

Radiographic changes : increase PDL space

-from the book for further understanding:
4)lateral luxation
-The tooth moves in a lingual or palatal direction with the
alveolar bone.
-Sensibility tests will likely give negative results.
-Management: reposition and splint (it needs longer time to get
back to its place, because the injury is affecting the bone) up to 4
weeks. If we have necrosis and the tooth was mature we do
RCT, but if it was immature we give it a chance to repair.

5)intrusive luxation
-The tooth moves inward.
- that upon precaution it produces a metallic sound
-It has worse prognosis compared with extrusive due to the cut
of the blood supply so the pulp will lose the vitality
-Management:
1)Teeth with incomplete root formation: Allow spontaneous
repositioning to take place. If no movement is noted within 3
weeks, recommend rapid orthodontic repositioning.
2)Teeth with complete root formation: The tooth should be
repositioned either orthodontically or surgically as soon as
possible

*favorable outcomes : Asymptomatic, +ve response with no

radiographic radiolucency or root/bone resorption
*unfavorable outcomes are the opposite

6)avulsion
Luxation dental trauma involving the tooth and periodontium .In
which the tooth is completely displaced (removed out) from its
socket in alveolar bone due to trauma. It is considered top
emergency in the dental treatment. Mainly occurs in children 7-
10years old.
ALWAYS ASK : When , How and Where
In general, After reinserting the tooth back in its socket we do a
composite splint. (splinting the tooth in its place with the
adjacent teeth to it using direct composite or composite and
wires.)
-what we should do when a tooth is knocked out of the
socket
1- Find the tooth
2- Hold the tooth by the crown
3- Plug the sink and rinse the tooth in cold tap water
4- We have different options:
a. Put the tooth back in its place
b. Place the tooth in a cup of milk or saline
c. When milk is not available, place the tooth in the mouth between the cheeks and
gums (not when the patient is young and might swallow the tooth, one of the
parents could do it)

5- Seek immediately specialized dental treatment, within a 2-

hour time period

-Factors affecting the prognosis of the case:

1-Storage media (suitable storage) which can be milk, saline or
saliva, or Hank’s Balanced Salt Solution (which can be found in
the emergency kit)
2-Extraoral time : how long has the tooth been outside the pt’s
mouth,can be devided to : a) less than one hour b) more than
one hour, because the management differs.
3-The quicker you seek a dental professional.
Management of a tooth with closed apex
The tooth has • Clean the area with water spray, saline or chlorhexidine.
been replanted • Do not extract the tooth.
prior to the • Suture gingival lacerations if present.
patient arriving in • Verify normal position of the replanted tooth both
the dental office clinically and radiographically
or clinic • Apply a flexible splint for up to 2 weeks

-after that:
Administer systemic antibiotics. Tetracycline is the first
choice (Doxycycline 2x per day for 7 days at appropriate
dose for patient age and weight). In young patients
Phenoxymethyl Penicillin (Pen V), in an appropriate dose for
age and weight, can be given as alternative to tetracycline

-if the avulsed tooth has contacted soil, and if tetanus

coverage is uncertain, refer to physician for evaluation and
need for a tetanus booster.
• Initiate root canal treatment 7 to 10 days after
replantation and before splint removal.
• Place calcium hydroxide as an intracanal medicament until
filling of the root canal.
The tooth has • If contaminated, clean the root surface and apical
been kept in foramen with a stream of saline and place the tooth in
special storage saline. Remove the coagulum from the socket with a stream
media (Hank’s of saline.
Balanced Salt • Examine the alveolar socket. If there is a fracture of the
Solution), milk, socket wall, reposition it with a suitable instrument.
saline, or saliva. • Replant the tooth slowly with slight digital pressure.
OR The extraoral Suture gingival lacerations.
dry time is less • Verify normal position of the replanted tooth both
than 60 minutes clinically and radiographically.
• Apply a flexible splint for up to 2 weeks

-the follow up visit is the same as the previous one

Extraoral dry •poor long term prognosis (periodontal ligament will be necrotic and
time longer than not expected to heal.)
60 minutes •the expected outcome is ankylosis and resorption of root
•Remove attached necrotic soft tissue with gauze.
•Root canal treatment can be done on the tooth prior to
replantation, or it can be done 7-10days later as for other
replantation.
•Immerse the tooth in a 2% sodium fluoride solution for 20
Minutes
• Replant the tooth slowly with slight digital pressure.
Suture gingival lacerations.
• Verify normal position of the replanted tooth both
clinically and radiographically.
• Apply a flexible splint for up to 2 weeks

-the follow up visit is the same as the previous one

-Patient instructions (they’re the same for all the cases):

1)Soft diet for up to two weeks.
2)Brush teeth with a soft toothbrush after each meal.
3)Use a chlorhexidine (0,1%) mouth rinse twice a day for 1
week. -Follow-up
Management of a tooth with opened apex :
replanted Same as closed apex but with one major difference we give
chance for revascularization (continued root formation) we gain
longer root with thicker walls, later on we can do standard RCT.
So RCT before the chance should be avoided unless there is
clinical and radiographic evidence of pulp necrosis.
Kept in Same as closed apex,we give a chance but , If available cover
special storage the root surface with minocycline hydrochloride microspheres
media (ArestinTM, OraPharma Inc.) before replanting the tooth.
Or <60 mins
extra-oral dry Same as closed apex
>60 mins

-pts instructions are the same

-The goal in doing delayed replantation is to promote alveolar bone growth to
encapsulate the replanted tooth (we preserve the alveolar bone).
- The expected eventual outcome is ankylosis (replacement resorption) and
resorption of the root.

-Follow-up procedures for avulsed permanent teeth:

1) Root canal treatment.
2) Clinical control. Replanted teeth should be monitored by
frequent controls during the first year (once a week during the
first month, 3, 6, and 12 months) and then yearly after that.
Clinical and radiographic examination will provide information
to determine outcome.
Favorable outcome:
1. Closed apex: Asymptomatic, normal mobility, normal percussion
sound. No radiographic evidence of resorption or periradicular osteitis;
the lamina dura should appear normal.
2. Open apex: Asymptomatic, normal mobility, normal percussion
sound. Radiographic evidence of arrested or continued root formation
and eruption. Pulp canal obliteration is the rule Unfavorable is the
opposite
**If the outcome was unfavorable, inflammatory resorption,
radiolucency or replacement resorption occur, we should initiate RCT
immediately, which is apexification or MTA plug. *note: Percussion
sound in the inflammatory resorption is dull while it has metal ring
sound in the replacement resorption.
-time of splinting
 Root resorption
- Dental resorption is the progressive loss of dental hard tissues
as a result of clastic activities.
- Resorption may occur as a physiologic (normal process
occurring in primary dentition) or a pathologic phenomenon (if
it happens in permanent teeth).
- Following pulp necrosis, or periapical pathology/inflammation
in general, bone resorption is usually noticed. But in fewer cases
root resorption might occur, why is root resorption rarer?

- Root resorption is rare because if we look at the root’s cross-

section, you’ll notice that the mineralized part forming the root
(dentine and cementum) is sandwiched by two non-
mineralized groups of layers.
-So mineralized tissues can be resorbed but what protects
them from resorption is the surrounding non-mineralized tissues.
- Mineralized tissues have a sequence of peptides (RGD:
Arginine, Glycine, and Aspartic acid). This sequence becomes
exposed if non-mineralized tissues are damaged and in turn
attracts odontoclasts or cementoclasts initiating root resorption.
- Resorption requires:
1- Damage to the the non-mineralized protective tissues
covering the external surface of the root, the precementum, or
internal surface of the root canal, the predentine.
2- Continuous stimulation (pressure, infection, inflammation).
3- Blood supply to the clasts.

- As you can see in the diagram we have two main types followed by
subtypes, along with additional information that can be used to describe
the case of resorption, Example (A): This premolar has an internal
inflammatory resorption in the middle of the root canal (site), it is
extensive especially in the distal side (extent) with no periapical
radiolucency (periapical disease).
1- External surface resorption:
- Small shallow superficial resorption cavities in the
cementum and sometimes in the outermost layers of the
dentine as a result of localized and limited injury to the
root surface (as subluxation or concussion injury) or any damage
to the surrounding periodontium.
- Self-limiting, heals uneventfully with new cementum, so no
need of intervention. (Just monitor)
- Sub-clinical condition/ without symptoms. Unlikely to be seen
on radiographs. But you may find it as an incidental finding in
radiograph. May be seen as cavitation (shallow) in the
cementum and dentine, or an alteration of the root contour.
*As you can see in this radiograph the bone and lamina dura are
intact without bone resorption. It is just a minor alteration of the
root contour.
2- External inflammatory resorption:
- Prolonged stimulus by infection or pressure with severe
damage to root surface.
- Starts with:
1- Trauma to root surface especially with luxation injuries,
avulsion, intrusion, extrusion or lateral luxation.
- Cementum and PDL will be damaged therefore the dentinal
tubules will be exposed.
- Bacteria and endotoxins diffuse to the pulp (through micro-
cracks) causing infection then necrosis, bacterial by-products
diffuse easily through the exposed dentinal tubules resulting in
2- Apical periodontitis.
And eventually the continuous stimulation by bacteria leads to
external inflammatory root resorption.
- The most common form of root resorption after luxation (5-
18%) and avulsion (30%) injuries.
- The resorption itself is subclinical unless accompanied by
acute inflammation of periapical tissues.
- This process can completely resorb roots in months.
-Radiographically, incidental radiographic finding. Presentation
will vary depending upon whether the process is infective or
sterile.
A- Sterile inflammatory external root resorption (pressure
resorption):
- Usually after orthodontic treatment due to excessive
forces, impacted tooth that exerts pressure on other
teeth, cysts, or tumors that apply pressure on roots.
- Radiography:
1- Shorted and blunted root apices appearing rounded.
2- Evidence of causative factor (ectopic tooth, cyst, or tumor).
- Usually asymptomatic and pulp is usually vital unless
pressure disturbs blood flow to the pulp causing sterile
necrosis (unless there are cracks or caries in the crown
that would superimpose infection and apical
periodontitis.)
- Management: remove the source of stimulation and the
process will stop.

B- Infective external inflammatory resorption:

- Same as explained before (Trauma, necrosis, infection,
then resorption).
- Radiography: irregular bowl shaped
concavity/concavities in the root with corresponding bone
resorption (differing from surface resorption that spared
bone).
-The resorptive area is associated primarily with the apex or a
lateral canal or both. Might also be associated with a crack of
fracture line.
- The tooth will NOT be responsive to EPT or thermal pulp
tests, as a pulp is necrotic.
- Management: prevent external inflammatory resorption from
occurring following trauma if possible, or arrest this type of
resorption if it is already present.
- Preventive protocol (directly after trauma):
1- Systematic Abs: doxycycline 100 mg -2 tablets on the 1st
day, then 1 tablet daily for 1 week. (Amoxicillin if
contraindicated, allergic people or patients less than 12 yrs).
2- IMMEDIATELY after replantation/repositioning and
stabilization with a flexible splint:
• Start RCT for the mature tooth (chemomechanical
preparation).
• Place a CS-AB paste intracanal dressing (Ledermix paste).
3- Then non-setting Ca(OH)2 intracanal dressing to induce
formation of an apical hard tissue barrier (if required).
4- Remove the splint and Complete root canal treatment after
formation of a hard tissue barrier.
5- Arrange to review after 6 months and then annually for at
least 5 years.
- Interceptive protocol (if disease already established): Assess
restorability, then same as preventive but without antibiotics.
Note: Ledermix active ingredients are the corticoid triamcinolone
acetonide (1%) in combination with demeclocycline (3%).

3- External invasive cervical resorption:

- Invasion of the cervical region of the root by fibrovascular
tissue derived from the PDL progressively resorbing cementum,
dentine and enamel, eventually involving the pulp if left
untreated.
- Often symptomless though there may
be a sensation of mild discomfort or
irritation from the surrounding gingival
tissues.
- EICR triad: Trauma, ortho treatment
and internal bleaching. If these 3
happen in combination EICR will
occur. Other factors mentioned in the
diagram.
- Appears is a pink spot in the cervical enamel and root surface,
probing the area elicits profuse bleeding and reveals a hard
rough surface differentiating the lesion from soft caries.
- A purulent exudate indicates a superimposed infective process.
- Unless the lesion is very extensive, the tooth
will be positive to vitality testing as the pulp
is not involved.
- Sometimes if the resorption is very extensive
it will result in thinning and undermining of
the crown of the tooth and you will see the
coronal segment of the tooth is highly mobile.

- Management: Curetting the resorptive tissue after etching it

with 90% Trichloroacetic acid. If the pulp is exposed after
curettage and tissue removal, then the RCT is indicated then the
tooth is restored. The treatment may involve a non-
surgical/surgical exposure of the resorption or, in severe cases,
extraction of the tooth.
- Success rate: Class 1+2 = 100% , Class 3 = 78%, Class 4 = 12.5 %.
Transient apical breakdown (TAB): Trauma induced non-
infective root resorption; it is similar to the surface resorption.
• Usually follow luxation injuries.
• Radiographically: confined periapical
radiolucency which resolves within a few
months.
• Positive sign to vitality test (increased
vascular supply to aid in pulp healing).
• Often there is an associated color change
the tooth getting red or pink due to increase
vascularity or intra-pulpal hemorrhage and
this may resolve spontaneously (50% of the
cases) if revascularization to the coronal pulp chamber occurs
(aesthetic problem if tooth color didn't go back to normal).
• In the longer term the internally resorbed apex will close
uneventfully and the root will gain again its normal contour.

4- External replacement resorption (ankyloses):

- Fusion of the tooth to the surrounding bone and loss of the
PDL.
- Often no symptoms but there may be clinical signs when 10-
20% of the root is affected. Three significant signs:
• High pitched or metallic sound to percussion.
 • Lack of mobility.
• Infra-occlusion.
- Radiography: Loss of lamina dura, root dentine will
appear either irregular or 'moth-eaten' as bone
progressively replaces dentine.
-The condition is progressive, eventually resorbing the entire
root.
- To date there is no means of arresting or reversing the
condition, once it started it will eventually result in loss of tooth
structure and complete replacement by bone and the crown part
of the tooth will fall off.
Risk factors: Avulsion with extra alveolar dry time >60 minutes,
or water as a storage medium for the tooth. Other risk factors are
early use of ca(OH)2 as intra-canal medicament immediately
following trauma (we use ledermix for at least two weeks first) ,
intrusive luxation, and prolonged rigid splint.
- Management options:
1- Accept if not affecting esthetics.
2- Autotransplantation (extract another tooth and replace).
3- Surgical repositioning.
4- Extraction and prosthetic replacement or adhesive bridge.
5- Decoronation, fill root canal with Ca(OH)2, suture, replace
with implants in appropriate age.
Internal root resorption:
- For internal root resorption to take place there should be
damage to the predentine, and this damage can occur as a result
of trauma, vital pulp therapy, or crown preparation.
- There must be vital pulp tissue apical to the odontoclasts to
provide blood supply for nutrients along with necrotic/infected
tissue coronal to the odontoclasts to maintain stimulation.
5- Internal surface resorption:
- Radiographically indistinguishable, only detected
histologically.
- Cause is unknown (possibly infection or trauma). It is self-
limiting without further stimulation. Osteoclastic activity is
initiated but eventually arrests.
6- Internal inflammatory resorption:
- Tooth is often partially vital and there may be the symptoms of
pulpitis. Vitality testing may be inconclusive.
- Both IIR and EIR may present with a 'pink spot' though
the histopathology and origin of these varies (external and
internal).
- Radiography: ovoid or irregular enlargement or
ballooning of pulp chamber or root canal.
- Differentiation between the two (IIR AND EIR) is largely
based upon radiographic examination using the parallax
technique, in IIR the root canal itself is enlarged so if you take
radiograph from a different angle you will see that the resorptive
defect is centered within the root canal while if it is EIR let’s say
the defect on the palatal sides of the root, if you take another
angled radiograph you will see that the radiolucency is moving
with you. Another thing you will notice in radiographs if it was
an IIR the resorptive defect will be continuous with root canal
while EIR you will see a circle representing the resorptive defect
and then you will see the lines of the canals overlying the
resorptive defect.
- Predisposing factors: The tooth may have a history of trauma,
vital pulp therapy or crown preparation.
7- Internal replacement resorption: Rare
- Radiography: Irregular enlargement of the canal space, diffuse
areas of mixed radiolucency and radio opacities reflecting
metaplastic changes of odontoblast and the pulp transforming or
becoming bone tissue, sometimes in advance stage It may lead
to obliteration of the canals space with cancellous-like bone.
- Replacement resorption may be very difficult to distinguish
from ECR. CBCT may be helpful.
- Mechanism not fully understood.
- Management:
•ISR: self-limiting there is no need for treatment.
• IIR AND IRR: Remove any necrotic tissue (stimulant) and
vital tissue (provides the nutrients) that may be allowing the
resorptive process to perpetuate.
• If the tooth is restorable, root canal treatment is usually
thetreatment modality of choice. Intracanal medicament
Ca(OH)2 is a must to get rid of the resorptive tissue and highly
vascularized granulation tissue within the canal space. (One visit
RCT not recommended.)

- All of these three cases

are incomplete roots
young patients, none of
them is a case of root
resorption.
Local Anesthesia

Definition

Armamentarium

Complications of local
anesthesia

Types of local
anesthesia
 Definition of Local anesthesia
Is the loss of sensation in a circumscribed (localized) area of the
body caused by depression of excitatory signals in nerve endings or
inhibition of conduction process in peripheral nerves.

Armamentarium of LA:
-Dental syringe - Needle -Cartridge

▪ The syringe:
A. Aspirating syringe
(recommended)

B. Non-aspirating syringe
The difference is that the
non-aspirating syringe does not
have a thumb ring or a harpoon.

▪ The Needle:
Long needle – 32 mm
Short needle – 20 mm
Ultra-short needle – 16 mm
-Do not bend the needle, and do not insert it to the hub.
-The ones in the clinics are long and short needles gauge 27.
-One hand scooping technique must be used to recap the needle.
 ▪ The cartridge:

Components:
▪ Anesthetic agents:
Articaine 4%, 1:100,000 epi,
1.8mL is the one we have in
the clinic.

▪ Vasoconstrictor:
▪ Mainly epinephrine
▪ Felypressin is not a sympathomimetic
drug and can be used in patients with
clinically significant cardiovascular
impairment.
▪ Don’t use felypressin in
pregnant ladies.

▪ Sodium chloride: to make an isotonic solution.

▪ Distilled water: gives volume.
▪ Preservative: sodium metabisulfite to prolong
epinephrine’s shelf life and prevent its oxidation.
Complications of local anesthesia

Vasovagal attack (fainting): lie the patient flat and elevate

his feet (most common)

Intravascular injection (Mainly with ID block):

May lead to trismus and hematoma/ temporary and

reversable myotoxicity.

Toxicity from overdose: Risk increases with fast injection

intravascularly, age, weight, and health status of the
patient.

It starts with an initial excitatory phase and progress

into a depressive phase.

Facial palsy: Injection too deep into parotid gland.

Ipsilateral.

Allergic reaction (rare): Due to the use of anesthesia that

contains esters.

Cardiovascular reactions: Tachycardia following

intravascular injection.

To avoid: aspirate and inject slowly.

Nerve injury: As paresthesia, hypesthesia, dysesthesia,
dysgeusia and xerostomia.
 Types of local anesthesia

Local Infiltration Field Block Nerve Block

-Anesthetize the small -Anesthetize the - Anesthetize the

terminal nerve larger terminal main nerve, away
ending, and usually nerve branch. from the site where
covers one tooth. the dental
-Administered
-Anesthesia deposited treatment is done.
above the apex of
supra-periosteal.
tooth and involve
-In maxilla, successful tissues all around
anywhere.
one to two teeth.
-In mandible,
- This is what we
successful in anterior
teeth only. usually do in clinic.
 Posterior superior alveolar nerve block

Structures anesthetized:
➢ Pulps of maxillary 3rd, 2nd, and
1st molars (In 72% of the cases,
the entire upper 1st molar will
get anesthetized, while in 28%
of the cases the MB root of the
maxillary 1stmolar will not get
anesthetized).
➢ Buccal periodontium and bone
overlying the teeth.

Indications:
• When treatment involves two or more
maxillary molars.
• When supra-periosteal injection
” infiltration” is contraindicated
(e.g., infection or acute inflammation).
• When supra-periosteal injection has
been proved ineffective.
Contraindications:
When the risk of hemorrhage is too great (as with a hemophiliac).
In this case a supra-periosteal “infiltration” or PDL injection is
recommended.
Technique of PSAN Block:
▪ Use a 27 short gauge needle.
▪ Partially open the mouth, pull the mandible to the side of injection.
▪ retract the cheek tissue taut.
▪ Insertion: height of the MB above the 2nd molar.
▪ Direction: upwards, inwards, and backwards at 45° angle.
▪ Depth of insertion: 16 mm.
▪ Give a full cartridge slowly.

Landmarks:
▪ Muco-buccal fold.
▪ Maxillary tuberosity.
▪ Zygomatic process of the maxilla.
 Middle superior alveolar nerve block

Structures anesthetized:
▪ Pulps of the maxillary first and
second premolars, and the MB root
of 1st molar.
▪ Buccal periodontal tissues and bone
over these teeth.

Indications:
▪ When the infra-orbital nerve
block fails to provide pulpal anesthesia distal to the maxillary canine.
▪ Dental procedures involving both maxillary premolars only.

Contraindications:
• Infection or inflammation at the area of injection.
• Where the MSA nerve is absent. Innervation is through a plexus formed by
the ASA nerve and the PSA nerve.

Technique:
• 27-gauge short or long needle
• Area of insertion: height of the muco-buccal fold
above the maxillary 2nd premolar.
• Penetrate the mucous membrane and slowly
advance the needle until its tip is located well
above the apex of the second premolar.
• Deposit 0.9 – 1.2 mL of the cartridge.
 Anterior superior alveolar nerve block

Areas Anesthetized:
Pulps of the maxillary canine, the
central and lateral incisors, and the
mucosa above these teeth, with
occasional crossover to the
contralateral maxillary incisors.

Technique:
▪ Use 25- or 27- gauge needle.
▪ retract the lip.
▪ Insert the needle into the intersection of the mucobuccal fold and the
apex/center of the canine or maxillary 1rst premolar at a 45-degree
angle.
▪ Advance the needle approximately 1-1.5 cm.
▪ Aspirate.
▪ Slowly inject 2 mL of local anesthetic and massage for 10-20 seconds.
 Mandibular nerve Block
Techniques

Halstead open-mouth Vazirani-Akinosi Gow-gates technique

method
Closed-mouth
mandibular block

ID block, Halstead open-mouth method:

Nerves anesthetized:
Inferior alveolar nerve, Incisive nerve, Mental
nerve, Lingual nerve (commonly).
Areas anesthetized:
▪ Mandibular teeth to the midline.
▪ Body of the mandible.
▪ Buccal mucoperiosteum & mucous membranes anterior to the mental
Foramen.
▪ Anterior two thirds of the tongue and floor of the mouth (lingual nerve).
▪ Lingual soft tissues and periosteum.
Indications:
▪ Procedures on multiple mandibular teeth in one quadrant.
▪ Buccal and lingual soft tissue anesthesia.
 Contraindications: (The same for gow gates and akinosi as well)
▪ Infection or inflammation in the area of injection.
▪ Patients who are likely to bite their lip or tongue like very young children
and mentally handicapped patients.

Technique:
• 25-gauge long needle is used.
• Area of insertion: mucous membrane
on the medial side of the mandibular
ramus; 6 – 10 mm above the occlusal
plane with the syringe barrel between
the contralateral 1st and 2nd lower premolars.
• Penetration depth: bone should be contacted about 20 – 25 mm in (3/4 of
the needle). The needle should be near the mandibular foramen.
• If bone is contacted too early, then you are too far anterior. Bring
the barrel of the syringe more towards the front of the mouth
• If bone is not contacted, then you are too far posterior. Bring the
barrel of the syringe more over the molars
• After bone touch, withdraw 1 mm, aspirate in two planes, deposit 1.5 mL.
• Slowly withdraw the syringe, and when approximately ½ of the needle is
in the tissues, re-aspirate, and give remaining solution – Lingual nerve
block.

Landmarks:
• Coronoid notch
• Pterygomandibular raphe
• Occlusal plane
 Vazirani-Akinosi (Closed-mouth mandibular block):

Nerves anesthetized:
Inferior alveolar, Incisive & Mental, Lingual, Mylohyoid.

(This technique does not anesthetize long Buccal Nerve)

Areas anesthetized:
Mandibular teeth to the midline, Body of the mandible, Buccal mucoperiosteum
and mucous membrane anterior to mental foramen, Anterior 2/3 of the tongue
and the floor of the mouth and Lingual soft tissues and periosteum.

Technique:
• 25-gauge long needle is used
• Area of insertion: Soft tissue overlying the medial (lingual) border of the

mandibular ramus directly adjacent to the maxillary tuberosity at the

height of the mucogingival junction adjacent to the maxillary third molar.

• Hold the syringe parallel to the maxillary occlusal plane.

• Penetrate the tissues at the area of insertion, advance the needle 25 mm,

aspirate in two planes, and deposit 1.8 mL.

• The anesthesia will decrease trismus and allow the patient to open his

mouth.

• No bone touch occurs in this

Technique.
 Gow-gates technique
(True mandibular nerve block)

Nerves anesthetized:
All branches of the mandibular division

of trigeminal nerve will be anesthetized:

Inferior alveolar, Mental & Incisive, Lingual,

Mylohyoid, Buccal nerve in 75% of patients,

Auriculotemporal nerve.

Areas anesthetized:
Mandibular teeth to the midline, Buccal mucoperiosteum

and mucous membranes, Anterior 2/3rd of the tongue and floor

of the mouth, Lingual soft tissues and periosteum, Body of the mandible.

Technique:
• 25-gauge long needle is used
• Area of insertion: Mucous
membrane on the mesial of the
mandibular ramus, on a line from
the inter-tragic notch to the corner of
the mouth, just distal to the
maxillary second molar.
• Target area: Lateral side of the
condylar neck, just below the
insertion of the lateral pterygoid
muscle.
 • Approach from the opposite side as in the ID block (Halstead technique).
• Align the needle with plane extending from the corner of the
mouth to the inter-tragic notch.
• Penetrate the tissues just below the MB cusp of the upper 2nd molar,
and distal to upper 2nd molar until bone is contacted.
• Depth of penetration: 25 mm
• Withdraw 1 mm, aspirate in two planes, and give the full cartridge.
• Ask the patient to keep their mouth open for 1 to 2 mins.

Long Buccal nerve block

Nerves anesthetized: Long buccal nerve.

Areas anesthetized: soft tissues and periosteum buccal

to the mandibular molar teeth.

Technique:

• 25-gauge long needle is used.

• Area of insertion: mucous membrane distal and
buccal to the most distal molar in the arch
• Landmarks: Mandibular molars, muco-buccal fold.
• The syringe should be parallel to the occlusal
plane, but buccal to it on the side of injection.
• Advance the needle until bone is contacted,
Withdraw 1 mm, aspirate in two planes, and
deposit 0.3 mL.
• Depth of penetration: 1 – 2 mm.
 Mental & Incisive Blocks

Nerves anesthetized: Mental & Incisive nerves.

Areas anesthetized:
Buccal mucous membranes anterior to the mental
foramen to the midline, and skin of the lower lip,
Skin of the chin (Mental nerve block)
pulps of PMs, Canine, and Incisors and alveolar
bone around them (Incisive nerve block).
Technique:
• 25-gauge short needle.
• Area of insertion: Muco-buccal fold or just anterior
to the mental foramen between the 1st and
2nd lower premolars.
• Orient the syringe, penetrate the tissues, advance
the needle until bone is contacted, withdraw 1 mm,
aspirate, and deposit 0.6 mL.

What to do if your ID block failed?

• Increase the dose – give another cartridge.

• If the mesial root of the lower 1st molar didn’t get anesthetized, then maybe
accessory innervation by mylohyoid nerve exists – anesthetize the mylohyoid
nerve or give PDL anesthesia.
• If lower anteriors did not get anesthetized; as there might be an overlap
innervation from the contralateral IAN, then give infiltration.
➢ If the patient can’t open his mouth, use Akinosi technique instead of the
Halstead.
➢ In case of inability to visualize landmarks for ID block, Akinosi or Gow-Gates
technique can be used.
 Supplemental injection technique

Intra-osseous Intra-pulpal

PDL Intra-septal Intra-osseous

(intra-ligamentary)
 How to confirm anesthesia?

• Ask the patient.

• Soft tissue testing (ex: using sharp probe).
• Electric pulp testing.
• Simple begin treatment.

Recommendations & Reminders:

• Insert the cartridge first, then the needle.

• Don’t exert force on the plunger as the glass may crack.
• Don’t forget to pull the tissues taut with all injection procedures.
• Corner of the mouth is where the premolars are.
• Bevel of the needle has to be towards bone, except when giving the Vazirani-
Akinozi Mandibular Nerve Block as it is oriented away from the bone.
• In patients with macroglossia, limited mouth opening or trismus, ID block and
gow gates are difficult to be performed, so Akinosi Method (closed mouth
technique) is advisable.
 Matrix systems
- Definition and functions of Matrix (plural- matrices): a
matrix provides and takes the place of the smooth and proximal
tooth surfaces that were removed, and provides a temporary wall
in order to restore the tooth contours and contact to their normal
shape and function, also to resist pressure necessary for
amalgam insertion, protect the adjacent tooth, maintain form
during placement and set of the amalgam/composite, and to
prevent gingival excess (overhang).
- Primary function: To restore anatomic contours and contact
areas.
- Matrix systems commonly have two main components:
1) Matrix band
2) Retainer: which holds and stabilizes the band in its site.
(Some systems don’t have retainers).
- Types of band materials (chemistry):
1- Metallic: Stainless steel, copper.
2- Clear bands: Polyester, cellophane, Myler strip (plastic), clear
plastic crown form.
- Types of bands according to circumference:
** Notes: Siquveland looks like tofflemire, the band is straight but tofflemire isn’t.

** Automatrix and T-band are retainerless.

** Ivory band can be sectional or circumferential form. It’s old and not used
anymore in presence of palodent.

** With Palodent, a ring that is called BiTine is used to stabilize the band and push
it toward the external surface of the cavity; it’s also used as a retainer. Palodent is
the ‘sectional matrix’ we use in the clinics and Composi-tight is the same but the
bands are clear for better curing.

- Types of bands according to shape: (Straight VS Curved VS

Curved and Contoured)
-Tofflemire band has several shapes, it can be straight (not
contoured and not curved) and this shape comes in a roll that
you cut from like the one we use in the clinics, or it can be
curved like in the picture below, and it can be curved and
contoured and this shape is usually used for premolars.
-T-shaped: some are curved and some are straight.
-Ivory: has several shapes, different thicknesses and widths,
curved but not contoured. (It also has holes for the retainer)
-Palodent: is contoured and
curved not straight, we prefer
palodent with composite while
we don’t use it amalgam cause
with condensation it will
move.
➢ Note that we use contoured bands in
pre molars and molars to restore contact
points. In composite we don’t use tofflemire, we use sectional bands –because
some sectional bands are contoured while circumferential bands are straight- even
in MOD cavities for composit, use sectional band in the mesial and then a sectional
band in the distal. You can use circumferential tofflemire if it is contoured.

- So as a summary:
*Palodent is sectional (less retentive), and it’s curved and
precontoured so it is used with composite, but not amalgam
because the condensation step interferes with the stability of the
band, while Tofflemire is circumferential (more retentive) so it’s
used with amalgam, but the straight type can’t be used with
composite.
Tofflemire matrix system:
- Universal retainer:
When assembling the band
and the retainer, you first
loosen the outer knob and
put the band then you
tighten it. Now you have a
defined diameter of the
band connected to the retainer, then if you want to adjust this diameter you can do
it through the inner knob; when you tight the inner knob, the vise go away from the
head which will make the diameter smaller and when you loosen it, the opposite
happen.

- Notes: Remember the retainer is mostly placed buccally to

avoid interference with the toungue and the anterior teeth, it’s
rarely place palatally or lingually. And the head opening
direction is gingivally, so when you remove it you pull in an
occlusal direction instead of pushing it gingivally and
traumatizing the vestibule and soft tissues.
-Remember to condense the box first.
- Before starting with the restorative material, the last thing that
should be added to the matrix assembly is insertion of the
wedge. In order to use the wedge; the margin of the matrix band
should be always beyond the margin (gingival to the gingival
wall), you mustn’t have an open margin.
Automatrix system:
- The automatrix system is an alternative to a universal retainer.
- There is no retainer, instead, bands are already formed into a
circle and are available in assorted sizes in both metal and
plastic, and each band has a coil like autolock loop.
- A tightening wrench is inserted into the coil and turned
clockwise to tighten the band and turned counterclockwise to
loosen the band. Removing pliers are used to cut the band.
- The indicated use of this matrix is for extensive Class II
preparations, especially restorations replacing two or more
cusps.
- Advantage: the autolock loop can be positioned on the facial or
the lingual surface with equal ease.
- Disadvantage: the bands are not precontoured, and
development of physiologic proximal contours is difficult.
- Difference between automatrix and tofflemire is that the auto
matrix covers the whole circumference of the tooth while the
tofflemire isn’t in contact with the tooth at the part connecting
the band to the retainer.
*We use wedges all the time regardless the type of the band.
Sectional matrix:
A thin polished palodent-type band and a tension ring produce a
tight anatomic contact for composite resin materials for class II
restorations.
- In sectional matrices there is a part of the band called Apical
flap, it should be placed gingivally:
Used when there’s extension of the cavity deeply toward the
gingiva (subgingival) the whole band can’t be inserted
between the tooth and the gingiva, so you need a part of the
band to be inserted to prevent stabilize it and prevent the
overhang.
In this type if the band isn’t well extended then it can’t be used
as a band, only a separation mean.
Clear matrix:
*A plastic matrix, also referred to as a celluloid matrix or
mylar strip, is used for class III and IV restorations in which
the proximal wall of an anterior tooth is missing.
*The matrix is placed interproximally before the etching and
priming of a tooth. This protects adjacent teeth from these
materials.
* After placement of composite material, a matrix is pulled
tightly with your fingers around the tooth to help reconstruct its
natural contour.
In fractured teeth or with extensive tooth loss, we prepare
silicon index, which is a matrix system to build a temporary
wall, it’s done by taking an impression, wax it up, then index it
on the cast, finally use it in the patients mouth. In this case we
start applying composite palatally and proximally, then we
remove the matrix and continue contouring until building the
last layer buccally.
Matrix assembly check list:
- Is the matrix band stable?
- Does the matrix band fit at the cervical margin?
- Has the band been burnished in the contact area so that the
contact point can be restored.
- Is the height of the band sufficient?
- Is the cavity clean and dry?
Wedges:
- A wedge is either triangular ( anatomical) or round and made
of wood or plastic.
- The wedge is inserted into the lingual embrasure to position
the matrix band firmly against the gingival margin of the
preparation. It should hold the matrix band firmly cervically.
- It should not be of such a height that it prevents the formation
of a contact point.
- Another function is to separate the teeth slightly so that when
it and the matrix are finally removed, the teeth return to their
original positions, closing the small space left by the thickness
of the matrix band.
- It helps in moisture control, and when they get moist they
expand so it presses on the gingiva which help in hemostasis in
the case of bleeding.
- The advantage of plastic wedges is that they are clear and
usually we use them with composite cause we need something
transparent to allow light curing.
- The advantage of wooden wedges is that they come in different
shapes and sizes also it can be customized; we can cut it with the
bur to make the desired form, shape and size.
Wedge placement:
1- Simple wedging: apply the
wedge by itself above the gingiva.
2- Piggy-back wedging: used in
subgingival cavities, one wedge
isn’t enough so we put two (large and small); the smaller
one is below.
3- Double-wedging: two wedges one buccally and the
other lingually (large width).
4- Wedge-wedging: two wedges are used, mainly used
between upper canine and first premolar because as we
know there is a concavity on the mesial side of upper 4.
Usually we put the wedge lingiually because the embrasure is larger
lingually and the contact between teeth is in the buccal third.
 Dental Composite
Restorative material used it to cover a defected tooth as a result of, Abrasion, erosion,
dental caries, or as esthetic restoration. (Most common in elderly people).
• Composition:
1. Mainly resin Matrix.
2. Filler (can’t bind to resin matrix so we use saline coupling agent) (give strength to
composite)
3. Saline coupling agent. (The glue between 1+2) (Adhesion material connects filler with
matrix)
4. Inhibitors (to increase shelf-life and ensure sufficient working time), Modifiers and
Opacifiers (change the color).
5. Initiator and Activators
• Composite polymerization: composite material we use is soft as a paste:
- In the past: They used to use chemical cure; (The material takes time to set by itself).
- Nowadays: They use light cure mainly; (You shape the material as you want, once
you put the light it gets rigid), This rigidity called polymerization thus the material
gets its optimal strength by exposing it to the light cure. As the light is very bright,
direct viewing of the light source will damage the eye, so even indirect (reflected)
observation of the curing light is contra-indicated (light shields should be used)
- Dual cure: chemical + light - You rigid it by light, but some of it needs time (chemical)
, We mainly use it in veneers.
- Polymerization of resin is responsible for Hardening and Bonding through forming a
highly cross-link plastics.
• Clinical application of composite:
o Two reasons why we don’t put composite as a bulk material:
1- The depth of cure: (the depth of penetration)
- The thickness of composite cured by a typical light source is called the depth of
cure=2mm, the depth of cure varies depending on; The time of light exposure, The
composite products and The shade of the composite.
2- Incremental addition: to Assure adequate polymerization and Minimize
polymerization shrinkage.
- NEVER put a composite directly on two walls that are opposite to each other , If you
put it on opposing walls, the center of shrinkage is in between, and it is going to
detach from the sides.
- Air inhibition: (oxygen inhibited layer) When composite materials are placed in
increments, each increment chemically bonds to the previous increment. The last
surface (the last micrometers of the layer) is exposed to the air, and the oxygen that
is found in the air prevents the full polymerization of the material, so when you use
light cure and examine the layer with probe you will notice that the material is steaky
(unreacted material), which helps the next layer (newly set composite) to be
 chemically bonded to it, when you finish; you start polishing the surface to remove
the oxygen inhibited layer.
- So chemical bounding occurs because addition polymerization is inhibited by the
atmosphere’s oxygen.
o Unreacted C=C bonds :
- Not only can composite materials be placed in layers and bond together, but new
composite will bond to old composite because not all C=C bonds react when dental
composite sets, typically only about 75% of the C=C bonds react.
- So, it is possible to repair or add to a composite restoration by cleaning the surface
and adding new material.
o Shades:
- Opaque materials are designed to prevent the underlying color from showing
through. They are used to hide stained or discolored dentine, first you put a dark
layer that mimics dentine, then layering as enamel, and translucent incisal edges (no
dentine).
• Types and properties of dental composite:
1- Macrofilled composites
2- Midfilled composites
3- Microfilled composites
4- Hybrid composites
5- Flowable composites:
have a decreased filler content to reduce viscosity and increase flow of these
material so a weaker, less abrasion resistant material results.
typically used as the initial increment of a composite restorations and then covered
with a hybrid material.
6- Condensable composites
• Detecting composite restorations:
- They do feel a bit softer than enamel to a sharp explorer.
- They appear either radiopaque or radiolucent on radiographs depending on the filler
in the product.
• Properties of composite that make it suitable for classes I, II:
1- It has enough strength.
2- It is insulative and therefore doesn’t require pulp protection with bases.
3- Tooth preparation is very conservative.
• Concerns about posterior composites:
- Wear: Composite restoration is weaker than tooth structure
- Leakage: happens when there is any contamination during placement of composite,
• Indications:
1- Small and moderate restorations, preferably with enamel margins.
2- Most premolar or first molar teeth especially when esthetics are of a concern.
3- A restoration that doesn’t provide all the occlusal contacts (wear resistance).
 4- Where proper isolation is possible.
5- Some restorations that may serve as foundations for crowns.
6- Some very large restorations that are used to strengthen weakened tooth structure
for interim or economic reasons: like in endo treatment for molars, most of the tooth
structure is missing because of the removal of big amounts of dentine & then just
thin layers of enamel remain all around the tooth, we can use composite to hold
these enamel walls together and strengthen the tooth structure (This composite
restoration is not a final restoration, it is better to do coverage)in such case tooth
structure wont be able to withstand amalgam.
• Types of posterior composite restorations:
1- Pit and fissure sealant.
2- composite and preventive resin restoration: preventive resin restoration is Used
with deep fissures that are expected to be class I with time due to bad oral hygiene.
3- Class VI, I and II
4- Complex composite restoration: when there is more than one surface as MOD ,
MODL ,MODB or all the surfaces together are involved
• Clinical Technique:
1- Anesthesia (Pt comfort, decrease salivary flow).
2- Occlusal assessment (determine design, adjust the restoration’s function).
3- shade selection.
4- Isolation (visibility, better restoration quality) multiple isolation with rubber dam.
5- Tooth preparation.
6- Pulp Protection. If needed.
7- Restoration.
• designs of cavity preparation for class I composite restoration:
1- Conventional class I preparation:
- Indication: large preparations or restorations subjected to heavy occlusal forces.
- Design: Like an occlusal amalgam preparation, facial and/ lingual extensions are
dictated by caries removal, old restorative material, and or enamel faults. ( 90° Cavo-
surface margin, flat pulpal floor, buccal and lingual walls are parallel or convergent,
mesial and distal walls are slightly divergent)
- Uniform depth.
- pulpal floor is usually flat and follows the DEJ.
- Preserve the strength of the cuspal and marginal ridge areas as much as possible.
- extensions into marginal ridges should result in 1.6mm thickness of remaining tooth
structure in premolars and 2mm in molars.
- If extension is required toward the cusp tips, the same approximate 1.5mm thickness
is maintained.
- No attempt is made to place bevels on the occlusal margin because it may result in
thin composite in areas with heavy occlusal forces (you can use bevels with class I
just in case of buccal or lingual extensions).
 2- Beveled Conventional class I preparation:
- Indication: large Class I with groove extension.
- Design: box like form and beveled walls on the groove extension walls.
- Uniform depth.
- pulpal floor is usually flat and follows the DEJ.
- Usually we use thin composite area(bevel) for 2 reasons:
1-To mask the color (shade) with natural tooth, used more in anterior teeth.
2-To achieve more retention due to higher exposure to enamel rods.
3- Modified class I tooth preparation: (just remove caries and place your restoration
without any specific form)
- Indications: minimally involved class I or faults.
- Design: less specific in form/ scooped out appearance.
- The initial depth is 1.5mm or .0.2 mm inside dentine, but the pulpal floor may not be
uniform.
• Proximal composite restorations (class II):
1- Access through the marginal ridge (MO,DO, box only, MOD):
- Access to carious dentine is by removal of enamel over the marginal ridge.
- Cleaning of dentino-enamel junction using a low-speed round bur
- Excavation of caries over the pulp
- Unsupported enamel is left in the cavity
- Several possible designs are available:

A. 90° amalgam prep: this cavity is suitable for both amalgam and
composite.

B. 45° bevel: this cavity with beveled margins could be filled with
composite if there is no interference with occlusion.

C. acute bevel or "hollow cut"-minimal design its end has C shaped with
undermined enamel, This design isn’t suitable for amalgam.
 2- Marginal ridge is preserved
We drill and clean all caries occlusally and the marginal ridge still intact and its
thickness is more than 1.5 mm and it’s strong, so we preserve it and restore the
teeth.
A. Occlusal approach
B. Buccal approach (suitable for teeth that are tilted lingually)
• Matrices for composite restoration:
- They are used to retain the filling material within the cavity and to give it the needed
shape & contour.
- Types of matrices:
1- Mylar strips: for class 3 & 4 cavities. When we use mylar strips in preparing a class
4 cavity, we need to do finishing and contouring for the excess composite to reach
the final shape needed according to our knowledge about the anatomy of the
tooth (specially the anatomy of the incisal edge, you have to know that the
mesioincisal angle in the upper central is sharper than the rounded distoincisal
angle).
2- Cellulose crown form: leaves just small excess on the margin of the restoration
and used for:
A. Large fractures.
B. Reshaping the whole tooth.
C. Preparing a composite resin crown.
D. Composite facing.
3- Cervical matrix: used for Class 5 cavities.

- Note: using the mylar strips & cellulose crown form results in a tooth surface that is
smoother than the natural tooth surface, and because of that, when we finally check
the occlusion, we do finishing only on the margins of the cavity.
- When there is a small defect (fracture) in the incisal edge, it is mostly corrected
without any restoration, we just do grinding/ finishing for this area in order to make it
more esthetically accepted (area is esthetically recontoured).
- When we want to restore the fractured incisal edge, we just do bevel labially, incisally
and lingually, and we make sure that the margins clinically are located away from the
area of occlusion (away from the point of contact with the opposing tooth) by using
mylar strips & cellulose crown forms.
 Amalgam
Amalgam – an alloy containing mercury as a major component.
• Dental Amalgam: (liquid + powder) is a liquid mercury (liquid) and metal alloy mixture
like silver, copper, tin zinc.... (powder), used in dentistry to fill cavities & considered as
the oldest dental material.
• Since mercury is a liquid at room temperature, it can be combined with solids to form an
alloy.
• The more surface area available for the reaction, the quicker the reaction between
metals can take place.
• Advantages:
1. Cheap.
2. Long history of satisfactory result.
3. Strong and durable. (More than composite & GI)
4. Easy to handle
5. Not technique sensitive.
6. Microleakage between tooth and amalgam decreases with time, it has self-sealing
property (Clinical Relevance After placement, amalgam restorations exhibit a gap
between the restoration and tooth structure, which fills with corrosion products during
time in clinical service). Corrosion products: group of metals which leak out of
Amalgam when it interacts with the oral cavity.
• Disadvantages:
1. Short working time. (Up to 8 min)
2. Mercury toxicity.
3. Non-aesthetic. (Not suitable to be used in anterior teeth.)
4. cant bind to tooth structure (no chemical reaction), which requires mechanical
adhesion provided by shaping the cavity (convergence &dove tail) , thus its less
conservative than composite.
5. Corrosion products may discolor tooth structure.
6. Brittle material: sudden fracture occurs when it reaches stress limit.
• Properties of dental Amalgam:
1. Strong in compression (commonly used for posterior teeth)
2. Weak in tension or bending (Pulling a bar of Amalgam from both sides will lead to
fracture).
3. Very small dimensional change upon hardening (no expansion after the chemical
reaction is completed); but delayed expansion may occur if it contains Zn.
4. High thermal conductivity compared to tooth; There should be an isolating material
between Amalgam and tooth structure in deep cavities in order to protect the pulp .
5. Coefficient of thermal expansion 2.2X tooth.
• Conventional (first used in dentistry) Amalgam Composition: this mixture (triturate) is
called G.V. Black mixture:
1. 50 w% Liquid - pure Hg
2. 50 w% Powder – Alloy:
o 65-70% Ag
o 28-29% Sn
o Cu < 6% may form Cu3Sn called epsilon ε phase
o Zn <1% if any
o Ag-Sn forms a solid intermetallic compound called gamma γ phase Ag3Sn ~ 28%
Sn.
• Main chemical reaction of Amalgam - Hg dissolves Ag and Sn
• Once you mix powder with liquid, Hg will react with Ag and Sn (γ phase), then 2 new
intermetallic compounds precipitate from solution:
o First γ1 phase (Ag2Hg3) – when it reacts with Ag
o Second γ2 phase (Sn7-8Hg) – when it reacts with Sn
o Residual γ phase (excess unreacted material) is embedded in a matrix of γ1 and γ2 - a
metal matrix composite.
• High Copper Amalgam (“high-copper alloys”):
o Gamma-two phase (weak phase) has the poorest corrosion resistance, it is the
weakest and has the lowest melting point of all the phases in set amalgam, so its
presence lowers the strength of Amalgam; because hard (rigid) Amalgam will leak out
corrosion products, thus spaces will be formed, then strength decreases.
o To solve this problem→ If original alloy powder contains >10% Cu, some or all the γ2
Sn7-8Hg is replaced with Cu6Sn5 η’ (eta phase), γ2 decreases; Cu competes with Hg,
Sn will react with Cu rather than Hg.
o A high-copper amalgam contains enough copper to eliminate the gamma-two phase.
Currently conc. is: 11< Cu wt% <30
o Clinically amalgams with little or no gamma-two have shown better clinical
performance and less marginal deterioration, less corrosion and more strength.
o These observations support the use of high copper content amalgam alloys.
• Alloy powder (other components)
o Pd, In: prevent Mercury evaporation from Amalgam.
o Zn: Deoxidizer.Role of Zn;
- prevents formation of other oxides in the material.
- Delayed expansion—The gradual expansion of a zinc-containing amalgam over a
period of weeks to months. This expansion is associated with the development of
hydrogen gas, which is caused by the incorporation of moisture in the plastic mass
during its manipulation in a cavity preparation. “bubbles” on the occlusal surface
resulting from gas formation.
• Manipulation of amalgam includes:
1. Selection of the alloy. 2. Proportioning of alloy to mercury.
3.Trituration. 4. Condensation.
5. Carving. 6. Finishing and polishing
1. Selection of the alloy:
• How to prepare alloy powder? Mixing the metals together, then heating the mixture at a
high temperature to let them dissolve together, then a rigid material will be formed,
then this material is cooled down then grinded, finally we get the powder.
• This process will give two powder shapes:
a. Lathe cut:
- Irregular in shape.
- More surface area.
- Less powder.
- Easier in carving
- Proportion powder to liquid is 1:1
b. Spherical:
- Spherical in shape
- Less surface area.
- More powder.
- Stronger than Latch cut.
- Proportion powder to liquid is >1:1
•The two powder shapes are either:

a. Single composition (uni-compositional):

- lathe cut only.
- Spherical only.
b. Admixed: All combinations of lathe cut and spherical powders.

• Things that you consider when choosing materials in your clinic:

1. Application (better adaptation or high pressure).
2. Condensability (Lathe cut and admixture resist condensation; better for proximal
contact).
3. Handling characteristics:
 - Working/setting times; normal set (4 min), fast set (2-3 min) or slow set (10 min).
- consistency, texture response to burnishing, Polish ability; spherical is more polished
than admixed and lathe cut.
4. Physical properties; high copper or low copper.
5. Clinical research. (Medically, which materials are the best).
6. Delivery system: capsules or Powder/Liquid mixing, nowadays capsules are more
commonly used.
7. Cost.
2. Proportioning (mixing powder with liquid by specific ratio):
- The recommended mercury/alloy ratio for the lathe - cut alloys is approximately 1:1
or 50% mercury,
- For spherical alloy, mercury should be 42% because spherical particles have lower
surface/volume ratios. (Because the surface area is low but the particles number is
high, so it does not need excess mercury)
- When the mercury contacts surface of the particles, a plastic mass is formed (Dough
stage, 3-4 min), which can be shaped and carved before it sets into a hard mass (8
min).
• Amalgam alloy could be supplied in the form of:
1- Powder. (Mixed with mercury) was used in the past
2- Pressed tablets (pellets) (the weight of the tablet is known, and you add the mercury
droplets to it),
3- Pre-weighted capsules: containing a specific weight of powder and mercury, and
separated from each other until ready to use, this form avoided the errors in
proportioning (mixed with amalgamator and the most commonly used nowadays) and
the most convenient as it is:
✓ Properly dispensed and proportioning of Hg/alloy ratio
✓ More hygienic as it is well sealed, and the operator will not be subjected to Hg
vapors.
✓ Lesser manipulation procedures
✓ no need for proportioning and squeezing
- Types: With or without pestle.
- Contains powder & liquid (mercury) in an envelope.
- Activation:
a. manually activated. (There is a button that must be pressed to eject the
mercury through membrane and mix it with the powder)
b. self-activated. (Auto: the envelope will parse while mixing in the
amalgamator)
- Amount/ Size: different amount (spill) because we have different cavity sizes
1. single spill (400mg)
2. double spill (600 mg)
 3. Triple spill (800mg)
- Setting time: 1. Slow set 2. Regular set 3. Fast set.
• placement :
Armamentarium- Instruments needed for amalgam
1) Mortar & Pestle: (Not used anymore)
- Mortar is thick like a bowl and pestle is thin like a pencil.
- Used to mix the alloy powder and mercury to make a homogenous mixture.
2) Amalgam carrier (Gun):
- Used to carry amalgam and dispense the amalgam in the cavity.
3) Matrix System:
a. Matrix band:
- It has a concave surface (upward) & one convex (downward).
- The convexity of matrix band should put up on the occlusal surface.
- Used to support the wall of class II and replace missing proximal walls of cavity
preparation for condensation of amalgam.
b. Wedges:
- Pointed sharp part should be applied between the teeth.
- Used to:
o tight the matrix band.
o compress the gingiva.
o separate the very tight contact between teeth.
o hold matrix band in place along gingival margin of class II.
- Wooden or Plastic:
o Wooden wedges absorb saliva then they expand and fill the space between teeth.
o it has low strength as compared to plastic wedge.
4) Condenser:
- Has cylindrical ends.
- Has different sizes (small, medium, large)
- Used to condense the amalgam (packing the amalgam into the cavity).
- Smooth or serrated tip.
5) Burnisher:
- Different shapes and sizes.
- We overfill the cavity with amalgam, because in the condensation step we are making
the amalgam particles closer to each other getting rid of the mercury which will be
placed on the surface, so we have to remove the superficial layer because it is full of
mercury this is done by smoothing it with the burnisher then by carving, this will give
us a cavity with suitable amalgam filling (not over or under filled).
6) Carver:
- Is used to:
1. remove the excessive material
 2. produce the normal tooth anatomy.
- Different shapes:
a) Ward’s Carver: (the one that we use) Pointed, sharp edges.
b) Fraham’s Carver: kite shaped.
c) Cleoid discoid carver
*Their function is the same, but they differ in their way of use.
• Steps of Amalgam Filling:
1- Examination.
2- Cavity preparation.
3- Matrix band application.
4- Lining / basing:
Lining :
- Lining is done before amalgam filling to protect the pulp in relatively deep cavities
(close to the pulp) This is because microleakage can occur beneath amalgam filling,
which can harm the pulp (cause sensitivity)
- Used in indirect (when you reach a layer of caries that you choose not to remove
because pulp exposure might happen) and direct (you already exposed the pulp) pulp
capping to enhance dentin formation.
- Most common liner: calcium hydroxide (dycal) and its applied using dycal applicator.
- notes: 1- don’t extend it to the external surface (cavosurface margin) apply it just over
the base, in order not to affect sealing (this is attributed to hydrolysis of the calcium
hydroxide by fluid contamination from dentinal tubules and microleakage).2- avoid
putting thick layer of the liner, because it is weak and when we do amalgam
condensation the liner thick layer may break.
Base:
- Used in very very deep cavities (optional)
- Thicker than linear.
- Prevents against galvanic shock, protect liner
- Most commonly: Glass ionomer-based cements
5- Varnish application:
- Cavity Varnish is a liquid consisting of one or more resins in an organic solvent.
- This material is placed within the entire preparation (walls and floor ) .
- It is used to fill the gap at amalgam-tooth interface until the corrosion products are
formed to fill this gap instead of varnish after it evaporates but nowadays amalgam
with better corrosion is made, so there will be no difference if we applied varnish or
not.
- later some research proved that tooth sensitivity is the same whether you use varnishes
or not because the solvent is volatile and evaporates quickly after application, thus
leaving a thin resin film, this resin cannot block the dentinal tubules.
- The use of varnish is contraindicated with composite resins and glass ionomer, because
dental varnish interferes with their bonding and setting reactions.
- Varnish Application accomplishes the following:
1- Seals dentinal tubules
2- Reduces microleakage around a restoration
3- Acts as a barrier to protect the tooth from highly acidic cements such as zinc
phosphate.
- Application of Varnishes:
o will be placed after the liner is applied.
o applied with a small disposable applicator or with a cotton pellet
o held in sterile cotton pliers.
o applied in two thin layers.
o a gentle air to dry first layer prior to applying the second.
- Cavity varnish is replaced by bonding agents and desensitizer agents.
6- Trituration/mixing (amalgamation):
a) HAND MIXING:
✓ A glass mortar and pestle are used.
✓ The mortar has its inner surface roughened to increase the friction.
✓ Usually, a period of 25 to 45 second is sufficient for hand mixing.
b) Mechanical trituration:
✓ By using mechanical amalgamator.
✓ Saves time and standardizes the procedure.
- Spherical alloys require less amalgamation time than lathe cut alloys.
- For a given alloy/mercury ratio increased trituration time and speed shortens the
working and setting time.
- Amalgamation time depends on the quantity.
7- Dispensing of amalgam
in the amalgam well or the dappen dish
• UNDER Triturated mix:
✓ rough and grainy and may crumble
✓ tarnish and corrosion can occur
✓ strength is less
✓ the mix hardens too rapidly
✓ excess mercury present
• NORMAL mix:
✓ Shiny surface, soft and smooth consistency.
✓ Warm when removed from capsule.
✓ Best compressive and tensile strength.
 ✓ Has luster after polishing.
✓ Increased resistance to tarnish and corrosion.
• OVER Triturated mix:
✓ Soupy (with bubbles) mix,
✓ difficult to remove from capsule.
✓ Working time increased.
✓ Higher contraction of amalgam.
✓ Creep is increased
- Amalgam is condensed inside the carrier first from the amalgam well, then delivered and
packed inside the cavity with pressure.
- in class II, first amalgam delivery should be into proximal box and condensed.
8- Condensation (to compact the alloy into the prepared cavity):
- should be promptly initiated, just after the mix is ready and its done layer by layer with
smooth flat plugger ( Amg Condenser).
- Condensation of partially set material probably fractures and break up the matrix that
has already formed.
- Use Small condenser first, then larger ones, to make sure that it enters in the small
areas.
- condense using the amalgam carrier especially when you are dealing will upper teeth.
- The field of operation should be dry before application, to reduce the hygroscopic
expansion of amalgam filling.
• Factors controlling proper condensation:
1. Elimination of moisture contamination and debris to avoid: Delayed expansion, Loss
of strength and Excessive corrosion.
2. Size and shape of the condenser/plugger should be of size slightly smaller than the
width of the cavity.
3. Addition of mix increment by increment in order to: Avoid layering, provide
maximum adaptation, remove maximum amount of excess Hg and Eliminate voids.
4. Forceful condensation is necessary in order to: Eliminate voids, remove excess Hg,
increase adaptation and Increase density of filling.
5. Any old mix, more than 5 minutes should be discarded and replaced by new freshly
mixed one, and if used, the restoration will be: Full of voids, Corrodible, Weak and
Non coherent
6. The cavity should be over filled in order to: Allow proper carving and Get the Hg rich
layer at the surface that will be removed with carving.
• Condensation is started at the center and then condenser point is stepped little by little
towards the cavity wall.
• The condensation force should be directed against cavity walls, line angles and point
angles.
• The force should be continued until the surface of the increment becomes soft
indicating release of excess Hg and a squeezing sound is heard.
• After condensation of each increment excess mercury should left over the first
increment so that it can bond with the next increment.
9- Pre-carve burnishing: "smearing" the final layer from the center towards all margins with
a round-ended burnisher.
- Burnisher shapes: Ball shaped, Football shaped and Acorn-shaped
- Double burnishing technique (Pre and post carving burnishing):
1) Pre-carving burnishing:
✓ Using large sized burnisher with heavy pressure.
✓ The amalgam is pre-carved burnished in a direction from the tooth to amalgam. It
provides the followings:
a) Increased adaptation of amalgam to cavity walls and margins
b) During this, some frictional heat is generated which helps the excess Hg to be
attracted to the surface and easily removed with carving.
c) More cohesive amalgam.
2) Post-carving burnishing:
✓ After carving finished, the amalgam is burnished with light pressure until the
surface acquires a homogenous stain or velveteen appearance.
✓ This will provide surface smoothening.
10- Carving
The carving is done by the sides of the carver and not the tip. Sides are supported by the
cusps, so you can get the final shape of the cavity.
• Aims:
✓ To reproduce the normal tooth anatomy and contours.
✓ To ensure efficient mastication and tooth function.
✓ To remove the superficial Hg rich layer.
Timing of carving:
✓ Carving should be utilized when amalgam starts initial setting.
✓ This is detected when a slight resistance of carver movement is felt.
✓ Early carving may result in: Improper reproduction of tooth anatomy, and formation
of sub-margins (Amalgam not covering the cavity walls)
11- post-carve burnishing
12- check the occlusion
- This is done following carving and post- carving burnishing.
- High spots are removed by carving.
13- Finishing and Polishing.
• Aims:
1. Removal of any premature contact, marginal flashes or marginal over hangs.
2. Provide a lustrous homogenous amalgam surface.
• Advantages:
1. Increases corrosion resistance.
2. Decreases bacterial plaque retention and liability to recurrent caries.
3. Minimizes gingival irritation.
4. Improves strength of amalgam, as it removes the surface irregularities that act as
stress concentration areas.
• Timing: After 24 hours of carving to avoid disturbing crystallization of amalgam. ( if
the amalgam was high , and you drill in it using the hand piece to make it lower , the
restoration will have cracks , because you applied a high vibration on it and it is not
set , so any polishing or finishing step should be done after complete setting.)
• Finishing:
- Using finishing bur in a direction from the tooth to restoration.
- Using sandpaper discs for accessible surface.
• Polishing: Using pumice with brush or rubber cup.
 Bonding systems…

Bonds can be of two types:

Ø occur within the same material
1.Primary (chemical bond) like: Ionic ,covalent ,metallic
or combinations
2.Secondary (attraction between molecules) like: Van der
waals , hydrogen bonds
Ø Adhesion between two different materials
1.Mechanical retention (not true adhesion) like implant
and screw
2.Chemical retention (true adhesion): complete denture
that is retained in the mouth due to saliva, or calculus and
plaque and tooth structure

Noteà

the doctor asked : so when we do a

composite restoration , what type of
retention we
do ? combination of both (mechanical
and chemical)

-Adhesion : attraction between different materials .

-Cohesion : attraction between the same materials.
When we put adhesive system or luting cement between
adherened 1 and adherened 2 (composite ,amalgam
,ceramic....) this is called dental joint.

*If the forces between two different materials were stronger

(than the internal forces) then we have a good wettability.

Three concepts contribute to understand bonding and its

strength:

1.Surfsce energy (tension).

Surface atoms have greater energy than the atoms inside the
structure because surface atoms are free from one side so its
can contact other materials while inner atoms are contacted
from all sides

2.Wetting and wettability.

the better you can wet the surface the stronger adhesion
between two different surfaces.
 If you want a high adhesion of composite to enamel, you
need to have a high surface energy of enamel and good
wetting of the bonding agent to the surface. This apply to
enamel (after itching to remove all contaminations), you aim
to have a perfect wettability of the surface via the primer.

3.Contact angle.
measure for the wettability, It is an angle formed between the
solid surface and angle formed by liquid.

so, a contact angle of zero is complete wetting like glass plate

, and a contact angle of 180 means no wetting ,however 0 and
180 are not occur in reality, the value usually is in between.
Basics of bonding to any substrate

1.Conditioning (cleaner)
2. Primer (wetting agent)
3- Bond (connect)

-Does putting a wetting agent affect the enamel? No ,you can

put bonding agent after etching without a primer because
enamel has a very high surface energy but you can put it ..

-don’t over dry or over etch dentine and keep it moist

Conditioning materials used:

1- Phosphoric acid 35-37% >> for

dentin and enamel.
2- Hydrofluoric acid 5-9% for glass etchable ceramic , ex:
lithium disilicate
3- Aluminum oxide 25-30 um>> (sandblasting) used to etch
metals , zircon materials, non-etchable ceramic
 Primers:

1-Hydrophilic monomers: used with enamel and dentine

2-Organic saline: used within etchable and non-etchable
ceramics.

Bonding agent can be either :

1-hydrophobic
2-Amphiphlic : having both hydrophilic and hydrophobic
parts

Bonding systems available :

1-Etch and rinse system

First you etch, rinse, clean and dry, add primer, then bonding.
So each component is in a separate bottle and it’s called three-
step (fourth generation).
or An etchant that is separated, with the primer and the
bonding agent being together in the same bottle called two
steps system (fifth generation). Very technique sensitive

-In etch and rinse system over-drying of dentine can occur

easily.
-when over etching dentine >10s collagen collapses and bond
will fail.

2-self etch system

-The conditioner with the primer together in same bottle and

the bonding agent is in a separate bottle,, called two steps self-
etch .(sixth generation).

-The conditioner with the primer with the bonding agent all
together in the same bottle, one step system. (Seventh
generation) Comes as either a Single compartment that is
already mixed or two compartments that should be mixed
before use, then it is applied in one step, but still a single
step.

-in self-etch system, there is no rinsing off so we can avoid

many problem like over dry.
Strong acid Ph.
<=1
weak &
moderate acid
PH>1.5

Enamel Dentine
Bonding agent Hydrophobic hydrophilic by
BIS-GMA – Mixing
TEGDMA BIS-GMA,
resins TEGDMA
with primer
Acid etch - Strong acid - Weak acid
PH<1 PH>1.5
- gives white Strong acids →
chalky appearance should be etched
- should be etched 5-10 seconds
for 15-60 (Max 15s )
seconds(min 15s) - Weak acids →
Should be etched
for up to 1 min
-you can over etch
sclerotic dentine,
 as in this case it is
recommended
to over etch
dentine for 20-
30sec.
primer Not needed Needed
bonding - Enamel should - Dentine should
be Completely dry be moist. (during
- Bonding to the etch & rinse
enamel is easy due system).
to its components - forms hybrid
(mostly minerals). layer
- Bonding to - bonding to
enamel occurs by dentine is
micromechanical difficult because
retention of:
- fundamental 1- smear layer
mechanism filling the
of bonding to dentinal tubules
enamel is and heterogeneous
essentially nature of dentine
based on: -Etch
2- it has water that
comes from the
pulp by dentinal
tubules so there is
water in the bond

3- Risk of over-
drying over-
etching(collagen
collapse) or -over
wetting that lead to
 phase separation
between the
hydrophobic and
hydrophilic
components of the
adhesive
Methods of drying Air syringe 1- Blowing Air at
after acid-etch a mirror which
will reflect it to the
tooth.
2) Blowing air at
an obtuse angle to
the tooth.
3) high volume
suction.
4) cotton roll
-Selective etching : a procedure where enamel margin
surfaces are etched with 35% phosphoric acid, so etchant is
placed on enamel surfaces only.

-Hybrid layer: Intermediate layer of resin, dentine and

collagen produced by acid etching of dentine and resin
infiltration.

-smear layer: is a 1-2 um adherent layer of debris composed

of hydroxyapatite crushed aggregates, fragmented and
denatured collagen, bacteria and their by-products.
-Resin tags :demineralized area of intertubular dentin where
the adhesive is supposed to penetrate

-The 3-step etch-and-rinse adhesives are still considered the

'gold-standard' adhesives, But.... They are technique sensitive.

I put some theoretical info because they said it important

regarding this topic
 RESTORATIVE MATERIAL SELECTION
Restorative material selection
Choice of restoration is based on:
- The tooth to be restored (Ant./Post.)
- Surface of the tooth to be restored (occlusal/buccal/proximal).
- Amount of destruction to the tooth structure.
Classification of restorations:
1. Based on fabrication:
• Direct restorations
Restorative materials placed directly in the cavity, e.g.
amalgam, composite, GIC.
• Indirect restorations
A restoration fabricated extra orally and cemented/luted on to
the tooth e.g. metal ceramic inlay and onlay.
2. Based on durability:
• Temporary
Restored for a period of weeks, to be observed and followed
by subsequent management, e.g. ZOE or intermediate
restorative material (IRM),
• Permanent
Restoration is done to restore form and function for a long
duration, e.g. amalgam, ceramic, or composite.
3. Based on esthetics
• Tooth colored.
Resin composite, ceramic, or GIC
• Non-tooth colored
Amalgam, metal inlay or onlay.
 4. Based on composition:
• Metallic restoration.
• Non-metallic restoration.
5. Based on location:
• Anterior restoration.
Primary concern is esthetic e.g. composite and ceramic
• Posterior restoration
Primary concern is strength e.g. amalgam, inlay, and onlay.
6. Based on mode of retention:
• Mechanical retention
This form of retention is primarily aided by the cavity design
e.g. inverted truncated cavity design of amalgam restoration
• Chemical retention
Constitutes of the cements reacts chemically with the
inorganic component of tooth structure. This requires
conditioning of the tooth prior to the placement of the
restoration, e.g. chemical adhesion by GIC.
• Micromechanical retention
Micropores are created by etching the enamel and dentine
with 37% phosphoric acid; and resin bonding agent is applied
to form resin tags into the pores, thus retaining the restorative
resin micromechanically into the tooth, e.g. composite resin.
• Tenso-frictional retention
Retention is achieved due to frictional retention between the
cast restoration and the cavity walls. This is the primary
mode of retention cast restorations.
What is an ideal restorative material (although there's no such material)?
1. Simple. 2. Durable. 3. Painless. 4. Acceptable. 5. Insensitive.
Those characteristics vary in each material (not all materials have all
these, some will be sensitive others will be insensitive and so on). We
need to look to the characteristics of the material to trace what we need
to use according to the case.
Dental materials available to use are:
▪ Amalgam.
▪ Composite Resin.
▪ Stainless steel crowns.
▪ Glass ionomer Cements.
▪ Resin modified glass ionomer cement.
▪ Polyacid modified composite resin (Compomer).
Selection depends on many factors such as:

− Patient's factors (age, economic status, aesthetic concerns, medical

conditions so if the patient has esophageal reflux... if we use GIass
ionomer restoration the continuous acid refluxes will cause
restoration resorption)
− Opposing restoration
− Occlusal forces
− Caries risk

COMPOSITE RESIN
Advantages
A. Aesthetic.
B. Adhesive so there is no need for retentive cavity form.
C. Reasonable wear resistance.
 D. There are no potential metal sensitivity/allergy issues.
Disadvantages
A. Technique sensitive (so it needs a high degree of isolation)
B. Secondary caries due to their shrinkage.
C. Intolerant of moisture/bleeding.

GLASS IONOMER
Advantages
A. Chemical bonding to enamel and dentine.
B. Thermal expansion similar to tooth.
C. Uptake and release of fluoride
D. Decreased moisture sensitivity (less sensitive than composite)
Disadvantage it isn't a very durable material as it has:
A. Poor wear resistance. B. Poor tensile strength.
C. Long setting time.

AMALGAM
Advantages
A. Amalgam fillings are stronger and longer lasting than composites
especially in large cavities.
B. Simpler than composites
C. Cheaper
D. Not technique sensitive and doesn't need a high degree of isolation
Disadvantages
A. Occupational and environmental hazard since it contains mercury
B. Requires mechanical retention (not adhesive)
POLYACID MODIFIED COMPOSITE RESIN (COMPOMER)
This material is basically a Composite resin with modest GIC
characteristics.
Advantages
A. Adhesion (came from the composite).
B. Aesthetic (more aesthetic than the GIC, this character came from
composite).
C. Ease of use (much easier to use it than the composite).
D. Better mechanical properties than GIC.
Disadvantages
A. Less fluoride release (10% that of GIC) compared to GIC.
B. Cannot be recharged with fluoride.
C. Less wear resistance than composite because it has GIC in it.

RESIN-MODIFIED GIC
A very good material.

− It is basically a Conventional GIC with added monomer (bis-

GMA) and photo-initiator (mostly glass ionomer with slightly
added composite in order to strengthen it).
− Sets by acid base reaction and curing of monomer.
− It could be powder-liquid where you mix it or as a capsules & has
a command set.
Advantages
A. Fluoride release (came from GIC)
B. Improved aesthetics (from the composite added).
C. Improved tensile strength (composite).
D. Adhesion to enamel and dentine.
E. Less moisture sensitive than composite.
 Clinical examination of TMJ and muscles of
mastication

-Clinical examination Aims to detect masticatory dysfunction

through examining: muscles, joints and teeth.

Patient positioning for the examination:

When we examine the pt , the dentist
either will stand or sit at 12 o’clock
position Between the range of 11
o’clock ( little bit to the right ) OR
1 o’clock (little bit to The left ) .
The pt is in a semi-reclined position
or fully reclined position . The position
where the dentist is setting behind the
pt in the 12 o’clock Position and the
pt is fully reclined is probably the best.

Neuromuscular examination :
There is no pain usually associated with the function or
palpation of a
healthy muscle. The muscles can be examined by 1- palpation
. 2- functional manipulation.
- Muscle palpation : When pain is felt during muscle palpation,
it can be deduced that the muscle tissue has been compromised
by either trauma or fatigue. When we start examining the pt ,
we use soft but firm pressure , applied with slight circular
motion , using the palmer surface of the middle finger , with
the index and the 4th finger testing the adjacent areas , and
then we ask the pt to classify the response of the palpation due
to 4 categories ( 0-1-2-3) :
1- either there is no pain felt at all (0 record ).
2- uncomfortable feeling (1 record )
3- definite discomfort of pain ( 2 record )
4- invasive action or eye tearing desire this area not to be
registered or recorded again ( record 3 )

A.Temporalis Palpation: Here we are palpating the

temporalis muscle , which is divided into 3 functional areas :
A- the anterior part : palpated above
the zygomatic arch anterior to the TMJ
B- the middle part : palpated directly
above the TMJ and superior to the
zygomatic arch .
C-posterior part : palpated above and
behind the ears . So ; the dentist will go into a fan shaped
route from the area anterior to the TMJ then posterior to the
ear.
B.Masseter Muscle : When we examine the masseter muscle ,
we examine the SUPERIOR and INFERIOR attachments , the
fingers are placed on the zygomatic
arch ,from which the origin of the
muscle and then drop down slightly
to palpate the deep down masseter
just anterior to the TMJ , the inferior
attachment ( the superficial masseter)
is palpated on the inferior border of the ramus , and be careful
!! Don’t go anterior to the ramus (where the buccinator muscle
is there ) Stick! To the lateral surface of the ramus from the
zygomatic arch superiorly until the inferior border of the
ramus inferiorly.
C.Medial pterygoid palpation : this muscle is palpated at its
insertion at the medial surface of the angle of the mandible ,
and the fingers are placed at the
inferior border of the mandible
and rolled medially and superiorly
The pt then can be asked to clench
his teeth together so medial pterygoid
can be felt easily . Because of the false positive , we do
recommend not to go DIRECT palpation for Medial OR lateral
pterygoid muscles , instead we go for FUNCTIONAL
MANIPULATION That means : muscle of medial pterygoid
responsible for moving the mandible to right and left , so we
ask the pt to move his mandible for right or left against, then
we ask if there is any pain or tenderness or discomfort that
arises in such movement.
D.Lateral pterygoid palpation : This muscle will be palpated
intraorally , it is better to be seated in front of the pt , the index
finger is placed in the maxillary
buccal vestibule and the pt is instructed
to 1-close partially 2-to move the
mandible to the side being examined.
when the patient (partially closing his mandible and moving
to the site of palpation) moves the coronoid process away from
the side of palpation , but again ; palpation of this muscle leads
to the highest false positive results !! It is narrow area and
doing the palpation forcefully in this area may elicit pain
✅sharp finger nails may also provoke pain, in addition ;
evidences suggest that this technique doesn’t actually reach the
lateral pterygoid attachments Go for FUNCTIONAL
MANIPULATION where we ask the pt to open his mouth
against resistance, putting the palm of the hand on the patient’s
chin and ask him to open against resistance.

TMJ evaluation
Is done by ; 1- palpation . 2- Auscultation .
1 -Palpation : We can start palpation in 2 ways :
A-Extra-meatal joint examination : In this way , the finger tips
are placed at the lateral aspects of the TMJ on both sides
simultaneously , the pt is asked to open and close his mouth ,
and if any pain was elicited , it should be recorded using the
same scale for the muscles from (0-3 )
B-Intrameatal joint examination : The little finger of both
hands is placed in the external auditory meatus , pushing
slightly forward , here TMJ should be evaluated in the static
position , and while opening and closing . Intrameatal
examination aims to evaluate symptoms from posterior and
lateral aspects of the joints .
2- Auscultation During extra and intra meatal joint
movements , we can hear joint sounds occurring when opining
and closing of the mouth :
A-clicking : . And its due to intra-joint disk when it stuck
(click) in the joint while opening or closing.
B- crepitation : . Its due to movement of the bones that has
some degeneration on the cartilage covering them.
( Sounds may be heard by the stethoscope or felt by placing the fingertips at the
lateral aspect of the TMJs. The severity of such sounds unilateral , bilateral, on
closing , opening or both should be noted)

Evaluation of mandibular movements

1.Determination of maximum interincisal opening (53-58 mm)
roughly 3 fingers: <40 mm is restricted. Even a child can open
up to 40mm.
If the patient opens comfortably to a certain measurement and
then opens more but with pain, both measurements should be
recorded.
Deviation: is a shifted mandibular movement from the midline
during opening that disappears with continued opening.
Deflection is a shifted mandibular movement from the midline
that becomes greater upon opening and does not disappear at
maximum opening.
2.Determination of lateral excursions (approximately 10mm)
a- Lateral movements less than 8 mm is considered restricted
b -Measure the distance moved from the midline (if there is a
shift in the teeth from the midline we will consider the tip of
the nose as our reference to the midline instead)
3.Determination of protrusion Range of protrusive movement
should be evaluated (5 mm or less).
 Mandibular movements

What are the compartments of TMJ?

TMJ is composed of two compartments called Superior &
Inferior compartments:
-Inferior Compartment is the condylar
head with the disc on top of it. It is
responsible for the rotational movement
of the mandible.(condylar disc complex)
-Superior Compartment is composed of the whole inferior
component (condyler disc complex) with the base of the skull.
It is responsible for the transitional movement of the mandible.

Rotational & Transitional Movements of the Mandible

-Rotational Movement: is the rotary movement of the
mandible around a horizantal axis connecting the
right & left Condyles. Just like earth around itself
( hinge movement, transverse horizontal axis movement, and
terminal hinge axis movement)
-Transitional Movement: is the gliding movement(bodily
movement)of the mandible in a transverse plane. Just like
earth around sun.
All the movements of the mandible are either transitional or
rotational or a combination between them.
-When we open our mouth, we do both movements. At the
beginning the movement will be purely rotational, and then the
mandible will move transitionally & rotationally so we can
open our mouth wide.
-The position where the mandible is retruded and the **
movement is purely rotational is called Centric Relation
(retruded axis Position)

Border Movement (Mandible movements)

Since it’s a 3D movement we're going to study 3 planes
)Sagittal, Horizontal and Coronal(

Outer range of motion limited by ligaments, articular •

surfaces &teeth
When the mandible moves through the outer range of •
motion, reproducible describable limits called border
movements
Border movements are limited by ligaments and teeth •
against the maximal effort of the muscles.
1.Sagittal Border Movement
Posterior opening border .1
Anterior opening border .2
Superior contact border .3
Functional .4
-Superior contact border movements are determined by
Occlusal & incisal surfaces of the teeth.
-Anterior & posterior border movements are determined by
ligaments & the morphology of the TMJs.
-Functional movements are not border movements They are
determined by the conditional responses of the neuromuscular
system.
-This movement starts when the mandible opens in purely
rotational movement, starting from the central incisor, then it
becomes a mixed rotational/transitional movement
-For a patient with teeth it would be different since the
superior border is determined with teeth
Frontal (Coronal) Border Movement
looks like a shield
Moves to the right or the left movement , the canines touch •
each other and guide the teeth (separate them) , something
called canine guidance.
Also the anterior and posterior teeth slide on each other on •
the same side and avoid hitting the other side , this is called
group guidance

“Shield-shaped”
Left lateral (LL) .1
superior border
LL opening border .2
Right lateral (RL) .3
superior border
RL opening border .4
Horizontal Border Movement
When the mandible moves towards one side , that side is
called the working side , while the site that the mandible
started its movement from is called the non working
side(working and non-working condyle)
-The working side can also be named as the rotating side
-This movement was named Bennett movement
-The bodily lateral movement in the rotation of the
working side condyle as the mandible makes a lateral
movement
-Side Shift : sudden medial or lateral shift , which makes some
interferences that needs to be considered.
-Bennett Angle : :The angle formed between the
sagittal plane & the average path of the balancing Condyle as
viewed in the horizontal plane during lateral mandibular
movements (appears on the non working side)
-All these movements are termed 'Posselt's Envelope of
Motion
 Intraoral radiography

Criteria of radiographic Quality

Every radiograph should provide
optimal diagnostic quality, in
case of periapical radiographs,
full length of the roots and at
least 2-3 mm of periapical bone
must be visible, since this is the
region where I expect to find
lesions.
In the case of bitewings, margins
between crowns (proximal
surfaces) should be visible
without overlapping and maintaining an open contact*, and
the bite block must be parallel to the occlusal plane.
*Open contact: describes the space between adjacent teeth
that you observe without overlapping of the margins, you
ensure open contact when the beam is on right angle to the
long axis of the tooth of interest.
When a full mouth series is indicated, it's not necessary to
retake a failed image as long as the missing information is
available on another image.
You can see how the margins overlap horizontally in the first
image due to misdirection of the X-ray tube in the horizontal
plane, while in the second image we can notice the open
contacts between crowns.
Radiographic projections

Intraoral anatomy on radiographs

 Radiographic errors and artifacts

Causes of faulty radiographs :

1- technique and projection errors
2- exposure errors
3- processing errors
HAZARDS
Hazard: anything that can cause harm.
Risk: the chance or probability of being harmed by this hazard.
In any working place assessment of hazard should go in specific steps:
1. Identifying the risks: hazards or anything that can cause harm to
anyone who could be in the working place and how severe and
common the hazard is.
2. Prioritize your list, which is more important, which is more
serious in terms of injury.
3. Identify the preventive measures (isolating), how could we
reduce this hazard.
4. Implement these measures properly in your working place.
5. Evaluate the results, risks and hazards and then repeat the
cycle.
− The most effective way to deal with hazard is to get rid of it but if
this is not possible then we should find an alternative.
− Then educate people and aware them of these hazards, also
personal protective equipments (goggles, face shield and gloves)
play a role.
Hazards that are found in the clinic could be:
- Salvia and blood of the patient and even his attitude could be a
hazard.
- Materials that we use. - Equipment. - Radiation. - Work stress.
- Instruments. - Posture, the posture you carry during the long hours of
clinic (the way you sit for long hours).
- The patient himself.
Hazards are classified into groups:
 1. BIOLOGICAL HAZARD:
To be exposed to microorganisms, which come from patient’s blood and
saliva.
These microorganisms could be:
▪ Viruses: Hepatitis B, Hepatitis C, Herpes simplex and Human
immune deficiency virus.
▪ Bacteria: Mycobacterium tuberculosis.
How can we get exposed to these microorganisms?
- Contact with blood or saliva with an injury or a contaminated
instrument.
- Through droplets while working in the patient’s mouth these droplets
might reach open wounds or to the eyes (high-speed rotary instruments
may cause droplets).
- Through air borne, main cause for respiratory infectious diseases.
Airborne doesn’t have to be a droplet that is visible to the eye, it
could be inhaled without noticing or it can reach surfaces in the room
and contaminate them.
How to prevent being exposed to biological hazards?
- Obtain medical history, yet always treat every patient as if he has an
infectious disease.
- Equipments that limit aerosols like rubber dam
- High volume (speed) evacuator (suction)
- Availability of sharps containers for disposal
- Proper disinfection of instruments.
- Vaccines and immunization of the co-workers.
- Recapping the needle
- Proper disposal of waste materials and contaminated instruments.
- Proper education for co-workers.
- Use PPE (personal protective equipment) including gloves, mask,
face shield, goggles, head cap and lab coat.
Lab coats and gowns should be changed daily or even changed
multiple times during the day according to the procedures you’re
working on.
- Proper work area design and ventilation, the clinic is divided into
clean zone and dirty zone; we need to identify the clean zone and
dirty zone in order to place the ventilator. The ventilator must carry
clean air from clean zone to the dirty zone NOT vice versa else the
ventilator would carry droplets from dirty zone to clean zone and
contaminate it.
Inoculation injuries:
It means any incidence that involves a contaminated object breaching
the integrity of your skin, mucus membrane, or your eyes.
Examples of inoculation injuries are:
1. Needle stick injury
2. When you are using a rotary instrument and a droplet comes from
the patient’s mouth to your eyes.
3. When the patient bites your fingers a scratch can occur, this is also
an inoculation injury.
4. When you are using sharp instruments and you cut or injure
yourself causing a cut injury with contaminated sharp instrument.
However if a biological injury happens do the following:
1. Stay calm
2. Ask the patient about any contagious disease he/she might have (re-
take the medical history)
3. Allow the injury to bleed under running water (but don't squeeze it),
make sure it's clean then cover it.
4. Report the incident and fill a form called incident report form and
write down the patient’s name and file number, and then go to the
emergency room for proper examination.
Now the diseases that we are concerned about mainly are hepatitis B, C
and HIV (HIV being the most important!)
- However the chances of HIV transmission are very small, it’s even
considered safer to work for a patient who has HIV rather than a patient
who has hepatitis C.
There are factors that might increase the chance of you being
infected with HIV like:
1. The deeper the injury from an HIV patient the higher the risk of
getting the infection.
2. If the needle that you have injured with has a visible blood drop or
has been penetrated the patient’s blood vessels this means that the
risk of being infected has also been increased.
3. The more advanced the condition of the patient, the higher the risk
of the infection being transferred.
If this happens, you follow the same procedures above IN ADDITION
you have to get within maximum one hour a prophylactic dose of anti-
retroviral drug, after one hour it’s useless to receive the drug.
It's better to act at the first 24 hours after getting the injury.

2. PHYSICAL HAZARDS:
1) Cuts:
From sharp medical instruments like scissors.
What is the difference between inoculation injury and cut injury?
Physical hazard (cut) is a sterile instrument that is not contaminated by
saliva or blood of the patient whereas in the biological hazard the
instruments are contaminated by blood or saliva or blood of the patient
Less important but still it happens.
How can we avoid or prevent such hazard?
1. By using kits that contain the safe instruments and the sharp ones
which should be wrapped and isolated in a bag as a separate kit,
because you don’t need to use the sharp instruments on every
patient.
2. Avoid using them if you don’t need them so use the alternative one
like blunt probes for periodontal pocket depth measurement.
3. Proper storage, Keep them at a distance from your work field.
4. Physical hazards could harm anyone in the clinic therefore your
staff should be educated about the physical hazards.
What about the treatment?
Apply water or alcohol then wipe it with gauze and put a plaster or a
band aid on it (you don't need to report it).
2) Fire:
The Bunsen burner or alcohol flame
3) Projectiles:
Objects that fly to a high distance at a high speed, e.g. a bur flying out of
the hand piece.
4) Compressed gas cylinders:
Sometimes we use it in surgeries (minor) or anesthesia.
How can I prevent getting harmed by compressed gas?
A. The cylinder has a cap, and it should be secured so that it doesn’t
open by accident. Always Follow the manufacturer instructions.
B. PPEs
5) Vibration and noise:
- Such as the scaler, rotary instruments, the suction sound especially the
high-volume suction.
- Noisy environment is a source of energy that travels through our
body.
- It travels in higher speed in solid materials than in liquids or gases.
- Modern dental chair and machines reduce these effects.
6) UV Light:
- The light cure. It can damage the retina of the eye if exposed to it too
much as the UV light is beyond our normal spectrum more than 480
nm.
How to reduce this?
1. Make sure that the light cure is modern one (shorter time, area
design) so the light is not close to you or your patient.
2. Use blue light filters, can be equipped to the light cure itself, or it
can be in the form of glasses one for you, and one for the patient,
and you ask the patient to close his eyes for more protection.
7) Burns from recently sterilized instruments (very hot)..
- Sometimes we put them in water before we use them to cool then
down.
How to avoid this? You either minimize the number of patients or you
buy more kits.
8) Laser beams and ionizing radiation:
- More serious than the none ionizing radiation because it carries the risk
of causing cancer, genetic effect, or reproductive effects.
The causes of radiation hazards are the following:
- Work area design. - Have the proper shielding or filters.
- Equipment design with minimal scatter. -The least radiation exposure
- Exposure monitoring patch: a patch that can be worn for a long time
(a month) to monitor how much radiations are you exposed to during
the whole month, and then evaluate your safety measures if they are
good enough or not.
- Replacement of old machines. - Proper education. - Use of lead
gloves as an extra safety measure.
9) Slips, trips and falls:
- Anyone who comes to your clinic is in at risk of having these physical
injuries.
Avoid all this by:
- The floor has to be straight and flat, using flooring that resist slipping
(clean, free of things on it such as wires and do not slide on the floor).
- Proper lightning system in narrow corridors or stair areas. - Use a
standard healthy design.
If any spillage happens, you have to have certain guidelines, which are:
1. Immediate clean up procedure. 2. Put a sign that says wet floor. 3.
Remove the sign after you make sure it’s safe.
 3. CHEMICAL HAZARDS:
Mainly from the materials we use. Not just by touching them directly,
but also by inhalation of the material.
1. Beryllium:
One of the dental materials used in the bridges and crowns partial
denture metal framework; during fabrication or during finishing
you can be exposed to such material especially by mechanical
exposure. At first it will be asymptomatic and when it accumulates
it will start showing symptoms such as, cough, shortness of breath,
chest pain, joint pain or it might develop into chronic beryllium
disease which we called attrition and scaring to the lung tissue.
2. Formaldehyde:
It’s mainly used for disinfection and cleaning agents, exposure by
having liquid contact or by inhalation of the Formaldehyde can
have a risk of severe abdominal pain vomiting and eye irritation.
3. Methyl Methacrylate (MMA):
Used in many dental materials, as filler in composites, complete
dentures … Very dangerous material, have a special smell. If it
contacts the skin you can have dermatitis and if you inhale it you
could get asthma, drowsiness, anorexia, headache, loss of appetite
and localized neuropathy, all these symptoms can happen only
from the main exposure to the material doesn’t have to be a long
life exposure.
Prevention of Beryllium, Formaldehyde and MMA hazards:
- Using alternative materials
- Have good ventilation in the workplace (air coming it n out).
- When mixing it, make sure you are mixing it in a closed special
device.
 - Education of the workers of procedure.
- Medical monitoring of workers, by annual checkup every (6m-1y)
especially for those who are responsible to work with it for a long
time such as lab technicians. + - PPEs
4. Silica:
It’s found in compomers, glass ionomer cement, composite,
impression material, it can accumulate in the body and cause
silicosis (serous lung disease). (Celiac disease can cause silicosis).
- Silicosis could lead eventually to cancer and DEATH!
Prevention:
- Use alternatives. - If there is no any proper ventilation and you
have to use it, wet it so its vapor doesn’t effuse in the air.
- If any slippage of silica occurred in the clinic then you have to use
a wet mop not a dry one to clean it so you increase vapor material.
- Make medical monitoring, wear gloves and heavy masks.
5. Mercury:
- We all know that it’s a major constituent of dental amalgam.
- Amalgam is considered safe to patient, but not for us as dentists we
use it twice at least daily.
- Exposure to mercury could be through:
1. Direct skin contact.
2. Inhalation. However inhalation is the primary route because
it’s transferred to other organs such as the kidneys, liver causing
nephritis (inflammation of the kidney) as these two organs are
responsible for detoxification of the blood, it can also be
transferred to the brain and the heart as well.
- The higher the temperature, the more vapor and the more
accumulating mercury in the lung.
 - Keep in mind that while you are removing the old amalgam you
should use water or any coolant system to reduce the heat and
therefore reduce the mercury vapor. (This concept is also applied for
finishing of new amalgam restoration)

What are the health risks associated with mercury exposure?

- These effects are extremely rare.
- Can cause almost anything, starting from tremor and convulsions as a
dangerous risk to a milder form of risks such as loss of appetite,
depression, fatigue, irritability, nausea, diarrhea, pigmentation in the
oral cavity (adjacent part of cheek near the restoration or in the
marginal gingiva) and sensitivity. However if it happened it would be
very serious.
- there is no scientific relation that’s been established in literature
between amalgam and depression.
Now, how to detect mercury poisoning??
- By urine analysis.
- The level of mercury that is considered neurologically measurable
is at least 500 micro gram/liter (worry if it reaches this num)
- The level of mercury that is considered safe to be present in air is
about 50 micro-gram (μg)/cc of air.
Prevention
- Alternatives such as composite. - Proper ventilation and exhaustion
system. - Proper use of the high-volume suction when removing an
old amalgam. - Monitoring the workers. – PPEs - Mixing of
amalgam capsules in a well closed and shielded amalgamator. -
Store product appropriately.
Management on mercury spills
 - Immediate clean-up using a wash rubber trap that is connected to
the low volume aspirator (suction) or plastic syringes or mercury
spills clean-up kit.
- After the clean-up has finished, you should dispose the cleaned-up
mercury in a special container not in the ordinary rubbish or drains
to avoid any hazards!
- Never use: 1. Sponges 2. Household vacuums

6. Latex:
It is a material found in gloves, rubber dam sheets and some plastic
materials that we use.
- We are so exposed to it, and it has an accumulative effect and
cause its effect when sufficient amount are accumulated.
- Sensitive persons who are exposed to latex may have one of the
following:
1. Irritation and non-allergic conditions such as skin redness, dryness,
dustiness. Removing the latex subsides the symptoms.
2. Allergic reaction (Delayed hypersensitivity reaction):
- Occurs within (6-48 hours) after being exposed to latex, it is less
dangerous.
- Symptoms include: dry skin, lathery, pustules, eruptions, sours,
blisters, the reaction goes on and on but it’s very much confined to
the area that’s been exposed there are certain creams to treat it.
3. Allergic Reaction (Immediate hypersensitivity reaction):
- This is the most severe response to latex.
- It happens within minutes.
- Symptoms are not confined to the exposed area (they are systematic),
they may involve parts of the body other than the skin and may cause
swollen lip, swollen tongue, irritated retina of the eye, dizziness,
 hypotension, abdominal pain, nausea, and anaphylactic shock, if it
wasn’t early identified and treated it may lead to death.
Prevention:
1. Latex free gloves (vinyl) and latex free rubber dam.
2. Monitor your equipment if they contain any traces of latex in them.
3. Examine your staff and your patients for latex sensitivity as well.
4. Adequate general ventilation.
5. Monitor your workers.

4. ERGONOMIC HAZARDS:
Ergonomic simply means the muscles and the skeletal system.
- It is related to the way we set on the dental chair, the way we hold our
instruments, to the movements we do!
- Not following the ergonomics may cause:
1. Neck pain. 2. Back pain 3. Muscle fatigue, etc...
- The most common ergonomic problem among dentists is lower back
pain followed by hand and shoulders .
- These problems are associated with repetitive movement and manual
handling of instruments.
- Another ergonomic problem is what is known as Carpal Tunnel
Syndrome:
It is a very painful syndrome affecting hands and feet. What happens
here is that a nerve known as Median nerve which is present in your
wrist becomes crushed in a certain point due to the repeated
movement of the wrist so we will have pain, numbness, and tender in
that area. This nerve supplies the thumb, middle, index, and a half of
the ring finger so the little finger and the other half aren't affected.
The symptoms of this syndrome include
1. Numbness. 2. Tingling. 3. Muscle weakness. 4. Severe pain.
-This syndrome can be treated by physiotherapy, but mostly it requires a
surgery.

5. PSYCHOSOCIAL HAZARD:
A. Stress:
- Dentists are proved to have more stress in their work field.
- If your patients are late to their appointments or if they have a low
threshold of pain that may cause a stress. Or if the patients are not
complying to your instructions, this may cause stress.
- Having problems with your boss or co-workers
- Might cause anxiety, sleep disorders.

B. Working alone and working late:

Unfortunately dentistry is the only profession that makes you work alone
and that causes a lot of psychological issues specially for the old aged
dentists, so try to work within a hospital or centers, and you have to have
a proper security.
C. Techno – stress:
Technology in dentistry is advancing every day, so you get stressed
because you’re worried that there might be a new technology that you
don’t know about, or that your colleagues have better devices than you.
D. Exposure to noise
Noise doesn’t only affect hearing it causes stress as well.
E. Limited exposure to fresh air (indoor environment)
Professional burn out: loss of interest of your career because of physical
and mental breakdowns.
How to prevent psychological hazards?
1) Attend courses that improve your resilience to stress. 2) Report any
sort of psychological abuse. 3) Well trained security guard just in
case you are working late in a building, or you need someone to
escort you to your car to ensure your safety.
4) Use name tags. 5) Good time management skills. 6) Setting
realistic goals. 7) Communication with your co-workers.