Jaypee Operative

Textbook of
Operative Dentistry
Textbook of
Operative Dentistry
Fourth Edition
Editors
Nisha Garg MDS
(Conservative Dentistry and Endodontics)
Professor and Head
Department of Conservative Dentistry and Endodontics
Bhojia Dental College
Baddi, Himachal Pradesh, India
Ex-Resident
Post Graduate Institute of Medical Education and Research (Pgimer)
Chandigarh, India
Government Dental College
Patiala, Punjab, India
Amit Garg MDS

Professor and Head
Department of Oral and Maxillofacial Surgery
Rayat and Bahra Dental College and Hospital
Mohali, Punjab, India
Ex-Resident
Pt BD Sharma Post Graduate Institute of Medical Sciences (Pgims)
Rohtak, Haryana, India
Foreword
Hyeon-Cheol Henry Kim
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Textbook of Operative Dentistry

First Edition: 2010
Second Edition: 2013
Third Edition: 2015
Fourth Edition: 2020
ISBN: 978-93-89587-58-6
Printed at
Dedicated to
Prisha and Vedant
contributors
Amit Garg MDS Neetu Jindal MDS

Professor and Head Professor
Department of Oral and Maxillofacial Department of Conservative Dentistry
Surgery and Endodontics
Rayat and Bahra Dental College and Hospital Surendera Dental College and Research
Mohali, Punjab, India Institute
Sri Ganganagar, Rajasthan, India
Anil Chandra MDS Nikhil Bahuguna MDS

Professor Diplomate – American Board of
Faculty of Sciences Aesthetic Dentistry
King George’s Medical University Board of Director, Indian Academy of
Lucknow, Uttar Pradesh, India Aesthetic and Cosmetic Dentistry
Deepak Mehta MDS PhD Nisha Garg MDS

Adjunct Faculty Professor and Head
Department of Dental Materials and Department of Conservative Dentistry and
Prosthodontics Endodontics
Yenepoya Dental College Bhojia Dental College and Hospital
Mangaluru, Karnataka, India Baddi, Himachal Pradesh, India
Jojo Kottoor MDS Poonam Bogra MDS

Reader Professor
Department of Conservative Dentistry and Department of Conservative Dentistry and
Endodontics Endodontics
Royal Dental College DAV Dental College
Iron Hills, Palakkad, Kerala, India Yamunanagar, Haryana, India
Pranav Nayyar MDS

Manoj Hans MDS Reader
Professor and Head
Department of Conservative Dentistry and
Department of Conservative
Endodontics
Dentistry and Endodontics
Bhojia Dental College and Hospital
Geetanjali Dental and Research Institute
Baddi, Himachal Pradesh, India
Udaipur, Rajasthan, India
Priya Titus Singh BDS

Mohan Bhuvaneswaran MDS Practising in Kharghar
Adjunct Professor
Navi Mumbai, Maharashtra, India
MAHSA University, Malaysia
Visiting Professor
Sri Ramachandra University
Chennai, Tamil Nadu, India
Rakesh Singla MDS Shabnam Negi MDS
Professor and Head Reader
Jan Nayak Ch. Devi Lal Dental College Bhojia Dental College and Hospital
Sirsa, Haryana, India Baddi, Himachal Pradesh, India
Renu Aggarwal MDS Tom Jm Dienya MDSC (Endo) FADI FICD

Professor Chairman
Department of Conservative Dentistry and Department of Conservative and Prosthetic
Endodontics Dentistry
Surendera Dental College and School of Dental Sciences
Research Institute University of Nairobi
Sri Ganganagar, Rajasthan, India Nairobi, Kenya
Roma Turetskiy Varinder Goyal MDS

Practicing Doctor Professor and Head
Specialist in Restoration and Department of Pediatric and Preventive
Aesthetic Dentistry Dentistry
Kiev, Ukraine Surendera Dental College and Research
Institute
Sri Ganganagar, Rajasthan, India
Sandhya Punia MDS Vinisha Pandey MDS

Professor and Head Associate Professor
Department of Conservative Department of Conservative Dentistry
Dentistry and Endodontics and Endodontics
Darshan Dental College and Hospital Maharana Pratap Dental College
Udaipur, Rajasthan, India Kanpur, Uttar Pradesh, India
Sanjay Miglani MDS FISDR Yogesh Gupta MDS

Professor Professor and Head
Faculty of Dentistry Surendera Dental College and Research
Jamia Millia Islamia Institute
New Delhi, India Sri Ganganagar, Rajasthan, India
foreword
Operative dentistry is the principle part of practical dentistry and most of the operative dental procedures are
routinely offered by the general practitioners in their everyday practice. As such, the operative procedures
are the primary dental care procedures which give the basic principles to either restorative or conservative
dentistry. Thus, a textbook for operative dentistry is of utmost important for all the dental students and
dentists.
This fourth edition of the Textbook of Operative Dentistry covers broad topics such as basic science of
cariology, restorative concepts for the operative and esthetic dentistry, material science and biomechanics,
most current minimal invasive dentistry and nanotechnology. I believe this textbook has followed and
updated the most contemporary technologies and concepts.
A textbook should present basic principles and rationales of the treatment procedures with the answers for What, Why,
When and Where. This textbook presents these requirements very well with a good text style and nice presentations of figures
and tables. Also, I am sure that this textbook is providing a profound knowledge and information which is a distillation of the
knowledge and experience of the authors. Therefore, it will be a favorite book for all readers including students and a book that
will help dentists re-live their intellectual interest throughout their career as clinicians.
I hereby congratulate all the authors and editors—Professors Nisha Garg and Amit Garg who dedicatedly wrote this textbook
for the publication of fourth edition. I also congratulate all the readers who may get the valuable knowledge and concept from
the fourth edition of Textbook of Operative Dentistry.
Hyeon-Cheol Henry Kim DDS MS PhD

Professor, Department of Conservative Dentistry
Dean, School of Dentistry
Pusan National University, Republic of Korea
Associate Editor, Restorative Dentistry and Endodontics
Associate Editor, European Endodontic Journal
Journal of Endodontics Scientific Advisory Board
APEC President-Elect, Asian Pacific Endodontic Confederation
preface to the fourth edition
Writing a book is harder than we thought and more rewarding than we could have ever imagined. First of all, we would thank
God who gave us power to believe in our passion and pursue our dreams. We could never have done this without having faith
in you, Almighty.
Our journey started in 2006 and since then, appreciation from our readers has kept us always motivated to bring this book
in its best form.
This book is simple, comprehensive, incorporating the most recent techniques and materials in restorative dentistry yet not
losing the sight of basics. To continually improve the book further, we incorporated clinical photographs and comments from
experts of this field.
We are especially thankful to Dr Roma Turetskyi, Dr Mohan Bhuvaneswaran, Dr Jojo Kottoor, Dr Deepak Mehta, Dr Nikhil
Bahuguna, Dr Varinder Goyal, and Dr Priya Titus for their ready to help attitude and providing us their excellent clinical cases
photographs as per our requirements, despite their busy schedules. We owe our sincere thanks to Dr Stephan Lampl, CEO
and Founder, Edelweiss Dentistry, Austria for providing clinical case photographs for the book. Case photographs provided by
them illustrate step-by-step procedure of restorative techniques for better understanding of the subject.
We would like to thank Dr Tom Dienya for editing Interim Restorations, Dr Anil Chandra for editing Direct Filling Gold,
Dr Poonam Bogra for Smile Designing in Operative Dentistry, Dr Sanjay Miglani for Pulp Protection, Dr Pranav Nayyar for
Evidence-based Dentistry, Dr Shabnam for Nanotechnology in Dentistry, and Dr Neetu Jindal for editing Noncarious Lesions
of Teeth.
We are extremely thankful to Dr Neetu Jindal for her constant critical evaluation to bring this book in best possible
form. We are thankful to Dr Sweety Gupta, senior resident of KGMC Lucknow for providing us photographs of direct filling
gold restorations. Completion of this project would not have been possible without support of our colleagues Dr Sandeep,
Dr Varinder, Dr Ruhani, Dr Jasdeep, Dr Achla, and Dr Arjun for their ready to help attitude and positive criticism which has
helped in improvement of the book.
We would like to compliment the wonderful team of our postgraduate students who whole heartedly helped in completing
this project. We are especially thankful to Dr Garima, Dr Komal, Dr Deeksha, Dr Sahiba, and Dr Amreen for their valuable time
for checking the manuscript repeatedly and critically evaluating and pointing out the mistakes in earlier drafts. Special thanks
to Dr Navneet for tirelessly clicking the photographs for the book. Thanks to Dr Bharat, Dr Sukhman, Dr Ankur, Dr Vivek,
Dr Akanksha, Dr Suvani, Dr Meghna, Dr Sachin and Dr Akshun for helping in this project in their best capacity possible.
We are grateful to our teachers, Dr RS Kang and Dr JS Mann for always guiding us to do our best.
We offer our humble gratitude and sincere thanks to Mr Vikram Bhojia (Secretory, Bhojia Trust), for providing healthy and
encouraging environment for our work.
We would like thank Hu-Friedy, Dentsply, GC India and Ivoclar Vivadent for letting us use HD photographs of their products.
We are extremely grateful to our parents for their love, prayers and sacrifices for educating and preparing us for our future.
We are indebted to our kids, Prisha and Vedant for their understanding, patience and emotional support when we were
busy in our book.
Thanks to everyone working on this project who helped us so much. Special thanks to Shri Jitendar P Vij (Group Chairman)
of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for showing his confidence in our work, his never-ending
motivation to bring best out of us. We are thankful to Mr Ankit Vij (Managing Director), Mr MS Mani (Group President),
Dr Madhu Choudhary (Publishing Head–Education), Ms Pooja Bhandari (Production Head), Ms Sunita Katla (Executive
Assistant to Group Chairman and Publishing Manager), Dr Astha Sawhney (Development Editor), Mr Rajesh Sharma
(Production Coordinator), Ms Seema Dogra (Cover Visualizer), Ms Uma Adhikari (Typesetter), Mr Laxmidhar Padhiary
(Proofreader), and Mr Gopal Singh Kirola (Graphic Designer), our amazing coordinators for all their support to work in this
project and make it a success.
Nisha Garg
Amit Garg
preface to the first edition
Operative dentistry is one of the oldest branches of dental sciences forming the central part of dentistry as practiced in primary
care. The clinical practice of operative dentistry is ever-evolving as a result of improved understanding of etiology, prevention
and management of common dental diseases. The advances and developments within the last two decades have drastically
changed the scope of this subject.
Since effective practice of operative dentistry requires not only excellent manual skills but also both understanding of
disease process and properties of dental materials available for use. The main objective of the book is to provide students
with the knowledge required while they are developing necessary clinical skills and attitude in their undergraduate and
postgraduate training in operative dentistry. We have tried to cover wide topics such as cariology, different techniques and
materials available for restorations, recent concepts in management of carious lesions, infection control, minimally intervention
dentistry and nanotechnology.
So we can say that after going through this book, the reader should be able to:
• Understand basics of cariology, its prevention and conservative management
• Tell indications and contraindications of different dental materials
• Apply modern pulp protective regimens
• Know the importance of treating the underlying causes of patient’s problems, not just the restoration of the damage that has
occurred
• Select suitable restorative materials for restoration of teeth
• Know recent advances and techniques like minimally intervention dentistry (MID), nanotechnology, lasers, diagnosis of
caries and advances in dental materials.
Nisha Garg
Amit Garg
contents
1. Introduction to Operative Dentistry 1 Clinical Presentation of Dental Caries 43

Nisha Garg Calcium Ion Migration in Carious Process 44
Introduction 1 Histopathology of Dental Caries 44
Definitions 1 Classification of Dental Caries 46
History 1 Diagnosis of Dental Caries 50
Indications of Operative Dentistry 3 Recurrent Caries (Secondary Caries) 54
Objectives/Purpose of Operative Dentistry 4 Root Caries 55
Scope of Operative Dentistry 4 Caries Risk Assessment 57
Recent Advancements 4 Caries Activity Tests 57
Prevention of Dental Caries 58
2. Tooth Nomenclature 6 Current Methods of Caries Prevention 63
Amit Garg Management of Dental Caries 64
Introduction 6
7. Instruments Used in Operative Dentistry 67
Types of Dentition 6
Nisha Garg
Tooth Notation Systems 712
Introduction 67
3. Structure of Teeth 12 History 67
Amit Garg Materials Used for Manufacturing Cutting
Introduction 12 Instruments 67
Enamel 12 Heat Treatment of Materials 68
Dentin 15 Classification 68
Dental Pulp 18 Nomenclature by Gv Black 68
Parts of Hand Cutting Instruments 68
Periradicular Tissue 192
Balancing 69
4. Physiology of Tooth Form 22 Instrument Formula 69
Amit Garg Different Instrument Designs 71
Introduction 22 Instrument Motions 71
Types of Teeth and their Functions 22 Description of Various Instruments 71
Functions of Teeth 22 Hand Cutting Instruments 73
Protective Functional Form of the Teeth 23 • Excavators 73
• Chisels 74
5. Occlusion in Operative Dentistry 27 • Other Cutting Instruments 75
Nisha Garg Restorative Instruments 76
Introduction 27 Instrument Grasps 77
Anterior-Posterior Interarch Relationship 28 Finger Rests 78
Interarch Tooth Relationships 28 Guards 79
Features of an Ideal Occlusion 29 Methods of Use of Instruments 80
Factors of Occlusion Affecting Operative Dentistry 29 Sharpening of Hand Instruments 80
Mandibular Movements 30 Rotary Cutting Instruments 81
Occlusal Schemes 32 Handpieces 81
Dental Burs 84
Significance of Occlusion in Operative Dentistry 33
Factors Affecting Cutting Efficiency of Bur 88
Occlusal Interferences 33
Recent Advances in Rotary Instruments 89
Occlusion Indicators 35
Abrasive Instruments and Materials in Conservative
Trauma from Occlusion 36
Dentistry 91
6. Dental Caries 39 Hazards and Precautions with Rotary Cutting
Nisha Garg Instruments 94
Introduction 39 8. Principles of Tooth Preparation 97
Definitions 39 Nisha Garg
Theories 39 Introduction 97
Etiology of Dental Caries 40 Definition 97
xvi Textbook of Operative Dentistry
Purpose of Tooth Preparation 97 13. Infection Control in Operative Dentistry 139

Indications of Restorative Intervention 97 Amit Garg
Objectives of Tooth Preparation 97 Introduction 139
Terminology 97 Rationale for Infection Control 139
Number of Line and Point Angles 99 Objective of Infection Control 140
Stages of Cavity Preparation 101 Universal Precautions 140
Initial Cavity Preparation Stage 102 Classification of Instruments 141
• Outline Form and Initial Depth 102 Instrument Processing Procedures/Decontamination
• Primary Resistance Form 104 Cycle 142
• Primary Retention Form 105 Sterilization of Dental Handpiece 145
• Convenience Form 106 Disinfection 146
• Final Stages of Tooth Preparation 106 Sterilization of Dental Unit Waterlines 146
• Removal of any Remaining Enamel Pit or Fissure, Infection Control Checklist 146
Infected Dentin and/or Old Restorative Material, if
Indicated 106 14. Pain Management in Operative Dentistry 149
• Pulp Protection 106 Amit Garg
• Secondary Resistance and Retention Forms 106 Introduction 149
• Procedures for Finishing the External Walls of Definition 149
the Tooth Preparation 107 Method of Control of Pain in Restorative Dentistry 149
• Final Procedures: Cleaning, Inspecting and Sealing 108 Pain Management Protocol 149
Recent Advances in Local Anesthesia 151
9. Patient Evaluation, Diagnosis and Treatment
Other Methods of Pain Control 153
Planning 110
Amit Garg 15. Matricing 154
Introduction 110 Nisha Garg
Patient Evaluation 110 Introduction 154
Clinical Evaluation 111 Matricing 154
Treatment Planning 113 Parts of Matrix 155
Quadrant Dentistry 113 Functions of a Matrix 155
Treatment Record/Documentation 114 Ideal Requirements of a Matrix 155
Classification 155
10. Patient and Operator Position 115
Ivory Matrix Holder (Retainer) No. 1 155
Nisha Garg
Ivory Matrix Band Retainer No. 8 156
Introduction 115 Tofflemire Universal Matrix Band Retainer
Operating Stool 115
(Designed by Dr Br Tofflemire) 157
Considerations for Dentists While Treating Patients 115
Steele’s Siqveland Self-adjusting Matrix Holder
Dental Chair Positions 116
for Tapering Teeth 160
Four Handed Dentistry 117
Compound Supported Matrix 160
Zones of Working Area/Activity 117
T-Shaped Matrix Band 161
Visibility 118
S-Shaped Matrix Band 161
11. Isolation of Operating Field 120 Aluminium or Copper Collars 161
Nisha Garg Transparent Crown Forms Matrices 162
Introduction 120 Window Matrix 162
Components of Oral Environment Need to Anatomic Matrix 162
be Controlled During Operative Procedures 120 Clear Plastic Matrix Strips 163
Advantages of Moisture Control 120 Aluminium Foil Incisor Corner Matrix 164
Methods of Moisture Control 120 Preformed Transparent Cervical Matrix 164
Isolation with Rubber Dam 121 Matrix Retainerless System 164
Pharmacological Means 130 Recent Advances in Matrix Systems for
Gingival Tissue Management 131 Class Ii Composite Restorations 165
Sectional Matrices and Contact Rings 166
12. Gingival Tissue Management 132
Nisha Garg, Amit Garg 16. Separation of Teeth 170
Introduction 132 Nisha Garg
Definition 132 Introduction 170
Indications of Gingival Tissue Management 132 Reason for Tooth Separation 170
Contraindications of Gingival Tissue Management 132 Methods of Tooth Separation 170
Advantages 132 Rapid or Immediate Tooth Separation 170
Methods of Gingival Tissue Management 132 Slow or Delayed Separation 174
Contents xvii
17. Pulp Protection 176 Advantages 225
Nisha Garg, Sanjay Miglani Disadvantages 225
Introduction 176 Indications 225
Pulpal Irritants 176 Contraindications 226
Effect of Caries on Dental Pulp 176 Types of Pins 226
Effect of Tooth Preparation on Dental Pulp 177 • Indirect Pins/Parallel Pins 226
Importance of Remaining Dentin Thickness 177 • Direct Pins/Nonparallel Pins 226
Need for Pulp Protection 178 Principles and Techniques of Pin Placement 229
Materials Used for Pulp Protection 178 Factors Affecting Retention of Pins in Dentin and
Cavity Sealers 178 Amalgam 231
Cavity Liners 179 Pins and Stresses 232
Base 179 Complications of Pin-retained Restorations 232
Guidelines of Using Liners, Bases, and Varnishes for Other Means of Retention in Complex Amalgam
Different Restorative Materials 180 Restorations 234
Management of Shallow, Moderate, and Deep Caries 181
Management of Deep Carious Lesion 181 21. Direct Filling Gold 237
Nisha Garg, Anil Chandra
Prevention of Pulpal Damage due to Operative
Procedure 184 Introduction 237
Properties of Gold 237
18. Interim Restorations 186 Advantages of Direct Filling Gold Restorations 237
Nisha Garg, Tom Jm Dienya Disadvantages of Direct Filling Restoration 238
introduction 186 Indications of Direct Filling Gold Restoration 238
Objectives of Interim Restorations 186 Contraindications 238
Requirements of Interim Restoration 186 Types of Gold 239
Purposes of Interim Restoration 186 Storage of Gold 241
Materials 187 Degassing/Annealing 241
For Intracoronal Preparations 187 Principles of Tooth Preparations 242
For Extracoronal Preparations 191 Class I Tooth Preparation 242
Class Ii Tooth Preparation 242
19. Amalgam Restorations 193
Nisha Garg Class Iii Tooth Preparation 242
Class V Tooth Preparation 244
Introduction 193
Compaction of Direct Filling Gold 245
Definitions 193
Steps of Direct Filling Gold Restoration 246
History of Dental Amalgam 194
Classification 194 Future of Gold in Dentistry 247
Composition 194 22. Cast Metal Restorations 248
Types 195 Nisha Garg
Setting Reaction/Amalgamation Reaction 196 Introduction 248
Physical Properties 196 Components of Cast Gold Alloys 248
Indications of Silver Amalgam 198 Classification of Cast Gold Alloys 249
Contraindications 199 Properties of Cast Gold Alloys 249
Advantages 199
Definitions 250
Disadvantages 199
Indications for Class Ii Gold Inlays 250
Recent Advances in Silver Amalgam 199
Contraindications 250
Class I Cavity Preparation for Silver Amalgam 202
Advantages 250
Class Ii Cavity Preparation for Amalgam Restoration 204
Disadvantages 251
Class Iii Cavity Preparation for Amalgam Restoration 210
Basic Design of Cast Metal Inlay 251
Class V Cavity Preparation 211
Cavity Preparation for Class Ii Cast Metal Inlays 255
Class Vi Cavity Preparation for Amalgam Restoration 212
Modifications in Class Ii 257
Steps for Amalgam Restoration 212
Cast Metal Onlay 258
Life of Amalgam Restorations 215
Failures of Amalgam Restoration 215 Technique of Making Cast Metal Restoration 260
Reasons for Failure of Amalgam Restorations 216 Casting Defects 267
Mercury Hygiene 218 Pin-retained Cast Restorations 271 73
Is Dental Amalgam Safe? 220 23. Adhesion in Operative Dentistry 273
Amalgam Wars 221 Nisha Garg
Phase Down of Amalgam 2215 Introduction 273
20. Pin-retained Restorations 225 Indications for Use of Adhesives 273
Nisha Garg Advantages of Adhesives 273
Introduction 225 History 273
Definition 225 Definitions 274
xviii Textbook of Operative Dentistry
Enamel Bonding 275 Advantages of Glass Ionomer Cements 353

Dentin Bonding 277 Disadvantages of Glass Ionomer Cements 354
Dentin Adhesive Systems 278 Indications of Glass Ionomer Cement 354
Evolution of Dentin-Bonding Agents 279 Contraindications of Glass Ionomer Cements 355
Hybridization 283 Clinical Steps for Placement 355
Smear Layer 283 Other Clinical Applications of Glass Ionomers 357
Classification of Modern Adhesives 284 Atraumatic Restorative Treatment 357
Glass Ionomer-based Adhesive System 285 Sandwich Technique 357
Failure of Dentin Bonding 285 Tunnel Preparation 359
24. Composite Restorations 288 27. Dentin Hypersensitivity 361

Nisha Garg Amit Garg, Neetu Jindal
Introduction 288 Introduction 361
Definition 288 Definition 361
History 289 Historic Review 361
Composition of Dental Composites 289 Theories of Dentin Hypersensitivity 361
Classification of Composites 291 Incidence and Distribution 362
Types of Composites 292 Etiology and Predisposing Factors 362
Recent Advances in Composites 293 Differential Diagnosis 363
Properties of Composite 297 Diagnosis 363
Degree of Conversion in Composites 299 Treatment 363
Steps of Clinical Procedure for Composite Restoration 301 Ideal Properties of a Desensitizing Agent 364
Tooth Preparations for Anterior Composite Classification of Desensitizing Agents 364
Restorations 307 Recent Trends to Treat Dentin Hypersensitivity 365367
• Class Iii Tooth Preparation 307
28. Tooth Whitening 367
• Class Iv Tooth Preparation 309 Nisha Garg
• Class V Tooth Preparation 309
Introduction 367
Tooth Preparation for Posterior Composite Restoration 310
Classification of Discoloration 367
• Pit and Fissure Sealants 313 Bleaching 369
• Preventive Resin and Conservative Composite Bleaching Agents 369
Restorations 314 Mechanism of Bleaching 369
• Class I Tooth Preparation 314 Bleaching of Vital Teeth 369
• Class Ii Tooth Preparation 316 Vital Bleaching Techniques 370
Stamp Technique of Restoration 318 Bleaching of Nonvital Teeth 372
Failures of Composite Restorations 318 Effects of Bleaching Agents on Tooth and
Repair of Composite Restorations 322 its Supporting Structures 373
Indirect Resin Composite 322
Classification of Indirect Composites 323 29. Minimally Intervention Dentistry 376
Tooth Preparation for Composite Inlays and Onlays 325 Nisha Garg
Introduction 376
25. Smile Designing in Operative Dentistry 329 Definition 376
Nisha Garg, Poonam Bogra Principles of Minimal Intervention 376
Introduction 329 • Early Diagnosis 377
Elements of Dental Aesthetics 329 • Caries Classification Based on Site and Size of
Facial Composition 329 Lesion 377
Dental Composition 331 • Assessment of Caries Risk 377
Hard Tissue Components of Smile Design 331 • Decreasing the Risk of Further Demineralization and
Soft Tissue Component of Smile Design 336 Arresting Active Lesion 378
Aesthetics and Operative Dentistry 337 • Remineralization of Initial Lesions and Reduction in
Veneers 340 Cariogenic Bacteria 378
Repair of Veneers 344 Different Remineralizing Agents 379
• Minimal Intervention of Cavitated Lesions 381
26. Glass Ionomer Cements 347 • Repair Instead of Replacement of the Restoration 383
Nisha Garg
• Disease Control 383
Introduction 347
Classification of Glass Ionomer Cements 347 30. Noncarious Lesions of Teeth 386
History 347 Neetu Jindal, Nisha Garg
Composition 348 Introduction 386
Recent Advances in Glass Ionomer Cement 349 Attrition 386
Setting Reaction of Glass Ionomer Cement 350 Abrasion 387
Properties of Glass Ionomer Cements 351 Erosion 388
Contents xix
Abfraction 389 Definition of Evidence-based Dentistry 414
Localized Nonhereditary Enamel Hypoplasia 390 Need of Evidence-based Dentistry 414
Localized Nonhereditary Enamel Hypocalcification 391 Steps of Evidence-based Dentistry 414
Localized Nonhereditary Dentin Hypoplasia 391 Application of Evidence‐based Dentistry from
Localized Nonhereditary Dentin Hypocalcification 391 Research Clinical Practice 415
Amelogenesis Imperfecta 391 Who Get Benefits from Evidence-based Dentistry? 41517
Dentinogenesis Imperfecta 392
33. Nanotechnology in Dentistry 417
31. Dental Ceramics 395 Amit Garg, Shabnam Negi
Nisha Garg Introduction 417
Introduction 395 History 417
Definitions 395 Definitions 417
History 396 Approaches in Nanotechnology 417
Classification 396 Nanotechnology in Dentistry 418
Composition 396 Applications of Nanotechnology in Dentistry 418
Properties of Ceramic 398 Barriers for Nanotechnology 420 422
Methods of Strengthening Porcelain 398
Advantages of Dental Ceramics 399 34. Lasers in Operative Dentistry 422
Disadvantages of Dental Ceramics 399 Amit Garg
Metal Ceramic Restorations 399 Introduction 422
Conventional Method of Fabrication of Pfm History 422
Restorations 400 Classification of Laser 422
All-Ceramic System 402 Principles of Laser Beam 423
All-Ceramic Restorations 404 Laser Physics 423
Porcelain Laminate Veneers 406 Laser Interaction with Biological Tissues 425
All-Ceramic Crowns 408 Laser Safety in Dental Practice 425
Fabrication of Ceramic Restorations 411hapter413 Applications of Lasers in Operative Dentistry 426
Advantages and Disadvantages of lasers 428
32. Evidence-based Dentistry 413
Amit Garg, Pranav Nayya Annexures 429
Introduction 413
What is Evidence-based Dentistry? 413 Index 435
Chapter
1
Introduction to Operative Dentistry
Chapter Outline
Introduction Objectives/Purpose of Operative Dentistry

Definitions Scope of Operative Dentistry
History Recent Advancements
Indications of Operative Dentistry
INTRODUCTION HISTORY
operative dentistry is foundation of the dentistry from The profession of dentistry was born during the early
which other branches have evolved. It plays an important middle ages. Barbers were doing well in dentistry by
role in enhancing dental health and now branched removing teeth with dental problems. Baltimore College
into dental specialties. Operative dentistry deals with of Dental Surgery (1840) in Maryland was world’s first
diagnosis, prevention, interception, and restoration of the dental college. Till 1900 AD, the term “Operative dentistry”
defects of natural teeth. Goal of the operative dentistry included all the dental services rendered to the patients,
is to maintain the health and integrity of teeth and their because all the dental treatments were considered to be
supporting structures. an operation which was performed in the dental operating
room or operatory. As dentistry evolved, dental surgeons
DEFINITIONs began filling teeth with core metals. In 1871, GV Black gave
Sturdevant—“Operative dentistry is defined as art and the philosophy of “extension for prevention”, for cavity
science of diagnosis, treatment planning and prognosis preparation design. Dr GV Black (Greene Vardiman)
of defects of the teeth that do not require full coverage is known as the “Father of operative dentistry”. He
restorations for correction. Such treatment should result provided scientific basis to dentistry because his writings
in the restoration of proper form, function and aesthetics developed the foundation of the profession and made the
while maintaining the physiologic integrity of the teeth in field of operative dentistry organized and scientific. The
harmonious relationship with the adjacent hard and soft scientific foundation for operative dentistry was further
tissues, all of which should enhance the general health expanded by Black’s son, Arthur Black.
and welfare of the patient”. In early part of 1900s, progress in dental science and
technology was slow. Many advances were made during
Gilmore—“Operative dentistry is that subject which 1970s in materials and equipment. By this time, it was
includes diagnosis, prevention, and treatment of defects of
also proved that dental plaque was the causative agent
the natural teeth, both vital and nonvital, so as to preserve
for caries. In the 1990s, oral health science started moving
the natural dentition and restore it to the best state of
toward an evidence-based approach for treatment of
health, function and aesthetics.
decayed teeth (Table 1.1). The recent concept of treatment
Mosby’s dental dictionary—“Operative dentistry deals of dental caries comes under minimally invasive dentistry.
with the functional and aesthetic restoration of the hard In December 1999, the World Congress of Minimally
tissues of individual teeth”. Invasive Dentistry (MID) was formed. Initially, MI dentistry
2 Textbook of Operative Dentistry
Table 1.1: Evolution of operative dentistry.
Era Year Major inventions/events

Prehistoric era 5000 BC A Sumerian text describes “tooth worms” as the cause of dental decay.
500–300 BC Hippocrates and Aristotle wrote about dentistry, including the eruption pattern of teeth, treating
decayed teeth.
166–201 AD The Etruscans practiced dental prosthetics using gold crowns and fixed bridgework.
700 A medical text in China mentioned the use of “silver paste,” a type of amalgam.
Pre 1700 1530 Artzney Buchlein, wrote the first book solely on dentistry. It was written for barbers and surgeons who
used to treat oral cavity, it covered topics like oral hygiene, tooth extraction, drilling teeth and placement
of gold fillings.
1563 Bartolomeo Eustachius published the first book on dental anatomy, “Libellus de dentibus”.
1683 Antonie van Leeuwenhoek identified oral bacteria using a microscope.
1685 Charles Allen wrote first dental book in English “The operator for the teeth”.
1700–1800 1723 Pierre Fauchard published “Le Chirurgien Dentiste”. He is credited as “Father of Modern Dentistry”
because his book was the first to give a comprehensive system for the practice of dentistry.
1746 Claude Mouton described a gold crown and post for root canal treated tooth.
1764 James Rae gave first lecture on the teeth at the Royal College of Surgeons, Edinburgh.
1771 John Hunter published “The natural history of human teeth” giving a scientific basis to dental anatomy.
1780 William Addis manufactured the first modern toothbrush.
1790 • John Greenwood constructed the first known dental foot engine by modifying his mother’s foot-
treadle spinning wheel to rotate a drill.
• Josiah Flagg invented the first dental chair
1800–1900 1832 James Snell invented the first reclining dental chair.
1830s–1890s The “Amalgam War” conflict and controversy generated over the use of amalgam as filling material.
1855 Robert Arthur introduced the cohesive gold foil method for inserting gold into a preparation with
minimal pressure.
1864 Sanford C Barnum developed the rubber dam.
1871 James Beall Morrison invented foot engine.
1877 Basil Manly Wilkerson invented first hydraulic dental chair and named it THE WILKERSON DENTAL CHAIR
1890 WD Miller formulated his “chemicoparasitic” theory of caries in “Microorganisms of the human mouth”.
1895 Lilian Murray became the first woman to become a dentist in Britain.
1896 GV Black established the principles of cavity preparation.
1900–2000 1900 Federation Dentaire Internationale (FDI) was founded.
1903 Charles Land introduced the porcelain jacket crown.
1907 William Taggart invented a “lost wax” casting machine.
1930–1943 Frederick S McKay, a Colorado dentist showed brown stains on teeth because of high levels of naturally
occurring fluoride in drinking water.
1937 Alvin Strock develoed Vitallium dental screw implant.
1950s First fluoride toothpaste was marketed.
1949 Oskar Hagger developed the first system of bonding acrylic resin to dentin.
1955 Michael Buonocore described the acid-etch technique.
1957 John Borden introduced a high-speed air-driven contra-angle handpiece running up to 300,000 rpm.
1960s Lasers were developed.
1962 Rafael Bowen developed Bis-GMA.
1989 The first commercial home tooth bleaching product was made available.
1990s New advances in aesthetic dentistry including tooth-colored restorative materials, bleaching materials,
veneers and implants.
Introduction to Operative Dentistry 3
focused on minimal removal of diseased tooth structure
but later it evolved for preventive measures to control
disease. Current minimally intervention philosophy
follows three concepts of disease treatment, viz. identify
the risk factors early, prevent disease by eliminating risk
factors and restore the health of oral environment.
INDICATIONS of operative dentistry

1. Dental caries: restoration of carious tooth is most
common indication in operative dentistry. Caries
can be present on pit and fissures, proximal, and root
surface of the teeth (Fig. 1.1).
Fig. 1.3: Fractured maxillary central incisor can be corrected by

restorative treatment.
Fig. 1.1: Dental caries.
2. Noncarious loss of tooth structure: Treatment of

lesions like attrition, abrasion, erosion to restore
function and aesthetics (Fig. 1.2).
Fig. 1.4: Operative dentistry is needed for aesthetic improvement.
Fig. 1.2: Noncarious loss of tooth structure requiring restorative

treatment.
Fig. 1.5: Replacement or repair of previous defective restoration.
3. Traumatic injuries: Restoration of traumatized or
fractured teeth involving the hard dental tissues and reasons, these restorations can be repaired or replaced
pulp (Fig. 1.3). in operative dentistry (Fig. 1.5).
4. Aesthetic improvement: Aesthetic corrections are 6. Developmental defects: Management of enamel and
needed for teeth affected by caries, stains, fractures, dentin hypoplasia, hypomineralization, amelogenesis,
diastema, etc. (Fig. 1.4). and dentinogenesis imperfecta, tetracycline stains,
5. Replacement or repair of previous defective resto peg-shaped laterals is done in operative dentistry
ration: existing restorations may fail due to various (Fig. 1.6).
Scope of operative dentistry

Scope of operative dentistry includes the following:
To know the condition of the affected tooth and other teeth.
1. To examine not only the affected tooth but also the oral
and systemic health of the patient.
2. To diagnose the dental problem and the interaction of
problem area with other tissues.
3. To provide optimal treatment plan to restore the tooth
to return to health and function, and increase the
overall well-being of the patient.
4. Thorough knowledge of dental materials which can be
used to restore the affected areas.
5. To understand the biological basis and function of the
various tooth tissues.
6. To maintain the pulp vitality and prevent occurrence of
Fig. 1.6: Developmental defects. pulpal pathology.
7. To have knowledge of dental anatomy and histology.
8. To understand the effect of the operative procedures on
objectives/purpose of operative the treatment of other disciplines.
dentistry
Recent Advancements
1. Diagnosis
Earlier concept of tooth preparation was the same as given
Diagnosis is determination of nature of disease, injury or by GV Black for many decades following principles of
other defect by examination, test, and investigation. extension for prevention. But modern concept of operative
dentistry is based on the conservation and prevention of the
2. Prevention diseases. Many advancements have been made in the area
of operative dentistry so as to meet its goals in better ways.
To prevent any recurrence of the causative disease and their 1. development in the diagnostic aids
defects, it includes the procedures done for prevention •• Ultrasonic illumination
before the manifestation of any sign and symptom of the •• Fiberoptic transillumination (FOTI)
disease. •• Digital imaging
•• Tuned-aperture computerized tomography (TACT)
3. Interception •• Magnetic resonance microimaging (MRMI)
•• Qualitative laser fluorescence
It includes the procedures undertaken after signs and
•• Diagnodent (quantitative laser fluorescence).
symptoms of disease have appeared, in order to prevent 2. Recent advances in treatment planning
the disease from developing into a more serious or full •• Minimal intervention dentistry
extent. •• Ozone therapy.
3. Recent advances in tooth preparation
4. Preservation •• Use of air abrasion technique
•• Chemomechanical caries removal
Preservation of the vitality and periodontal support of
•• Use of lasers in tooth preparation
remaining tooth structure is obtained by preventive and
•• Use of ultrasonics in tooth preparation
interceptive procedures.
•• Management of smear layer.
4. Improvements in adhesive dentistry
5. Restoration •• Packable composites
It includes restoring form, function, phonetics and •• Flowable composites
aesthetics. •• Smart composites
•• Compomers
•• Ceromers
6. Maintenance •• Nanocomposites
After restoration is done, it must be maintained for •• Sonicfill composite
providing service for longer duration. •• Fiber reinforced composites.
Introduction to Operative Dentistry 5
5. Recent advances in techniques and equipment 2. List the indications for operative dental procedures.
•• Incremental packing and C-factor concept in 3. Discuss various advancements that have revolu
composites tionized the current practice of operative dentistry.
•• Soft start polymerization 4. Write short notes on:
•• High intensity QTH polymerization. a. Scope and purpose of operative dentistry.
6. Recent advances in handpieces and rotary b. Recent advances in operative dentistry.
instruments
•• Fiberoptic handpiece Viva questions
•• Smart prep burs
1. Define operative dentistry.
•• CVD burs
2. What is the scope of operative dentistry?
•• Fissurite system. 3. Who invented the first dental chair?
4. What was the name of first hydraulic dental chair?
CONCLUSION 5. Write the objectives of operative dentistry.
During the beginning of dentistry, it was merely an art 6. What is the name of “father of operative dentistry”?
practiced by barber-surgeons or artisans. With time, due to 7. Who gave the concept of “extension for prevention”?
advances in science and technology, dentistry came into
hands of dentists/surgeons. Slowly and gradually operative Bibliography
dentistry became one of the major branches of dentistry 1. Black AD. Operative dentistry: a review of the past seventy-five
and focus was on restoring and preserving of teeth. It is years. Dent Cosmos. 1934:76(1):63-65.
especially the current age of cosmetic dentistry that has 2. Craig RB. Restorative dental materials, 10th edition. St. Louis,
been a real advantage for the public and the profession. It Mosby-Year Book; 1997.
3. Fillebrown T. A textbook of operative dentistry. Philadelphia, P
has spurred the development of many new techniques and
Blakiston, Sons & Co; 1889.
materials and made a wide variety of cosmetic procedures 4. Glenner RA. The modern reclining dental chair. J Hist Dent.
available to majority of patients. 1996;44(3):122-24.
With the innovations and discoveries of new equipment, 5. Morrant GA, Stephens RR. The development and application
techniques, materials, and methods, operative dentistry of modern methods in cavity preparation. VI-The evolution of
continues to refine and grow towards bright future of oral turbine handpieces. Brit Dent J. 1960;109(6)215-19.
6. Prinz H. Dental chronology—a record of the more important
health.
historic events in the evolution of dentistry. Philadelphia. Lea
and Febiger; 1945.
EXAMINER’S CHOICE QUESTIONs 7. Schulein TM. The era of high speed development in dentistry. J
Hist Dent. 2002;50(2):131-7.
1. Define operative dentistry. What is the scope of 8. Webb MH. Notes on operative dentistry. Philadelphia, SS White
operative dentistry? Manufacturing Company; 1883.
Chapter
2
Tooth Nomenclature
Chapter Outline
Introduction Tooth Notation Systems

Types of Dentition
INTRODUCTION Between six and twenty-four months of a baby life,

twenty teeth progressively appear: eight incisors, four
Man has a heterodont set of teeth, that is, different canines, and eight molars.
forms and dimension of teeth. It is to meet the needs of Around 6 years of age the eruption of 32 permanent
omnivorous alimentation. In each set, incisors and canines teeth begins. Total, 32 permanent teeth are present in an
are present to cut and tear food, molars and premolars are adult mouth, 16 teeth in each arch. Maxilla and mandible
present to mince the food (Fig. 2.1). each has six anterior teeth which includes four incisors, two
canines, ten posterior teeth which include four premolars
and six molars.
Oral cavity has two arches; maxillary and mandibular.
For an easier identification of a tooth in the oral cavity,
whether the upper teeth or the lowers, they are divided by
Fig. 2.1: Human dentition comprising incisors, canines,

premolars and molars.
types of dentition
Man has a diphyodont dentition, characterized by two
different dentitions during his life: deciduous dentition
(primary or calf teeth) and permanent dentition (secondary
or definitive) (Fig. 2.2). Fig. 2.2: Deciduous and permanent dentition.
Tooth Nomenclature 7
an imaginary line, called median line, in two hemiarchs, Permanent teeth
the right’s, and the left’s ones. Thus, the set of teeth are
Permanent teeth are numbered 1–8, where 1 is central
described into four quadrants as:
incisor, 4 is first premolar and 8 is third molar.
1. maxillary right
2. maxillary left
3. mandibular right Primary Teeth
4. mandibular left.
Primary teeth are designated as A, B, C, D, E, where A is
TOOTH NOTATION SYSTEMS central incisor and E is second molar (Figs. 2.3 and 2.4).
Each quadrant has unique L-shaped symbol to designate
There are different tooth notations for identifying specific the quadrant to which tooth belongs. For example, for
tooth. The three most common systems used are the “FDI
maxillary right, maxillary left, mandibular right and
World Dental Federation” notation, the “Universal” system
mandibular left symbols are , , , respectively.
and the “Zsigmondy-Palmer” system. The FDI system is
used worldwide and the universal is used predominantly
in the USA. Advantages
◆◆ Simple and easy to use
1. Zsigmondy-Palmer System/Angular/Grid
◆◆ Less chances of confusion between primary and perma
System nent tooth as there is different notation, e.g. permanent
This is the oldest method of tooth notation introduced by teeth are described by numbers while primary teeth by
Zsigmondy in 1861. Also known as angular or grid system. alphabets.
A B
Figs. 2.3A and B: Zsigmondy-Palmer tooth notation system for permanent dentition.
A B
Figs. 2.4A and B: Zsigmondy-Palmer tooth notation system for primary dentition.
Disadvantages ◆◆ If teeth have been extracted or missing, they are also

numbered.
◆◆ Difficulty in communication
◆◆ Confusion between upper and lower quadrants, while
Primary teeth
communication and transferring a data.
◆◆ In the original system, primary teeth were numbered in
2. Universal (National) System/ADA System the same order as permanent teeth, except that a small
letter “d” followed each number, thus a first tooth on
This system was introduced by the American Dental
the upper right side would be 1d and the last tooth on
Association in 1968. it is most popular in the United
the lower right side would be 20d.
States. Universal numbering system uses a unique letter or
◆◆ But this method was modified where primary teeth
number for each tooth.
are by English upper case letters A through T instead
Permanent Teeth of numbers 1 to 20, with A being upper right second
primary molar and T being the lower right second
Numbering starts from maxillary right posterior tooth primary molar (Figs. 2.6A and B).
where tooth number 1 is the patient’s upper right third
molar and follows around the upper arch to the upper left Advantage
third molar, tooth 16, descending to the lower left third
molar, tooth 17, and following around the lower arch to the Unique letter or number for each tooth avoiding confusions.
lower right third molar, tooth 32 (Figs. 2.5A and B).
◆◆ If a third molar is missing, the first number will be 2 Disadvantage
instead of 1, acknowledging the missing tooth. Difficult to remember each letter or number of tooth.
A B
Figs. 2.5A and B: Universal tooth notation system for permanent dentition.
A B
Figs. 2.6A and B: universal tooth notation system for primary dentition.
3. Federation Dentaire Internationale (FDI) 3—canine,
System 4 and 5—1st and 2nd premolars respectively
6, 7, and 8—1st, 2nd, and 3rd molars.
◆◆ This two-digit system was first introduced in 1971 ◆◆ Quadrants are designated 1 to 4
and subsequently adopted by the American Dental 1—upper right
Association (1996). 2—upper left
◆◆ FDI system is known as a “Two-Digit” system because 3—lower left
it uses two digits; the first number represents a tooth’s 4—lower right.
quadrant, and the second number represents the ◆◆ This results in tooth identification a two-digit combi
number of the tooth from the midline of the face (Figs.
nation of the quadrant and tooth, e.g. the upper right
2.7A and B).
canine is “13” (one three) and the upper left canine is
◆◆ Both digits should be pronounced separately in
“23” (two three).
communication. For example, the lower left permanent
second molar is “37”; it is not termed as “thirty-seven”,
but “three seven”. Deciduous Teeth
◆◆ In the deciduous dentition the numbering is corres
Permanent Teeth pondingly similar except that the quadrants are
◆◆ In FDI notation, teeth are numbered as 1, 2,….8 where designated 5, 6, 7, and 8 (Figs. 2.8A and B).
1—central incisor, ◆◆ Teeth are numbered from number 1 to 5, 1 being central
2—lateral incisor, incisor and 5 is second molar.
A B
Figs. 2.7A and B: FDI tooth notation system for permanent dentition.
A B
Figs. 2.8A and B: FDI tooth notation system for primary dentition.
Table 2.1: Permanent teeth.
Zsigmondy-Palmer Notation
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Universal Numbering System
Upper Upper
right left
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Lower Lower
right left
FDI Two-digit Notation
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Table 2.2: Deciduous teeth.
Palmer Notation
E D C B A A B C D E
E D C B A A B C D E
Universal Numbering System
Upper Upper
right left
A B C D E F G H I J
T S R Q P O N M L K
Lower Lower
right left
FDI Two-digit Notation
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Advantages Zsigmondy Palmer and FDI system of tooth notations

each having own advantages and disadvantages. Tooth
◆◆ Simple to understand notations are necessary in clinical practice for recording
◆◆ Simple to learn data of present or missing teeth, for communication and
◆◆ Simple to pronounce reference purpose.
◆◆ No confusion
◆◆ Each tooth has specific number EXAMINER’S CHOICE QUESTIONs
◆◆ Easy to record on computers
◆◆ Easy for charting. 1. What are the different nomenclatures of teeth? Discuss
the FDI system in detail. Why is it widely used?
Disadvantage 2. Write short notes on:
a. Zsigmondy-Palmer system.
May be confused with universal tooth numbering system. b. Universal system.
The summary of all the tooth notation systems have been c. FDI system.
described in Tables 2.1 and 2.2. d. Two-digit notation.
Conclusion
viva QUESTIONs
Tooth nomenclature is an established method as basis 1. Name different types of tooth notation system.
for communication. Though various tooth numbering 2. Which is the oldest method of tooth notation system?
systems have been given, most widely used are Universal, 3. What is another name of zsigmondy-palmer system?
4. What is the advantage of universal system over other teeth, 2nd edition; 2008. p. 35. Available from: http://www.
tooth numbering system? ada.org/sections/professionalResources/pdfs/dentalpractice_
5. What is the another name of FDI system? abbreviations.pdf [Last accessed on 2008 Dec 14] FDI Two
Digit Notation. Available from: http://www.fdiworldental.org/
6. What does the two digits indicate in FDI system? two-digit-notatio.
3. Blinkhorn AS, Choi CL, Paget HE. An investigation into the use
bibliography of the FDI tooth notation system by dental schools in the UK.
1. Ash Major M, Nelson SJ. Wheeler’s Dental Anatomy, Physiology, Eur J Dent Educ. 1998;2:39-41.
and Occlusion, 8th edition; 2003. p. 198. 4. Carlsen O- Dental morphology, Copenhagen; 1987.
2. American Dental Association. Council on Dental Practice: 5. ISO 3950:2009 Dentistry—Designation system for teeth and
Dental Abbreviation, Symbols and Acronyms. Designation for areas of the oral cavity.
Chapter
3
Structure of Teeth
Chapter Outline
Introduction Dental Pulp

Enamel Periradicular Tissue
Dentin
Introduction Significance: Poorly mineralized enamel appears whiter

and more mineralized enamel appears more translucent.
Tooth is composed of three hard mineralized tissues
(enamel, dentin, and cementum), and one soft tissue
2. Structure
(pulp). The outermost layer, enamel, is the hardest tissue
in the body. It covers the crown of the tooth. The middle Enamel is mainly composed of enamel rods/prisms
layer of the tooth is dentin, which forms the main bulk of covered by rod sheath and joined by interrod substance.
tooth and extends almost the entire length of tooth, being Their number ranges from 5 to 12 million. Each rod is
covered by enamel on coronal portion and cementum on keyhole or paddle-shaped having head and tail, head
root part. Dentin is nourished by the pulp, which is the is directed occlusally and tail toward cervical area. In
innermost portion of the tooth. In this chapter, we will transverse sections, enamel rod appears as hexagonal,
round or oval resembling fish scales.
discuss the structures present in teeth and their clinical
Rods are oriented perpendicular to dentinoenamel
significance.
junction and follow a wavy course in clockwise and
anticlockwise direction. Toward incisal/occlusal surface,
ENAMEL these become almost vertical. At pit and fissures, rods
converge in their outward course. In the cervical region,
Tooth enamel is the hardest and highly mineralized tissue
there is difference in the direction of the enamel rods of
which covers crown of the tooth. It is responsible for
deciduous and permanent teeth (Fig. 3.1).
aesthetics, texture, and translucency of tooth.
Significance: Cervical enamel rods of deciduous teeth are
inclined incisally or occlusally, while in permanent teeth
1. Composition these are inclined apically. Therefore to avoid unsupported
It is highly mineralized structure. The main inorganic enamel rods at gingival floor, cavosurface bevel (15 to
content is hydroxyapatite. 20°) at gingival margin is given by using gingival margin
trimmer (GMT).
Composition of enamel
◆◆ Inorganic contents (by volume): Hydroxyapatite—
3. Thickness
96%
◆◆ Organic contents (by volume) organic content and Average thickness of enamel at incisal edges is 2 mm and at
water 4%. cusp tip of molars, it ranges from 2.3 to 3.0 mm. Thickness
Structure of Teeth 13
Fig. 3.3A: Translucent gray or bluish color of enamel

at the incisal edges.
Fig. 3.1: Enamel rods showing keyhole pattern.
decreases gradually from cusps or incisal edges to cervical

area and terminates at cementoenamel junction (CEJ) as
knife edge (Fig. 3.2).
Fig. 3.3B: Fluorosis showing brown discoloration of teeth.
5. Hardness
Enamel is the hardest substance in human body. It is as
hard as steel. Its Knoop hardness number is 343, whereas
of dentin is 68. High modulus of elasticity and low tensile
strength makes it rigid and brittle in nature.
Fig. 3.2: Thickness of enamel at cusp tips is more which
ends cervically as knife edge.
Significance: Because of more compressive strength of
dentin than enamel, dentin acts as a cushion for enamel
when masticatory forces are applied on it. Therefore, dur-
4. Color ing tooth preparation, to have maximum strength of un-
Enamel is translucent in nature. Color of tooth mainly derlying remaining tooth structure, all enamel rods should
depends on: be supported by healthy dentin base.
i. Thickness of enamel; young anterior teeth appear
translucent gray or bluish near incisal edges. It
6. Structures Present in Enamel
appears yellowish in cervical areas due to thin enamel 1. Gnarled Enamel
from which color of underlying dentin is visible (Fig. Gnarled enamel consists of bundles of enamel rods which
3.3A). entwine in an irregular manner with other group of rods,
ii. Shade of underlying dentin. finally taking a twisted and irregular path towards the
iii. Presence of stains in enamel. tooth surface (Fig. 3.4). It is seen near incisal, occlusal,
iv. Anomalies occurring during developmental and and cervical areas.
mineralization stage, antibiotic usage and fluorosis, Significance: In these areas, enamel is not easy to break as
etc. affect the color of teeth (Fig. 3.3B). regular enamel.
Significance: Spindles serve as pain receptors, therefore

when enamel is cut, patient complains of pain.
6. Striae of Retzius
These appear as brownish bands in ground sections and
illustrate incremental pattern of enamel. Striae of Retzius
represent the rest periods of ameloblast during enamel
formation, therefore, also called as growth circles, similar
to annual rings on a tree.
7. Prismless Layer
Fig. 3.4: Gnarled enamel showing twisted course of enamel rods. It is a structureless layer of enamel near the cervical
line and to a lesser extent on the cusp tip which is more
2. Hunter-Schreger Bands mineralized.
Hunter-Schreger bands are dark and light strips which
occur due to change in direction of rods. These are seen 8. Dentinoenamel Junction
in large ground sections when viewed under microscope Dentinoenamel junction is scalloped interface of
(optical phenomenon). enamel and dentin. DEJ is 2–15 µm in thickness and is
hypermineralized structure. It is scalloped in outline in
Significance: H-S bands resist and disperse the strong
which rounded projections of enamel fit into shallow
forces.
depressions of dentin. This helps in better interlocking
3. Enamel Tufts between enamel and dentin. Surface area of dentin is
Enamel tufts are ribbon-like structures which run from much larger at DEJ than on cavity or pulp side.
dentin to enamel. They are named so because they Significance:
resemble tufts of grass. They originate from DEJ and extend ◆◆ Scalloped shape and interlocking of enamel and dentin
into enamel along the long axis of the crown (Fig. 3.5). at dentinoenamel junction prevents tearing of enamel
Significance: Enamel tufts are hypomineralized structure during functions.
in enamel, thus play role in spread of dental caries. ◆◆ Due to presence of branching of odontoblastic processes,
there is more sensitivity in this area.
4. Enamel Lamellae
These are thin, leaf-like defects, originate at enamel surface 9. Occlusal Pits and Fissures
and may extend to DEJ (Fig. 3.5). These contain organic Pits and fissures are formed by faulty coalescence of
substances and are caused by “imperfect calcification of developmental lobes of premolars and molars (Fig.
enamel tissue”. 3.6). Grooves are formed when there is sound union of
Significance: Lamellae at base of fissure provides pathway enamel lobes. These provide an escapeway for food during
for bacteria and initiates caries. mastication. Fissures are faulty union between enamel
lobes.
5. Enamel Spindles
Significance:
Odontoblastic processes sometimes cross DEJ and their
◆◆ Thickness of enamel at the base of pit and fissure is less,
ends are thickened, called enamel spindles.
causing early spread of caries to dentin.
Fig. 3.5: Schematic representation of enamel lamellae, enamel tufts

and dentinoenamel junction. Fig. 3.6: Occlusal pit and fissures.
◆◆ Fissures favor the food impaction making them caries 3. Acid etching: Acid etching forms micro- and macrotags
prone areas. in enamel which improves bonding between resin and
◆◆ Caries occur five times more on occlusal fissures than enamel. Initially, it removes about 10 μm of surface
facial or lingual fissures. Caries on facial and lingual enamel which does not contain any rod structure,
fissures are 2.5 times more to occur than proximal after this, it exposes rods and interrods. Dissolution of
fissures. this rod and interrod substance causes macroporosity.
Etched enamel has high surface energy so resin flows
Functions of Enamel up to 20 μm in depth.
4. Permeability: Enamel is semipermeable, that is why
◆◆ Hardest structure of tooth which supports masticatory
various fluids, pigments, ions, demineralization,
forces.
remineralization, fluoride intake, and vital bleaching
◆◆ Mainly responsible for aesthetics, surface texture and
are possible. Hypomineralized areas present in
translucency of tooth.
◆◆ Protects the underlying dentin and pulp. enamel are more permeable than mineralized area.
When teeth are dehydrated (during mouth breathing
or rubber dam application), enamel appears chalky
Clinical Significance white and lighter in color. Thus shade matching should
1. Color: Color of the enamel varies because of age, be done with full spectrum of light before rubber dam
ingestion of tetracycline or fluoride during the formative isolation.
stages, extrinsic stains and developmental defects of 5. Enamel strength and resilience: Enamel is brittle in
teeth. In early caries, subsurface enamel porosity results nature. Crystals in enamel rods run parallel to length
from demineralization, it appears as chalky white spot of enamel rods and enamel rods run parallel to the
on drying the enamel. When demineralization reaches tooth surface. Therefore, to avoid fracture of tooth
DEJ, this white opacity becomes visible in both dry and and restoration, enamel walls should be supported
wet enamel. It takes 4 to 5 years for this white spot by underlying dentin and preparation walls should
lesion to progress through enamel. When dentin gets be made parallel to direction of enamel rods because
involved, it appears as blue or grayish. enamel rod boundaries are natural cleavage lines
2. Attrition: It is mechanical wear of enamel on occlusal through which fracture can occur.
and proximal surfaces (Fig. 3.7). Normal physiologic 6. Remineralization: Remineralization occurs because
wear rate of enamel is 15–29 µm per year. Tooth wear of enamel’s permeability to fluoride, calcium, and
causes loss of vertical dimension of tooth which can phosphate (available from saliva or other sources).
be counteracted by active tooth eruption and apical
cementogenesis. DENTIN
In patients with bruxism, attrition can occur when
natural teeth come in occlusion with porcelain. In these Dentin is the most voluminous mineralized connective
patients, restore the occlusal surface with restorative tissue of tooth. It is covered by enamel in crown portion
material that wears at a same rate as enamel. and cementum in root part. Coronal dentin provides both
color and elasticity for enamel.
1. Composition
Dentin contains 64% inorganic hydroxyapatite crystals
and 36% organic content (collagen) and water.
2. Color
Dentin is slightly darker than enamel. It is yellow white
in young teeth and gets darker with age due to constant
exposure to oral fluids, irritants and deposition of
secondary or tertiary dentin.
3. Thickness
Dentin thickness (3 to 3.5 mm) is more on cusp tip and less
in cervical area of tooth. Its thickness increases with age
Fig. 3.7: Attrition of occlusal aspect of posterior teeth. due to deposition of secondary and tertiary dentin.
4. Hardness 2. Predentin
Hardness of dentin is one-fifth of enamel. Hardness at DEJ Predentin is 10 to 30 µm unmineralized zone between the
is 3 times more than near pulp. Low modulus of elasticity mineralized dentin and odontoblasts. It lies close to pulp
of dentin makes it more flexible than enamel which tissue which is just next to cell bodies of odontoblasts.
provides support or cushion effect to overlying brittle
enamel. Hardness of dentin increases with age due to its 3. Peritubular Dentin
mineralization. Table 3.1 shows differentiating features It lines the dentinal tubules and is more mineralized than
between enamel and dentin. intertubular dentin and predentin (Fig. 3.9).
Table 3.1: Differences between enamel and dentin.
Enamel Dentin
Whitish blue or white Yellowish white or slightly
Color gray darker than enamel
Sharp, high-pitched Dull low-pitched sound on
sound on moving fine moving fine explorer tip
Sound explorer tip
Hardest structure of Softer than enamel
Hardness tooth
More shiny surface Dull and reflects less light
and reflective to light than enamel
Reflectance than dentin
5. Structure
Fig. 3.9: Schematic representation of peritubular and
1. Dentinal Tubules intertubular dentin.
Dentinal tubules follow a gentle “S”-shaped curve in
crown and become straighter in incisal edges, cusps and 4. Intertubular Dentin
root areas (Fig. 3.8). Ends of the tubules are perpendicular
Intertubular dentin is present between the tubules which
to dentinoenamel and dentinocemental junctions. Each is less mineralized than peritubular dentin. It determines
dentinal tubule is lined with a layer of peritubular dentin, the elasticity of the dental matrix.
which is more mineralized than surrounding intertubular
dentin. Number of dentinal tubules increases from 15,000–
5. Primary Dentin
20,000/mm2 at DEJ to 45,000–65,000/mm2 toward pulp.
Diameter of dentinal tubules ranges from 0.5–0.9 µm at Primary dentin is formed before root completion, gives
DEJ and 2.5 µm near pulp. Tubules comprise 10% of the initial shape of the tooth. It continues to grow till 3 years
dentinal volume. after tooth eruption.
6. Secondary Dentin
Secondary dentin is formed after completion of root
formation. In this, the direction of tubules is more
asymmetrical and complicated as compared to primary
dentin. Secondary dentin forms at a slower rate than
primary dentin (Fig. 3.10).
7. Tertiary Dentin
Also known as:
◆◆ Reactive dentin
◆◆ Reparative dentin
◆◆ Irritation dentin
◆◆ Replacement dentin
◆◆ Adventitious dentin
Fig. 3.8: Dentinal tubules. ◆◆ Defense dentin.
8. Sclerotic Dentin
It occurs due to aging or chronic and mild irritation (such
as slowly advancing caries) which causes a change in the
composition of the primary dentin. Here, deposition of
apatite crystals and collagen occurs in dentinal tubules.
Due to filling of dentinal tubules with hydroxyapatite
crystals, refractive indices of intertubular and peritubular
dentin are equalized, giving transparent appearance to
dentin. Sclerotic dentin is harder, denser, less sensitive, less
permeable, and more protective of pulp against irritations
when compared to primary dentin.
Sclerotic dentin is commonly seen in roots of teeth
of elderly people, therefore, it can be used in Forensic
odontology as one of the criteria for age determination
Fig. 3.10: Diagrammatic presentation of primary, secondary and using Gustafson’s method. This method is based on
tertiary dentin. morphological and histological changes in teeth to
estimate the age.
Tertiary dentin is formed in response to external stimuli
like dental caries, attrition and trauma. Odontoblasts die if 9. Dead Tracts
injury is severe. Within 3 weeks, fibroblasts or mesenchymal Dead tracts represent empty tubules filled with air. In
cells of pulp differentiate into odontoblast like cells and this, due to caries, erosion, attrition, etc. degeneration of
form dentin with irregularly organized tubules. Rate of odontoblasts occur which results in empty dental tubules.
formation, thickness and organization of reparative dentin These appear black when ground sections of dentin is
depends on intensity and duration of stimulus. Table 3.2 viewed under transmitted light, hence the name is dead
is showing differences between primary, secondary and tracts. These appear white in reflected light.
tertiary dentin.
10. Eburnated Dentin
Table 3.2: Difference between primary, secondary, and tertiary dentin.
It is the exposed portion of reactive sclerotic dentin.
Primary Secondary Tertiary
Eburnated dentin is commonly seen in case of slow/
Definition Dentin Formed Formed as a static, stationary caries with large open cavity with
formed after root response to any lack of food retention, for example, caries on proximal
before root completion external stimuli
completion such as dental
surface of teeth where adjacent tooth has been extracted.
caries, attrition, and In this, superficially retained and decalcified dentin
trauma gets gradually burnished until it takes a brown stain
Type of cells Formed by Formed by Secondary with polished appearance and hard in nature making
primary primary odontoblasts or it resistant to further carious attack. This is called
odontoblasts odontoblasts undifferentiated eburnation of dentin.
mesenchymal cells
of pulps
Functions of Dentin
Location Found in It is not Localized to only
all areas of uniform, area of external a. Provides color and elastic foundation for the enamel
dentin mainly stimulus b. Offers protection of pulp
present over c. Form bulk of the tooth
roof and
floor of pulp
d. Provides strength and durability of the crown
chamber e. Responds to external thermal, chemical or mechanical
stimuli.
Orientation Regular Irregular Atubular
of tubules
Rate of Rapid Slow Rapid between 1.5
Clinical Considerations
formation µm/day and 3.5 1. Dentin support: Tooth should be preserved during tooth
µm/day depending
preparation. Maximum biting force is 738 N. Resistance
on the stimuli
to tooth fracture is compromised by increasing depth
Permeability More Less Least
and width of the cavity. In endodontically treated
teeth, only 1/3rd of fracture resistance is present when

compared to the normal tooth.
2. Outer dentin: Though odontoblastic process extend no
farther than inner 1/3rd of dentin, cavity preparation
with remaining dentin thickness of 2 mm or more than
that provides sufficient physiologic barrier to pulp. But
even the shallow tooth preparations should be done
under constant water spray to avoid heat generation
which can damage the underlying pulp.
3. Inner dentin: This dentin is near the pulp. Inner dentin
is 22 times more permeable than outer dentin. One
should be very careful to avoid pulp damage.
4. Infected and affected dentin: Infected dentin is soft
dentin which is invaded by microorganisms, and
cannot be remineralized. It has to be removed during
tooth preparation. Affected dentin contains intact Fig. 3.11: Diagrammatic representation of dental pulp.
dentin which is invaded by very few microorganisms,
and can be remineralized. It can be left during tooth
preparation. Histology
5. Dentin hypersensitivity: Stimulus on exposed dentin Pulp consists of 75% water and 25% organic material.
results in inward or outward movement of dentinal
fluid and stimulates the mechanoreceptor of the Structural or Cellular Elements
odontoblast, resulting in dentinal sensitivity.
6. dentin permeability: chemical irritation to pulp can Odontoblasts
occur by diffusion of irritating agents through dentin. They are present on outer periphery of the pulp. Their
Type of dentin from highest to lowest permeability number ranges from 59,000 to 76,000/mm2 in coronal
are: dead tract dentin > Globular dentin > tertiary dentin which decreases in root dentin. Odontoblasts
dentin > secondary dentin > primary dentin > synthesize mainly Type I collagen and proteoglycans.
sclerosed dentin. When active, odontoblasts become large and columnar,
7. Remaining dentin thickness: Underlying pulp should and during state of inactivity, they acquire small and
be protected by using liner, base or varnish underneath flattened shape.
the restoration.
8. Dentin bonding: Dentin is hydrophilic, composite Fibroblasts
is hydrophobic, so for optimal bonding primer is
required as intermediate between the two. It has both Fibroblasts are spindle-shaped cells, mainly present in
hydrophilic and hydrophobic ends to achieve bonding cell rich zone. These remodel pulp matrix and collagen by
to both dentin and composite. producing collagen and ground substance and eliminating
9. Smear layer: When tooth is cut, considerable excess collagen by action of lysosomal enzymes.
quantities of cutting debris made up of small particles
of mineralized collagen matrix are formed. These debris Undifferentiated Mesenchymal Cells
form the smear layer on prepared tooth surface. for Undifferentiated mesenchymal cells are descendants
bonding of restorative materials to tooth structure, this of undifferentiated cells of dental papilla which can
smear layer has to be removed or modified by etching be differentiate and then redifferentiate into many cell
or conditioning. types.
Defense Cells
DENTAL PULP
Histiocytes, macrophages, polymorphonuclear leukocytes,
Dental pulp is soft tissue of mesenchymal origin located in lymphocytes, and mast cells take part in host defense.
the center of the tooth (Fig. 3.11). It consists of specialized
cells, odontoblasts arranged peripherally in direct contact
Extracellular Components
with dentin matrix. This close relationship between
odontoblasts and dentin is known as “Pulp-dentin The extracellular components include fibers and the
complex”. ground substance of pulp:
Fibers ◆◆ Presence of dystrophic calcification and pulp stones
◆◆ Decrease in sensitivity
Fibers are principally type I and type III collagen.
◆◆ Reduction in number of blood vessels.
Collagen is synthesized and secreted by odontoblasts and
fibroblasts.
Physiologic Changes (Changes in Function)
Ground Substance ◆◆ Decrease in dentin permeability provides protected
environment for pulp-reduced effect of irritants.
It is a structure less mass with gel-like consistency consis
◆◆ Possibility of reduced ability of pulp to react to irritants
ting of glycosaminoglycans, glycoproteins and water. It
and repair itself.
forms bulk of pulp, supports the cells, and acts as medium
for transport of nutrients from the vasculature to the cells
and of metabolites from the cells to the vasculature. Clinical Considerations
◆◆ Try to maintain thick remaining dentin thickness to
Anatomy decrease chances of pulpal injury.
◆◆ Water coolant during tooth preparation prevents pulpal
Pulp lies in the center of tooth and shapes itself to
damage.
miniature form of tooth. This space is called pulp cavity
◆◆ During inflammation, blood flow and capillary perme
which is divided into pulp chamber and root canal.
ability is increased leading to increase in interstitial fluid
Pulp Chamber pressure. But this edema and increase in interstitial
fluid pressure is confined to inflamed area due to
It is that portion of pulp cavity present in crown portion. presence of numerous arterioles, and arteriole-venules
The roof of pulp chamber consists of dentin covering the anastomoses. This inflammation causes outward flow
pulp chamber occlusally. of dentinal fluid.
◆◆ Most sensory fibers are A delta fibers or unmyelinated
Root Canal C fibers. Conduction velocity of A delta fibers is 13
m/sec. These have low sensitization threshold and
It is that portion of pulp cavity which extends from canal
present sharp pain. C fibers have low conduction
orifice to the apical foramen. shape of root canal varies
velocity of 0.5–1.0 m/sec. They have high threshold
with size, shape, number of the roots in different teeth.
and get activated by stimuli capable of creating tissue
destruction just like high temperature or pulpitis.
Functions C fibers are not affected by tissue hypoxia, so pain
1. Formative may persist even if tooth is anesthetized, infected or
non-vital. Stimulation of C fibers presents burning and
Formation of primary, secondary, and tertiary dentin.
throbbing pain.
2. Nutritive
PERIRADICULAR TISSUE
It provides nutrition to dentin. Nutrients exchange across
capillaries into the pulp interstitial fluid, which in turn, Periradicular tissue consists of cementum, periodontal
travels into the dentin through the network of tubules. ligament and alveolar bone.
3. Innervative 1. Cementum
Through the nervous system, pulp transmits pain, Cementum can be defined as hard, avascular connective
sensations of temperature and touch. tissue that covers the roots of the teeth. It is light yellow
in color and can be differentiated from enamel by its lack
4. Defensive/Protective of luster and darker hue. It is very permeable to dyes and
Odontoblasts form dentin in response to injury particularly chemical agents, from the pulp canal and the external root
when original dentin thickness has been compromised as surface. It is softer than dentin. Sharpey’s fibers, which
in caries, attrition, trauma or restorative procedure. are embedded in cementum and bone, are the principal
collagenous fibers of periodontal ligament.
Age Changes
Composition
Morphologic Changes (Changes in Appearance) ◆◆ Inorganic content—45 to 50% (by weight)
◆◆ Reduction in pulp volume due to increase in secondary ◆◆ Organic matter—50 to 55% (by weight)
dentin deposition ◆◆ Water.
Types 5. Apical fibers: These fibers are present around the root
apex.
◆◆ Acellular cementum:
6. Interradicular fibers: Present in furcation areas of
•• Covers the cervical third of the root.
multirooted teeth.
•• Formed before the tooth reaches the occlusal plane.
Apart from the principal fibers, oxytalan and elastic
•• As the name indicates, it does not contain cells.
fibers are also present.
•• Thickness is in the range of 30 to 230 µm.
•• Abundance of Sharpey’s fibers.
Cells
•• Main function is anchorage.
◆◆ Cellular cementum: The cells present in periodontal ligament are:
•• Formed after the tooth reaches the occlusal plane. ◆◆ Fibroblast
•• It contains cells. ◆◆ Macrophages
•• Less calcified than acellular cementum. ◆◆ Mast cells
•• Sharpey’s fibers are present in lesser number as ◆◆ Neutrophil
compared to acellular cementum. ◆◆ Lymphocytes
•• Mainly found in apical third and interradicular. ◆◆ Plasma cells
•• Main function is adaptation. ◆◆ Epithelial cells rests of Malassez.
2. Periodontal Ligament Nerve Fibers

Periodontal ligament is a unique structure as it forms The nerve fibers present in periodontal ligament is either
a link between the alveolar bone and the cementum. of myelinated or nonmyelinated type.
Periodontal ligament houses the fibers, cells, and other
structural elements such as blood vessels and nerves. Blood Vessels
The periodontal ligament receives blood supply from the
Periodontal Fibers (Fig. 3.12)
gingival, alveolar, and apical vessels.
periodontal ligament fibers are composed mainly of
collagen type I arranged in the following patterns: Functions
1. Horizontal group: These fibers are arranged
horizontally emerging from the alveolar bone and ◆◆ It supports the tooth and is suspended in alveolar
attached to the root cementum. socket.
2. Alveolar crest group: These fibers arise from the ◆◆ This tissue has very rich blood supply. So, it supplies
alveolar crest in fan-like manner and attach to the root nutrients to adjoining structures such as cementum,
cementum. These fibers prevent the extrusion of the bone and gingiva by the way of blood vessels.
tooth. ◆◆ It also provides lymphatic drainage.
3. Oblique fibers: These fibers make the largest group in ◆◆ These fibers perform the function of protection
the periodontal ligament. They extend from cementum absorbing the occlusal forces and transmitting to the
to bone obliquely. They bear the occlusal forces and underlying alveolar bone.
transmit them to alveolar bone. ◆◆ The cells of PDL help in formation of surrounding
4. Transseptal fibers: These fibers run from the cementum structures such as alveolar bone and cementum.
of one tooth to the cementum of another tooth crossing ◆◆ The resorptive function is also accomplished with the
over the alveolar crest. cells such as osteoclasts, cementoclasts, and fibroblasts
provided by periodontal ligament.
3. Alveolar Bone
Bone is specialized connective tissue which comprises
inorganic phases that is very well-designed for its role as
load-bearing structure of the body.
Cells and Intercellular Matrix

◆◆ Cells present in bone are:
•• Osteocytes
•• Osteoblasts
Fig. 3.12: Schematic representation of periodontal ligament fibers. •• Osteoclasts.
◆◆ Intercellular matrix: c. Difference between acellular and cellular
•• Bone consists of two-thirds of inorganic matter cementum.
and one-third of organic matter. Inorganic matter d. Functions of periodontal ligament.
is composed mainly of minerals calcium and e. Difference between enamel and dentin.
phosphate along with hydroxyapatite, carbonate, f. Discuss age changes in pulp.
citrate, etc. while organic matrix is composed mainly g. Brief about periodontal ligament and in
of collagen type I (90%). periodontal fibers.
•• Bone consists of two plates of compact bone h. Alveolar bone.
separated by spongy bone in between. In some i. Contents of pulp.
areas, there is no spongy bone. j. Reparative dentin.
•• Spaces between trabeculae of spongy bone are filled k. Sclerotic dentin.
with marrow which consists of hemopoietic tissue in
early life and fatty tissue later in life. Viva questions
1. Name three mineralized tissue of tooth.
Significance of Periodontium 2. What is composition of enamel?
◆◆ Poor quality of restoration, for example, marginal 3. On which part of crown, gnarled enamel is found?
discrepancy and roughness, overhanging, over- and 4. What is clinical significance of enamel tufts and
undercontouring, traumatic occlusion, or defective enamel lamellae.
proximal contact impairs the periodontal health. 5. What is the natural color of enamel?
◆◆ Marginal discrepancy should be less than 10 micro 6. What is the natural color of dentin?
meter for cast metal restorations and less than 50 7. What is composition of dentin?
micrometer for ceramic restorations. Discrepancy can 8. What is the shape of dentinal tubules?
occur because of using thick cement and faulty tooth 9. Maximum number of dentinal tubules are present
preparation. This can lead to inflammation, bone loss, towards which part of tooth?
biofilm retention, etc. 10. Name the zones of pulp.
◆◆ Overhanging, over or undercontoured restoration 11. What is significance of enamel permeability?
can result in food impaction, gingival inflammation, 12. What is rate of formation of secondary dentin?
attachment loss, and bone loss. 13. What is normal wear rate of enamel?
14. What is Gustafson’s method?
Conclusion
BIBLIOGRAPHY
One should have thorough knowledge of hard and 1. Brännström M, Aström A. The hydrodynamics of the dentin:
soft tissues of the teeth for having strong foundation its possible relationship to dentinal pain. Int Dent J. 1972;22:
of operative dentistry. One should know the clinical 219-27.
significance of micro- and macroscopic structures of 2. Butler WT, Ritchie H. The nature and functional significance
enamel, dentin, cementum, pulp and relationship of teeth of dentin extracellular matrix proteins. Int J Den Biol.
1995;39:169-79.
to adjacent supporting tissues so as to have optimal results
3. Sasaki T, Garant PR. Structure and organization of odontoblasts.
of cavity preparation and restoration. Anat Rec. 1996;245:235-49.
4. Silverstone LM, Saxton CA, Dogon IL, et al. Variation in the
EXAMINER’S CHOICE QUESTIONs pattern of acid etching of human dental enamel examined by
scanning electron microscopy. Caries Res. 1975;9:373-87.
1. Describe the composition and structure of enamel in 5. Warshawsky H, Nanci A. Stereo electron microscopy of enamel
brief. Also discuss the clinical significance of enamel. crystallites. J Dent Res. 1982;61:1504-14.
2. Write short notes on: 6. Weber DF, Glick PL. Correlative microscopy of enamel prism
orientation. Am J Anat. 1975;144:407-19.
a. Difference between primary, secondary, and 7. Yoshida S, Ohshima H. Distribution and organization of
tertiary dentin. peripheral capillaries in dental pulp and their relationship to
b. Functions of pulp. odontoblasts. Anat Rec. 1996;245:313-26.
Chapter
4
Physiology of Tooth Form
Chapter Outline
Introduction Functions of Teeth

Types of Teeth and their Functions Protective Functional Form of the Teeth
introduction Table 4.1: Types of teeth and their functions.

Tooth Name Position Function Number
Normal tooth form and alignment in jaws improves
efficiency in mastication along with stabilization of teeth. Incisors Central Two teeth of Biting, 08
Form not only means the shape but also biomechanical and each quadrant cutting,
lateral which are incision and
attributes that contribute to maintenance of teeth and
incisors closest to shearing
supporting tissues. The relationship of tooth form and its midline
supporting structures plays an important role in optimal
functioning of teeth. To have adequate form, function and Canine Canine 3rd tooth from Cutting 04
(Cuspid) midline in each tearing,
aesthetics of the dentition, one should have an adequate
quadrant piercing and
knowledge about anatomy and the functional aspects of holding
contacts and contour so as to reproduce them by using
Premolars 1st and 4th and 5th Tearing, 08
restorative material.
(Bicuspid) 2nd teeth from holding and
premolars midline grinding
TYPES OF TEETH AND THEIR FUNCTIONS Molars 1st, 2nd 6th, 7th, 8th Grinding 12
Table 4.1 summarizes types of teeth and their functions. and 3rd teeth from
molars midline
Functions of teeth
The functions of teeth are as follows:
1. Mastication
Teeth play an important part during mastication of food.
Incisors—incisal edge of central and lateral incisors is
used to punch and cut.
Canines—sharp cusp of canine helps in tearing and
shearing of food.
Premolars and molars—two or three cusps of premolars
and molars help in grinding of food.
Physiology of Tooth Form 23
2. Speech
Teeth are important in pronunciation of certain sounds
and thus play vital role during speech.
3. Aesthetics
The form, alignment, and contour of anterior teeth play
important role in maintaining aesthetics of face.
4. Protection of Supporting Tissues

Teeth help in protection of supporting structures such as
gingiva, periodontium, and alveolar bone.
A B
Figs. 4.1A and B: Schematic representation of height of contour in
protective functional form of (A) Anterior and (B) Posterior teeth.
the teeth
◆◆ Normal deflection of food away from gingiva provides
Following are the protective functional forms of the teeth:
physiological stimulation of gingiva.
1. Contour of teeth
2. Marginal ridges Problems with overcontouring or
3. Embrasures undercontouring of Teeth
4. Interproximal area.
i. Overcontouring (Fig. 4.2B): Here restoration contains
excessive restorative material which alters the
1. Contour of Teeth normal contour of the tooth. Overcontouring causes
It is prominence present on mesial, distal, buccal and deflection of food, resulting in under-stimulation of
lingual surfaces of the crowns of teeth. All protective gingiva and thereby atrophy of gingiva. It is commonly
contours are most functional when the teeth are in seen in interproximal restorations, cast restorations,
proper alignment. Buccal and lingual surfaces of teeth and pontics.
possess some degree of convexity (Figs. 4.1A and B). This
convexity is generally located at:
◆◆ Cervical third of facial surfaces (all teeth)
◆◆ Cervical third of lingual surfaces (anterior teeth)
◆◆ Middle third of lingual surfaces (posterior teeth).
Significance
◆◆ protects gingival tissue against bruising and trauma
caused from food (Fig. 4.2A).
◆◆ Prevents food being packed into gingival sulcus.
A B C
Figs. 4.2A to C: Schematic representation of normal, overcontour and undercontour. Arrows show the pathway of food during mastication:
(A) optimal contour allows adequate stimulation and protection of periodontium; (B) Overcontour causes deflection of food and thus under-
stimulation of gingiva; (C) Undercontour results in food impaction and trauma to periodontium.
ii. Undercontouring: It means too little contouring, so

that a space occurs between margins and the cavity
walls. It leads to food impaction and trauma to the
attachment apparatus (Fig. 4.2C).
2. Marginal Ridges
Marginal ridges are defined as rounded borders of enamel
which form the mesial and distal margins of occlusal
surfaces of premolars and molars and mesial and distal
margins of lingual surfaces of the incisors and canines
(Fig. 4.3).
Fig. 4.4: Common faults that occur during the restoration

of marginal ridge.
Fig. 4.3: Marginal ridge (orange arrow) in molar and premolar.
Importance A
◆◆ Help in balancing of teeth in both the arches
◆◆ Improve the efficiency of mastication
◆◆ Prevent food impaction in interproximal areas.
Clinical Significance
◆◆ During restoration, marginal ridges should be restored
in two planes, i.e. buccolingually and cervico-occlusally
(Fig. 4.4). This feature is essential when an opposing
functional cusp occludes with the marginal ridge.
Restoring marginal ridges in two planes prevent food
lodgement which causes damage to the periodontium.
◆◆ Restore adjacent marginal ridges at the same height. B
Figs. 4.5A and B: Clinical photographs showing buccal/lingual and
incisal/gingival embrasures.
3. Embrasures
embrasures can be defined as V-shaped spaces that
ii. Incisal/occlusal Embrasures
originate at proximal contact areas between adjacent
teeth. These are named according to the direction in which These are spaces that widen out from area of contact
they radiate (Figs. 4.5A and B). These are: incisally/occlusally.
i. Labial/buccal and Lingual Embrasures iii. Gingival Embrasure

These are spaces that widen out from the area of contact These are the spaces that widen out from the area of
labially or buccally and lingually. contact gingivally.
Physiology of Tooth Form 25
Functions of Embrasure
◆◆ Provides a spillway for food during mastication
◆◆ Prevents food for being forced through contact area.
Significance
◆◆ Correct relationships of embrasures, marginal ridges,
contours, grooves of adjacent and opposing teeth
provide escape of food from occlusal surfaces during
mastication
◆◆ If embrasure size is decreased/absent, then additional
forces are created in teeth and supporting structures A
during mastication (Fig. 4.6)
Fig. 4.6: Embrassure. x–depicts a correct embrasure form; y–depicts B

improper contour of restoration resulting in improper embrasure form. Figs. 4.7A and B: Interproximal spaces.
◆◆ If embrasure size is enlarged, food impaction occurs

Labial/buccal aspect: It shows the relative position
in interproximal space by opposing cusp, resulting in
of contact area cervicoincisally or cervicoocclusally
damage to supporting tissues.
(Fig. 4.8A).
Facts Incisal/occlusal aspect: It shows the relative position of
contact area labiolingually or buccolingually (Fig. 4.8B).
•• Incisal/occlusal embrasure increases in size from anterior to
posterior teeth. Types of Proximal Contact
•• Cervical embrasure decreases in size from anterior to
posterior teeth. ◆◆ Point contact: It is seen in young persons with newly
•• Incisal embrasure of maxillary lateral incisor and canine is erupted teeth. Here teeth contact at a point only. For
longest.
•• Incisal embrasure of maxillary canine and premolar is widest.
4. Interproximal Spaces
Interproximal space is triangular-shaped area that is
usually filled by gingival tissue. In this triangular area,
the base is formed by alveolar process, sides by proximal
surfaces of contacting teeth and apex is the contact area.
Interproximal space varies with form of teeth in contact
and relative position of contact areas (Figs. 4.7A and B).
Proximal Contact Areas
Each tooth in the arch has two contacting membranes
adjoining it, one on mesial side and other on distal side.
proximal contact area denotes area of proximal height
of contour of the mesial or distal surface of a tooth that
contacts its adjacent tooth in the same arch.
Proximal contact areas must be observed from two Fig. 4.8A: Labial/buccal aspect showing relative position of contact
different aspects: area cervico-incisally or cervico-occlusally in anterior and posterior teeth.
Improper proximal contact area can result in:

◆◆ Food impaction
◆◆ Periodontal disease
◆◆ Carious lesions
◆◆ Mobility of teeth.
Conclusion
The relationship between restoration and periodontal
health of the teeth is inseparable; maintenance of
Fig. 4.8B: Occlusal aspect showing relative position of contact area gingival health constitutes one of the keys for tooth and
labiolingually or buccolingually in posterior teeth. dental restoration longevity. One should have thorough
knowledge of relationship between periodontal tissues
example, distal of canine and mesial of premolars has and restorative dentistry to ensure adequate form, function
point contact. and aesthetics.
◆◆ Contact area: It is formed due to wear of one proximal
surface against another during physiologic tooth EXAMINER’S CHOICE QUESTIONS
movement. As we move posteriorly, size of contact area 1. Explain in detail the physiology of tooth form.
increases (Fig. 4.9). 2. Write short note on importance of contacts and
contours.
3. Importance of interproximal area.
Viva questions
1. Name the protective functional form of the teeth.
2. What is the clinical significance of embrasure area?
3. What are different types of proximal contacts?
4. Define embrasures.
5. Define marginal ridge.
6. Discuss clinical significance of marginal ridge.
Fig. 4.9: Schematic representation of position of contact area in ante-
rior and posterior teeth. 7. What are functions of embrasure?
8. What are problems with overcontouring and under
contouring?
Importance of Proper Contact Relation 9. What are interproximal spaces?
i. Stabilizes the dental arches by combined anchorage 10. How does contact area move as we move posteriorly
effect of all the teeth from midline?
ii. Keeps food away from packing between the teeth 11. What is significance of proper contact relation?
iii. Protects interdental papillae. 12. What is significance of marginal ridges?
Viva Voce Bibliography

All teeth contact adjacent teeth at proximal contact area, 1. Baum L, Phillips RW, Lund MR. Textbook of Operative Dentistry,
except: 2nd edition. Philadelphia: WB Saunders Company; 1985.p.81.
•• Distal of last tooth in the arch 2. Burch, JG. Ten rules for developing crown contours in
•• Diastema restorations. DCNA. 1971;15:611-18.
•• Caries (proximal) 3. Eissmann HF, Radke RA, Noble WH. Physiologic design
•• Faulty restorations. criteria for fixed dental restorations. Dent Clin North Am.
1971;15:543-68.
4. Linkow L. Contact areas in natural dentition and fixed
Facts prosthodontics. J Prostho Dent. 1962;12:132-7.
•• In any tooth in the arch, distal contact is more cervically 5. Marzouk MA, Simonton AL, Gross RD. Operative Dentistry—
located than mesial contact. Modern Theory and Practice, 1st edition. Tokyo: Ishiyaku
•• Contact area moves cervically from anterior to posterior. EuroAmerica, Inc. Publishers; 1989. pp. 240-5.
6. Wagman SS. The role of coronal contour in gingival health. J
•• Contact increases in size from anterior to posterior.
Prosthet Dent. 1977;37:280.
Chapter
5
Occlusion in Operative Dentistry
Chapter Outline
Introduction Occlusal Schemes

Anterior-Posterior Interarch Relationship Significance of Occlusion in Operative Dentistry
Interarch Tooth Relationships Occlusal Interferences
Features of an Ideal Occlusion Eliminating Interferences
Factors of Occlusion Affecting Operative Dentistry Occlusion Indicators
Mandibular Movements Trauma from Occlusion
INTRODUCTION Operative dentistry follows the concept of functional

or physiologic occlusion. Functional occlusion is the one
According to Sturdevant, occlusion is defined as the contact which can function efficiently without pain and remains
of opposing dental arches, when they are in contact (static) in the state of health regardless of relationship between
and various jaw movements (dynamic). maxillary and mandibular teeth.
Definitions
1. Occlusion: Any contact between the incising or masticating surfaces of the upper and lower teeth.
2. Static occlusion: It is defined as contact of teeth when jaws are closed.
3. Dynamic occlusion: It is defined as tooth contact during mandibular movements.
4. Malocclusion: Any deviation from a physiologically acceptable contact of opposing dentition is called “malocclusion”.
5. Occlusal contact: Any contacting or touching of tooth surfaces is called occlusal contact.
6. Parafunctional (nonfunctional) contacts: Normal tooth contacts that have been subjected to excessive use through bruxism,
clenching, etc.
7. Interferences: Abnormal contacts that may occur in functional or parafunctional activity.
8. Hyperfunction: An abnormal amount of a normal or parafunctional activity is called hyperfunction.
9. Bruxism: It is parafunctional grinding of teeth which generally takes place during sleep and patient is not aware of the condition.
10. Bruxomania: It is the condition which occurs during the day time and patient is conscious about it.
11. Clenching: The exertion of force in a static tooth-to-tooth relationship is called clenching.
12. Centric occlusion: In centric occlusion, there is maximum intercuspation of upper and lower teeth when jaws are closed. Centric
occlusal contacts should be checked in both functional and nonfunctional position.
13. Centric relation: This is maxilla to mandible relationship in which the condyles are in most retruded position in the glenoid
fossa, regardless of any tooth-to-tooth relationship. Here the condyles are in the most superior position they can attain in the
glenoid fossa. If a healthy joint is correctly positioned and aligned in centric relation, it can resist maximum loading in function
with no sign of tension or tenderness.
14. Maximum intercuspation: It is the maximum occlusal contact or intercuspation irrespective of condylar position. This type of
contact may or may not occur on the path of the centric relation closure.
Anterior-Posterior Interarch Interarch Tooth Relationships

Relationship (Figs. 5.1A to D) The interarch relationship of an individual tooth can be of
Edward Angle (father of modern orthodontics) classified following two types:
anterior-posterior arch relationship on the basis of relative 1. Surface contact.
position of the maxillary first molar. He used the location 2. Cusp and fossa apposition.
of mesiobuccal cusp of maxillary first molar in relation
to the mandibular first molar to classify the interarch 1. Surface Contact/Incisor Relationship
relationship as following: It occurs in incisor teeth in which the incisal edges of
1. Class I: Neutrocclusion: Here, the mesiobuccal cusp of mandibular incisors contact palatal surfaces of maxillary
maxillary first molar should align with the buccal incisors during function. This type of contact results in
groove of the mandibular first molar. overjet (horizontal overlap) and overbite (vertical
2. Class II: Distocclusion: In this, the mesiobuccal cusp overlap). Variations in incisor relationships can be open
of maxillary first molar is located in facial embrasure bite, deep bite or cross-bite (Figs. 5.2A to D).
between the first mandibular molars and second
premolars. Clinical Significance
3. Class III: Mesiocclusion: In this case, mesiobuccal increase in overjet and overbite results in incisor trauma,
cusp of maxillary first molar lies in distofacial grooves problems with speech and mastication and occlusal
mandibular first molar. interferences.
A C
B D
Figs. 5.1A and D: Anterior-posterior interarch relationship showing Angle’s classification: (A) Angle’s class I occlusion; (B) Angle’s class II divi-
sion 1 malocclusion; (C) Angle’s class II division 2 malocclusion; (D) Angle’s class III malocclusion.
A B C D
Figs. 5.2A to D: Schematic representation of incisor relationship of maxillary and mandibular arch.
Occlusion in Operative Dentistry 29
2. Cusp and Fossa Apposition/Molar ◆◆ Mandible should freely move forward.
Relationship (Fig. 5.3) ◆◆ During various excursions, gliding of occlusal contacts
should occur smoothly.
In a normal occlusion, the mesiobuccal cusp of maxillary ◆◆ No tooth should get any thrust either buccally or
first molar falls in central fossa of mandibular first molar. lingually during centric closure.
This relationship helps in mastication and acts as a stabilizer ◆◆ Occlusal guidance should always be on the working
in alignment of teeth. Distopalatal cusps of maxillary molars side.
lie in the distal triangular fossae and marginal ridge of ◆◆ Soft tissue should be free of any kind of strain or trauma.
mandibular molars. Similarly the palatal cusps of maxillary ◆◆ There should be no restriction of the gliding between
premolars lie in contact with triangular fossae of mandibular the centric relation and centric occlusion.
premolars. In the similar manner, the mesiobuccal cusps
of mandibular molars lie in contact with distal fossa, or FACTORS OF OCCLUSION AFFECTING
marginal ridge surrounding it and distobuccal cusps of OPERATIVE DENTISTRY
mandibular molars lie in contact with central fossae of
maxillary molars. But these cusp fossa relationships can be Important Features of Posterior Cusps
changed in cases of posterior cross-bite.
◆◆ Cusps are blunt, rounded or pointed projections of
FEATURES OF AN IDEAL OCCLUSION crowns of the teeth which are separated by distinct
developmental grooves.
Since restored occlusal surface has important effects on the ◆◆ Cusps have four cusp ridges or slopes and the name
number and location of occlusal contacts. The occlusion of cusp ridge is derived from the direction of incline of
should be restored in both dynamic and static conditions. cusp. For example, lingual cusp ridge is the ridge, which
An ideal occlusion has following characteristic features: occurs on lingual surface of cusp.
◆◆ When the teeth come in contact in centric relation and ◆◆ There are inner ridges of cusps which are wider at
in centric occlusion, then there should be firm and base and narrower when they reach at cusp tip, and
stable jaw relationship. are termed as triangular ridges (named so because the
slopes of each side of ridge are inclined to resemble
two sides of a triangle). Triangular ridges are named
according to the cusps to which they belong.
Functional Cusp/Supporting Cusp/Stamp Cusp/

Centric Holding Cusp
A centric holding cusp is that which ideally occludes along
the line of the central grooves of opposing teeth (Figs. 5.4A
to C). These are the lingual cusps on the maxillary and
buccal on the mandibular teeth.
Characteristic Features of Supporting Cusps

◆◆ Contact the opposing tooth in centric occlusion.
◆◆ Lie nearer to the faciolingual center of the tooth in
Fig. 5.3: Cusp and fossa apposition of maxillary and comparison to nonsupporting cusps.
mandibular teeth. ◆◆ Support the vertical dimension of the face.
A B C
Figs. 5.4A to C: (A) Functional cusps of maxillary and mandibular teeth; (B) Functional cusps of mandibular teeth are buccal cusps;
(C) Functional cusps of maxillary teeth are palatal cusps.
A B C
Figs. 5.5A to C: (A) Nonfunctional cusps of maxillary and mandibular teeth; (B) Nonfunctional cusps of maxillary teeth are facial cusps;
(C) Nonfunctional cusps of mandibular teeth are lingual cusps.
◆◆ Outer incline has the potential for contact.

◆◆ Have broader, more rounded cusp ridges.
Significance of Supporting Cusps

◆◆ During mastication, the maximum forces and the
longest duration of contact occur at centric occlusion.
Since they also prevent drifting and passive eruption
of the teeth, they are also known as centric holding
cusps.
◆◆ During restorations of teeth, the supporting cusps
should not contact the opposing tooth, because it can
cause lateral deflection of tooth.
Nonfunctional Cusp/Nonsupporting Cusp/

Noncentric Cusp/Gliding Cusps
These cusps overlap the opposing tooth without contacting
Fig. 5.6: Rotational movement in mandible.
the tooth. They are buccal cusps of maxillary teeth and
lingual cusps of mandibular teeth (Figs. 5.5A to C).
Terminal hinge movement is used as reference
Significance Nonsupporting Cusps movement during restoration of tooth. Initial contact
between teeth during terminal hinge closure is termed
Nonsupporting cusps keep soft tissue such as tongue and
as centric occlusion. Maximum rotational opening in
cheek away from teeth and prevent self-injury to these soft
terminal hinge is 25 mm between incisal edges of the
tissues during chewing.
teeth. Rotation can occur in sagittal axis, horizontal axis or
vertical axis. Rotation in sagittal and vertical axes results in
Mandibular Movements lateral excursions and rotation in horizontal axis results in
All mandibular motions are either rotation or translation. opening and closing movement (Figs. 5.7A to C).
Rotation occurs when the mandible makes a hinged
movement. Translation occurs when the mandible moves Translational/Gliding Movement
into a protrusive or lateral position or a combination of
It is bodily movement of head of condyle in upper compart
two.
ment of TMJ (Fig. 5.8). If opening of mandible is more
than 25 mm, translation of mandible occurs.
Rotational Movement Most mandibular movements during chewing,
It occurs when head of the condyle rotates around an swallowing and speech are combination of rotation and
imaginary axis (Terminal hinge axis). terminal hinge axis translation.
is an imaginary axis around which mandible may rotate
(Fig. 5.6). It is a simple hinge movement which occurs
Variable Mandibular Movements
during opening or closing of mouth. It is repeatable, can be
transferred to the articulator and allows change in vertical Keeping the starting position as centric relation, from
dimensions of occlusion. which mandible can move into:
A B C
Figs. 5.7A to C: Rotation in sagittal and vertical axis.
1. Opening and closing movement: It can be pure

rotational or in combination with translation when
opening occurs to maximum opening position (Figs.
5.9A and B).
2. Protrusive movement: It occurs when both condyles
move forward and downward along inclines of articular
eminence. Posteriorly, it is guided by articular eminence
inclines (condylar guidance) and anteriorly by sliding
of incisal edges of lower teeth on palatal concavities of
upper teeth (incisal guidance).
3. Lateral movement: When mandible moves laterally,
one condyle moves forward and inward, while other
condyle shifts slightly in anteroposterior (rotate in
vertical axis) direction (Fig. 5.10). Side on which
mandible moves is working side, side opposite to
working side is balancing or nonworking side.
4. Bennett’s movement is lateral bodily shift of mandible
Fig. 5.8: Translation/gliding movement in mandible. at working side (Fig. 5.11) due to movements of
A B
Figs. 5.9A and B: Opening and closing movement: (A) Rotational movement; (B) Rotational and translation movement of mandible.
Fig. 5.10: Lateral movement in mandible.

Fig. 5.12: Posselt’s motion/Posselt’s envelope.
Fig. 5.11: Bennett’s movement leads to a shift in the mandible to the

working side.
condyles in lateral jaw movements. Bennett angle

is angle formed between sagittal plane and average
path of advancing condyle at balancing side as seen in Fig. 5.13: In unilateral balanced occlusion, during lateral movements,
the buccal cusps of posterior teeth on working side are in contact.
horizontal plane during lateral mandible movements
during lateral inclines. All these movements occur
within an envelope of movement called Posselt’s
envelope. of posterior teeth on working side are in contact (Fig.
5.13). For group function to be effective in reducing
Posselt’s Motion/Posselt’s Envelope the stress, the cusp inclines must be in harmony with
lateral border movement of jaw.
In 1952, Posselt described motion of mandible, the resultant 2. Canine guided or protected occlusion: During lateral
diagram has been termed as Posselt’s motion/Posselt’s mandibular movements, opposing maxillary and
envelope. The path of mandible during each movement in mandibular canines of working side contact, thereby,
each three directions (sagittal, horizontal and vertical) is causing disocclusion of all posterior teeth of both sides.
described to points beyond which mandible is not capable It normally serves as corner stone of mutually protected
of further movement. These points are defined as border occlusion (Fig. 5.14). When it becomes impossible
limitations of mandibular movements, and moving the to distribute stresses over many teeth, disocclusion
mandible to these points is called border movements of
of teeth is accomplished by using canine in canine
mandible (Fig. 5.12).
protected occlusion. Basically, canines play the role as
guidance that causes vertical function rather than as
OCCLUSAL SCHEMES resistor to lateral stresses.
Three basic schemes of occlusion are: 3. Balanced occlusion: It is defined as the simultaneous,
1. Group function occlusion/unilateral balanced bilateral contacting of maxillary and mandibular teeth
occlusion: During lateral movements, the buccal cusps in anterior and posterior occlusal areas in centric
Requirements of Occlusal Stability
1. There should be stable stops on all the teeth when
condyles are in centric relation.
2. There should be disocclusion of all the posterior teeth
in protrusive movements and on nonworking side.
3. Anterior guidance should be in harmony with the
border movements of envelope of motion.
4. In lateral movements, supporting cusps should
have slight freedom in centric and occlude in
groove or embrasure on opposing teeth, to facilitate
noninterfering passage of cusps.
Signs of Occlusal Instability

i. Excessive wear.
ii. Hypermobility of one or more teeth.
Fig. 5.14: In canine guided occlusion, during lateral excursions,
iii. Migration of one or more teeth like intrusion, supra
disocclusion of all teeth occur by canines.
eruption, etc.
Occlusal Interferences
Occlusal interference exists when teeth are not in harmony
with the joints and mandibular movements. Interferences
may result in mandibular deviation during closure to
maximum intercuspation or may hinder smooth passage
to and from the intercuspal position. Interferences can be
1. Centric relation interferences.
2. Lateral excursion interferences.
a. Working interferences.
b. Nonworking interferences.
3. Protrusive interferences.
Fig. 5.15: In balanced occlusion, simultaneous, bilateral contact of
maxillary and mandibular teeth occur. In natural teeth, balanced Eliminating Interferences
occlusion causes hypermobility, premature contacts, occlusal wear
and TMJ disturbances. 1. Centric Relation Interferences
In this mandible is closed in centric relation until initial
and eccentric positions. In natural teeth, balanced tooth contact occurs. If increasing the closing forces
deflects the mandible, premature contacts occur (Fig.
occlusion causes hypermobility, premature contacts,
5.16). Deflection of mandible can be in posterior, anterior
occlusal wear, periodontal ligament breakdown and
and/or lateral directions.
TMJ disturbances. It is seen in cases of advanced
attrition of teeth (Fig. 5.15).
Significance of Occlusion in
Operative Dentistry
A dental restoration once placed in a tooth, becomes one
of the essential component of stomatognathic system. If
done improperly without taking care of contact, contour,
embrasure, etc., a restoration can predispose myriad of
pathological processes. For example, creating a broader
contact will produce an interdental area which is less
cleansable, open contact can cause food impaction and
thereby periodontal problems, and an over or under-
contoured restoration can cause gingivitis. Fig. 5.16: Centric relation interference.
Fig. 5.17: Interferences to the arc of closure.
Centric relation interferences can be interferences in

arc of closure and in line of closure.
a. Interferences to the arc of closure (Fig. 5.17): As Fig. 5.19: Working interference.
the condyles rotate on their terminal hinge axis, each
lower tooth follows an arc of closure. Most of the occur on working side and this causes anterior teeth to
deviations from arc of closure displace the condyle to disocclude (Fig. 5.19).
move down and forward, also known as anterior slide. b. Nonworking interferences: these occur when contact
It is usually corrected by grinding the mesial inclines between maxillary and mandibular posterior teeth
of the upper teeth and the distal inclines of the lower occurs on nonworking side when mandible moves
teeth (MUDL). in lateral excursions (Fig. 5.20). This is destructive in
b. Interferences to the line of closure (Fig. 5.18): It nature because of nonaxial nature of forces causing
refers to those interferences that cause mandible to leverage of mandible.
deviate to the left or right from the first point of the
contact to the most closed position. If deviation occurs
toward cheek, grind the buccal inclines of upper and
lingual inclines of lower teeth (BULL). If deviation
occurs toward tongue, grind the lingual inclines of
upper teeth and buccal inclines of the lower teeth
(LUBL).
Fig. 5.20: Nonworking interference.
3. Protrusive Interferences
Fig. 5.18: Interferences to the line of closure. These interferences occur when distal facing inclines of
maxillary posterior teeth contacts the mesial facings of
mandibular posterior teeth during protrusive movements
2. Lateral Excursion Interferences (Fig. 5.21). These are destruction forces due to closeness
of teeth to muscles, nonaxial nature of forces and inability
These occur on working and nonworking side of the of the patient to incise the food.
mandible. Protrusive interferences are removed by grinding the
a. Working interferences: these occur when contact distal inclines of upper and mesial inclines of lower teeth
between maxillary and mandibular posterior teeth (DUML).
of coloring agent and a bonding agent between the two
layers of the film. On occlusal contact, coloring agent is
expelled from film. Marking is seen as central area that is
devoid of the colorant and surrounded by a peripheral rim
of the dye.
ii. Articulating Silk

It is made of color pigment, embedded in a wax-oil
emulsion. It has soft texture, and used for ceramic
restorations.
iii. Articulating Film

Fig. 5.21: Protrusive interference. It is very thin film with thickness of less than 8 µm.
iv. Metallic Shim Stock Film

Occlusion Indicators
It has a metallic surface on one side and color coding on
occlusion indicators can be broadly classified as
other side.
qualitative and quantitative indicators.
Qualitative indicators v. High Spot Indicator

These materials help in localization of occlusal contact It is supplied in liquid form and is used in the laboratory
points but sequence or density of the occlusal contacts to check proximal contacts of crowns, inlays, onlays, etc.
cannot be determined. Following can be used as qualitative
indicators (Figs. 5.22A to D). Quantitative Indicators
i. Articulating Paper i. T-scan Occlusal Analysis System
Articulating papers are the most frequently used qualitative It is a Microsoft compliant system which identifies time,
indicators. These are hydrophobic in nature, consisting magnitude and the distribution of the occlusal contacts.
A B
C D
Figs. 5.22A to D: Occlusion indicators: (A) Articulating paper; (b) articulating silk; (c) high spot indicator; (D) metallic shim stock film.
ii. Virtual Dental Patient

Here three-dimensional dental patient is assembled from
the data scanned from the casts of a patient’s dentition.
This provides quantitative information that would aid in
the assessment of his chewing function and in identifying
the occlusal interferences.
Trauma from Occlusion

Periodontal tissue injury caused by repeated occlusal
forces that exceeds the physiological limits of tissue
tolerance is called trauma from occlusion (TFO).
The periodontium tries to accommodate the forces
exerted on the crown. This adaptive capacity varies from
person to person at different times. When occlusal forces
exceed the adaptive and reparative capacity of periodontal Fig. 5.23: Periodontium responds to increase in magnitude of forces
tissues, trauma from occlusion results. by widening of periodontal ligament space and increase in the density
of alveolar bone.
Factors that Help Increase Traumatic Forces

1. When Magnitude of Occlusal Forces is
Increased (Fig. 5.23)
The periodontium responds with a widening of the
periodontal ligament space, an increase in the number
and width of periodontal ligament fibers and increase in
the density of alveolar bone.
2. Direction of the Occlusal Forces (Fig. 5.24)

The periodontal ligament fibers are arranged so that the
occlusal forces are applied along the long axis of the tooth.
Change in the direction of the occlusal forces lead to
change the orientation of periodontal ligament fibers.
3. Duration and Frequency of Occlusal Forces Fig. 5.24: Trauma from occlusion due to change in the direction
of occlusal forces.
Constant pressure on the bone is more injurious than
intermittent forces. The more frequent is application of
an intermittent force, more injurious is the force to the
periodontium.
Classification
1. Depending Upon Duration of Cause
i. Acute Trauma from Occlusion
It results from an abrupt occlusal impact, such as that
produced by biting on hard object (example–an olive pit).
In addition, restorations or prosthetic appliances that
interfere with the direction of occlusal forces on teeth Fig. 5.25: High points should be removed after restoration to avoid
may induce acute trauma. Clinically it presents as pain, acute trauma from occlusion.
sensitivity to percussion and tooth mobility (Fig. 5.25).
ii. Chronic Trauma from Occlusion changes in occlusion produced by tooth wear, drifting
It is more common than the acute form and is of greater movement and extrusion of teeth, combined with
clinical significance. It most often develops from gradual parafunctional habits (Fig. 5.26).
tooth or teeth with abnormal periodontal support (Fig.
5.28).
Clinical Features of TFO

◆◆ Mobility
◆◆ Pain on chewing or percussion
◆◆ Fremitus
◆◆ Occlusal prematurities/discrepancies
◆◆ Wear facets in the presence of other clinical indicators
◆◆ Tooth migration
◆◆ Chipped or fractured tooth/teeth
◆◆ Thermal sensitivity.
Radiographic Findings of TFO

Fig. 5.26: Chronic trauma from occlusion occurs from gradual changes ◆◆ Increased width of periodontal ligament space.
in occlusion produced by tooth wear combined with parafunctional ◆◆ Thickening of lamina dura.
habits. ◆◆ Vertical or angular bone loss.
◆◆ Radiolucency in furcation areas.
2. Depending on Nature of Cause
Treatment of TFO
i. Primary Trauma from Occlusion
A tissue reaction, which is elicited around a tooth with A goal of periodontal therapy in the treatment of occlusal
normal height of the periodontium (no attachment loss). traumatism should be to maintain the periodontium
It can be caused by high filling, faulty restorations or fixed in comfort and function. In order to achieve this goal,
and removable prosthesis, causing large force on the treatment can be:
abutment or opposing teeth. i. Short-term treatment: Occlusal splints/devices
which are used for short period to relieve myofascial
ii. Secondary Trauma from Occlusion
pain and to check if proposed change in occlusal
It is related to situations in which occlusal forces cause
scheme is tolerated by patient.
damage in a periodontium of reduced height (attachment
ii. Definitive treatment: In includes, orthodontic
loss present) (Figs. 5.27Aand B). tooth movement to correct malalignment, removal
iii. Combined Trauma from Occlusion of deflective occlusal contacts by elective grinding,
It is the injury that occurs to the periodontium resulting replacement of missing teeth to produce more
from abnormal occlusal forces that are applied to a favorable distribution of forces.
A B
Figs. 5.27A and B: In secondary trauma from occlusion occlusal forces cause damage in a periodontium of reduced
height i.e. attachment loss: (A) Radiograph showing attachment loss in premolar and molar; (B) Line diagram showing attachment loss.
3. What are the different factors affecting occlusion in

operative dentistry?
4. Explain occlusal interferences in detail.
viva questions
1. Define occlusion.
2. What are different types of occlusion?
3. What is difference between bruxism and bruxomania?
4. What is supporting cusp/stamp cusp/centric holding
cusp?
5. What is nonsupporting/noncentric cusp/gliding cusp?
6. What is Posselt’s motion/Posselt’s envelope?
7. What is group function/unilateral balanced occlusion?
8. What is canine guided or protected occlusion?
9. Discuss the significance of occlusion in operative
Fig. 5.28: Combined trauma from occlusion results from abnormal
occlusal forces that are applied to teeth with abnormal periodontal dentistry.
support. 10. What are occlusal indicators?
11. Discuss the different types of occlusal indicators.
12. What is trauma from occlusion?
conclusion 13. What are clinical features of TFO?
Occlusion is fundamental to practice of dentistry, in 14. Discuss the treatment of TFO.
providing a biologically functional restoration and
for comprehensive patient care. It is the integrated Bibliography
relationship of tooth, periodontium, TMJ and
1. Angle EH. Classification of malocclusion. Dent Cosmos.
neuromuscular system. There is complex interaction 1899;41:248-64, 350-7.
of many components of masticatory system. Changes 2. Celenza FV, Nasedkin JN. Occlusion: the state of the art.
in one component affect the entire system. Before Chicago: Quintessence 1978.
restoration is planned, one should see all components 3. Celenza FV. The centric position: replacement and character. J
Prosthet Dent. 1973;30(4 Pt 2):591-8.
of stomatognathic system to conform to existing occlusal
4. Hallmon WW. Occlusal trauma: effect and impact on
pattern and not to disturb it. periodontium. Ann Periodontol. 1999;4(1):102-8.
5. Korioth TW. Number and location of occlusal contacts in
EXAMINER’S CHOICE QUESTIONs intercuspal position. J Prosthet Dent. 1990;64(2):206-10.
6. Millstein P, Maya A. An evaluation of occlusal contact marking
1. What are the different schemes of occlusion? indicators. A descriptive quantitative method. J Am Dent Assoc.
2. Explain Trauma from occlusion in detail. 2001;132(9):1280-6.
Chapter
6
Dental Caries
Chapter Outline
Introduction Diagnosis of Dental Caries

Definitions Recurrent Caries (Secondary Caries)
Theories Root Caries
Etiology of Dental Caries Caries Risk Assessment
Clinical Presentation of Dental Caries Caries Activity Tests
Calcium Ion Migration in Carious Process Prevention of Dental Caries
Histopathology of Dental Caries Current Methods of Caries Prevention
Classification of Dental Caries Management of Dental Caries
introduction 3. A localized posteruptive pathological process of

external origin involving softening of the hard tissue
Oral cavity consists of diverse niches and ample supply and proceeding to the formation of a cavity. —WHO
of nutrients which are undoubtedly conducive for the
unrestricted formation of natural microbial biofilms.
Oral microbial communities consists of more than 700
Cariology
different bacterial species. Dental caries results from the It is a science which deals with the study of etiology,
disturbance of the equilibrium of this complex ecosystem, histopathology, epidemiology, diagnosis, prevention, and
where population shifts lead to overrepresentation of treatment of dental caries.
pathogenic species which contribute to the onset and
progression of caries. Dental caries remains the most THEORIES
prevalent chronic disease in both children and adults, even
though it is largely preventable. In India, the prevalence As we know, dental caries is a multifactorial disease of
of caries among preschool children is approximately tooth that has been explained by many theories. Though
40–70%. Dental caries not only causes damage to the there is no universally accepted theory of the etiology of
tooth, but is also responsible for several morbid conditions dental caries, following three theories are considered in
of the oral cavity like increase in tooth loss before time, etiology of dental caries:
malocclusion, etc. i. Acidogenic theory
ii. Proteolytic theory
iii. Proteolysis-chelation theory.
Definitions
1. Microbial disease of the calcified tissues of the teeth, Acidogenic Theory/Chemicoparasitic Theory
characterized by demineralization of calcified tissues
and destruction of the organic substance of the teeth. it is the most accepted theory given by Miller in 1890.
—Shafer Miller said, “Dental decay is a chemicoparasitic process
2. An infectious microbiological disease of teeth that consisting of two stages, the decalcification of enamel,
results in localized dissolution and destruction of which results in its total destruction, as a preliminary
calcified tissues. —Sturdevant stage; followed by dissolution of the softened residue of
Flowchart 6.1: Role of carbohydrates in caries formation.
Fig. 6.1: Diagrammatic representation of caries balance theory.
are bacteria, poor dietary habits and xerostomia. Protective

the enamel and dentin”. This whole process is supported
factors include saliva, antimicrobial agents (chlorhexidine,
by the presence of carbohydrates, microorganisms, and
xylitol), fluoride, pit and fissure sealants, and an effective
dental plaque. All the preventive steps have been based on
diet. Any change in balance of these factors can result in
this theory (Flowchart 6.1).
carious lesion. For example, if a person is healthy today
and develops xerostomia, he may develop severe carious
Proteolytic Theory lesions months later.
it was given by Heider, Bodecker in 1878. According to
this theory, organic portion of the tooth plays an important Etiology of dental caries
role in the development of dental caries. Enamel structures Dental caries is an ecological disease in which diet,
which are made of the organic material, such as enamel host, and microbial flora interact with each other in a
lamellae and enamel rods prove to be the pathways for the specific period of time in such a way that it increases
advancing microorganisms. Microorganisms invade the demineralization of the tooth structure with resultant
enamel lamellae and the acid produced by the bacteria caries formation.
causes damage to the organic content. Some races have higher incidence of dental caries,
e.g. white American and English people. Some races (e.g.
Proteolysis-chelation Theory Indians and black Americans) due to hereditary patterns
This theory was put forward by Schatz and his coworkers have lower incidence of dental caries. In 1960s, Keyes
in 1955. This theory states that enamel is demineralized by showed that microflora, tooth, and diet must be present
chelating agents at neutral pH. Bacterial attack on enamel for decay to occur. Combination of these factors is known
is initiated by keratinolytic microorganisms. This causes as Keyes triad (Figs. 6.2A and B). Later on, many studies
the breakdown of the protein chiefly keratin, resulting in were conducted which extended Keyes model with many
formation of soluble chelates which decalcify enamel even other factors affecting the interplay between these primary
at neutral pH. Enamel contains mucopolysaccharides, factors. This triad was modified by Newburn in 1982. He
lipids, and citrate which are susceptible to bacterial attack added time as a factor in this, so that above three factors
and act as chelators. occur together for a minimum amount of time for caries to
develop and named it NewBurns Tetrad.
“Caries Balance Concept” (Proposed by
Featherstone) A. Primary Factors
According to this theory, caries does not result from a 1. Tooth
single factor; rather it is the outcome of the complex i. Susceptible areas on tooth: Susceptible areas on
interaction of pathologic and protective factors tooth for caries are deep and narrow occlusal fissures,
(Fig. 6.1). Pathological factors involved in a carious lesion deep buccal or lingual pits, exposed root surfaces, area
Dental Caries 41
A B
Figs. 6.2A and B: Keyes triad showed that caries are caused by microflora, tooth, and diet. This triad was modified by Newburn in 1982
by adding time as a factor, which means these three factors occur together for a minimum amount of time for caries to occur.
immediately gingival to contact areas and margins of c. Vitamin content of diet:

existing restorations. Also, enamel is quite thin at base Vitamin A: Deficiency or excess is not related to
of such deep pits and fissures. dental caries.
ii. Position of tooth: Tooth position also affects the Vitamin D: Enamel hypoplasia can result due to
initiation of dental caries. If a tooth is out of position, vitamin D deficiency. It can result in early
rotated, or malaligned, it becomes difficult to clean, attack of caries.
retains more food and debris, and thus becomes more Vitamin K: Vitamin K has enzyme-inhibiting action in
prone to decay. carbohydrate degradation cycle, and this
iii. Biochemical structures of teeth: Surface enamel can be used as an anticariogenic agent.
is more mineralized than subsurface enamel, and Vitamin B: Many types of vitamin B are important
it also contains more fluoride, zinc, and lead than growth factors for the oral acidogenic
subsurface enamel. Therefore, in initial carious lesion, flora which serve as component of the
the subsurface enamel shows marked deminerali
coenzymes involved in glycolysis. Vitamin
zation even though outer enamel is relatively intact.
B6 acts as anticariogenic because it
The enamel of newly erupted teeth is highly susceptible
promotes the growth of noncariogenic
to caries because of more carbonate content in enamel
organisms.
crystals. Lack of enamel maturation or presence of
developmental defects, deficiency in minerals like calcium, Vitamin C: it is required for the normal health of the
phosphorus, fluorides, and hypoplasia due to deficiencies gingiva.
of vitamins A and D make teeth more susceptible to tooth d. Frequency of carbohydrate intake: Greater the time
demineralization. With advancing age, enamel becomes lapse between acid attacks, better are the chances for
more resistant to caries due to maturation in composition the repair process (remineralization) to occur.
of enamel, deposition of secondary and tertiary dentin, Stephan curve describes the changes in pH occurring
and increased fluoride levels in teeth. within dental plaque when it is subjected to a
challenge, usually a cariogenic food (Fig. 6.3). When
2. Substrate (diet) challenged with a fermentable carbohydrate, the pH
within plaque drops rapidly reaching a minimum in
a. Physical nature of diet: More refined and less fibrous
approximately 5–20 minutes. This is followed by a
foods stick stubbornly to the teeth and can not be
gradual recovery to its starting value usually over 30–60
removed easily due to lack of roughage. This favors
stagnation of food on tooth surfaces. minutes. The relationship of the shape of the Stephan
b. Chemical nature of diet: more refined foods, such as curve to the critical pH can be used to assess the relative
glucose, fructose, and sucrose make the diet cariogenic. cariogenicity of food.
Complex carbohydrates, such as starch are relatively Following factors affect the shape of the Stephan curve:
harmless because they are not completely digested ◆◆ Microbial composition of the plaque: Presence of
in the mouth. Sorbitol, mannitol and xylitol are not significant numbers of aciduric, acidogenic bacteria in
metabolized by bacteria so show reduced cariogenicity. plaque produces the lowest pH (4.5 or even lower).
help the Streptococcus mutans to adhere firmly to teeth

and inhibit diffusion of salivary buffers. By this, local
environment becomes acidic which causes dissolution
of tooth structure. After this, filamentous bacteria,
lactobacilli get established in the lesion.
Viva Voce
On coronal surface, initiation of caries is caused by
Streptococcus mutans and on root surface mainly by
Actinomyces viscosus.
Presence of high Lactobacillus acidophilus count in saliva
indicates the occurrence of active carious lesion.
4. Time Period
Fig. 6.3: Stephan curve. Time period during which all above three principal factors,
i.e. tooth, microorganisms, and substrate are acting jointly
◆◆ Nature of fermentable source: Carbohydrate which is should be adequate to produce acidic pH which is critical
metabolized more slowly results in less acid production for dissolution of enamel leading to carious lesion.
and a higher terminal pH.
◆◆ Rate of diffusion of bacterial metabolites into and B. Modifying Factors
out of plaque: it is governed by the density of plaque
1. Saliva
and access by saliva. Thus, less dense plaque exposed
to saliva flow rapidly exchanges metabolites with the i. Composition of saliva: Saliva is rich in calcium,
surroundings. This will enable substrates to diffuse into phosphate, and fluoride, and these materials help
the plaque rapidly and allow microbial byproducts to in remineralization of the enamel. Under normal
diffuse out. conditions, the tooth is continually in touch with
◆◆ Salivary components, such as bicarbonate and saliva saliva. Calcium and phosphate ions present in the
flow rate: Saliva dilutes and carries away metabolites saliva help in remineralization of the very early stages
out of the plaque and it supplies bicarbonate ions which of carious lesion (Table 6.1).
diffuse into plaque and neutralize the byproducts of ii. pH of saliva: The critical pH at which inorganic
fermentation. This acid neutralization effect is enhanced material of tooth begins to dissolve is 5.5; above this
by the increase in salivary bicarbonate associated with pH, saliva is supersaturated with Ca2+ and PO42– ions.
increased saliva flow which coincides with eating.
Acid production during caries occurs at a localized
site on the tooth which is covered by plaque. This
Facts plaque prevents the diffusion of buffering ions from
Fluoride content is lesser in carious enamel and dentin as saliva into the tooth.
compared to a sound tooth.
In sound enamel and dentin, fluoride content is 410 ppm Table 6.1: Functions and components of saliva.
and 873 ppm, respectively. Functions of saliva Components of saliva
In carious enamel and dentin, fluoride content is 139 ppm
and 223 ppm. Antimicrobial action Lysozyme, lactoperoxides,
Dentin requires higher levels of fluoride for mucins, cystines,
remineralization (100 ppm) than enamel (5 ppm). immunoglobulins and IgA
Maintaining mucosa integrity Water, mucins and electrolytes
Lubrication Mucin, glycoproteins and water
3. Bacteria
Cleansing Water
Dental caries do not occur if the oral cavity is free of
Buffer capacity and Bicarbonate, phosphate,
bacteria. Streptococcus mutans is considered main remineralization calcium and fluorides
causative factor for caries because of their ability to adhere
to tooth surfaces, produce abundant amounts of acid, and iii. Quantity of saliva: Continuous flow of saliva causes
survive and continue metabolism at low pH conditions. mechanical removal of bacteria and food debris from
Streptococcus mutans makes use of sucrose to produce tooth surfaces. Caries incidence increases in patients
the extracellular polysaccharide glucan. Glucan polymers with less or no saliva flow.
Dental Caries 43
iv. Viscosity of saliva: Higher the viscosity of saliva, more disorders and mental disorders. Prolonged use of drugs,
is the incidence of dental caries. such as antihistaminics, antidepressants, and diuretics
v. Antibacterial properties: Lysozymes, lactoferrin, can decrease the salivary flow, therefore, may cause caries.
sialoperoxidase, thiocyanate ions, IgA, etc. present in
saliva are responsible for antibacterial properties of 7. Occupation
saliva.
Workers of bakery shops, truck drivers, and confectionery
Causes of Hyposalivation: industries are more prone to dental caries because of
i. Physiologic: Salivary flow rate is decreased: frequent eating and irregular eating schedules.
•• During sleep
•• During periods of anxiety clinical presentation of dental
•• Dehydration
caries (Fig. 6.4)
•• Age-related changes in salivary gland.
ii. Drug induced: Medications associated with xerostomia
•• Atropine
•• Antidepressants
•• Antihypertensives
•• Antihistamines
•• Opioids
•• Diuretics
•• Benzodiazepines
iii. Systemic diseases:
•• Sjögren’s syndrome
•• Sicca syndrome (“sicca” simply means dryness).
iv. Other causes:
•• Mouth breathing
•• Water or metabolite loss (for example, during Fig. 6.4: Diagrammatic representation of pit and fissure and
hemorrhage, vomiting, diarrhea, and fever) proximal caries in enamel and dentin.
•• Irradiation of the salivary gland.
clinical picture of caries varies according to the location
2. Age onto which they develop.
Young and older persons are more affected by caries. In
young patients, newly erupted teeth have deep pits and 1. Pit and Fissure Caries
fissures which are more retentive to food and thus more
Shape of pits and fissures contributes to their high
prone to caries. Older patients have more prevalence of
susceptibility to caries because of entrapment of bacteria
root caries because of other factors like gingival recession,
and food debris in them. Initially, caries of pits and fissures
poor salivation which can be due to medications and
appear brown or black in color and with a fine explorer, a
inability to keep proper oral hygiene.
“catch” is felt. Enamel at the margins of pits and fissures
3. Sex appear opaque bluish-white. At dentinoenamel junction,
caries spread laterally rather than pulpally giving it
Females are affected more than males (due to early triangular in shape.
eruption of teeth). In longitudinal sections, it appears as triangular in
shape with the apex facing the surface of tooth and the
4. Race
base toward the DEJ.
Caries incidence varies in different races because of
cultural and dietary differences. 2. Smooth Surface Caries
5. Hereditary Smooth surface caries occurs on gingival third of buccal
and lingual surfaces and on proximal surfaces below
Genetics also influences caries incidence. Many studies the contact point. The earliest manifestation of incipient
have shown that caries are inherited from parents. caries of enamel is seen beneath dental plaque as areas
of decalcification (white spots). As caries progresses, it
6. Systemic Health
appears bluish-white in color. As it goes deeper, the caries
Any disease which leads to poor oral hygiene, results in forms a triangular pattern or cone-shaped lesion with
dental caries, for example, in patients with motor skill the apex toward DEJ and base toward the tooth surface.
Finally, there is loss of enamel structure, which gets eventually fuse at base of fissure. The entrapped organic
roughened due to demineralization, and disintegration of material gets attacked by enzymatic and bacterial action
enamel prisms. causing initiation of caries. Later, these pits and fissures
At DEJ, it spreads laterally than pulpally. In dentin, it become storehouse of bacteria causing dissolution of
forms cone shape with base toward DEJ and apex toward remaining enamel and later spread of caries in dentin.
pulp. Almost all teeth are affected by pits and fissures caries
except lower incisors and canines. Since enamel rods flare
3. Root Surface Caries laterally at the base of pits and fissures, caries follow path
of enamel rods. These caries form inverted V-shaped lesion
Root caries are seen in older individuals of those having with base toward dentin and apex toward pit.
gingival recession exposing the cementum, thus increased
prevalence of root caries. Root caries is found at CEJ or Incipient Enamel Caries
apical to CEJ. It is U-shaped in cross-section and spreads
rapidly because dentin is less resistant to caries than These are covered with dental plaque. When plaque
enamel. is removed and tooth is dried, incipient caries appear
opaque and turn translucent on wetting.
CALCIUM ION MIGRATION IN CARIOUS
PROCESS Cavitation
If enamel lesion advances further, demineralization
One must understand migration of calcium ions in enamel
progresses resulting in cavitation, i.e. break in enamel. By
during carious process. Migration of calcium ions through
this, bacteria gain entry into deeper tooth structure.
enamel pores toward outer surface results in white spots
on the enamel. With passage of time, these white spots
attain dark stain. Zones of Enamel Caries (Fig. 6.5)
This migration of calcium ions is an electrochemical Different zones are seen before complete disintegration
process. Fluid within enamel acts an electrolyte. Outer of enamel. Early enamel lesion seen under polarized light
surface of enamel acts as cathode and inner surface of reveals four distinct zones of mineralization. Starting from
enamel acts as anode. The electrical potential between surface, proceeding toward DEJ, the zones of enamel
these two poles is maintained by balance in metabolic caries are as following:
activity within the tooth. Balance gets disturbed by 1. Surface zone:
change in electric potential between inner and outer •• This zone is least affected by caries
surfaces of enamel. Application of acid to enamel •• Greater resistance probably due to greater degree of
changes the electric potential which draws calcium ions mineralization and greater fluoride concentration
toward the surface. If tooth is otherwise healthy, calcium •• It is less than 5% porous
ions are rapidly replaced and normal electric potential is •• Its radiopacity is comparable to adjacent enamel.
regained. 2. Body of the lesion:
If tooth is not able to counteract the action potential •• Largest portion of the incipient caries
from acid of plaque, this acid flows deep into enamel. •• Found between the surface and the dark zone
Calcium ions move toward outer surface resulting in •• It is the area of greatest demineralization making it
white patches of decalcified enamel. As calcium ions are more porous.
lost, millipores in enamel are enlarged and byproducts of
microorganisms reach into dentin causing destruction of
organic matter of dentin. Here, clinically surface enamel
appears intact whereas dentin gets damaged.
If decalcified area occurs in cleansable area, carious
activity can be arrested by keeping the area clean and by
applying remineralization agent. If decalcification occurs
in noncleansable area and if destruction involves DEJ,
tooth preparation and restoration is indicated.
HISTOPATHOLOGY of dental caries

Enamel Caries
Caries begin once bacterial plaque gets deposited in pits
and fissures. Caries start on lateral walls of tissues which Fig. 6.5: Zones of enamel caries.
Dental Caries 45
3. Dark zone: microorganisms. Each tubule is packed with one form
•• It lies adjacent and superficial to the translucent of bacteria, e.g. one tubule packed with coccal forms
zone and the other tubule with bacilli.
•• Usually present and thus referred as positive zone ◆◆ As the microorganisms proceed further, they are
•• Called dark zone because it does not transmit distanced from the carbohydrate substrate that was
polarized light needed for the initiation of the caries. Therefore,
•• Formed due to demineralization. proteolytic organisms might appear to predominate in
4. Translucent zone: the deeper caries of dentin, while acidophilic forms are
•• Represents the advancing front of the lesion more prominent in early caries.
•• Ten times more porous than sound enamel
•• Not always present. Advanced Dentinal Changes
Dentinal Caries ◆◆ In advanced lesion, decalcification of the wall of the

individual tubules takes place resulting in confluence
When enamel caries reaches the dentinoenamel junction, of the dentinal tubules. Sometimes, the sheath of
it spreads rapidly laterally because it is least resistant to Neumann shows swelling and thickening at irregular
caries. intervals in the course of dentinal tubules. The diameter
Spread of caries is more in dentin as compared to of dentinal tubules increases because of packing of
enamel because of: microorganisms.
1. Decreased calcification ◆◆ There occurs the formation of tiny liquefaction foci,
2. Presence of dentinal tubules creating pathways for described by Miller. They are formed by the focal
spread of caries. Dentinal tubules act as a tract along coalescing and breakdown of dentinal tubules. These
which microorganisms travel to pulp. are ovoid areas of destruction parallel to the course of
In children and young teeth, caries in dentin spread tubules which are filled with necrotic debris. These areas
faster than in older teeth because: expand which produce compression and distortion of
1. Dentinal tubules are short and wide adjacent dentinal tubules leading to course of dentinal
2. Lesser mineralization tubules being bent around the liquefaction focus.
3. Less thickness of enamel and dentin and wider pulp ◆◆ Destruction of dentin by decalcification and then
chamber. proteolysis occurs in numerous focal areas. It results in
In enamel, caries lesion appears small but when caries a necrotic mass of dentin with a leathery consistency.
reach dentin, a large cavity is formed. ◆◆ Clefts occur in the carious dentin that extends at right
angles to the dentinal tubules. These account for the
Viva Voce peeling off of dentin in layers while excavating.
Dentinal caries appear brown because of color produced by:
Pigment producing microorganisms Zones in Dentinal Caries (Fig. 6.6)
Chemical reaction which occurs when proteins break down
in the presence of sugar Caries in dentin form a triangular shape with base toward
Exogenous stains. DEJ and apex toward pulp with five distinct zones. These
zones are clearly distinguished in chronic caries than in
Early Dentinal Changes
◆◆ Initial penetration of the dentin by caries causes
an alteration in dentin known as dentinal sclerosis.
It is more prominent in slow chronic caries. Here,
calcification of dentinal tubules occurs which prevent
further penetration of microorganisms. Micro
organisms found in tubules are called pioneer bacteria.
◆◆ When dentinal tubules are completely occluded by
the mineral precipitate, section of the tooth gives a
transparent appearance in transmitted light; this dentin
is termed as transparent dentin.
◆◆ In transparent dentin, intertubular dentin is deminera
lized and lumen is filled by calcified materials, which
provide softness and transparency to the dentin
compared to sound dentin.
◆◆ This initial decalcification involves the walls allowing
them to distend as the tubules are packed with Fig. 6.6: Zones of dentinal caries.
acute caries. beginning from the pulpal side, these zones Table 6.2: Differences between infected and affected dentin.
are as following: Infected dentin Affected dentin
Zone 1: Normal dentin
• It is deepest layer with normal collagen, • Soft, demineralized dentin • Demineralized dentin but
invaded with bacteria not invaded by bacteria
odontoblastic processes, and intertubular
dentin. • Soft leathery tissue which can • Does not flake easily though
be flaked easily soft in nature
Zone 2: Subtransparent dentin
• Intertubular dentin is demineralized • Irreversible denaturation of • Uninterrupted collagen
• Dentinal sclerosis, i.e. deposition of calcium collagen cross-linking
salts in dentinal tubules takes place • Cannot be remineralized • Can be remineralized
• There are no bacteria in this zone. Hence, this • Caries detecting dyes can • Does not stain
zone is capable of remineralization. stain
Zone 3: Transparent dentin
• Further demineralization of intertubular
dentin leads to softer dentin. ii. Smooth surface caries (Fig. 6.7B): Smooth surface
• No bacteria are seen and collagen cross- caries are seen on all smooth surfaces of teeth, viz.
linking is intact. Therefore, this zone is capable gingival third of buccal and lingual surfaces and
of remineralization. proximal surfaces.
Zone 4: Turbid dentin iii. Root caries (Fig. 6.7C): Root caries occur on exposed
• It shows widening and distortion of the root surface. These are most commonly seen in older
patients.
dentinal tubules which are filled with bacteria
• Dentin is not self-repairable because of less
mineral content and irreversibly denatured
collagen
• This zone should be removed during tooth
preparation.
Zone 5: Infected dentin
• Outermost zone
• Consists of decomposed dentin filled with
bacteria
• It must be removed during tooth preparation.
• Clinically, zones 2 and 3 constitute the
affected dentin and zones 4 and 5 form
infected dentin.
Histopathology of Root Caries

Root caries progresses around rather into the tooth Fig. 6.7A: Pit and fissure caries.
because of proteolysis of Sharpey’s fibers.
Spread of bacteria occurs along the Sharpey’s fibers or
in between the bundles of Sharpey’s fibers.
Table 6.2 summarizes the differences between affected
and infected dentin.
CLASSIFICATION of dental caries

Carious lesions can be classified in different ways:
1. Based on Anatomical Site

i. Pit and fissure caries (Fig. 6.7A): Pit and fissure
caries are seen in pit and fissures on occlusal surface
of posterior teeth and buccal and lingual surfaces of
molars and on lingual surface of maxillary anterior
teeth. Fig. 6.7B: Smooth surface caries.
Dental Caries 47
ii. Chronic caries: This is slowly progressing long-
standing caries. It is hard in consistency and
dark-colored.
iii. Rampant caries (Fig. 6.9): rampant caries is suddenly
appearing, widespread, and rapidly burrowing type
of caries resulting in early involvement of the pulp
and affecting those teeth that are usually regarded as
immune to caries.
Davies said that caries are rampant if:
i. Lesions are >10 in number
ii. Appearance of new and recurrent lesions in 6–10
month’s time
iii. Caries present on otherwise caries immune surfaces
Fig. 6.7C: Root caries.
iv. Extensive loss of tooth structure
v. Soft, mushy, and ivory-colored dentin indicating rapid
progression of lesion.
2. Based on Whether Lesion is New One or
Attacking
i. Primary caries (Fig. 6.8A): It denotes lesions on
unrestored surfaces.
ii. Recurrent/secondary caries (Fig. 6.8B): Lesions
developing adjacent to restorations are referred to as
either recurrent or secondary caries.
Fig. 6.9: Rampant caries.
iv. Arrested caries: Arrested caries are caries which have

Fig. 6.8A: Primary caries. become stationary or static and do not show tendency
for further progression. These are seen in caries of
occlusal surface with large open cavity which no longer
retains food and becomes self-cleansing. Dentin
shows marked brown pigmentation and induration of
the lesion, so called eburnation of dentin.
4. Based on Treatment and Restoration Design

i. Class I: Pit and fissure caries occur in the occlusal
surfaces of premolars and molars, the occlusal
two-third of buccal and lingual surface of molars, and
palatal surface of maxillary incisor (Fig. 6.10A).
ii. Class II: Caries on proximal surface of premolars and
Fig. 6.8B: Recurrent/secondary caries. molars (Fig. 6.10B).
iii. Class III: Caries in the proximal surface of anterior
teeth, not involving the incisal angles (Fig. 6.10C).
3. based on Speed of Caries Progression
iv. Class IV: Caries in the proximal surface of anterior
i. Acute caries: Rapidly invading caries involving several teeth involving the incisal angle (Fig. 6.10D).
teeth. If untreated, acute caries can result in pulp v. Class V: Caries on gingival third of facial and lingual
exposure. It is soft in consistency and light-colored. or palatal surfaces of all teeth (Fig. 6.10E).
A B C
D E F
Figs. 6.10A to F: (A) Class I dental caries; (B) Class II dental caries; (C) Class III dental caries; (D) Class IV dental caries; (E) Class V dental caries;
(F) Class VI dental caries.
vi. Class VI: Caries on incisal edges of anterior and cusp 6. Based on Extent of Caries
tips of posterior teeth without involving any other
surface (Fig. 6.10F). i. Incipient caries: It is first evidence of caries activity,
visible as white spot. It consists of demineralized
5. Based on Pathway of Caries Spread enamel which has not extended to DEJ. This lesion can
be remineralized by proper preventive procedures,
i. Forward caries: When the caries cone in enamel is
hence called as reversible caries.
larger or of same size as present in dentin, it is called
ii. Occult caries: these are seen in patients with
as forward caries.
ii. Backward caries: When spread of caries along low caries rate commonly suggestive of increased
dentinoenamel junction exceeds the caries in fluoride exposure. Increased fluoride exposure
contiguous enamel, the caries extend into enamel encourages the remineralization of surface enamel,
from DEJ. Since spread of caries here is in backward while cavitation continues in the dentin, thus lesion
direction. It is called backward caries (Fig. 6.11). gets masked by relatively intact enamel surface.
These hidden lesions are called as fluoride bombs or
fluoride syndrome.
iii. Cavitated caries: In this, caries extend beyond enamel
into the dentin. This lesion cannot be remineralized,
so also termed as irreversible caries.
7. Based on Number of Tooth Surfaces

Involved
Simple caries: Caries involving only one tooth surface is
termed as simple caries.
Compound caries: If two surfaces are involved, it is termed

as compound caries.
Fig. 6.11: Backward caries means lateral spread of caries exceeds
the caries in contiguous enamel and caries occur from DEJ into this Complex caries: If more than two surfaces are involved, it
enamel. is called as complex caries.
Dental Caries 49
8. Based on Chronology 11. WHO System of Caries Classification
i. Early childhood caries: It is a term used to describe This classification is based on shape and depth of carious
dental caries present in small children as nursing or lesion which can be scored on a four-point scale:
bottle caries and rampant caries. Bottle caries or nursing
Scalepoints Features
caries are seen in primary dentition of infants and
1. D1 Clinically detectable enamel lesions with
young children. The clinical pattern is characteristic
intact surfaces
with the four maxillary deciduous incisors most
severely affected, specially seen in bottle feeders. 2. D2 Clinically detectable cavities in enamel
ii. Adolescent caries: This type of caries is a variant of 3. D3 Clinically detectable cavities in dentin
rampant caries commonly seen in teenagers due 4. D4 Lesions extending into the pulp.
to dietary habits. It is of rapidly burrowing type
with small enamel opening. Presence of large pulp 12. Radiographic Classification of
chamber increases the chances of pulp exposure. Dental Caries
iii. Adult caries: with recession of gingiva and decreased
salivary functions, root caries are commonly seen at A. Incipient caries: Caries involving less than 1/2 the
the age of 55–60 years. thickness of enamel
B. Moderate caries: Caries involve more than 1/2 the
thickness of enamel and do not involve the DEJ
9. Based on Tooth Surface to be Restored C. Advanced caries: Caries involve enamel and DEJ and
This classification uses initials of the involved tooth less than 1/2 the distance to the pulp cavity
surfaces to be restored. D. Severe caries: Caries involve dentin more than 1/2
O. Occlusal surface the distance to the pulp cavity.
M. Mesial surface
D. Distal surface
F. Facial surface
B. Buccal surface
L. Lingual surface
10. Based on Whether Caries is Completely

Removed or Not During Treatment
A B
Residual caries (Fig. 6.12): this is the caries which is left
in the prepared cavity even after restoration is completed.
It can be left by intention or neglect. If left by neglect, it is
not acceptable. It can be left intentionally in case of deep
caries management, so as to avoid pulp exposure.
C D
Figs. 6.13A to D: Radiographic classification of dental caries.
13. Graham Mount’s Classification

This classification system is based on two simple
parameters:
1. Location of carious lesion
2. Size of carious lesion.
Here, the system is designed to recognize carious lesions
beginning at the earliest stage, in which remineralization
Fig. 6.12: Residual caries. is indicated (Table 6.3).
Table 6.3: Graham Mount’s caries classification according to location 3. Visual tactile method
and size of carious lesion.
It makes use of both visual along with tactile sensitivity
Size 1 Size 2 Size 3 Size 4 with explorer.
Cavity site (minimal) (moderate) (enlarged) (extensive)
i. European system: it depends on detailed visual
Site 1 Pit and 1.1 1.2 1.3 1.4 examination. Tooth surfaces are dried with compressed
fissure air and examined. It takes 10 minutes per subject.
Site 2 Contact 2.1 2.2 2.3 2.4 ii. The American Dental Association criteria: it uses
area softened enamel that catches the explorer and resists
Site 3 Cervical 3.1 3.2 3.3 3.4 its removal. It allows the explorer to penetrate the
region proximal surfaces with moderate-to-firm probing
pressure. Here, teeth are well-lit but not cleaned or
Table 6.4: Comparison between enamel hypoplasia and incipient
dried. It takes 3 minutes per subject.
lesion.
Characteristic 4. Radiographic Examination
features Enamel hypoplasia Caries/white spot
Surface Hard Softer than enamel For detecting caries radiographically, conventional,
On drying the Opaque in Opaque in
intraoral, periapical and bitewing radiographs are used.
surface appearance appearance Among these, bitewing radiographs are of more value in
detecting proximal caries, to check margins of proximal
On wetting the Opaque in Translucent in
surface appearance appearance restorations and to see pulp anatomy.
DIAGNOSIS Of dental caries Caries of Different Surfaces of Teeth

1. Caries of occlusal surfaces (Fig. 6.14A): Radiographic
1. Visual Examination diagnosis of pits and fissures decay is difficult in earlier
Visual examination is based on the criteria like cavitation, stages because decalcified, radiolucent tooth structure
surface roughness, opacification and discoloration of is small in percentage compared to the healthy
clean and dried teeth under adequate light source. surrounding tooth structure. Detection is possible
Advantage: when the decay is more advanced in the dentin; once
Preferred overprobing because of harmful effects of in dentin, the classical radiographic appearance is
probing. broad-based thin radiolucent zone in dentin with little
Disadvantages: or no apparent change in the enamel is seen.
i. Discoloration of the pits and fissures which is found 2. Caries of proximal surfaces (Fig. 6.14B):
in normal healthy teeth, can be mistaken for the Bitewing radiographs are preferably used to detect
presence of caries. interproximal caries. Lesions confined to enamel may
ii. Even when demineralization is detected in the pits not be evident radiographically until approximately
and fissures, it is difficult to assess the level of caries 30–40% demineralization has occurred. Shape of early
penetration. lesion in enamel is triangular with its broad base at
the tooth surface. Once the lesion crosses the DEJ and
2. Tactile Examination invades into the dentin, it appears as another triangle
Here explorer is used to detect softened tooth structure. with base at DEJ and apex toward the pulp chamber.
Since demineralization does not always involve sufficient 3. Caries of buccal and lingual surfaces: It is difficult
softening of enamel, when an explorer sticks, it indicates to differentiate between buccal and lingual caries
decay. However, when it does not stick, it does not on a radiograph. Buccal or lingual caries appears as
necessarily mean that decay is not present. Explorers used well-defined radiolucency surrounded by a uniform,
for detection of caries are right angle probe, Shepherd’s noncarious region of enamel.
crook, back action probe, cowhorn with curved end, and 4. Root surface caries (Fig. 6.14C): Root caries appear
sharp curved probe. as diffuse radiolucent areas with ill-defined borders
explorer is used with gentle pressure just to blanch a on proximal aspects of teeth in the cervical areas.
fingernail without causing any pain. Tactile examination is 5. Secondary caries (Fig. 6.14D): Secondary caries are
done carefully because sharp edge of explorer can cavitate difficult to diagnose in radiograph because it may get
the enamel and actually create an opening through which obscured by the radiopaque image of the restoration.
cariogenic bacteria can penetrate. Cariogenic bacteria Recurrent caries at cervical margins are best observed
on the tip of the probe can be seeded into other pits and in bitewing films, since the central ray is directed
fissures, so that an uninfected tooth can be infected. along the plane of the cervical areas.
Dental Caries 51
A B
C D
Figs. 6.14A to D: (A) Occlusal caries on mandibular 1st molar; (B) Incipient interproximal caries;
(C) Root surface caries; (D) Secondary caries.
Cervical burnout (Fig. 6.15)

Cervical burnout is an apparent radiolucency found just below the CEJ due to anatomical variation or a gap between the enamel and
bone covering the root, mimicking root caries.
Posterior cervical burnout: It appears because invagination of the proximal root surfaces allows more X-rays to pass through this
area, resulting in a more radiolucent appearance on the radiograph. When radiograph is taken at different angles, X-rays pass through
more tooth structures and radiolucency disappears.
Anterior cervical burnout: Space between the enamel and bone overlying the tooth appears more radiolucent than either the
enamel or the bone-tooth combination.
Fig. 6.15: Cervical burnout (arrow).

5. Dye Penetration Method converts them into one of 256 discrete gray levels.
It consists of a video monitor and display processing
Dyes differentiate mineralized from demineralized dentin. unit. (3) “Graphy” part of RVG unit consists of
a. Dyes for detection of carious enamel: digital storage apparatus. It can be connected to
i. Procion: Problem with dye is that it reacts with printer or mass storage devices for immediate or
nitrogen and hydroxyl groups of enamel. later viewing.
ii. Calcein: It complexes with calcium.
b. Dyes for detection of carious dentin: Dyes do not stain
bacteria but the organic matrix of less mineralized
dentin, this makes them less specific. Dyes used for
caries in dentin are 0.5% basic fuchsin in propylene
glycol and 1% acid red in propylene glycol.
6. Ultraviolet illumination
Ultraviolet light increases optical contrast between
carious area and the surrounding healthy tissue. Natural
fluorescence of enamel is decreased in carious areas
because of less mineral content. Carious lesion appears
dark spot against a fluorescent background. This method
is more sensitive method as compared to the visual tactile
methods but it difficult to differentiate developmental
defects and caries.
Fig. 6.16: Photograph showing sensor of RVG.
7. Fiberoptic Transillumination (FOTI)
A carious lesion has a lower index of light transmission, so Advantages Disadvantages
appears as a darkened shadow. It is a noninvasive method • Low radiation dose • Expensive
in which fiber-optic probe can be placed in buccal or • Dark room is not required • Life expectancy of CCD is not
lingual embrasure and caries appears as dark shadow. • Elimination of hazards of film fixed
development • Solid state sensors when used
Advantages Disadvantages • Contrast and resolution can for bitewing examination are
• Noninvasive method • Not possible in all anatomic be altered, and images can small as compared to size-2
• Useful in patients with locations be viewed in black and white film
posterior crowding • Considerable intra- and inter color (Figs. 6.17A to E) • Bulky sensor with cable
• No radiation hazards observer variation and no • Images are displayed attachment which can make
• Comfortable to patient permanent records instantly placement in mouth difficult
• Lesions which cannot be • Infection control and toxic
diagnosed radiographically waste disposal problems
can be diagnosed by this associated with radiology are
method eliminated
Recent Methods of Caries Detection b. Phosphor imaging system: Imaging using a

photostimulable phosphor plate can also be called
1. Digital Dental Radiography as an indirect digital imaging technique. The image is
Digital imaging systems require an electronic sensor or captured on a phosphor plate as analog information
detector, an analog to digital converter, a computer and a and is converted into a digital format when the plate is
monitor or printer for image of the components of imaging processed.
system.
a. Radiovisiography (RVG): It is composed of three Advantages Disadvantages
major parts (Fig. 6.16)—(1) its radio part consists of • Low radiation dose • Cost
a conventional X-ray unit and a tiny sensor to record • Almost instant image (20–30 • Slight inconvenience of
seconds) plastic bags
the image. Sensor transmits information via fiber-
• X-ray source can be remote
optic bundle to a miniature charge coupled device from PC
(CCD). (2) “Visio” portion of the system receives • Image manipulation facilities
and stores incoming signals during exposure and
Dental Caries 53
4. Tuned Aperture Computed Tomography (TACT)
TACT is a tomosynthetic technique which conquers the
shortcomings of conventional radiography. With this
technique, a three-dimensional image can be formed by
generating a series of cross-sectional images of an object
and then combining them.
A B
5. Digital Imaging Fiberoptic Transillumination (DIFOTI)
light from DIFOTI probe is positioned on the tooth, tooth
is illuminated, and resultant images are captured by a
digital electronic charge-coupled device (CCD) camera
and displayed on computer.
Advantages Disadvantages
C D • Noninvasive • Does not measure the depth
• Instant image projection of the carious lesions
• Can detect even incipient and • Does not differentiate dental
recurring caries caries and stained deep
fissures
6. Endoscopic Filtered Fluorescence (EFF) method

E It is based on observing the fluorescence that occurs when
tooth is illuminated with blue light, carious lesion appears
Figs. 6.17A to E: Visio part displays the captured images. Diagnostic darker than enamel. In this, camera can be used to store
capability is increased by changing the color, contrast, and magnifica- the image. It can easily diagnose the incipient caries but it
tion of the area. is expensive and time-consuming method.
7. Electrical Conductance Measurement

2. Xeroradiography
Sound tooth enamel is a good electrical insulator due
In this technique, the image is recorded on an aluminium to its high inorganic content. Electrical conductivity is
plate coated with selenium particles. Plate is removed from directly proportional to the amount of demineralization.
the cassette and subjected to relaxation which removes Vanguard electronic caries detector measures the
old images, then these are electrostatically charged and electrical conductivity of the tooth. The electrical
inserted into the cassette. Radiations are projected on conductivity is expressed numerically on a scale from 0 to
films which cause selective discharge of the particles 9, indicating a change from sound tooth to an increased
forming a latent image. This is converted to a positive degree of demineralization.
image by a process called “development” in the processor
unit. This technique offers “edge enhancement” (“edge Advantages Disadvantages
enhancement” means differentiating areas of different • Very effective in • Can only recognize demineralization
densities especially at the edges). detecting early pit and not caries specifically
and fissure caries • A sharp metal explorer is utilized
• It can monitor the which is pressed into the fissure
3. Digital Subtraction Radiography progress of caries causing traumatic defects
In this technique, images which are of no diagnostic • Separate measurements are required
for different sites making full mouth
value are subtracted so that changes in radiographs can
examination quite time-consuming
be accurately detected. Here, standardized radiographs
produced with identical exposure geometry are used. The
8. Qualitative laser fluorescence
first one is reference image and subsequent images are
taken for comparison. Reference image is displayed on This technique uses argon laser (488 nm) with a filtered
screen over which subsequent images are superimposed. blue light source. Fluorescence of tooth structure is due to
Difference between reference image and subsequent the presence of chromophores within the enamel. Carious
images can be seen as dark areas. It has advantage of enamel results in increase in light scattering and resulting
producing better images but is expensive. in less fluorescence.
In this technique, blue light is used to irradiate the 10. Optical Coherence Tomography (OCT)
surface of the tooth and the resultant fluorescent image is
It utilizes broad bandwidth light sources and advanced
captured in a computer. QLF shows demineralization or
fiber-optics to achieve images. It uses reflections of
incipient lesions as a dark spot. Caries and plaque appear
infrared light with considerable penetration into tissue.
red in color indicating bacterial presence. The images can
be stored, measured and quantified in terms of shape of an
area. Advantages Disadvantage
• High probing depth in • Loss of penetration depth
Advantages Disadvantages scattering media occurs in OCT images, thus
• Helps in detecting incipient • It provides moderate • High depth and transverse it is difficult to use it in early
caries sensitivity and specificity resolution decay
• Can detect failing fissure • Expensive • Noninvasive operation
sealants • Not able to differentiate • More sensitive method for
• Can monitor enamel erosion caries or hypoplasia detection of recurrent caries
• Convenient and fast
11. Dye-enhanced Laser Fluorescence (DELF)
9. DIAGNOdent (Fig. 6.18)
DELF approach is based on the hypothesis that if a
Based on principle of fluorescence, it uses a diode laser fluorescent dye penetrates an early carious lesion,
light source and a fiberoptic cable that transmits light to a detection of early mineral loss could be enhanced. One
hand held probe. Before using DIAGNOdent, the unit must of the dyes used is Pyrromethene 556. In the absence
be calibrated with the selected tip and a patient-specific of plaque, DELF is a better diagnostic tool than LF in
baseline must be established. detection of demineralization in artificial tissues.
Place the tip on the area to be evaluated. Use a rocking
motion with the tip. Note and record the peak value. Based RECURRENT CARIES (SECONDARY CARIES)
upon in vivo studies, the following correlations can be
made: Secondary or recurrent caries are defined as caries on
the tooth surface which is in contact with the restoration.
Value 0–14 : No caries
Secondary caries may be present at surface enamel
Value 15–20 : Histological caries within enamel
surrounding the restoration or extend below it along
Value 21–99 : Histological dentinal caries
the margins. Therefore, these are also referred as caries
Advantages Disadvantages adjacent to restorations and sealants (CARS).
• Because of its good • Increase likelihood of false-
reproducibility, it can be used positive diagnosis Etiology
to monitor caries regression • Sensitive to the presence of
or progression stains
◆◆ Main causative factor is marginal leakage around the
• Measures both sensitivity and • Any changes in the physical restorations
specificity of the lesion structure of enamel-like ◆◆ Fracture of the marginal tooth structure, microleakage
• Detection of occlusal and hypoplasia may give false ◆◆ Presence of overhangs
accessible smooth surface readings ◆◆ Rough surface of the restoration along with poor oral
lesions • It can not detect secondary hygiene
caries ◆◆ Unpolished enamel surfaces.
Fig. 6.18: DIAGNOdent.

Dental Caries 55
Microbiology ◆◆ Stains at the margins of tooth-colored restorations are
difficult to differentiate from recurrent caries.
In the outer surface lesion, acid production is predisposed ◆◆ Catch formed while probing tooth restoration interface
by bacteria present on the tooth surface. In wall lesion, acid
may not be carious, though it appears to be.
production is predisposed by the penetration of bacteria
◆◆ Two-dimensional radiographic picture.
along the tooth-restoration interface. This depends upon
◆◆ Radiopacity of restoration obstructs the lesion.
type and amount of plaque present on tooth surface.
◆◆ The burnout at the cervical margin may make the
Most common microorganisms with recurrent caries
interpretation difficult.
are Streptococcus mutans, lactobacilli, and actinomyces
viscosus. Classification by Espelid and Tveit (1991)
Clinical Diagnosis ◆◆ S-1: Initial carious lesion characterized by discolora
tion only
◆◆ Secondary caries has been described as occurring in two ◆◆ S-2: Lesions characterized by softness in enamel
ways: An “outer lesion” and a “wall lesion” (Fig. 6.19). ◆◆ S-3: Lesions with cavitation on the root surfaces.
◆◆ Chemical and histological processes involved in “outer
lesions” are the same as primary caries. “Wall lesion” Treatment
is the lesion which is present on the preparation One should consider reburnishing and repairing the
walls. It occurs because of microleakage of oral fluids, defects at restoration margins rather than going for
percolation of hydrogen ions and lytic enzymes replacement of restoration.
from plaque, and bacterial colonization along the If there is any doubt about diagnosis, exploratory
cavosurface wall. preparation into the restorative material adjacent to the
◆◆ If there is only outer lesion is present but not the wall defect determines the extent and forms a firm diagnosis.
lesion, it can be due to closure of the interface between This will determine the need for repair or replacement of
the preparation wall and the restoration because of the restoration (Flowchart 6.2).
corrosion products.
◆◆ If only wall lesion is present, it can be due to the ROOT CARIES
resistance of the occlusal enamel to demineralization. Root caries, as defined by Hazen, is a soft, progressive
lesion that is found anywhere on the root surface that
Difficulties in Diagnosis of Secondary Caries has lost its connective tissue attachment and is exposed
to the environment. Root caries occurs at or apical to the
◆◆ Small size of the initial lesion. cementoenamel junction (CEJ) (Fig. 6.20).
◆◆ Color change is, dusty white to brownish, difficult to
interpret in amalgam restorations. Etiology
◆◆ It is difficult to examine wall lesion clinically unless
Microflora responsible for root caries consists of
there is adequate demineralization which is seen
Streptococcus mutans, Lactobacillus, and Actinobacillus.
through the overlying enamel.
Factors affecting occurrence of root caries:
Flowchart 6.2: Tooth management in case of presence of a previous

restoration.
Fig. 6.19: Diagrammatic representation of an outer lesion and wall

lesion in a secondary caries.
◆◆ Most commonly, they are seen in mandibular molars,

followed by premolars, canines, and incisors. This order
is reversed in the maxilla.
Diagnosis
◆◆ Tooth surface should be cleaned before examination
since plaque covering the lesion can lead to
misdiagnosis.
◆◆ Accurate radiographs can also help in diagnosis but they
should be free from overlapping or burnout (Table 6.5).
◆◆ Special dyes can be useful for detecting root caries,
these dyes stain the infected dentin and thus allow the
clinician to detect caries.
Fig. 6.20: Root caries.
Table 6.5: Differential diagnosis of root caries.
Intraoral Factors Active root Arrested root Extrinsic stain

caries caries on root surface
◆◆ Xerostomia
Color Light brown Dark brown to Dark in color
◆◆ Low salivary buffer capacity black
◆◆ Poor oral hygiene
Surface Soft, leathery, Hard and Hard and
◆◆ Periodontal disease and periodontal surgery texture and elastic in cannot be rough texture
◆◆ Gingival recession nature compressed
◆◆ Frequency of carbohydrate intake
◆◆ Unrestored and restored coronal and root caries Facts
◆◆ Overdenture abutments and removable partial dentures
◆◆ Malocclusion Demineralization of enamel starts at pH of 5.3.
◆◆ Abfraction lesions Demineralization of root surface takes place at the pH of 6.4.
Rate of demineralization of root occurs at higher pH and is
◆◆ Tipped teeth which make areas of teeth inaccessible for
much faster than that of enamel because the root has much
cleaning. less mineral content (55%) than that of enamel (99%).
Extraoral Factors
Prevention
◆◆ Advanced age
◆◆ Medications that decrease the salivary flow ◆◆ Proper preventive measures of plaque removal, diet
◆◆ Lower educational and socioeconomic levels modification, and the use of topical fluoride should be
◆◆ Antipsychotics, sedatives, barbiturates, and advocated.
antihistamines ◆◆ Special attention should be given to root caries-prone
◆◆ Diabetes, autoimmune disorders (e.g. Sjögren’s patients who are wearing dental prostheses. This can be
syndrome) done by avoiding the placement of restoration margins
◆◆ Radiation therapy apical to the surrounding tissue to avoid plaque
◆◆ Gender—males are affected more than females accumulation.
◆◆ Physical disability where patients have limited manual ◆◆ In patients with low salivary flow, xylitol-containing
dexterity for cleaning of teeth chewing gum which stimulates salivary flow and
◆◆ Limited exposure to fluoridated water decreases plaque formation has shown to decrease the
◆◆ Consumption of alcohol or narcotics. caries.
Features of Root Caries Treatment

◆◆ Root surface caries are initiated when there is ◆◆ For proper restoration, sufficient access and isolation
periodontal attachment loss exposing the root surface are needed to evaluate the carious lesion (Flowchart
to the oral environment. 6.3).
◆◆ It is a soft, irregular, and progressive lesion occurring at ◆◆ To begin with, root surface is cleaned with pumice to
or apical to the CEJ. remove the plaque.
◆◆ An area where root caries has taken place may appear as ◆◆ Then, the excavation of carious tooth tissue is done
round or oval in shape which then may spread radially. and restoration walls are prepared. The margins and
◆◆ More common in males than females. retention design depend on the restorative material
Dental Caries 57
Flowchart 6.3: Tooth management in case of root caries. CARIES RISK ASSESSMENT
Main objective of caries risk assessment in dentistry is
to deliver preventive and restorative care specific to an
individual patient. Caries risk assessment of a person can
be done by caries activity tests. Assessment of a caries risk
at screening or initiation of therapy allows better appraisal
of caries activity and refinement of the treatment planning.
For example, children at high risk of caries require intense
prevention to primarily prevent caries initiation and
secondarily to arrest caries progression.
High Caries Risk

used. For example, when a tooth is to be restored with A patient is said to be at high caries risk, if there is:
amalgam, retention grooves are required occlusally ◆◆ One new lesion on smooth surface during past 1 year
and gingivally. For composites, beveling of the coronal ◆◆ New carious lesion on root surface
margins of the preparation is required. ◆◆ Patient on medication which causes hyposalivation
◆◆ Systemic disorder
Restorative Materials Used for Treatment ◆◆ Past dental history with multiple restorations
of Root Caries ◆◆ Exposure to sugary snacks for more than three times a
Direct filling gold was material of choice because of its day
ability to adapt the preparation walls with good marginal ◆◆ Senility.
adaptation. But since isolation of these areas is difficult, Factors commonly seen in patients with high caries risk:
the use of direct filling gold is decreased. ◆◆ Status of oral hygiene:
Dental amalgam is easy to manipulate, can be used •• Poor oral hygiene
in areas which are difficult to isolate, and has self-sealing •• Nonfluoridated toothpaste
property. •• Low frequency of tooth cleaning
Traditional glass-ionomer cements have the desirable •• Orthodontic treatment
properties of being biocompatible, bonding chemically •• Partial dentures.
to tooth and showing anticariogenicity (Figs. 6.21A and ◆◆ Dental history:
B). But they have poor aesthetics and excessive wear with •• History of multiple restorations
time. •• Frequent replacement of restorations.
Resin-modified glass ionomers are biocompatible, ◆◆ Medical factors:
bond to tooth, have thermal expansion and contraction •• Medications causing xerostomia
characteristics that match tooth structure, and fluoride •• Gastric reflux
releasing feature. •• Sugar-containing medications
Microfilled composites are recommended for root •• Sjögren’s syndrome
surface restorations as they have lower elastic modulus ◆◆ Behavioral factors:
than hybrid composites. This is an advantageous •• Bottle feeding at night
property, since the teeth flex during mastication and a •• Eating disorders
flexible material will be a better choice to restore the root •• Frequent intake of snacks
surface. •• More sugary foods
•• Nonfluoridated toothpaste.
◆◆ Socioeconomic factors:
•• Low education status
•• Poverty
•• No fluoride supplement.
Caries Activity Tests

Caries activity tests help in the following ways:
A B ◆◆ In determining the need for caries control measures
Figs. 6.21A and B: GIC restorations: (A) Preoperative view; (B) Post- ◆◆ In determining the optimal time for restoration
operative view. ◆◆ In determining the results of preventive measures.
Unstimulated Salivary Flow Test −− Fluorides

−− Iodides
Patient is asked to sit upright in chair to drool into a
−− Zinc chloride
collection cup for 5 minutes.
◆◆ More than 0.25 – Normal −− Silver nitrate
◆◆ 0.1–0.25 – Low −− Bisbiguanides.
◆◆ Less than 0.1 – Very low c. Application of remineralizing agents
It can also be done by visually assessing the saliva d. Use of pit and fissure sealants.
production from the minor salivary glands on the lower
labial mucosa. For this, revert the lower lip, block labial 1. Methods to Reduce Demineralizing
mucosa with a piece of tissue and observe the time. Factors
◆◆ Less than 30 seconds – High
◆◆ 30–60 seconds – Normal A. Dietary Measures
◆◆ More than 60 seconds – Low
i. Sugar substitutes like xylitol and sorbitol can be
used. xylitol is nonfermentable, noncariogenic sugar.
Saliva Viscosity Test First chewing gum form of xylitol was introduced in
Visually inspect the viscosity of resting saliva. If it is frothy Finland in 1975. Currently, xylitol is available in many
or bubbly, it indicates low water content in saliva. forms like chewing gums, chewable tablets, lozenges,
toothpastes and mouthwashes (Fig. 6.22). Xylitol
Resting pH of Unstimulated Saliva causes reduction in plaque formation, bacterial
adherence, enamel demineralization and increases
To measure pH of resting saliva, drop the saliva on pH salivary flow and concentration of amino acids which
paper strip, and note the value. neutralizes the plaque acidity.
◆◆ Healthy resting pH = 6.8–7.8 ii. Avoid excessive intake of sugary and sticky foods,
◆◆ Moderately acidic resting pH = 6.0–6.6 such as cakes, biscuits, jams, and sweets.
◆◆ Acidic resting pH = 5.0–5.8 iii. Intake of raw fruits and vegetables helps in
increasing the salivary flow, thereby removal of food
Salivary Buffering Capacity Test debris from the oral cavity. These foods contain
For this test, add stimulated saliva to a test strip. Acids natural phosphates, phytates, and nondigestible
present in test strip dissolve and there occurs decrease fibers; moreover, they do not stick to teeth.
in the pH. If saliva can buffer, the pH will rise and the iv. Low caloric sweeteners: Use of aspartame, saccharin,
indicator will show final pH. and cyclamate is considered useful to prevent caries.
v. Fats form a protective barrier on enamel or
S. mutans, Lactobacillus Test carbohydrate surface, so that it becomes less available
for bacteria. They also speed up the clearance of
In this test, S. mutans count is estimated. For this, rotate the carbohydrate from oral cavity, thus decreasing
spatula on the patient’s tongue and incubate it in a special cariogenic potential.
culture medium. After this, compare the results with the vi. Cheese causes increase in salivary flow, increase in
manufacturer’s chart to estimate the S. mutans count. pH, and clearance of sugar.
vii. Trace elements also have an effect on dental caries.
PREVENTION of dental caries
Main objectives of dental caries prevention are to reduce
number of cariogenic bacteria that cause demineralization
and to create an environment favorable for remineralization
of the tooth. These objectives can be met as following:
1. Methods to reduce demineralizing factors:
a. Dietary measures
b. Methods to improve oral hygiene
c. Chemical measures.
2. Methods to increase protective factors:
a. Methods to improve flow, quantity and quality of
saliva
b. Chemicals altering the tooth surface or tooth
structure: Fig. 6.22: Xylitol.
Dental Caries 59
Table 6.6 showing minerals and their effects on caries. c. Interdental brushes: These are cone-shaped
brushes with nylon bristles of different sizes. These
Table 6.6: Minerals and their effects on dental caries. are used in cases of wide interdental spaces (Fig.
Effects Minerals 6.24C).
Cariostatic Fluoride (F), Phosphate (PO4)
C. Chemical Measures
Mild cariostatic Fe, Li, Cu, B, Mo, V, Sr, and Au
Doubtful Co, Zn, Br, and I i. Substances interfering with carbohydrate degra
dation through enzymatic alterations: Vitamin K;
Caries inert Al, Ni, Ba, and Pd
it prevents acid formation, when added in incubated
Caries promoting Mg, Cd, Pb, and Si mixtures of glucose and saliva.
ii. Substances interfering with bacterial growth and
B. Methods to Improve Oral Hygiene metabolism
Oral hygiene can be improved by dental prophylaxis, a. Chlorhexidine gluconate: Chlorhexidine, a
toothbrushing, and interdental cleaning. bisbiguanide, is active against several bacteria,
with low concentrations being bacteriostatic and
i. Dental prophylaxis: In dental prophylaxis, polishing
high concentrations bacteriocidal. Chlorhexidine
of roughened tooth surfaces and replacement of faulty
binds to the bacterial cell wall, interferes with
restorations are done so as to decrease the formation
membrane transport systems, and causes
of dental plaque, and thereby decreasing incidence of
cytoplasmic protein precipitation.
caries.
b. Metal ions like zinc, copper, and strontium:
ii. Toothbrushing: Nowadays, toothbrushing and other
These ions show antimicrobial effects depending
mechanical cleaning procedures are considered
to be the most reliable means of controlling
plaque and provide clean tooth surface. Many
toothbrushing techniques have been described and
being promoted as being effective. Bass technique
is most recommended as it emphasizes sulcular
placement of bristles, while in periodontal cases,
sulcular technique with vibratory motion is preferred
(Fig. 6.23).
iii. Interdental cleaning: interdental surfaces which
cannot be cleaned by ordinary toothbrushes, should
be cleaned by means of dental floss, tape, and
interdental brushes.
a. Dental floss and tape: These are made up of nylon,
yarn, or teflon. It can be waxed or nonwaxed. It
is used in persons with normal proximal contact
between their teeth (Fig. 6.24A).
b. Wooden sticks: They are indicated in patients
with wide interdental spaces because of gingival
recession and/or loss of periodontal attachment
(Fig. 6.24B). Fig. 6.23: Different motions of toothbrushing.
A B C
Figs. 6.24A to C: (A) Dental floss; (B) Wooden sticks; (C) Interdental brushes.
on free ion concentration in the oral cavity. Metal A

ions have antiglycolytic effects and also reduce the
adherence of the dental biofilm to the tooth.
c. Triclosan: Triclosan, a nonionic bisphenol,
is a broad-spectrum antibacterial agent with
high substantivity. Triclosan is an inhibitor of
phosphotransferases and causes lysis of the
bacterial cell membrane, resulting in leakage and B
death of the organism.
d. Sodium dodecyl sulfate: It acts as a surfactant
and inhibits bacterial enzymes, such as gluco
syltransferase, phosphoenolpyruvate, and
phosphotransferase.
e. Iodine: Iodine is a strong antimicrobial that kills
on contact. Application of iodine is done only at Figs. 6.25A and B: Formation of fluorapatite crystals.
office, and it is not suggested for patient for home
use.
iv. Inhibits bacterial metabolism
f. Urea and ammonium compounds: Urea on
v. Inhibits plaque formation
degradation releases ammonia, neutralizes the
vi. Reduces “wettability of surfaces of tooth.
acids, and interferes with bacterial growth.
Fluoride products:
g. Nitrofurans: These compounds are believed to
i. Professional topical fluorides: Commonly used
have both bacteriostatic and bactericidal action
products under professional applications are:
on gram-positive and gram-negative organisms.
• 2.72% acidulated phosphate fluoride (APF)
h. Glutaraldehyde: 2 minutes of daily application
gel (Fig. 6.26A): It has 3.5 pH and contains
of glutaraldehyde reduces mineral loss in dentin
12,300 ppm fluoride. It is made from sodium
caries due to collagen fixation and reducing
fluoride and 0.1 M phosphoric acid.
diffusion of ions out of the carious lesion.
• 2% sodium fluoride gel (Fig. 6.26B): It
contains 9,200 ppm fluoride. It is preferred in
2. Methods to Increase Protective Factors composite restorations because APF etches
A. Methods to Improve Flow, Quantity, and Quality of glass filler particles of the composites.
Methods of use:
Saliva
i. Determine total fluoride exposure of the
If normal salivary flow is reduced, incidence of caries patient. Administer 0, 1, 2, 3, and 4 times a
increases. Strategies should be made to increase the year as indicated by caries risk level.
quantity and quality of salivary flow. Salivary flow can be ii. Isolate the teeth and apply gel for 4 minutes.
improved by chewing sugar-free candies or xylitol chewing iii. Advise patient to avoid rinsing, drinking, or
gum several times a day. In patients with hyposalivation, eating for 30 minutes after application
baking soda may help to neutralize acids. The mouth rinse iv. Apply at age of 3, 7, 11 and 13 years of age
is prepared by mixing two teaspoons of baking soda in and 4 applications each year at one week
eight oz of water. interval.
ii. Fluoride varnish: Duraflor (Fig. 6.26C) is
B. Chemicals Altering the Tooth Surface or Structure commonly used fluoride varnish which contains
1. Fluorides: Fluoride ions increase the resistance of 5% NaF. Fluor protector (Fig. 6.26D) contains
hydroxyapatite in enamel and dentin to dissolution 0.7% silane fluoride and is used as a cavity
by plaque acids. The maximum benefit from fluoride varnish. For high-risk patient, fluoride varnish
is accomplished when there is a constant low level is applied every 3 months. For moderate-risk
available for remineralization. Sources of fluoride in patient, fluoride varnish is applied every 6
human diet are potatoes, bananas, tea leaves, rock months. Although the caries benefits are similar
salt, salmon, and sardines. to topical fluoride gels, less total fluoride is
Effects of fluorides: released into the oral cavity during treatment
i. Formation of fluorapatite (less soluble than when compared to fluoride gels.
hydroxyapatite) (Figs. 6.25A and B) iii. Mouthrinses (Fig. 6.26E): A mouthrinse may
ii. Inhibits demineralization contain active ingredients like chlorhexidine
iii. Induces remineralization gluconate, essential oils, triclosan, and sodium
Dental Caries 61
Fig. 6.26A: Acidulated phosphate fluoride (APF) gel. Fig. 6.26D: Fluor protector.
Fig. 6.26B: Sodium fluoride gel. Fig. 6.26E: Mouthrinse.
dodecyl sulfate. Daily rinsing with 0.05% NaF

(226 ppm F), and use of 0.2% NaF (900 ppm F)
once every 2 weeks has shown to be effective.
Because of chances of fluoride ingestion, mouth
rinsing is not recommended for children under 6
years of age.
iv. Dentifrices: Dentifrices are considered as
principal means of delivering topical fluoride.
Factors affecting anticariogenicity of a dentifrice
are:
−− Frequency of dentifrice use: Brushing twice per
day is more effective than once per day.
−− Duration of brushing.
−− Rinsing after brushing: Rinsing after tooth
brushing affects the rate of fluoride clearance.
−− Time of day that dentifrice is used: When
Fig. 6.26C: Fluoride varnish. compared to daytime application, bedtime use of
fluoride dentifrice results in retention of fluoride

because of decreased salivary flow during sleep.
−− Concentration of fluoride in dentifrice: Higher
the fluoride concentration, greater is the fluoride
diffusion toward the tooth surface.
−− Fluoride supplements: While prescribing the
fluoride supplements, the dosage must be taken
into account and it should be scheduled according
to patient need.
−− Fluoridated salt: Intake of fluoridated salt is an
alternative where the water fluoridation is not
feasible. Concentration of fluoride in salt should
depend on salt intake and the availability of
fluoride from other sources. Fig. 6.27: Mechanism of action of CPP-ACP on enamel surface.
Different sources of fluoride used in dentifrices
are stannous fluoride (SnF2), sodium monofluoro
(CPP), and amorphous calcium phosphate (ACP)
phosphate (Na2PO3F) (MFP), and sodium fluoride
complexes.
(NaF). All dentifrices are formulated to contain
Mechanism of action of CPP-ACP:
either 1,000 or 1,100 ppm fluoride in the form of
◆◆ CPP stabilizes calcium phosphate in solution and
NaF and MFP.
increases the level of calcium phosphate. Thus,
2. Silver nitrate: Silver is thought to be responsible
CPP-ACP nanocomplexes act as a reservoir of calcium
for plugging the enamel either by organic invasion
and phosphate ions so as to have supersaturation state
or inorganic invasion pathways. It combines with with respect to tooth enamel and buffer plaque pH (Fig.
soluble inorganic portion of enamel to form a less 6.27).
soluble combination. ◆◆ CPP-ACP inhibits caries by concentrating ACP in dental
3. Zinc chloride: Zinc chloride is considered to have plaque, preventing demineralization, and increasing
some role in prevention of caries. remineralization.
C. Application of Remineralizing Agents D. Use of Pit and Fissure Sealants

Ideally, remineralizing agents are required to rapidly “A pit and fissure sealant is a material that is placed in the
precipitate on partially demineralized tooth structure and pits and fissures of teeth in order to prevent or arrest the
transform into a more stable, less acid-soluble apatite than development of dental caries”. For better results, sealants
the hard tissue replaced. For optimal remineralization, the should be placed soon after eruption because of more
agent must also be able to diffuse into the pellicle covered susceptibility of caries during the posteruption period.
enamel surface. if the mineral phase is soluble in saliva
or acids, it will be rapidly lost and its benefits are not Advantages
◆◆ Seal pits and fissures mechanically making them
achieved. Since it is almost impossible to diffuse calcium
resistant to food impaction
and phosphate ions into the deeper layers of the decay,
◆◆ Make pits and fissures self-cleansable
most of the remineralization is restricted to the surface of
◆◆ Halt incipient carious lesion.
decay.
Remineralizing approaches: Remineralizing agents are Case selection
available in various forms like dentifrices, mouthwashes, ◆◆ In children with medical, physical, or intellectual
chewing gums, lozenges, and foods and beverages. Various impairment
approaches to enhance remineralization are: ◆◆ In children with signs of acute caries activity
◆◆ Combining remineralizing agents with fluoride (to ◆◆ Children and young people with no signs of caries
increase anticariogenicity of fluorides). activity but having potentially susceptible areas like
◆◆ Combining remineralizing agents with a lower dosage deep fissures.
of fluoride to decrease the possibility of dental fluorosis Table 6.7 shows indications and contraindications of
without losing effectiveness. pit and fissure sealants.
◆◆ Use of remineralizing materials as independent agents.
Commonly used agents are calcium glycerophosphate Types of pit and fissure sealants
and calcium lactate, dicalcium phosphate dihydrate Resins: Resin sealants are bonded to enamel by acid-etch
(DCPD), calcium carbonate, casein phosphopeptide technique.
Dental Caries 63
Table 6.7: Indications and contraindications for pit and fissure 4. Washing and drying: Tooth is washed and then dried
sealants. with compressed air for 15 seconds to have a chalky
Indications Contraindications and frosted appearance.
5. Application of sealant: Sealant is applied in liquid
• Children and young adults • Children and young adults
form in pit and fissures and allowed to remain
with high-risk for caries having low-risk for caries
undisturbed for 20 seconds before applying curing
• Teeth showing signs of • Teeth with easily cleanable light. Evaluate sealant for retention, flaws and
incipient caries fossa and grooves occlusion.
• In adult patients with • Stained occlusal pits and
potentially susceptible area fissures
like deep fissures • Cases in which isolation of CURRENT METHODS OF CARIES PREVENTION
tooth is difficult
1. Genetic Modalities in Caries Prevention
• Young permanent teeth • Teeth showing resistance to
having deep retentive pits caries after 3–4 years In an attempt to produce the strains of S. mutans which
and fissures cannot cause caries, various researches were conducted
at genetic level to control caries. Genes for enzyme
glycosyltransferase were decoded, resulting in new strains
Compomers: Their properties are comparable to resins. of S. mutans which lacked the capability to produce lactic
Glass ionomer cement (GIC): They bond chemically to tooth acid responsible for caries.
structure with active fluoride release into the surrounded
enamel. i. Genetically Modified Foods
Technique for placement of resin sealants (Figs. Research has been carried out to produce genetically
6.28A to E): modified foods in an attempt to prevent tooth decay.
1. Surface cleaning: Before application of pit and fissure They can be given as “probiotics”. These modified fruits
sealant, surface should be cleaned properly in order to and vegetables are being developed by incorporating
obtain optimal bonding. antagonist peptides to work against glycosyltransferase.
2. Isolation: Isolation by rubber dam is important
because salivary contamination decreases the bond ii. Genetically Modified Organisms
strength of sealant. S. mutans causes tooth decay by converting sugar into
3. Etching: Etching is done by using 37% phosphoric lactic acid which causes dissolution of tooth tissue with
acid to make surface little rough. the help of enzyme lactodehydrogenase. A new strain of
A B C
D E
Figs. 6.28A to E: Steps for placement of pit and fissure sealant: (A) Tooth preparation; (B) Application of etchant; (C) Washing and drying; (D)
Application of sealant; (E) Light curing of sealant.
S. mutans has been created which lacks lactodehydrogenase Three Routes have been tried to Achieve Caries Immunity
gene, thus unable to produce lactic acid. in Animal Studies
Lactobacillus zeae: lactobacillus zeae is genetically ◆◆ Systemic route
modified bacteria which produce antibodies so as to ◆◆ Mucosal route
attach to surface of S. mutans resulting in their death. ◆◆ Passive route.
i. Systemic immunization: Here, antibody level
Probiotic approach: In this, S. mutans strain is modified especially IgG has found to be increased in saliva after
to increase the production of enzyme urease. This subcutaneous immunization with S. mutans. In this
urease converts urea into ammonia which helps in route, injections of S. mutans were given in salivary
remineralization of enamel. glands so as to increase salivary IgA antibody levels.
But this route has drawback that function of salivary
2. Lasers gland gets disturbed by repeated injections.
CO2 lasers have been found effective in prevention of ii. Mucosal route: To cover drawback of systemic route,
mucosal immunization is tried by oral route. When the
caries. It gets absorbed by the tooth structure and makes
ingested antigens come in contact with gut, associated
the enamel surface hard which is more resistant to
lymphoid tissue induces SIgA response at distant
caries attack. Laser causes reduced enamel permeability
mucosal surfaces. Antigens stimulate lymphoblasts
with a reduced solubility due to melting, fusion, and
which move into lamina propria of mucosal tissue
recrystallization of enamel crystallites which could seal
including the salivary glands. On setting the local clonal
the enamel surface. Application of laser with fluoride
growth of cells, maturation into IgA antibody producing
increases the fluoride uptake, thus further helping in plasma cells is induced as a result of local stimulus by
remineralization. an antigen. This is “common mucosal immune system”
which is generated by ingestion of whole cells of
3. Caries Vaccine S. mutans encapsulated with gelatin matter.
iii. Passive route: Here, systemic immunization of cow
Vaccine is an immunological substance designed to is done with vaccine from whole S. mutans cells
produce specific protection against a given disease. It generated IgG. This results in formation of antibodies
stimulates production of protective antibodies and other in both serum and milk which are passed on further.
immune mechanism. Many studies have been tried to form the yolk with
antibodies from eggs of the chicken immunized with
Rationale of Caries Vaccine S. mutans.
◆◆ Rationale for caries vaccine is that immunization with
Appropriate Animal Models for Testing Caries Vaccine
S. mutans should induce an immune response so as to
prevent organisms from colonizing the tooth surface Rodents are animals of choice for conducting studies, as
and thus prevent carious decay. being economical and easy to maintain. Monkeys have
◆◆ General public should be well-exposed to vaccine. morphology and pattern of development of dentition,
◆◆ Vaccine should be given before eruption of deciduous immune response, and microbiology similar to humans,
teeth so as to achieve maximum benefits. they are considered as more appropriate than rodents
in spite of their high cost of maintenance, small size of
experimental groups, and long-term experiments.
Problems in Development of Caries Vaccine
◆◆ Since complete etiology of caries is not known, 100% MANAGEMENT of dental caries
effectiveness of vaccine is not possible.
Restoration of a decayed tooth involves the use of a drill,
◆◆ Due to variation in number of etiological micro
low or high speed for tooth preparation. But nowadays,
organisms, infective dose also varies.
other procedures have also been used for removal of
◆◆ Even with same level and type of S. mutans, variation in
caries. For example, chemomechanical caries removal,
severity of disease occurs due to other factors.
ozone, air abrasion and lasers.
◆◆ Cross-reactivity of S. mutans cell antigens is seen with
heart muscles.
◆◆ Lack of immunological competence can result in lack of
1. Chemomechanical Caries Removal
response to S. mutans. Chemomechanical caries removal (CMCR) involves
◆◆ There is no availability of human models to study the selective removal of carious dentin. The reagent is
immunological response. prepared by mixing solutions of amino acids and sodium
Dental Caries 65
hypochlorite. Reagents commonly available in market are lesion with hand instruments and after 30 seconds, carious
Caridex and Carisolv. dentin can be gently removed. Another application
may be required until no more carious dentin remains
Caridex consists of two solutions, viz. solution I containing
(Fig. 6.29).
sodium hypochlorite and solution II containing glycine,
aminobutyric acid, sodium chloride, and sodium Advantages
hydroxide.
The two solutions are mixed immediately before use. ◆◆ Volume required is less
◆◆ Does not require heating or a delivery system
The solution is applied to the carious lesion by means
◆◆ Since it involves gel not liquid, it is much easier to use
of applicator. Application is done until the sound dentin
than Caridex
comes.
◆◆ Better contact with the carious lesion.
Advantages Disadvantage
◆◆ No need for local anesthesia
Use of rotary instruments may still be required for some
◆◆ Suited for treatment of anxious and pediatric patients
cavities.
◆◆ Indicated in medically compromised patients
◆◆ Conservation of sound tooth structure
◆◆ Reduced risk of pulp exposure. 2. Ozone Treatment of Dental Caries
At the decay interface inside the tooth preparation,
Disadvantages there are three types of dental tissues: (1) Soft (decayed
◆◆ Instruments may still be needed for the removal of dentin and enamel), leathery (infected dentin), and hard
caries or material (healthy tissue). Very soft tissues must be removed from
◆◆ It leaves a surface with many overhangs and undercuts the cavity. (2) Leathery tissues, if given, the proper ionic
◆◆ Large volumes of solution are needed compartment, can remineralize and harden. (3) Hard
◆◆ Procedure is slow tissues are generally healthy and should be left intact.
◆◆ It is ineffective in the removal of hard eburnated parts Ozone occurs naturally when molecular oxygen
of the lesion (O2) is photodissociated into activated ions (O–) which
◆◆ Unpleasant taste. further combines with other oxygen molecules (O2) to
In 1998, Carisolv was introduced. It is available in form transient radical anions (O3). Ozone ultimately
two syringes, one containing the sodium hypochlorite decomposes to a hydroxyl radical which is a powerful
and other a pink viscous gel consisting of lysine, oxidant. It oxidizes biomolecules like cysteine, methionine,
leucine, and glutamic acid. Amino acids, together with and histidine resulting in cell death. Just 20–40 seconds
carboxymethylcellulose make it viscous and erythrosin exposure of ozone kills all oral microbes and their
makes it readily visible during use. protective biofilm environment. Because of this change
The contents of the two syringes are mixed together in microenvironment, the remineralization of enamel and
immediately before use. The gel is applied to the carious dentin can be accomplished.
Technique of Using Ozone Therapy

Entry to the carious tooth is carried out by using airotor.
Disposable sterile cup on the ozone is used to form a seal
around the prepared tooth. Once the seal is obvious, ozone
is delivered, and refreshed 300 times per second, for 40
seconds. Remineralizing solution which contains xylitol,
fluoride, calcium, phosphate, and zinc, is applied to the
demineralized tooth surface. Tooth is restored with glass
ionomer cement. Carving and finishing of glass ionomer
cement is done. Over it, after confirming remineralization,
place composite restoration.
3. Caries Removal Using Air Abrasion

Here, kinetic energy is used to remove carious lesion. In
Fig. 6.29: Photograph showing Carisolv for removing the caries. this method, a powerful fine stream of aluminium oxide
particles is targeted against the surface to be removed. 5. Which one is the most accepted theory of caries
The abrasive particles hit the tooth with high velocity and formation?
remove small amounts of tooth structure. Air abrasion 6. Who gave the caries balance concept?
technique is not indicated in patients with dust allergy, 7. What is caries balance concept?
asthma, advanced periodontal disease, fresh extraction, 8. Name the bacteria responsible for caries of crown
and recent placement of orthodontic appliances. portion of tooth.
9. Name the bacteria responsible for caries of root
4. Lasers portion of tooth.
10. What is critical pH?
Lasers have shown to remove caries selectively while
11. What is caries triad?
leaving the sound enamel and dentin. They can be used
12. What is caries tetrad?
without application of local anesthetics. Commonly used
13. What is WHO system of caries classification based on
lasers for caries removal are erbium:yttrium-aluminium-
shape and depth of carious lesion.
garnet lasers and erbium, chromium:yttrium-scandium-
14. Name the zone of enamel caries.
gallium-garnet lasers. These lasers can remove soft caries
15. Name the zone of dentinal caries.
as well as hard tissue. Added advantages of lasers include
16. What is cervical burn out?
little noise, no smell, and vibrations.
17. What is SLOB rule?
18. Name different components of rvg.
Conclusion 19. Name the caries activity test.
Dental caries is most commonly seen problem in dental 20. Classify dental caries.
practice. One should have the thorough understanding 21. What is CPP-ACP and what is its use?
of etiology of dental caries. Due to recent advances in 22. Name the bacteria used for caries vaccination.
diagnostic methods, it has become possible to diagnose 23. Name the chemical used to remove caries.
the caries at very initial stages. Due to diagnosis of incipient 24. What is remineralization?
lesions and caries risk assessment, it has been possible to
prevent and manage the dental caries by minimal invasive bibliography
dentistry. 1. Anusavice KJ. Management of dental caries as a chronic
infectious disease. J Dent Educ. 1998;62(10):791-802.
EXAMINER’S CHOICE QUESTIONs 2. Bader JD, Brown JP. Dilemmas in caries diagnosis. J Am Dent
Assoc. 1993;124(6):48-50.
1. Define dental caries. What are different theories of 3. Bader JD, Shugars DA. A systematic review of the performance
dental caries? of a laser fluorescence device for detecting caries. J Am Dent
2. Explain in detail Keyes triad of dental caries. Assoc. 2004;135(10):1413-26.
3. Classify dental caries. What is histopathology of 4. Beltrán-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride
enamel caries? varnishes. A review of their clinical use, cariostatic mechanism,
efficacy and safety. J Am Dent Assoc. 2000;131(5):589-96.
4. How will you diagnose dental caries? Explain
5. Brännström M, Lind PO. Pulpal response to early dentinal
diagnosis. caries. J Dent Res. 1965;44(5):1045-50.
5. Explain in detail prevention of dental caries. 6. Brown JP, Lazar V. The economic state of dentistry, an overview.
6. Write in short about the current methods of caries J Am Dent Assoc. 1998;129(2):1682-91.
prevention. 7. Brown JP. Indicators for caries management from the patient
7. Write short notes on: history. J Dent Educ. 1997;61(11):855-60.
a. Infected and affected dentin. 8. Elderton RJ, Mjör IA. Changing scene in cariology and operative
b. Diagnosis of initial carious lesion. dentistry. Int Dent J. 1992;42(3):165-9.
9. Fusayama T. Two layers of carious dentin; diagnosis and
c. Role of saliva in prevention of dental caries. treatment. Oper Dent. 1979;4(2):63-70.
d. Caries vaccine. 10. Hudson P. Conservative treatment of the Class I lesion: a new
e. Chemomechanical caries removal (CMCR). paradigm for dentistry. J Am Dent Assoc. 2004;135(6):760-4.
f. Caries activity tests. 11. Kidd EA. The histopathology of enamel caries in young and old
g. Advantages and disadvantages of Caridex. permanent teeth. Br Dent J. 1983;155(6):196-8.
h. Advantages and disadvantages of Carisolv. 12. Mjor IA. Frequency of secondary caries at various anatomical
i. Ozone treatment of dental caries. locations. Oper Dent. 1985;10(3):88-92.
13. Ripa LW. Occlusal sealants: rationale and review of clinical
trials. Int Dent J. 1980;30(2):127-39.
viva questions 14. Sarnat H, Massler M. Microstructure of active and arrested
dentinal caries. J Dent Res. 1965;44(6):1389-1401.
1. Define dental caries. 15. Stephan RM. Intra-oral hydrogen-ion concentrations associated
2. What is cariology? with dental caries activity. J Dent Res. 1944;23(4):257-66.
3. What is composition of dental biofilm. 16. van Houte J. Bacterial specificity in the etiology of dental caries.
4. Name the theories of caries. Int Dent J. 1980;30(4):305-26.
Chapter
7
Instruments Used in Operative Dentistry
Chapter Outline
Introduction Restorative Instruments

History Instrument Grasps
Materials Used for Manufacturing Cutting Instruments Finger Rests
Heat Treatment of Materials Guards
Classification Methods of Use of Instruments
Nomenclature by GV Black Sharpening of Hand Instruments
Parts of Hand Cutting Instruments Rotary Cutting Instruments
Balancing Handpieces
Instrument Formula Dental Burs
Different Instrument Designs Factors Affecting Cutting Efficiency of Bur
Instrument Motions Recent Advances in Rotary Instruments
Description of Various Instruments Abrasive Instruments and Materials in Conservative Dentistry
Hand Cutting Instruments Hazards and Precautions with Rotary Cutting Instruments
Introduction ◆◆ George Hollenback: Developed pneumatic condenser.

◆◆ Waldon I Ferrier: Developed Ferrier set of instruments
A wide range of specific hand or rotary instruments which were more refined with uniform thickness on
are required for tooth preparation and other operative cutting edge.
procedures. Rotary instruments help in gross cutting and
final refining of the preparation whereas hand instruments MATERIALS USED FOR MANUFACTURING
are used for examination, producing minor details of the
tooth preparation and for insertion, compaction, and
CUTTING INSTRUMENTS
finishing of the restoration. Material Stainless steel Carbon steel Stellite
Black described hand instruments such as chisels, Composition Chromium—18% Carbon—1% Cobalt—65–90%
hatchets, hoes, excavators, and margin trimmers—terms Carbon—1% Manganese Chromium—35%
which might have been taken from wood working and Iron—81.4% —0.2% Trace amounts-
Silicon—0.2% Tungsten,
gardening. Iron—98.4– Molybdenum,
98.6% Iron
History Advantages Chromium Harder than High resistance
◆◆ GV Black: Gave first acceptable nomenclature for present in stainless steel to acid hardness
alloy reduces
classification of hand instruments. corrosion by
◆◆ Arthur D Black: Developed many instruments and depositing an
techniques. oxide layer on
◆◆ Charles E Woodbury: First to modify Black’s instru surface of metal.
mentation and designed 39 sets of hand instruments for Remains lustrous
under most
class III preparations and gold foil restorations.
conditions
◆◆ Wedelstaedt: Developed Wedelstaedt chisel, now
referred as curved chisel. Contd…
Contd… iii. Retractors: Mouth mirror, blunt bladed restoring

Material Stainless steel Carbon steel Stellite instruments, plastic instruments, tongue
Dis– Tendency to dull Prone to depressors.
advantages with time. corrosion iv. Probes/Explorers: Straight, right angled, inter-
Uses Mainly used for Manufacture proximal explorer.
working points of mixing v. Separators.
and cement and restorative 2. Instruments for tooth structure removal
instruments instruments i. Hand cutting instruments
a. Excavators: Hatchet, hoes, spoon, discoid,
Heat Treatment of Materials cleoid, angle formers.
Heat treatment is the controlled heating and cooling of b. Chisels: Straight, monoangle, binangle and triple
metals to alter their physical and mechanical properties angle.
without changing the original shape. It can be done as c. Special forms of chisel: Enamel hatchets, gingival
hardening and tempering treatment. marginal trimmers, Wedelstaedt chisel, offset
hatchets, triangular chisel, and hoe chisel.
Hardening treatment Tempering treatment
ii. Rotary cutting and abrasive instruments
Steel is heated to 1500–1600°F It is done by reheating a. Handpieces
(815°C) and then quenched in the instrument at a lower
oil to increase hardness. Though temperature and quenching it in
b. Burs
it increases hardness of the solutions of oil, acid or mercury iii. Ultrasonic instruments
alloy but, it also increases the at 200–450°C for 10 min. Cutting 3. Restoring instruments
brittleness, especially when the edges are tempered to relieve i. Mixing instruments: Stainless steel or plastic
carbon content is high. the stresses and brittleness of spatulas, plastic instruments.
the instrument. ii. Condensing instruments: Rounded, triangular,
diamond, or parallelogram condensers.
CLASSIFICATION iii. Burnishing instruments: Ball/egg/conical-shaped
GV Black Classification burnishers.
iv. Carvers: Hollenback’s discoid and cleoid, diamond-
1. Cutting shaped carvers.
A. Excavators v. Files: Hatchet/parallelogram-shaped.
i. Ordinary Hatchet vi. Knives: Bard parker knife and Stein’s knife.
ii. Hoe excavator 4. Finishing and polishing instruments: Burs, stones,
iii. Angle former brushes, rubber (wheel, cups or cones), cloth or felt.
iv. Spoon excavator.
B. Chisels
Nomenclature by GV Black
i. straight
ii. Curved/Wedelstaedt Dr GV Black gave following way to describe instruments
iii. Binangle for their easier identification similar to biological
iv. Enamel hatchet classification.
v. Gingival marginal trimmer. 1. Order: Function or purpose of the instrument, e.g.
C. Others excavator, condenser.
i. Knives 2. Suborder: Position, mode or manner of use, e.g. push,
ii. Files pull.
iii. Carvers; Discoid-Cleoid. 3. Class: Design or form of the working end, e.g. hatchet,
2. Noncutting spoon excavator.
i. Amalgam condenser 4. Subclass: Shape of the shank, e.g. binangle, contra angle.
ii. Mirrors These names are combined to give a complete
iii. Explorer description of the instrument. Naming of an instrument
iv. Probes. generally moves from 4 to 1, for example, Binangle hatchet
excavator.
Marzouk’s Classification
This classification is based upon different procedures Parts of Hand Cutting Instruments
performed by different instruments. Each hand instrument is composed of three parts
1. Exploring instruments (Fig. 7.1):
i. For drying: Tweezers/cotton pliers 1. Handle or shaft
ii. For illumination: Source of light, intraoral light, 2. Shank
and mirrors 3. Blade or nib.
Instruments Used in Operative Dentistry 69
Fig. 7.1: Parts of hand cutting instrument; a: Cutting edge/blade,

b: shank, c: shaft/handle.
Fig. 7.4: Instruments with different shank designs.
◆◆ The shank may be straight or angled. angulation

of instrument is provided for access and stability.
Depending on number of angles, shank can be classified
as straight (no angle), monoangle (one angle),
Fig. 7.2: Different designs of handle of instrument. biangle (two angles), triple-angle (three angles), and
quadrangle (four angles) (Fig. 7.4).
Handle or Shaft
Blade or Nib
◆◆ handle is used to hold the instrument.
◆◆ It can be small, medium or large, smooth or serrated for ◆◆ Blade is working part of the instrument which is
better grasping and developing pressure (Fig. 7.2). connected to the handle by shank. For cutting instru
◆◆ Handles can be joined or separable from the shank. ments, blade is beveled to create the cutting edge.
Separate type of handle is known as cone socket Depending on bevels, instruments can be single beveled,
handle, this allows replacement of various working bibeveled, triple beveled or circumferential beveled.
ends; for example, mouth mirrors and condensers ◆◆ For noncutting instruments, working part is termed as
(Figs. 7.3A and B). nib which is used to place, condense, and burnish the
◆◆ On the handle, there are two numbers; one is the material in the tooth.
instrument formula, which describes the dimensions
and angulation of the instrument, the other number is Balancing
the manufacturer’s number which is used for ordering Balancing of an instrument is achieved by designing
purposes. the angles of shank so that cutting edge of blade lies
within 2–3 mm of long axis of the handle. This principle
Shank of instrument design is also called as contra-angling
◆◆ Shank connects the handle to the blade. (Figs. 7.5A and B).
◆◆ It tapers from the handle down to the blade and is
normally smooth, round or tapered. Advantages of Balancing of Instruments
◆◆ Prevents rotation of instruments when in use
◆◆ Generates maximum force at tip of the instrument
◆◆ Improves accessibility and visibility of operating site.
INSTRUMENT FORMULA
GV Black established an instrument formula for describing
A B dimensions of blade, nib or head of instrument, and
angles present in shank of the instrument. Formula is
usually printed on the handle consisting of a code of three
or four numbers separated by spaces. Formula uses metric
Figs. 7.3A and B: Cone socket handle of a mouth mirror. system. For designating angles, centigrades are used.
Figs. 7.5A and B: (A) Balancing of instrument means cutting edge Fig. 7.7: Schematic representation of measurement of
of blade lies within 2–3 mm of long axis of the handle; (B) Lack of primary cutting edge angle.
balancing of instrument.
1 centigrade is equal to 1/100th of a circle, i.e.

1/100 × 360 = 3.6°.
Four-Number Formula (Fig. 7.6)

It is used for the instruments in which primary cutting edge
is not at right angle to long axis of the blade, e.g. gingival
margin trimmer and angle former.
i. 1st number: Blade width—expressed in 1/10th of
mm.
ii. 2nd number: Primary cutting edge angle, i.e. angle
between the primary cutting edge and handle of the
instrument and is expressed in centigrade (Fig. 7.7).
iii. 3rd number: Blade length—expressed in mm. Fig. 7.8: Schematic representation of an instrument with
iv. 4th number: Blade angle—it is the angle between four-number formula (15-95-8-12).
long axis of the blade and the long axis of the handle,
2nd number—primary cutting edge angle—95°
it is expressed in centigrades.
3rd number—blade length, i.e. 8 mm.
Example of a Four-Number Formula 4th number—blade angle—12°.
Instrument with formula 15-95-8-12 (Fig. 7.8) represents
the following:
Three-Number Formula (Fig. 7.9)
1st number—blade width—15 × 1/10 = 1.5 mm. It is used for the instruments in which cutting edge is at
right angle to the long axis of the blade, e.g. emamel hatchet
◆◆ 1st number—blade width—expressed in 1/10th of mm.
◆◆ 2nd number—blade length—expressed in mm
◆◆ 3rd number—blade angle—it is the angle between long
axis of the blade and the long axis of the handle, it is
expressed in centigrades.
Fig. 7.6: Schematic representation of four-number formula. Fig. 7.9: Schematic representation of three-number formula.
Most instruments have 3 number formula. An instru i. Instruments with slight blade curvature, e.g.
ment having instrument formula of 15-8-14 indicates Wedelstaedt chisel.
following: ii. Instruments with cutting edge perpendicular to axis of
◆◆ 1st number is blade width, i.e. 15 × 1/10 = 1.5 mm the handle, e.g. binangle chisel.
◆◆ 2nd number is blade length, i.e. 8 mm. iii. Hoes.
◆◆ 3rd number is blade angle, i.e. 14 degree centigrade.
2. Bibeveled Instruments
Different instrument designs If two additional cutting edges extend from the primary
cutting edges, then the instrument with secondary cutting
Bevels in Cutting Instruments
edges is called bibeveled instrument. Only hatchets and
1. Single-beveled Instruments (Figs. 7.10A and B) hoes are bibeveled instruments. These instruments cut by
pushing them in the direction of long axis of the blade.
◆◆ Most of the instruments have single bevel that forms
the primary cutting edge, e.g. gingival margin trimmer,
enamel hatchet, and spoon excavator.
3. Triple-beveled Instrument
◆◆ These can be right or left bevel and mesial or distal If three additional cutting edges extend from the primary
bevel instruments. cutting edge, then the instrument is called triple-beveled
instrument. It results in three distinct cutting edges and
Right and left bevel instruments: Single-beveled direct
increases cutting efficiency of the instrument.
cutting instruments such as enamel hatchets are made in
pairs having bevels on opposite sides of the blade. These are
named as right- and left-bevel instruments. To determine 4. Circumferential Bevel
right or left side of the bevel, primary cutting edge is held Here instrument blade is beveled at all its peripheries, e.g.
down pointing away. If bevel appears on right, it is the right spoon excavator (Fig. 7.11).
instrument of the pair and if bevel appears on the left, it is
left instrument of the pair. During use, move the instrument
from right to left in right-beveled instrument and from left Instrument motions
to right in left-bevel instrument. ◆◆ Pulling: Instrument is moved toward operator’s hand.
Mesial and distal bevel instruments: If we observe the ◆◆ Scraping: Instrument is moved side to side or back and
inside of the blade curvature and the primary bevel is not forth on the tooth surface.
visible then the instrument has a distal bevel and if the ◆◆ Pushing: Instrument is moved away from operator’s
primary bevel can be seen from the similar view point hand.
the instrument has a mesial or reverse bevel. If these ◆◆ Cutting: Instrument is moved parallel to the long axis
instruments have no angle in the shank or an angle of of handle.
12° or less, used for push and scraping motion. If these
instruments have angle more than 12°, used in pull (distally DESCRIPTION OF VARIOUS INSTRUMENTS
beveled) and push (mesially beveled) motion.
Following single-beveled instruments have either Mouth Mirrors
mesial or distal bevels: Mouth mirror is used as supplement to improve access
to instrumentation. It has handle, shank and a mirror
attached to a round metal disk at one end.
B
Figs. 7.10A and B: Single bevel instruments: (A) Spoon excavator; Fig. 7.11: Schematic representation of circumferential
(B) Gingival margin trimmer. bevel in a spoon excavator.
Fig. 7.12: Different sizes of mouth mirror.
Sizes of mouth mirrors (Fig. 7.12)

Size 1 Size 2 Size 3 Size 4 Size 5
16 mm 18 mm 20 mm 22 mm 24 mm
Fig. 7.14: Use of mirror for indirect visualization.
Types
Mouth mirrors are of various types (Fig. 7.13):
◆◆ Front surface reflecting mirror: Here the coating is
present on front surface of the mirror to prevent image
distortion. It is most commonly used due to good
quality of image.
◆◆ Plane or flat surface: It produces double image also
called ghost image, therefore not recommended much,
though it resists the scratch because reflecting surface
is on back of the mirror lens.
◆◆ Concave surface: It is used to provide different degrees
of magnification, but it causes image distortion.
Uses
◆◆ Direct visualization of operating field
◆◆ Indirect visualization of oral structures that cannot be
seen directly (Fig. 7.14)
◆◆ Illumination of operating area by reflecting light on to Fig. 7.15: Illumination of operating area by reflecting light
the tooth surface (Fig. 7.15) on teeth surface.
◆◆ Retraction of soft tissues like the tongue, cheeks or lips
for improved accessibility and visibility of the operating
site (Fig. 7.16).
Explorer
Explorer is commonly used as a diagnostic aid in evaluating
condition of teeth especially pits and fissures.
Fig. 7.16: Retraction of cheek or lips for better accessibility

Fig. 7.13: Different surfaces of mouth mirror. and visibility.
Types of explorer (Figs. 7.17A to D)
Fig. 7.18: Tweezer.
Fig. 7.19: Probe.
HAND CUTTING INSTRUMENTS

C
A. Excavators
I. Ordinary Hatchet
An ordinary hatchet excavator is a beveled hatchet in which
cutting edge of blade is directed in same plane as that of
long axis of the handle. It differs from enamel hatchet that
cutting edge has two bevels and enamel hatchet is larger
and heavier than this (Fig. 7.20).
D Uses
i. for preparing and sharpening line angles
ii. For preparing retentive areas for direct filling gold in
Figs. 7.17A to D: Different types of explorers: (A) Interproximal;
(B) Pigtail or cowhorn; (C) Shepherd’s crook or curved; (D)Straight. anterior teeth.
Tweezer (Fig. 7.18)

Tweezer has angled tip and is available in different sizes.
It is used to place and remove cotton rolls and other small
materials to and from the mouth. Fig. 7.20: Ordinary hatchet.
Probe (Fig. 7.19)

II. Hoe Excavators (Fig. 7.21)
Though probe almost looks like straight explorers, but it has
blunt end which is marked with graduations. Probe is used Primary cutting edge of blade is perpendicular to the long
for measuring pocket depth but in operative dentistry, it is axis of handle. It is a single-planed instrument which cuts
used to check dimensions of tooth preparation. in vertical, push and pull, right, and left motions.
Uses
◆◆ To shape and plane the tooth preparation walls
◆◆ To form line angles in class III and V restorations for A
direct filling gold.
Fig. 7.21: Hoe excavator.
III. Angle Former C

Angle former is a type of excavator which is monoangled Figs. 7.23A to C: Spoon excavator.
with the cutting edge sharpened at an angle to long axis
of the blade (Fig. 7.22). Angle of cutting edge to blade B. Chisels
axis lies between 80° and 85°. Blade of angle former
is beveled on sides as well as at the end, this forms Chisels have a blade which ends in cutting edge formed
three cutting edges, thus resulting in a triple-beveled by bevel on one side only. The cutting edge of chisel is
instrument. It is available as paired instrument (right perpendicular to the axis of handle. Chisels are used for
and left) with four unit instrument formula. It cuts in cleaving, planing, and lateral scraping. In other words, they
vertical push or pull motion for accentuating line and are used to split tooth enamel, to smoothen the preparation
point angles, to establish retention form in direct filling walls, and to sharpen the preparations. Chisels are used
gold restoration. with a push motion. Chisels can be of following types:
I. Straight Chisel
It has straight blade in line with shank and handle (Fig.
7.24). It is used with straight thrust force in push motion
for cutting enamel. In this, primary cutting edge is in a
plane perpendicular to long axis of the handle. It has
either a mesial or distal bevel. Distal-beveled chisel is
also called as reverse-beveled or contra-beveled. It is used
Fig. 7.22: Angle former excavator. with a push or pull motion for smoothening proximal and
gingival walls.
Uses
For sharpening the line angles and creating retentive
features in dentin for gold restorations.
Fig. 7.24: Straight chisel.
IV. Spoon Excavator

II. Curved/Wedelstaedt Chisel
Spoon excavator is a modified hatchet. It is a double-ended
This instrument is almost similar to straight chisel except
instrument with a spoon, claw, or disk-shaped blade shank
for slight vertical curvature in its shank (Fig. 7.25). It can be
is bin- or triple-angled to facilitate accessibility (Figs.
mesially or distally beveled. It is mainly used for cleaving
7.23A to C).
undermined enamel.
Uses
◆◆ Remove caries and debris in the scooping motion from
the carious teeth.
◆◆ For carving amalgam restorations and wax patterns. Fig. 7.25: Wedelstaedt chisel.
III. Binangle Chisel ◆◆ Distal GMT: In this, cutting edge of instrument makes
acute angle with edge of blade farthest from handle.
It has two different angles—one at the working end and Unit II no. in distal GMT is 95 and 100.
other at the shank (Fig. 7.26). It is mesially or distally ◆◆ GMT is used in lateral scraping motion. Mesial GMT
beveled and is used to cleave the undermined enamel. is used to bevel a mesial gingival margin or accentuate
a distal axiogingival angle. Distal GMT is used to
bevel a distal gingival margin or accentuate a mesial
axiogingival angle.
Fig. 7.26: Bin-angled chisel. Uses

◆◆ Used in proximal box of class II preparation with
IV. enamel Hatchet (Fig. 7.27) horizontal strokes to scrape the gingival wall and
Any instrument where the cutting edge is parallel or close margin.
to parallel to axis of the handle of the instrument is called ◆◆ Used to plane facial and lingual wall in vertical strokes.
a hatchet.
Hatchet is a paired instrument in which blades makes Viva Voce
45–90° angle to the shank. In paired right and left hatchets, Gingival marginal trimmer (GMT) versus hatchet
blades are beveled on opposite sides to form their cutting GMT has a curved blade, hatchet has straight blade. Curved
edges. blade helps in the lateral scraping skill of the GMT
Cutting edge of the GMT makes an angle with the plane of
the blade whereas cutting edge of the hatchet makes a 90°
angle to the plane of the blade.
C. Other Cutting Instruments

Fig. 7.27: Enamel hatchet.
I. Knives
Uses
◆◆ These are finishing knives having thin knife-like blade.
Hatchet is used for cleaving enamel and planing cavity ◆◆ These are used in scrap and pull motion for removing
dentinal walls so as to have sharp outline of the preparation. excess restorative material on gingival, facial or lingual
margins of a proximal restoration.
V. Gingival Margin Trimmer ◆◆ For contouring surface of class V restoration.
Gingival margin trimmer (GMT) is a modified hatchet

which has working ends with opposite curvatures and
bevels (Figs. 7.28). It is available in a set of two double-
ended styles and is used in pairs.
◆◆ Mesial GMT: In this, cutting edge of the instrument
makes an acute angle with edge of the blade nearest to
the handle. Unit II no. in Mesial GMT is 75 and 85. Fig. 7.29: Files.
II. Files
Blades of files have serrations called teeth. These are
used in push and pull motion to remove excess material
especially at gingival margins (Fig. 7.29).
III. Carvers: Cleoid-Discoid

◆◆ It is modified chisel with different shape of cutting
edges (Fig. 7.30).
◆◆ In cleoid, it is claw-like and in discoid it is disk-like.
These instruments have sharp cutting edges as spoon
excavators but blade to shaft relationship is similar to
Fig. 7.28: Mesial and distal gingival margin trimmer (GMT). chisels.
Fig. 7.30: Cleoid discoid carver. Fig. 7.32: Plastic filling instrument.
III. Condensers (Fig. 7.33)

Uses
Condensers are used to pack material into prepared cavity.
◆◆ For removing caries Hand condensers are double-ended instruments with
◆◆ Carving occlusal anatomy of amalgam restorations or different types of nibs, sizes, and shapes. Force applied
wax patterns. through nib is inversely related to its size. Nibs can be round,
◆◆ To trim or burnish inlay–onlay margins. elliptical, diamond, triangular, parallelogram, etc. Depending
upon serrations they can be serrated (for spherical amalgam)
RESTORATIVE INSTRUMENTS and nonserrated (for admixed amalgam).
Following are the commonly used instruments when
temporary or permanent restoration is being done.
I. Cement Spatulas (Fig. 7.31)

Cement spatula is made up of stainless steel or plastic,
having wide nib with blunt edges, straight shank, and
handle. Blunt end is used for mixing impression materials
and cements.
Fig. 7.33: Different types of condensers.

(Courtesy: Hu-Friedy).
Fig. 7.31: Cement spatulas. IV. Amalgam Carrier

Amalgam carrier carries the freshly prepared amalgam
II. Plastic Filling Instrument (Fig. 7.32) restorative material to the prepared tooth. It can be both
It is a double-ended instrument with flat nib at one end single and double ended. Amalgam carrier has hollow
and round condenser nib at other end. working end, called barrel, into which the amalgam is
packed for transportation (Fig. 7.34). Lever of amalgam
Uses carrier is located on top of the carrier. When lever is
◆◆ To carry and place cement into the cavity. depressed, the amalgam is expelled into the preparation.
◆◆ To check convenience form of tooth preparation. After restoration is completed, any remaining amalgam
alloy is expelled out from the carrier into the amalgam
well, otherwise if the amalgam is allowed to harden in the
carrier, it will no longer be serviceable.
B
Figs. 7.36A and B: Burnisher. (A) Ball burnisher;
(B) Egg-shaped burnisher.
(Courtesy: Hu-Friedy)
Uses
Fig. 7.34: Amalgam carrier. ◆◆ Final condensation of amalgam
(Courtesy: Hu-Friedy). ◆◆ Initial shaping of occlusal anatomy of amalgam
◆◆ Shaping of metal matrix bands
V. Carvers (Fig. 7.35) ◆◆ Shaping of occlusal anatomy in posterior resin
composite before polymerization of resin
Carvers have sharp cutting edges to shape and contour
◆◆ To bend cast gold near the margins to burnish it to tooth
the surface of filling materials in their plastic state, waxes,
surface (beaver tail).
molds, and patterns. They have different designs and
shapes, for example,
vii. Composite Resin Instruments (Fig. 7.37)
◆◆ Hollenback carver (knife edged elongated bibeveled)
◆◆ Diamond (frahm’s carver) These are set of instruments with a coating of titanium
◆◆ Ward ‘C’ carver nitride. Since Titanium Nitride is 40% harder than stainless
◆◆ Discoid cleoid carver steel, it is not scratched by filler particles of composite
◆◆ Interproximal carver. resin. It also resists sticking of resin.
In Hollenback, diamond, and Ward C carvers, one
blade is parallel to long axis of handle and other end is
perpendicular to long axis of instrument.
Fig. 7.37: Instruments used for composite restorations.
INSTRUMENT GRASPS
Modified Pen Grasp
Fig. 7.35: Carvers.
(Courtesy: Hu-Friedy). It provides greatest delicacy of touch. Modified pen grasp
is similar to the pen grasp except the operator uses the pad
of the middle finger on the handle of the instrument rather
vi. Burnisher (Figs. 7.36A and B)
than going under the instrument (Fig. 7.38). Positioning
Burnisher is a double-ended instrument with smooth of the fingers in this manner creates a triangle of forces
spherical working ends to produce surface of restoration or tripod effect, which enhances the instrument control.
shiny and lustrous. Nibs can be egg shaped, ball shaped, Here palm of the operator faces away from the operator.
beaver tail shaped, apple shaped, conical, bullet shaped, This position stabilizes the instrument and allows the
fish tail or hourglass shaped. middle finger to help push the instrument down.
Fig. 7.38: Modified pen grasp. Fig. 7.40: Palm and thumb grasp.
Inverted Pen Grasp ◆◆ To achieve the thrust action with the fingers and palm,
In inverted pen grasp, finger positions are the same as instrument is forced away from the tip of the thumb
for the modified pen grasp except that hand is rotated which is at the rest position.
so that palm faces toward the operator (Fig. 7.39). This ◆◆ This grasp has limited use only while operating on
grasp is most commonly used for preparing a tooth in the maxillary anterior teeth.
lingual aspect of maxillary anterior and occlusal surface of ◆◆ it is used for holding a handpiece while cutting incisal
maxillary posterior teeth. retention for a class III preparation in maxillary
incisor.
Modified Palm and Thumb Grasp

◆◆ instrument is held like the palm grasp but the pads
of all the four fingers press the handle against the
palm and pad and first joint of the thumb. Here tip
of the thumb rests on the tooth being prepared or the
adjacent tooth.
◆◆ Modified palm and thumb grasp provides more control
to avoid slipping of instrument. This grasp is commonly
used in maxillary anterior teeth.
Fig. 7.39: Inverted pen grasp.

FINGER RESTS
The finger rest helps to stabilize the hand and the
Palm and Thumb Grasp instrument by providing a firm rest to the hand during
This grasp is same as that for holding the knife for peeling operative procedures. Finger rests may be intraoral or
the skin of an apple. Here, instrument is grasped very near extraoral.
to its working end so that thumb can be braced against
the teeth so as to provide control during instrument
Intraoral Finger Rests
movements. shaft of the instrument is placed on the palm
of the hand and grasped by the four fingers to provide firm
Conventional
control, while the thumb is free to control movements and
provide rest on an adjacent tooth of the same arch (Fig. In this, the finger rest is just near or adjacent to the working
7.40). tooth (Fig. 7.41).
Fig. 7.41: Conventional intraoral finger rest. Fig. 7.43: Extraoral palm up finger rest.
Cross-arch Palm Down

In this, the finger rest is achieved from tooth of the opposite Palm down rest is obtained by resting the front surface of
side but of the same arch (Fig. 7.42). the middle and fourth fingers on the lateral aspect of the
Opposite Arch mandible on the left side of the face (Fig. 7.44).
Here, the finger rest is achieved from tooth of the opposite
arch. Guards
Hand instruments like mouth mirror, cheek retractor,
Finger on Finger
lip retractor, interproximal wedges or clinician’s own
In this, rest is achieved from index finger or thumb of finger of other hand are used to protect soft tissues from
nonoperating hand.
contact with sharp cutting or abrasive instruments.
These guards are placed in direction of movement of
Extraoral Finger Rest
instrument.
It is used mostly for maxillary posterior teeth.
Palm Up: Advantages of guards

Palm up rest is obtained by resting the back of the middle ◆◆ Avoid accidental slippage of the instrument
and fourth finger on the lateral aspect of the mandible on ◆◆ Prevent tissue injuries.
the right side of the face (Fig. 7.43).
Fig. 7.42: Cross-arch intraoral finger rest. Fig. 7.44: Extraoral palm down finger rest.
METHODS OF USE OF INSTRUMENTS Mechanical

◆◆ Instrument is effectively used when it is moved from It is bench type piece of equipment in which honing disks
bevel to nonbevel side. are mounted. On top disk rotates up to 7,000 rpm. It saves
◆◆ Instrument should always be held parallel to the wall time, e.g. honing machine.
being worked upon. Holding an instrument at this angle
may increase its cutting but it may also cause damage Mounted Stones
or fracture of the tooth
In this, stones are mounted on metal mandrel and used
◆◆ For buccal wall, one side of instrument is used and for
with slow speed handpiece. Most common mounted
lingual wall, the other side of instrument should be
stones are Arkansas and Ruby. Various shapes such as
used.
cylindrical, conical, or disk shaped are available. Mounted
stones are not preferred in routine because they:
SHARPENING OF HAND INSTRUMENTS ◆◆ Tend to wear down quickly
Goals ◆◆ Result in generation of frictional heat
◆◆ Difficult to control during sharpening.
◆◆ To produce a functionally sharp edge
◆◆ Maintain the shape of instrument Unmounted/Handhold Stones
◆◆ Maintain the life of instrument.
These are commonly used for instrument sharpening.
These come in variety of sizes and shapes. Stone can be
Advantages of Sharp Instruments
rectangular with flat, rectangular with grooved surfaces or
◆◆ Improved efficiency cylindrical in shape.
◆◆ Improved tactile sensations ◆◆ Flat stone is ideal for moving technique
◆◆ Less pressure and force ◆◆ Cylindrical stone for removing wire edges.
◆◆ Improved instrument control Stone type can come in natural or synthetic form:
◆◆ Minimized patient discomfort ◆◆ Natural–Arkansas (preferred)
◆◆ Less treatment time. ◆◆ Synthetic:
•• India stone
Principles •• Ceramic stone
•• Composition stone.
Some basic principles used during sharpening are:
◆◆ Select the appropriate type of stone according to type
of instrument.
Guidelines
◆◆ Instrument should be clean and sterile before ◆◆ When sharpening GMT, chisels, hatchets and hoes,
sharpening. place the cutting edge against the flat stone and push or
◆◆ Establish proper angle between stone and surface of pull the instrument so that acute cutting angle moved
instrument on the basis of design. forward (Fig. 7.45).
◆◆ Lubricate the stone during sharpening as it reduces
the clogging of sharpening stone and heat generated
during sharpening.
◆◆ Maintain stable and firm grip of both instrument and
stone during sharpening.
◆◆ Avoid excessive pressure during sharpening.
◆◆ When sharpening is completed observe the cutting
edge for wire edges. Wire edges should be removed.
(Wire edges are unsupported metal fragments that
extend beyond the cutting from the lateral side or face
of blade).
◆◆ Resterilize the sharpened instruments.
Devices
◆◆ Mechanical
◆◆ Mounted stone
◆◆ Handhold stones (Unmounted). Fig. 7.45: Schematic representation of sharpening the bevel of hoe.
◆◆ If cutting edge digs in during an attempt to slide the
instrument forward over the surface, instrument is
sharp.
Thumbnail Test
◆◆ Hold the instrument at 45° to the nail.
◆◆ Apply mild pressure on instrument.
◆◆ If it scrapes the nail, instrument is sharp.
◆◆ If it slips away, instrument is dull.
Rotary Cutting Instruments

A B C
Rotary cutting instruments are those instruments which
Figs. 7.46A to C: Different bevels of sharpened instruments: (A) Blunt rotate on an axis to do the work of abrading and cutting on
level—incorrect; (B) Correct level with 45°; (C) Steep bevel—incorrect.
tooth structure.
◆◆ Bevel of instrument should make 45° angle with face of Types of Rotary Cutting
blade. So, while sharpening, blade should make a 45°
◆◆ Handpiece: It is a power device.
angle with the sharpening surface (Figs. 7.46A to C).
◆◆ Bur: It is a cutting tool.
◆◆ While sharpening spoon excavators, cleoid and discoid
carvers, rotate the instrument as the blade is moved on
the sharpening stone. Handpieces
◆◆ Move the instrument with bevel against the stone
Handpiece is a device for holding rotating instrument,
surface and cutting edge placed perpendicular to the
transmitting power to it and positioning it intraorally.
path of movement (Fig. 7.47).
◆◆ For curved or round cutting edge instrument, handle
of edge instrument should be moved in an arc to keep Evolution of handpieces
the cutting edge perpendicular to direction of cutting
stroke. 1. Foot engine
First “dental engine” was developed in 1871 by Dr James B
Sharpness Tests Morrison. It was adapted from sewing machine concept
as Foot engine. In this rotation of cutting instrument was
Scrape Test made by long belt running over series of pulleys to the back
◆◆ Sharpness is tested by lightly resting the cutting edge on of straight handpiece. When angle hand piece was needed,
the hard plastic surface. it could be attached to the shaft of straight handpiece
(Fig. 7.48).
Fig. 7.47: Sharpening of cleoid carver is done in such a way that

handle is moved in an arc to rotate the blade as bevel end is pulled on
sharpening stone surface. Fig. 7.48: First dental engine developed in 1871.
2. electric engine could operate at speed of 100,000 rpm. It showed good

speed and visibility but changing instruments was time
electric engine was incorporated in dental unit in 1914. consuming.
Handpiece equipment, speed in RPM of 5000 remained
until 1946. But it was seen that carbide and diamond 7. Air turbine handpiece
instruments perform better at high speed so aim was
to increase the speed of air rotor. To obtain 10,000 to Air turbine handpiece was made available in 1956. In
15,000 rpm, replacement of small pulley by the larger 1956, first clinically successful air turbine handpiece
one was done. When in 1949, it was seen that speed of became available with free running speed of 300,000 rpm.
more than 60,000 rpm is more effective in tooth cutting, In early models, handpiece, control box, foot control,
improvements were made in rotary handpieces but heat, and source of compressed air were attached to the dental
vibration, and wear were the major problems to deal. chair. On activating foot control, compressed air flowed
During this time abrasive technique and ultrasonics came into control box and then to handpiece via flexible hose.
into light. Cutting instruments were inserted into shaft of turbine
and held by friction grip. Air turbine handpiece runs
3. Air abrasive technique at the speed of 300,000 rpm. The application of turbine
principle to straight handpiece eliminated necessity of
It came into light in 1951. In this abrasive particles having electric engine as part of standard dental unit.
(aluminium oxide) were targeted to tooth structure at This simplified the design and construction of modern
high speed. In this, patient acceptance was good and dental chairs.
pulp response was minimal. But it showed problems Table 7.1 shows development of rotary cutting instru
like precise angles and margins were difficult to obtain, ments in dentistry.
surface of mirror was rendered useless due to rebounding
of abrasive particles, health hazard due to inhalation of
Table 7.1: Development of rotary cutting instruments in dentistry.
abrasive particles and inability to effectively remove the
spent dust by suction apparatus. Maximum
speed
Year and instrument (in rpm)
4. Ultrasonics
• Ultralow speed
Ultrasonics came in dentistry in 1952 in which hard tooth
−− 1728: Finger-rotated instruments 300
structure was removed by vibrating slurry of abrasive
particles (aluminium oxide) on the target using preformed −− 1871: Foot engine 700
instrument tips. It was based on the principle of converting −− 1874: Electric engine motor driven 1,000
alternating current into high frequency mechanical • Low speed
vibration by phenomenon of magnetostriction. It −− 1914: Dental unit (Electric motor as a power 5,000
showed tooth cutting with precise shape without feeling source)
of vibration, noise or pressure with full tactile control −− 1942: Diamond cutting instruments 5,000
so patient acceptance was good. But its disadvantages
• Medium speed
included slow cutting, low visibility, inability to effectively
remove caries and resilient filling material like gold and −− 1947: High-speed electric engines with tungsten 12,000
carbide burs
maintenance problems.
−− 1953: Ball bearings handpieces 25,000
5. Belt-driven • High speed

−− 1955: High-speed engine with water cooling 50,000
Belt-driven handpiece called page chayers was made turbine angle handpiece
available in 1955. It was the first handpiece to operate at
−− 1955: Belt-driven water cooling angle handpiece 150,000
100,000 rpm. It was attached to conventional dental unit
with an electric motor as source of power. Its advantage • Ultrahigh-speed
was being free of maintenance problems but it had many −− 1957: Air turbine angle handpiece with coolant 200,000
moving parts and had high-pitched noise on function. • Super ultrahigh speed
−− 1960: Air turbine angle handpiece with coolant 300,000
6. Water turbine handpiece −− 1961: Air turbine straight handpiece with 25,000
Water turbine handpiece was major development which coolant (Air motor)
came with hydraulic driven handpiece with elimination −− 1994: Contemporary air turbine handpiece with 300,000 to
of gears and belt-driven sections of angle hand piece. This coolant 400,000
Types of handpiece
I. Contra-angle handpiece
In this, head of handpiece is first angled away from and
then back toward the long axis of the handle. Because of
this design, bur head lies close to long axis of the handle
of handpiece which improve accessibility, visibility, and
stability of handpiece while working. A
A. Air-rotor contra-angle handpiece (Fig. 7.49 A):
◆◆ It gets power from the compressed air supplied by the
compressor.
◆◆ This handpiece has high speed and low torque.
◆◆ Speed range is 100,000 to 300,000 rpm.
◆◆ Used for tooth preparation and removal of old
restorations.
◆◆ Operates with friction grip burs and diamonds.
B. Micromotor (fig. 7.49B):
B
◆◆ It gets power from electric micromotor or airmotor.
◆◆ It has high torque and low speed.
◆◆ Used for finishing and polishing procedures.
II. Straight handpiece

◆◆ In straight handpiece, long axis of bur lies in same plane
as long axis of handpiece.
◆◆ Can be attached to micromotor or airmotor.
◆◆ It is used in oral surgical and laboratory procedures
(Fig. 7.49C). C
Table 7.2 summarizes rotary speed ranges in operative
Figs. 7.49A to C: (A) Air-rotor contra-angled handpiece; (B) Micromo-
dentistry with their advantages and disadvantages. tor contra-angle handpiece; (C) Straight handpiece.
Table 7.2: Rotary speed ranges in operative dentistry.

Commonly used bur
Speed Range (rpm) (with this speed) Uses Advantages Disadvantages
Low speed Less than 12,000 Steel burs with or • Polishing and • Good tactile sense • Ineffective cutting
without lubricant finishing • Time consuming
• Drilling holes for • Operator fatigue
implants • Produce patient
• Excavation of caries discomfort
Medium speed 12,000 to 200,000 Diamond burs with • Tooth preparations • Fine tactile sense • More heat
lubricant • Making small tooth production
preparations • Not fit for larger
• Refining tooth preparations
preparations • Large preparations
• Refining occlusion can cause operators
fatigue
High speed More than 200,000 Tungsten carbide • Tooth preparations • Ease for operator • Overcutting is
burs with lubricant • Removal of old • Faster preparation possible
restorative materials takes less time • Less tactile sense
• Crown preparations • Less fatigue for • Iatrogenic errors are
for fixed prosthesis patient and operator more common
• Quadrant dentistry is • Impairment of
possible visibility due to
• Bur life is enhanced air-water spray
• Less chances of
apprehension and
strain for patient
Dental Burs •• Latch type

•• Friction grip type
Bur is a rotary cutting instrument which has bladed cutting 2. According to composition:
head. It removes tooth structure either by chipping it away •• Stainless steel burs
or by grinding. William and Schroeder made first diamond •• Tungsten carbide burs
dental bur in 1897. modern diamond bur was introduced •• Combination of both
in 1932 by WH Drendel by bonding diamond points to 3. According to motion:
stainless steel shanks. •• Right bur: A right bur is one which cuts when it
revolves clockwise.
Materials used for bur •• Left bur: A left bur is one which cuts when revolving
anticlockwise.
I. Stainless steel burs 4. According to the length of their head:
These were the first developed burs, designed for slow speed •• Long
<5,000 rpm. Steel burs are cut from blank steel stock by means •• Short
of a rotary cutter that cuts parallel to the long axis of the bur. •• Regular
Bur is hardened and tempered till Vicker’s hardness number 5. According to use:
reaches 800. Usually a bur has eight blades with positive rake •• Cutting burs
angle for active cutting of dentin. But this makes steel burs •• Finishing burs
fragile and thus prone to fracture. Steel burs are used for •• Polishing burs
cutting soft carious dentin and finishing procedures. 6. According to head shape:
•• Round bur
II. Tungsten carbide burs (Fig. 7.50) •• Inverted cone
•• Pear-shaped
Tungsten carbide burs are best for making precise •• Wheel-shaped
preparation features and smooth surfaces on enamel and •• Tapering fissure
dentin. Metal in head of carbide bur is formed by sintering •• Straight fissure
or pressure molding, tungsten carbide powder and cobalt •• End-cutting bur.
powder under heat and vacuum. Tungsten carbide is cut
into small cylinders and then attached to steel rods by Parts of a Bur
soldering or welding to form blanks. tungsten carbide
head is machined with large diamond disks to create Following are the parts of a bur (Fig. 7.51):
specific head for the type of bur being formed.
Most of the burs used for cutting have 6 or 8 blades. Burs Shank
used for finishing have 12, 20, or even 40 blades. shank is that part of the bur that fits into the handpiece,
accepts the rotary movement from the handpiece and
Classifications of burs controls the alignment and concentricity of the instrument.
1. According to their mode of attachment to the Shank design: Depending upon mode of attachment to
handpiece: handpiece, shanks of burs are of following types (Figs.
7.52A to C):
Fig. 7.51: Parts of dental bur.
C
Figs. 7.52A to C: Different types of bur: (A) Straight bur;
Fig. 7.50: Tungsten carbide burs. (B) latch type; (C) Friction grip.
I. Straight handpiece shank: In these burs, shank part is
like a cylinder into which bur is held with a metal chuck
which has different sizes of shank diameter. These are used
for finishing and polishing of restorations.
II. Latch-type angle handpiece shank: Here, posterior
portion of shank is made flat on one side so that end of
bur fits into D-shaped socket at bottom of bur tube.
instrument is not retained in handpiece with chuck but
with a latch which fits into the grooves made in bur shank.
These instruments are commonly used in contra-angle
handpiece for finishing and polishing procedures.
III. Friction-grip angle handpiece shank: Here, shank
is simple cylinder which is held in handpiece by friction
between shank and metal chuck. In these, shank is much
smaller than latch-type instruments. This design is used for
high-speed handpiece.
Fig. 7.53: Schematic representation of designs of bur heads.
Neck
Neck connects head and shank. It is tapered from shank Straight-fissure Bur
to the head. For optical visibility and efficiency of bur,
dimensions of neck should be small but at the same time It is parallel-sided cylindrical bur of different lengths and
it should not compromise the strength. Main function of is used for amalgam tooth preparations.
neck is to transmit rotational and translational forces to
the head. Tapering-fissure Bur
It is tapered-sided cylindrical but sides tapering toward tip
Head and is used for inlay and crown preparations.
Head: The term “bur shape” refers to the contour or
End-cutting bur
silhouette of the bur head. It is working part of the bur. Bur
head can be of different shapes and sizes. Depending upon It is used for carrying the preparation apically without
shape of bur head, burs are named as round, inverted, axial reduction.
pear, straight, tapered, etc.
Modifications in Bur Design
Types of bur (Fig. 7.53) Because of introduction of handpieces with high-speed
ranges, many modifications have been made in design of
Round bur
bur. Since cutting efficiency of carbide burs increase with
◆◆ Spherical in shape increase in speed, the larger diameter carbide burs have
◆◆ Used for initial entry into the tooth, removal of caries, been replaced by small-diameter burs.
extension of the preparation and for the placement of
retentive grooves. I. Reduced Number of Crosscuts
Since at high speed, crosscuts tend to produce rough
Inverted Cone Bur
surface, newer burs have reduced number of crosscuts.
◆◆ It has flat base and sides tapered toward shank.
◆◆ Used for establishing wall angulations and providing II. Extended Head Lengths
undercuts in tooth preparations. Burs with extended head length have been introduced so
as to produce effective cutting with very light pressure.
Pear-shaped Bur
III. Rounding of Sharp Tip Corners
◆◆ Head is shaped like tapered cone with small end of
cone directed toward shank. Sharp tip corners of burs produce sharp internal angles,
◆◆ Used in class I tooth preparation for gold foil. resulting in stress concentration. Burs with round tip
◆◆ A long length pear bur is used for tooth preparation for corners produce rounded internal line angles and thus
amalgam. lower stress in restored tooth.
Bur Size Bur Blade

Bur size represents the diameter of bur head. Different Blade is a projection on the bur head which forms a cutting
numbers have been assigned to burs which denote bur edge. Blade has two surfaces (Fig. 7.54):
size and head design. Earlier burs had a numbering system ◆◆ Blade face/Rake face: It is the surface of bur blade on
in which burs were grouped by 9 shapes and 11 sizes. the leading edge.
But later because of modifications in bur design this ◆◆ Clearance face: It is the surface of bur blade on the
numbering system was modified. For example, after trailing edge.
introduction of crosscut burs, 500 numbers was added to
the bur equivalent to noncrosscut size and 900 was added Rake Angle
for end-cutting burs. Thus, we can say that no. 58, 558,
This is angle that the face of bur tooth makes with the radial
and no. 958 burs all have same dimensions of the head
line from center of the bur to the blade (Fig. 7.55). It can be
irrespective of their head design (Tables 7.3 and 7.4).
◆◆ Positive rake angle: When radial line leads the face.
◆◆ Negative rake angle: When rake face is ahead of radial
Bur Design line.
Bur head consists of uniformly spaced blades with concave ◆◆ Zero rake angle: When rake face and radial line
areas in between them. These concave depressed areas are coincide each other.
called chip or flute spaces. More positive the rake angle, more acute is the edge of
blade and more effective is the cutting action. But it also
Bur Tooth results in the weaker edge so makes the bur more prone
to fracture. Thus, blades are usually made with negative
Bur tooth terminates in cutting edge or blade. It has two or neutral rake angles and wider bases. Though these are
surfaces, tooth face which is side of the tooth on the leading slightly less efficient but because of greater bulk they are
edge and back or flank of the tooth, which is the side of the less likely to fracture. Carbide burs have blades with slight
tooth on the trailing edge. negative rake angle and edge angle of approximately 90°.
Table 7.5 Summarizes definitions related to bur design.
Table 7.3: Correlation of bur head diameter and its respective number.
Shape of head Head diameter (mm) Number

Round 0.5 ¼
0.6 ½
1.0 2
1.4 4
Straight fissure 0.6 55½
0.8 56
1.0 57
Tapered fissure 0.9 169
1.2 271 Fig. 7.54: Bur design showing rake angle, clearance angle,
Inverted cone 0.6 33½ and edge angle.
0.8 34
Crosscut 1.0 557
1.2 558
End cutting 1.0 957
Table 7.4: Standard bur head sizes.
Head shape Head diameter (mm)

0.5 0.6 0.8 1.0 1.2 1.4
Round ¼ ½ 1 2 3 4
Inverted cone 33½ 34 35 36 37
Straight fissure 55½ 56 57 58 59
Tapered fissure 700 701
Fig. 7.55: Positive, negative and zero rake angle.
Table 7.5: Definitions related to bur design. Significance: If blade angle is increased, it reinforces
Feature Definition the cutting edge and thus reduces fracture of bur. But
clearance angle, blade angle, and rake angle cannot be
• Rake face (Blade face) Surface of bur blade on leading edge
varied independent of each other, e.g. increase in blade
• Clearance face Surface of bur blade on trailing edge
angle, decreases the clearance angle. Usually, the carbide
• Rake angle Angle between rake face and the radial burs have negative rake angles and 90° of blade angle so
line
as to reduce their chances of fracture. For better clearance
−− Positive rake angle Rake face trails the radial line of debris, the clearance faces of carbide burs are made
−− Negative rake angle Rake face ahead of the radial line curved to provide adequate flute space.
−− Zero rake angle Rake face and radial line coincide each
other Tooth Angle
Radial Line This is measured between the face and the back. If land is
present, it is measured between face and the land.
It is the line-connecting center of the bur and the blade.
Concentricity
Land
It is a direct measurement of symmetry of the bur head.
It is the plane surface immediately following the cutting
In other words, concentricity evaluates whether blades
edge.
are of equal length or not. It is measured when the bur is
Clearance Angle static.
This is the angle between clearance face and the work Run Out
(Fig. 7.54). If a land is present on the bur, clearance angle
is divided into It measures the accuracy with which all the tip of blades
pass through a single point when bur is moving (Fig. 7.57).
Primary clearance angle: It is the angle which land makes It evaluates the maximum displacement of bur head from
with the work. its center of rotation. Run out is directly proportional to
Secondary clearance: It is the angle formed between back length of bur shank.
of the bur tooth and work.
When back surface of tooth is curved, the clearance is
called the radial clearance.
Significance: Clearance angle provides a stop to prevent
the bur edge from digging into the tooth and provides
adequate chip space for clearing debris. Smaller the
clearance angle, stronger is the cutting blade. But if angle
becomes too small, back of blade may rub against the
cut surface thus generating heat and reducing cutting
efficiency (Fig. 7.56).
Blade Angle/Edge Angle

It is the angle between the rake face and the clearance
face.
Fig. 7.57: Relationship between length of bur, shank and run out.
Facts
Run out occurs if:
Bur head is off center on axis of the bur
Bur neck is bent
Bur is not held straight in handpiece chuck.
Run out causes
Increase in vibration during cutting
Fig. 7.56: Clearance angle provides a stop to prevent bur edge from
Causes excessive removal of tooth structure.
digging into the tooth.
Factors affecting cutting efficiency

of bur
Following factors affect the cutting efficiency of a bur:
1. Rake Angle, Clearance Angle, and Blade Angle

Positive rake angle increases cutting efficiency of bur,
increase in rake angle causes:
◆◆ Decrease in bulk of bur blade, bur can easily curve,
flatten or even fracture.
◆◆ Produces larger chips, therefore causes clogging of flute
space (Fig. 7.58). Clearance angle reduces the friction
between cutting edge and the work. It also prevents the
bur from digging excessively into the tooth structure.
Increase in clearance angle reduces the blade angle,
thus decreases the bulk of bur blade.
Increasing the blade angle reinforces the cutting edge Fig. 7.59: Photograph showing spiral crosscuts of bur.
and reduces the chances of blade edge to fracture.
2. End-cutting or Side-cutting Bur 5. Linear Surface Speed

According to particular task, choice of bur can be end Within the limit, faster the speed of cutting instrument,
cutting, side cutting, or combination of both. For example, faster is the abrasive action, and more efficient is the
end-cutting bur is used to make entry into the enamel and tooth-cutting instrument.
side-cutting bur is used to make preparation outline.
6. Application of Load
3. Neck Diameter of Bur Load is force exerted by operator on tool head. Normally
If neck diameter of bur is large, it may interfere with for high-speed instruments, load should range between 60
accessibility and visibility. But if diameter is too short, it and 120 g and for low-rotational speeds, it should range
will make bur unable to resist the lateral forces. between 1,000 g and 1,500 g. Cutting efficiency decreases
when load is applied.
4. Spiral Angle and Crosscuts
7. Concentricity and Run Out
Burs with smaller spiral angle when used at high speeds
show better cutting efficiency. Average clinically acceptable run out is 0.023 mm (Figs.
Notches in the blade edges improve cutting efficiency 7.60A to C). Increase in run out causes increase in
at low and medium speed (Fig. 7.59). Crosscuts effectively vibrations of bur and excessive removal of tooth structure.
increase both cutting pressure resulting from rotation and
perpendicular pressure holding the blade edge against the 8. Lubrication
tooth. Lubricant applied to tooth and bur during cutting
increases the cutting efficiency and decreases the rise in
temperature during cutting.
9. Heat Treatment of Bur

Heat treatment of bur preserves the cutting edges and
increases shelf life of the bur.
10. Number of Blades

Usually a bur has 6–8 number of blades. Decrease in
number of blades reduces the cutting efficiency but causes
Fig. 7.58: Increase in the clearance angle causes reduction in the faster clearance of debris because of larger chip space
bulk of the bur blade. (Figs. 7.61A and B).
A B
Figs. 7.62A and B: Star cut and revelation design of flute ends.
B
12. Design of Flute Ends
There are two types of flute ends (Figs. 7.62A and B):
1. Star cut design: Here, the flutes come together in a
common point at the axis of bur.
2. Revelation design: Here, the flutes come together at two
junctions near diametrical cutting edge. It has better
efficiency in direct cutting.
Recent Advances in Rotary

Instruments
C
◆◆ Fiberoptic handpiece
◆◆ Smart prep burs
Figs. 7.60A to C: (A) Concentricity; (B) Run out; (C) Run out causes ◆◆ Chemical vapors deposition (CVD) diamond burs
excessive removal of tooth structure. ◆◆ Fissurotomy burs.
1. Fiberoptic Handpiece
To avoid shadow or visibility problem associated with
external lightening, handpieces with a built-in optics
have been made available. This fiberoptic delivers a high
beam of light to the handpiece head directly on working
site (Fig. 7.63).
Fig. 7.63: Fiberoptic handpiece.
2. Smart Prep Burs

B
Smart prep instrument is also known as polymer bur/smart
bur/dentin safe bur (Fig. 7.64). It is made from polymer
Figs. 7.61A and B: (A) Schematic representation of blades and flutes
of a bur; (B) Less number of blades decrease cutting efficiency but that safely and effectively removes decayed dentin without
cause better debris clearance due to larger chip space. affecting the healthy dentin. The Knoop hardness number
of enamel is 380–400 and of dentin is 66–80 and carious
11. Visual Contact with Bur Head dentin is 30 KHN. So as to effectively remove only carious
part of the tooth, polymer bur was devised with KHN of 50,
For efficient tooth cutting, it is mandatory to maintain this makes the smart prep bur with self-limiting property,
visual contact with bur head while working. i.e. it will not cut the healthy dentin.
artificial diamond layer over the molybdenum substrate.

These tips require only slight touch to promote tooth
grinding.
Application of excessive pressure and force results in
excessive heat generation, decreased cutting efficiency,
pain, and fracture of the molybdenum substrate.
Advantages
◆◆ Less noise
Fig. 7.64: Smart prep burs. ◆◆ Greater durability
(Courtesy: SS White) ◆◆ Better access and visibility
◆◆ Better cooling
Availability ◆◆ Effective tooth preparation
◆◆ Sizes 2, 4, 6. ◆◆ Improved proximal access
◆◆ Used with slow-speed handpiece (500–800 rpm). ◆◆ Reduced risk of metal contamination
◆◆ Single patient use. ◆◆ Preservation of tooth structure and also minimal
Advantages damage to gingival tissues.
◆◆ Used for deep caries removal in lieu of indirect capping Disadvantages

procedure
◆◆ Technique sensitive
◆◆ Chances of iatrogenic pulp exposure are less
◆◆ Very costly.
◆◆ Minimum removal of tooth structure.
Disadvantages 4. Fissurotomy Burs (Fig. 7.66)

◆◆ Technique sensitive These are specially designed for ultraconservative
◆◆ This instrument leaves large amount of decayed portion preparation of pit and fissure lesions. Available in three
unexcavated different shapes and sizes:
◆◆ Expensive i. Original fissurotomy: head length of 2.5 mm, used
◆◆ Chances of damage of bur are more if it touches the for conservative preparation in permanent teeth.
enamel or sound dentin during and after the procedure. ii. Original fissurotomy micro-NTF: head length of
2.5 mm. It is mainly indicated for small caries and
3. Chemical Vapor Deposition Diamond Burs
enlarging the fissure in permanent molars.
In 1996, chemical vapor deposition (CVD) diamond burs iii. Original fissurotomy micro-STF: head length of 1.5
attached to an ultrasonic handpiece were introduced to mm. It is suitable for primary teeth, adult premolars,
eliminate problems faced with diamond burs (Fig. 7.65). enameloplasty, etc.
the bur tips are made in a reactor in which mixture
of methane and hydrogen gas results in formation of
Advantages
◆◆ Minimum heat build-up and vibration
◆◆ Conservation of tooth structure
◆◆ Increased patient comfort.
Fig. 7.65: Chemical vapor deposition diamond burs. Fig. 7.66: Fissurotomy burs.
Disadvantages
◆◆ Should be used with suitable restorative materials
◆◆ Expensive.
Abrasive Instruments AND MATERIALS

IN CONSERVATIVE DENTISTRY
The head of these instruments consists of small angular
particles of a hard substance held in a matrix of softer
material called as the binder. Different materials used for a
binder are ceramic, metal, rubber, shellac, etc.
Abrasive instruments can be divided into:
◆◆ Diamond abrasives
◆◆ Other abrasives. Fig. 7.68: Powdered diamond abrasive.
Diamond Abrasive Instruments

These were introduced in 1942. They have greater
resistance to abrasion, lower heat generation and longer
life to be preferred over tungsten carbide burs. Diamond
instruments consist of three parts (Fig. 7.67):
1. A metal blank.
2. Powdered diamond abrasive: Abrasive diamond can
be natural or synthetic which is crushed to a powder of
desired particles (Fig. 7.68).
3. Bonding agent: It holds the abrasive particles together
and binds the particles to metal blank. Most commonly
used binding agents for diamond instruments are
ceramic and metal.
Classification of Abrasives According to Abrasive Particle

Size (Fig. 7.69) FIg. 7.69: Coarse, medium, fine, superfine diamond points.
◆◆ Coarse grit diamond burs (125–150 µ particle size)—Green

◆◆ Medium grit diamond burs (88–125 µ particle
size)—Blue ◆◆ Very fine grit diamond burs (30-40 µ particle
◆◆ Fine grit diamond burs (60–80 µ particle size)—Red size)—Yellow.
Abrasive stones are available as mounted and
unmounted. The mounted stones have abrading head
which is joined to the shank and the attachment part.
In unmounted stones, the abrading head is supplied
separately which can be attached to the mandrel when
required.
Factors Influencing the Abrasive Efficiency and

Effectiveness
◆◆ Size of the abrasive particles: Abrasive nature is
directly proportional to size of abrasive particle.
Rapid removal of material occurs with coarse grit burs
compared to medium or fine grit burs.
◆◆ Shape of the abrasive particles: The abrasive particles
with irregular shape show more efficiency because they
present a sharp edge (Fig. 7.70).
◆◆ Density of the abrasive particles: Coarse grit burs have
Fig. 7.67: Parts of abrasive instrument. a low density compared to fine grit burs.
i. Soft moulded instruments: these use flexible

materials like rubber as matrix and are used for
finishing and polishing procedures.
ii. Rigid moulded instruments: These use ceramic as
matrix and are used for grinding and sharpening
Fig. 7.70: sharp, irregular particles cause more abrasion than procedures.
rounder particles.
2. Coated abrasive instruments (Figs. 7.72A and B):
These are mostly disks which have a thin layer of
◆◆ Hardness of the abrasive particle: The hardness of the abrasive cemented to a flexible backing. They are used
abrasive particles should be more than the hardness of
in the finishing of enamel walls of tooth preparations
the surface on which it is to be used.
and restorations. The abrasives used here can be silicon
◆◆ Clogging of the abrasive surface: Clogging of the
carbide, aluminium oxide, garnet, quartz, pumice,
spaces between the particles by grinding debris
cuttlebone, etc.
decreases efficiency.
◆◆ Pressure: Excessive pressure causes the loss of 3. Finishing and polishing instruments:
diamonds, thus, decrease their cutting efficiency. i. Finishing burs: Finishing burs are usually made of
◆◆ Miscellaneous: Individual dental techniques, diffe stainless steel or tungsten carbide. Bur should be
rence in pressure, differences in handpieces, etc. also at least 12 fluted (Fig. 7.73A). The main function
affect abrasive efficiency of instrument. of finishing bur is to remove excess of restorative
material rather than cutting the surface. These burs
Other Abrasive Instruments also make the surface smoother. Burs are available
They are used for shaping, finishing and polishing resto in different shapes and sizes, i.e. tapered, inverted
rations in the clinic and in the laboratory. They are of two cone, rounded and pear-shaped, etc.
types: ii. Brushes: Several types of shapes, i.e. wheels,
1. Moulded abrasive instruments (Figs. 7.71A and cylinders or cones are available, which may be
B): These have heads made by moulding mixture of screwed in handpiece either attached to mandrel
abrasive and matrix around the roughened end of the or having their own attachment (Fig. 7.73B). These
shank. They are of two types: brushes can be used for finishing alone or with
A A
B B
Figs. 7.71A and B: (A) Molded abrasive are durable but when the Figs. 7.72A and B: Coated abrasive instruments have thin layer of
surface layer wears, the subjacent layers still possess the same abrasive cemented to a flexible base.
characteristics; (B) Moulded abrasive instrument set.
Fig. 7.73C: Abrasive rotary instruments.

Fig. 7.73A: Finishing and polishing carbide burs.
Fig. 7.73D: Abrasive disks.
Fig. 7.73B: Brushes for finishing.
abrasive pastes. They are used in polishing cast

restorations.
iii. Diamond instruments: They are available in
the form of abrasive rotary instruments and
metal backed abrasive strips (Fig. 7.73C). These
instruments should always be used with light force
and copious water spray. These are mainly used on
ceramic and composite materials.
iv. Paper-carried abrasives: These are usually
abrasives, i.e. sand, garnet or boron carbide
Fig. 7.73E: Rubber cups.
attached to paper disks or strips (Fig. 7.73D).
These are preferably used in back and forth motion
polishing (similar to shoe polishing). vi. Cloth: Cloth, carried on metal wheel can be used
v. Rubber-ended rotary tools: These type of in final stages of polishing with/without polishing
instruments are available in variety of shapes, medium, for exampler; buffing wheel (Fig. 7.73F).
i.e. cups, wheels, etc. (Fig. 7.73E). These can be vii. Felt: Felt is used for obtaining luster for metallic
attached to handpiece with the help of mandrel or restorations with polishing agent. It is available
with their own extension. These are used with other in the different shapes such as wheel, cones and
abrasive or polishing pastes. cylinders (Fig. 7.73G).
7. Aluminium oxide: It is white powder, used as bonded

abrasive, coated abrasive and air propelled abrasive.
It is used for finishing metal alloys, composites and
ceramics.
8. Tin oxide: It is very fine abrasive. It is mixed with
water and glycerine to form paste and used to polish
enamel and metallic restorations.
9. Quartz: It is hard, colorless, transparent material.
Quartz particles are used as coated abrasive disks. It is
used for grinding tooth enamel and metal alloys.
10. Synthetic silicon carbide: It is hard abrasive, used for
cutting metal alloys, acrylic resins and ceramics.
11. Sand: It consist of silica with rounded to angular
shape. It is coated on paper disks.
12. Cuttle: It is white calcareous powder available as
Fig. 7.73F: Buffing wheel. coated abrasive. It is used for polishing metal margins
and amalgam restorations.
13. Tripoli: It is derived from siliceous rock which is
ground and made into bars with soft binders. It is of
white, gray, pink, red or yellow in color. It is used for
polishing metal alloys.
14. Zircon: It is off white mineral ground to different
particle sizes. It is component of prophylaxis pastes.
15. Synthetic diamond: It has consistent size and shape.
Blocks with embedded diamond particles are used for
teeth, ceramics and composites.
16. Dentifrices: Available as toothpaste, gels and
powders. Dentifrices cause abrasive and detergent
action to polish teeth.
HAZARDS AND PRECAUTIONS WITH

Fig. 7.73G: FELT. ROTARY CUTTING INSTRUMENTS
High-speed rotary cutting instruments can result in many
Commonly Used Abrasives in Restorative hazards, can be avoided or reduced by taking certain
Dentistry precautions. These are as follows:
1. Chalk: It is white abrasive composed of calcium Pulpal Damage

carbonate. It is used to polish enamel, gold foil and
Pulp can be injured during tooth preparation because of
amalgam.
mechanical vibration, improper tooth preparation, and
2. Corundum: It is mineral form of aluminium oxide. It
heat generation during cutting. Dull burs and diamond
is available as bonded abrasive in several shapes. It is
instruments have poor efficiency and also produce more
used for grinding metal alloys.
heat, further resulting in pulpal trauma.
3. Emery: it is natural form of aluminium oxide, grayish
corundum. It is used for polishing metal alloys.
4. Garnet: it is dark red, hard material coated on paper Precautions to Avoid Pulpal Trauma
or cloth with glue. It is used for grinding metal alloys Tooth should be treated only with adequate finger rests
or acrylic resin materials. and good visibility of the operating field.
5. Pumice: It is siliceous powder formed by crushing Debris clogging the burs should be cleaned before tooth
pumice stone. Its abrasive action is not very much. It is preparation.
used to polish enamel, gold foil, amalgam and acrylic Coolant should be used while using rotary instrument
resins. to control the heat rise. For this, air-water spray should be
6. Rouge: It consists of iron oxide which is fine red used as it acts as a coolant, moistens the tissues, lubricates
abrasive. It is blended with soft binders to a cake form. and clean the rotary cutting instruments and also cleans
It is used to polish high noble metal alloys. the operating site.
Damage to Soft Tissue or protective eyeglasses should be used while using laser
equipment or light-curing machine.
Lacerations may occur in the lips, tongue, cheeks and floor
of the mouth if proper precautions are not taken. During
cutting procedures, sudden movement by the patient due
Conclusion
to gagging, swallowing, or coughing can also result in soft Though many instruments were used in operative
tissue injury. dentistry since ages but introduction of rotary and hand
instruments especially for restorative procedures is one of
Precautions the major advances in operative dentistry. These advances
have further led us to move from operative dentistry
◆◆ Use good visibility and accessibility to the operative
to the conservative dentistry. Proper understanding
field
of each instrument, its method of use and functions,
◆◆ Isolate the operating site preferably by the rubber dam
understanding of speed and its implications will help in
◆◆ Patient should be instructed not to make sudden
providing the best possible results of the treatment.
movement while working
◆◆ All the burs and rotary instruments should be perfectly
centric. Even a slightly eccentric bur can damage the EXAMINER’S CHOICE QUESTIONs
surrounding dental tissues. 1. Classify hand instruments and its parts.
2. Explain different instrument groups.
Damage to Ear 3. Classify burs. Explain in detail bur design.
4. Enumerate various factors affecting efficiency of bur
When compared to conventional rotary instruments,
cutting.
air turbine handpiece produces high noise level and
5. Write short note on instrument formula for hand
frequency of vibration (ranges from 75–100 decibels
cutting instruments.
with the frequency more than 2,000 cycles per second).
6. Discuss recent advances in rotary instruments.
But when noise level reaches 85 decibels with frequency
7. Write short notes on:
ranging more than 5,000 cycles per second, it is always
a. Instrument formula.
preferred to practice protective measures like:
b. Gingival margin trimmer (GMT).
◆◆ Sound proofing of the room with sound absorbing
c. Sharpening of hand instruments.
materials
d. Hand cutting instruments.
◆◆ Use of ear plugs
e. Bur design.
◆◆ Lubrication of ball bearings so as not to further increase
f. Use of high speed in dentistry.
the noise level.
g. Abrasives and burs used in operative dentistry.
Inhalation Problems
VIVA QUESTIONS
Aerosols and vapors are produced during cutting of
tooth structure and use of restorative materials. Aerosols 1. Name the material used for manufacturing the cutting
are fine dispersions in air consisting of water, cutting instruments.
debris, microorganisms, and restorative materials. 2. Classify of hand cutting instruments.
While removal of amalgam restoration mercury 3. What is GV black nomenclature of hand instruments?
vapors are released and while polishing composite 4. What is GV black instrument formula for hand
restoration monomers are released. These aerosols instruments?
can be inadvertently inhaled by the patient or dentist 5. What are the parts of hand cutting instruments?
resulting in alveolar (lung) irritation, tissue reactions or 6. What is name of tip of the noncutting instruments?
may transfer infectious diseases. Their inhalation can be 7. Difference between three and four number instrument
prevented by the use of rubber dam, use of disposable formula.
masks, and eye wear, etc. 8. What are different instrument motions?
9. Name the different type of explorer.
Eye Injuries 10. What are the different types of gingival marginal
trimmer?
When tooth tissue, calculus or any old restorations are 11. Name the stone used for sharpening of hand
removed at high speeds, injury to eyes can occur because instruments.
of flying particles, microorganisms, and other debris. 12. What are the different types of dental handpiece?
These can be avoided by using protective glasses worn by 13. What are the parts of dental bur?
the patient and the dental personnel. Also, plastic shields 14. What are different types of rake angle?
15. What is concentricity? 6. Eames WB, Reder BS, Smith GA. Cutting efficiency of diamond
16. What is run-out? stones: effect of technique variables. Oper Dent. 1977;2:156-64.
17. What are advantages of balancing of instruments? 7. Eames WB, Nale JL. A comparison of cutting efficiency of
air-driven fissure burs. J Am Dent Assoc. 1973;86:412.
18. What is modified palm and thumb grasp?
8. Eames WB, Nale JL. A comparison of cutting efficiency of
19. What are advantages of sharp instruments? air-driven fissure burs. J Am Dent Assoc. 1973;86:412-5.
20. What are the principles used during sharpening? 9. Eames WB, Reder BS, Smith GA. Cutting efficiency of diamond
21. What is thumb nail test? stones. Effect of technique variables. Oper Dent. 1977;2:156.
22. What are different parts of bur? 10. Frentzen M, Koort HJ, Thiensiri I. Excimer lasers in dentistry:
23. What is rake angle? future possibilities with advanced technology. Quintessence
24. What is significance of rake angle? Int. 1992;23:117-33.
11. Grajower R, Zeitchick A, Rajstein J. The grinding efficiency of
25. What are different factors affecting cutting efficiency
diamond burs. J Prosth Dent. 1979;42:422.
of bur? 12. Hartley JL, Hudson DC, Richardson WP. Cutting characteristics
26. What are recent advances in rotary instruments? of dental burs as shown by high speed photomicrography.
27. What do you understand by chemical vapor deposition Armed Forces Med J. 1957;8:209.
diamond burs? 13. Hartley JL, Hudson DC. Modern rotating instruments: burs and
28. What are fissurotomy burs? diamond points. Dent Clin North Am. 1958;737.
29. Name different abrasive materials used in conservative 14. Henry EE, Peyton FA. The relationship between design and
dentistry. cutting efficiency of dental burs. J Dent Res. 1954;33:281-92.
15. Henry EE. Influences of design factors on performance of the
30. What is rogue?
inverted cone bur. J Dent Res. 1956;35:704-13.
31. What is difference between moulded and coated 16. Leonard DL, Charlton DG. Performance of high-speed dental
abrasives? handpieces. J Am Dent Assoc. 1999;130:1301-11.
32. How many flutes are present in finishing bur? 17. Merritt R. Low-energy lasers in dentistry. Br Dent J. 1992;172:90.
33. What is aluminium oxide abrasive? 18. Morrant GA. Burs and rotary instruments introduction of a new
34. What is tripoli? standard numbering system. Br Dent J. 1979;147:97-8.
19. Myers GE. The air abrasive technique: a report. BDJ. 1954;46:241.
20. Myers TD. Lasers in dentistry. J Am Dent Assoc. 1991;122:46-50.
Bibliography 21. Nelson RJ, Pelander CE, Kumpula JW. Hydraulic turbine contra-
1. Atkinson DR, Cobb CM, Killoy WJ. The effect of an air-powder angle handpiece. J Am Dent Assoc. 1953;47:324-9.
abrasive system on in vitro root surfaces. J Periodontol. 22. Peyton FA. Effectiveness of water coolants with rotary cutting
1984;55:13-8. instruments. J Am Dent Assoc. 1958;56:664-75.
2. Boyde A. Airpolishing effects on enamel, dentin and cement. Br 23. Peyton FA. Temperature rise in teeth developed by rotating
Dent J. 1984;156:287-91. instruments. J Am Dent Assoc. 1955;50:629-30.
3. Chrinstensen GJ. Air abrasion tooth cutting. State of the art. 24. Sockwell CL. Dental handpieces and rotary cutting instruments.
JADA. 1998;129:484. Dent Clin North Am. 1971;15:219-44.
4. Coluzzi DJ. Fundaments of lasers in dental science. Dent Clin 25. Taylor DF, Perkins RR, Kumpula JW. Characteristics of some air
North Am. 2004;48:751-70. turbine handpieces. J Am Dent Assoc. 1962;64:794-805.
5. Dahlin T. Efficient and high quality cavity preparation. Quint 26. Westland IN. The energy requirement of the dental cutting
Int. 1982;5:20. process. J Oral Rehabil. 1980;7:51.
Chapter
8
Principles of Tooth Preparation
Chapter Outline
Introduction Terminology
Definition Number of Line and Point Angles
Purpose of Tooth Preparation Stages of Cavity Preparation
Indications of Restorative intervention Initial Cavity Preparation Stage
Objectives of Tooth Preparation Final Stages of Tooth Preparation
introduction Objectives of tooth preparation

The most important procedure of operative dentistry is the ◆◆ Removal of all defects.
tooth preparation so as to receive a restoration that can ◆◆ Provide necessary pulp protection.
fulfill all its requirements. Therefore, it is a must for every ◆◆ Preservation of tooth structure.
operative clinician to be well aware of all the fundamentals ◆◆ To allow for functional and aesthetic placement of
of tooth preparation. restorative material.
◆◆ Prepare tooth such that under masticatory forces, the
DEFINITION tooth and restoration do not fracture and restoration
does not get displaced.
Tooth preparation is the mechanical alteration of a
defective, injured or diseased tooth in order to best receive
a restorative material which will re-establish the healthy Factors Affecting Cavity Design
state of the tooth including aesthetics correction when for Restoration
indicated along with normal form and function.
1. Extent of the defect.
—Sturdevant
2. Properties of restorative material.
3. Occlusal relationship.
PURPOSE OF TOOTH PREPARATION
4. Aesthetic needs of the patient.
Restoration is usually required to repair a diseased, 5. Assessment of pulpal and periodontal status.
injured or defective tooth structure. The restoration helps 6. Economic status of the patient.
in maintaining proper form, function and aesthetics. 7. Type of dentition, i.e. primary or permanent.
8. Quality of tooth (hypoplasia), location and type of
INDICATIONS OF RESTORATIVE tooth.
INTERVENTION
◆◆ Restoration of decayed tooth. TERMINOLOGY
◆◆ Repair of fractured tooth.
◆◆ Restoration of teeth with congenital malformations.
Simple Tooth Preparation
◆◆ Repair or replacement of defective restoration. A tooth preparation involving only one tooth surface
◆◆ Replacement of missing teeth. is termed simple preparation (Fig. 8.1), for example,
◆◆ Need for aesthetic improvement. occlusal preparation.
Fig. 8.1: Simple tooth preparation involves only one tooth surface. Fig. 8.2: Compound tooth preparation involves two surfaces.
Compound Tooth Preparation

A tooth preparation involving two surfaces is termed as
compound tooth preparation (Fig. 8.2), for example,
mesio-occlusal or disto-occlusal preparation.
Complex Tooth Preparation

A tooth preparation involving more than two surfaces
is called as complex tooth preparation (Fig. 8.3), for
example, MOD preparation.
For communication and records purpose, the surface
of tooth preparation is abbreviated by capitalizing the first
letter.
For example,
◆◆ Preparation on the occlusal surface as “O”. Fig. 8.3: Complex tooth preparation involves more than
◆◆ Preparation on the distal and occlusal surfaces as “DO”. two surfaces.
◆◆ Preparation on mesial, occlusal and distal surfaces as
“MOD”.
Walls
i. Internal Wall
It is a wall in the preparation, which is not extended to the
external tooth surface (Fig. 8.4).
ii. External Wall (Fig. 8.4)

An external wall is a wall in the prepared tooth that extends
to the external tooth surface. External wall takes the name
of the tooth surface toward, which it is situated.
iii. Pulpal Wall

A pulpal wall is an internal wall that is toward the pulp and
covering the pulp (Fig. 8.5). It may be both vertical and Fig. 8.4: Schematic representation showing internal and external
perpendicular to the long axis of the tooth. walls of tooth preparation.
Principles of Tooth Preparation 99
Fig. 8.5: Schematic representation showing pulpal floor Fig. 8.7: Schematic representation of gingival and pulpal floor.
and axial wall.
Fig. 8.8: Schematic representation showing the cavosurface angle.

Fig. 8.6: Class III tooth preparation showing axial wall.
iv. Axial Wall Line Angle

It is an internal wall which is parallel to the long axis of the It is a junction of two surfaces of different orientations
tooth (Figs. 8.5 and 8.6). along the line. Its name is derived from the involved
surfaces.
Floor
Floor is a prepared wall which is usually flat and perpendi Point Angle
cular to the occlusal forces directed occluso-gingivally, for It is a junction of three plane surfaces or three line angles
example, pulpal and gingival floor (Fig. 8.7). of different orientations. Its name is derived from its
involved surfaces or line angles.
Facts
When two or more surfaces are combined, the –al ending of the
NUMBER OF LINE AND POINT ANGLES
prefix word is changed to an –o. The angle formed by lingual Number of line angles and point angles in different tooth
and gingival wall is termed as “linguogingival” line angle. An preparations are enumerated in Table 8.1.
MOD preparation is called mesio-occlusodistal preparation. Line and point angles of class I to class V tooth
preparations are enlisted as following:
Cavosurface Angle Margin Class I Cavity Preparation

Cavosurface angle is formed by the junction of a prepared For simple class I tooth preparation involving only the
tooth surface wall and external surface of the tooth (Fig. occlusal surface of molars, eight line angles and four point
8.8). angles are named as follows (Fig. 8.9):
Table 8.1: Number of line angles and point angles in different tooth
preparation designs.
Type of tooth
preparation Line angles Point angles
Class I 8 4
Class II 11 6
Class III 6 3
Class IV 11 6
Class V 8 4
Fig. 8.10: Class II tooth preparation showing line and point angles.
3. Distopulpal
4. Axiofacial
5. Axiolingual
6. Axiopulpal
7. Axiogingival
8. Faciopulpal
9. Faciogingival
10. Linguopulpal
11. Linguogingival.
Fig. 8.9: Class I tooth preparation showing line angles and point Point Angles
angles.
1. Distofaciopulpal point angle.
Line Angles 2. Distolinguopulpal point angle
3. Axiofaciopulpal point angle.
1. Mesiofacial line angle.
4. Axiofaciogingival point angle.
2. Mesiolingual line angle.
5. Axiolinguopulpal point angle
3. Mesiopulpal line angle.
6. Axiolinguogingival point angle.
4. Distofacial line angle.
5. Distolingual line angle.
6. Distopulpal line angle Class III Cavity Preparation
7. Faciopulpal line angle. For class III preparation on anterior teeth, 6 line angles,
8. Linguopulpal line angle. and 3 point angles are as follows (Fig. 8.11):
Point Angles Line Angles

1. Mesiofaciopulpal point angle. 1. Faciogingival
2. Mesiolinguopulpal point angle. 2. Linguogingival
3. Distofaciopulpal point angle. 3. Axiofacial
4. Distolinguopulpal point angle. 4. Axiolingual
5. incisal
6. Axiogingival.
Class II Cavity Preparation
For class II preparation (mesio-occlusal or disto-occlusal) Point Angles
11 line angles and 6 point angles are as follows (Fig. 8.10): 1. Axiofaciogingival point angle.
Following is the nomenclature for mesio-occlusal tooth 2. Axiolinguogingival point angle.
preparation: 3. Axioincisal point angle.
Line Angles Class IV Cavity Preparation

1. Distofacial For class IV tooth preparation on anterior teeth, 11 line
2. Distolingual angles, and 6 point angles are as follows (Fig. 8.12):
Fig. 8.13: Class V tooth preparation showing line

Fig. 8.11: Class III tooth preparation showing line and point angles.
and point angles.
4. Axiolinguogingival point angle.

5. Mesiofaciopulpal point angle.
6. Mesiolinguopulpal point angle.
Class V Cavity Preparation

For class V tooth preparation, 8 line angles, and 4 point
angles are as follows (Fig. 8.13):
Line Angles
1. Axiogingival
2. Axioincisal
3. Axiomesial
4. Axiodistal
5. Mesioincisal
Fig. 8.12: Class IV tooth preparation showing line 6. Mesiogingival
and point angles. 7. Distoincisal
8. Distogingival.
Line Angles Point Angles

1. Mesiofacial 1. Axiodistogingival point angle.
2. Mesiolingual 2. Axiodistoincisal point angle.
3. Axiomesiogingival point angle.
3. Mesiopulpal
4. Axiomesioincisal point angle.
4. Axiofacial
5. Axiolingual
6. Axiopulpal Facts
7. Axiogingival Earlier when the affected tooth was prepared because of caries,
8. Faciopulpal cutting of the tooth was referred to as cavity preparation.
9. Faciogingival But nowadays many indications other than caries lead to
preparation of the tooth. Hence, the term cavity preparation has
10. Linguopulpal been replaced by tooth preparation.
11. Linguogingival.
Point Angles STAGES OF CAVITY PREPARATION

1. Axiofaciopulpal point angle. Cavity preparation involves a systemic approach based on
2. Axiolinguopulpal point angle. the mechanical and physical principles which should be
3. Axiofaciogingival point angle. followed in an orderly sequence. The design of the cavity
preparation for either a tooth with initial caries or the “Extension for prevention means placing the margins of
replacement of a restoration depends upon the location preparation at areas that would be cleaned by the excursions of
of caries, the amount and extent of the caries, the amount food during chewing”. For this, all pits and fissures are involved,
of lost tooth structure, and the restorative material to be margins of restoration are placed on line angles of the tooth
used. But there are some basic principles which should be and proximal line angles are extended buccally and lingually
through embrasures and cervically below the gingival margin.
followed while doing tooth preparation. Tooth preparation
The advantage of extension is that it prevents recurrence of
is divided into two stages, each consisting of many steps. decay in the tooth surface adjoining the restoration and results
Though each step should be done to perfection, but in self-cleaning embrasure areas.
sometimes modifications can be made in steps. This principle has changed to “Prevention of extension” due to:
Natural remineralization (via calcium and phosphate from
Steps of Cavity Preparation saliva).
Fluoride-induced remineralization (through water,
Stage I: Initial cavity preparation stage dentifrices, restorative materials).
1. Outline form and initial depth. Advancements in instrumentation.
2. Primary resistance form. Advancements in restorative materials.
3. Primary retention form. Modifications in tooth preparation designs.
4. Convenience form.
Stage II: Final cavity preparation stage ◆◆ Internal outline form which refers to the shape of
5. Removal of any remaining enamel pit or fissure, infected internal form of the preparation.
dentin and/or old restorative material, if indicated. During tooth preparation, the margins of the prepara
6. Pulp protection, if indicated.
tion not only extend into sound tooth tissue but also
7. Secondary resistance and retention form.
8. Procedures for finishing the external walls of the tooth
involve adjacent deep pits and fissures in preparation. This
preparation. was referred to as “extension for prevention” by GV Black.
9. Final procedures: Cleaning, inspecting and sealing.
Factors Affecting the Outline and Initial Depth
form of Tooth Preparation
Initial Cavity Preparation Stage i. Extension of carious lesion.
ii. Proximity of the lesion to other deep structural surface
1. Outline Form and Initial Depth defects.
iii. Relationship with adjacent and opposing teeth.
Definition iv. Caries index of the patient.
Outline form is defined as “placing the preparation v. Need for aesthetics.
margins in the position they will occupy in the final tooth vi. Restorative material to be used.
preparation except for finishing enamel walls and margins”.
It also includes preparing the initial depth of 0.2–0.8 mm Principles
into the dentin. It can be divided into (Fig. 8.14): i. Removal of all weakened and friable tooth structure.
◆◆ External outline form which refers to the marginal ii. Removal of all undermined enamel.
boundaries. iii. Incorporate all faults in preparation.
iv. Place all margins of preparation in a position to afford
good finishing of the restoration.
Features for Establishing a Proper

Outline Form (Fig. 8.14)
1. Preserving cuspal strength.
2. Preserving strength of marginal ridge.
3. Minimizing the buccolingual extensions.
4. If distance between two faults is less than 0.5 mm,
connect them.
5. Limiting the depth of preparation 0.2–0.8 mm into
dentin.
6. Using enameloplasty wherever indicated.
Outline Form for Pit and Fissure Lesions

Fig. 8.14: Schematic representation of external and internal ◆◆ Remove all defective portion and extend the
outline form. preparation margins to healthy tooth structure. Rather
than being straight, the outline form should form the
smooth curves so as to preserve as much strong cusps
as possible. This is called circumventing the cusps.
◆◆ Remove all unsupported enamel rods or weakened
enamel margins.
◆◆ Limit the depth of preparation to 0.2 mm into dentin,
though the actual depth of preparation may vary from
1.5–2 mm depending on the steepness of cuspal slopes
and the thickness of the enamel (Fig. 8.15).
◆◆ Circumventing of cusps should be followed to have
smooth free flowing outline form.
◆◆ If the thickness of enamel between two preparation
sites is less than 0.5 mm, connect them to make one
preparation, otherwise prepare as separate cavity
preparations.
◆◆ Avoid ending the preparation margins in high stress
areas, such as cusp eminences.
◆◆ Extend the preparation margins to include all pits and
fissures which cannot be managed by enameloplasty.
◆◆ isthmus width should be 1/4th of the intercuspal
distance (Fig. 8.16).
◆◆ Extend the outline form to facilitate the convenience for
preparation and restoration.
Fig. 8.15: Outline form for pit and fissure lesions.
Outline Form for Smooth Surface Lesions—
Outline Form of Proximal Caries (Class II, III and
IV lesions)
Factors Affecting the Outline Form of Proximal
Preparations
◆◆ Extent of the caries on the proximal side.
◆◆ Dimensions of the contact area in the affected tooth.
◆◆ Contact relationship with adjacent tooth.
◆◆ Age of the patient.
◆◆ Position of gingiva.
◆◆ Alignment of teeth and masticatory forces likely to fall
on restorative material (Figs. 8.17A and B). Fig. 8.16: isthmus width should be 1/4th of the intercuspal distance.
◆◆ Aesthetic requirement of the patient.
Viva Voce
Axial wall should:
Be placed into dentin 0.5–0.8 mm from dentinoenamel
junction (DEJ).
Follow curvature of DEJ buccolingually. A
Follow curvature of DEJ occlusogingivally.
A class II cavity preparation consists of:

◆◆ Occlusal segment.
◆◆ Proximal segment.
Rules for Making Outline Form for Proximal Preparation

B
(Fig. 8.18)
Figs. 8.17A and B: Proper alignment of teeth requires less faciolin-
◆◆ Extend the preparation margins until sound tooth gual extensions as compared to malaligned teeth. It also offers better
structure is reached. cleanliness of embrasure area.
A B
Figs. 8.20A and B: Enameloplasty: (A) Tooth with deep pit and fissure;
(B) Removal of superficial enamel resulting in rounding of deep pit and
fissure caries making it self-cleansable.
Fig. 8.18: Ideal class II cavity preparation of mandibular 1st molar. Indications
◆◆ It is done when caries is present in less than one-third
thickness of the enamel.
◆◆ Presence of a shallow fissure crossing facial or lingual
ridge.
Significance
enameloplasty does not extend the outline form. This
procedure should not be used unless a fissure can be made
into saucer shaped area with mild removal of enamel.
2. Primary Resistance Form

Definition
Fig. 8.19: In proximal tooth preparation, gingival margin should Primary resistance form is that shape and placement
clear adjacent tooth by 0.5 mm. of preparation walls to best enable both the tooth and
restoration to withstand, without fracture, the stresses of
masticatory forces delivered principally along the long
◆◆ Restrict the depth of axial wall 0.2–0.8 mm into dentin. axis of the tooth.
◆◆ Axial wall should be parallel to external surface of the
tooth. Factors Affecting Resistance Form
◆◆ In class II tooth preparation, place gingival seat apical
to the contact but occlusal to gingival margin and 1. Amount of occlusal contact.
have a clearance of 0.5 mm from the adjacent tooth. 2. Type of restoration used.
This clearance provides space for proper accessibility, 3. Amount of remaining tooth structure.
visibility, instrumentation, and restoration (Fig. 8.19).
Features of Resistance Form (Fig. 8.21)
Rules for Class V Cavities 1. Box-shape or mortise form of preparation with flat
pulpal and gingival floor (Fig. 8.21). Flat gingival
◆◆ Outline form is limited by extent of the lesion.
and pulpal floors help in resisting masticatory forces
◆◆ Extensions are made mesially, distally, occlusally and
directed along the long axis of the tooth, thereby prevent
gingivally till sound tooth structure is reached.
the tooth fracture from wedging forces resulting from
◆◆ Axial depth is limited to 0.8–1.25 mm pulpally.
opposing cusps (Figs. 8.22 A and B).
2. Adequate thickness of restorative material depending
Enameloplasty on its respective compressive and tensile strengths
Enameloplasty is removal of sharp and irregular enamel to prevent the fracture of both the remaining tooth
margins of the enamel surface by “rounding” or “saucering” structure and the restoration (Fig. 8.23).
it and converting it into a smooth groove making it a self 3. Restrict the extension of external walls to allow strong
cleansable area (Figs. 8.20 A and B). marginal ridge areas with sufficient dentin support.
3. Primary Retention Form
Definition
Primary retention form is that form, shape and configu
ration of the tooth preparation that resists the displacement
or removal of restoration from the preparation under
lifting and tipping masticatory forces.
Retention Form for Different Restorations

1. Amalgam: Retention is increased in amalgam resto
ration by the following:
•• Providing occlusal convergence (about 2–5°) of the
Fig. 8.21: Box-shape or mortise form of preparation with flat dentinal walls toward the tooth surface (Fig. 8.23).
pulpal and gingival floor. •• Giving slight undercut in dentin near the pulpal wall.
•• Providing occlusal dovetail (Figs. 8.24A and B).
2. Cast metals: Retention is increased in cast restorations
by the following:
•• Close parallelism of the opposing walls with slight
occlusal divergence of 2–5°.
•• Making occlusal dovetail to prevent tilting of
restoration in class II preparations.
•• Use of secondary retention in the form of coves,
skirts and dentin slot.
A B
Figs. 8.22A and B: (A) Resistance form of tooth preparation provided
by flat pulpal and gingival floor; (B) In case of rounded pulpal floor,
the rocking motion of restoration results in wedging force which may
result in failure of restoration.
Fig. 8.23: Features of resistance and retention form for amalgam.
4. Inclusion of weakened tooth structure to avoid fracture

under masticatory forces.
5. Rounding of internal line angles to reduce the stress
concentration points in tooth preparation (Fig. 8.23).
6. Consideration to cusp capping depending upon the
amount of remaining tooth structure.
Viva Voce
Type of restoration Minimum occlusal thickness
Cast metal 1–2 mm
B
Amalgam restorations 1.5 mm
Ceramics 2 mm Figs. 8.24A and B: Retention to amalgam retention is provided by:
Composite 1–2 mm (A) Convergence of walls; (B) Dovetail.
•• Give reverse bevel in class I compound, class II, and Table 8.2: Difference between infected and affected dentin.
MOD preparations to prevent tipping movements. Infected dentin Affected dentin
3. Composites: In composites, retention is increased by:
• It is a superficial layer of • It is a deeper layer
•• Micromechanical bonding between the etched and
demineralized dentin
primed prepared tooth structure and the composite
• Cannot be remineralized • Can be remineralized
resin.
•• Providing enamel bevels. • Lacks sensation • It is sensitive
4. Direct filling gold: Elastic compression of dentin and • In this, intertubular layer is • In this, intertubular layer is
starting point in dentin provide retention in direct gold demineralized with irregularly only partly demineralized
fillings by proper condensation. scattered crystals
• Collagen fibers are broken • Distinct cross bands are
4. Convenience Form down, appear as only present
indistinct cross bands
Definition • It can be stained with: • It cannot be stained with any
−− 0.2% propylene glycol solution
The convenience form is that form which facilitates and −− 10% acid red solution
provides adequate visibility, accessibility, and ease of −− 0.5% basic fuchsin
operation during preparation and restoration of the tooth.
enamel and dentin. So, while in use, these effectively
Features of Convenience Form remove the infected dentin without harming effect
i. To have adequate width and lateral extensions for dentin.
restorative material. Table 8.2 shows the difference between infected dentin
ii. To provide proximal clearance from the adjacent and affected dentin.
tooth during class II preparation.
iii. Refining of line and point angles for starting points of Removal of Old Restorative Material is
direct filling gold. Indicated, if:
iv. To provide occlusal divergence for cast gold inlays.
◆◆ It affects aesthetics of new restoration.
Final Stages of Tooth Preparation ◆◆ Has secondary caries beneath (seen on radiograph).
◆◆ Tooth is symptomatic.
5. Removal of Any Remaining Enamel ◆◆ It compromises new restoration.
◆◆ Marginal deterioration of old restoration.
Pit or Fissure, Infected Dentin and/or
Old Restorative Material, if Indicated 6. Pulp Protection
Definition When remaining dentin thickness is less, pulpal injury can
It is defined as removal of any infected carious tooth occur because of heat production, high speed burs with less
structure or faulty restorative material which is left in the effective coolants, irritating restorative materials, galvanic
tooth after initial preparation. While removing the carious currents due to restoration of dissimilar metals, excessive
dentin, one should remove only infected dentin not the masticatory forces transmitted through restorative
affected dentin. This is done by using: materials to the dentin and ingress of microorganisms and
i Large sized round steel bur at slow speed with their noxious products through microleakage.
light force in wiping motion. Large sized instrument Pulp protection is achieved using liners, varnishes and
minimizes the force per square millimeter applied bases depending upon:
to affected area, reducing the chances of mechanical ◆◆ Amount of remaining dentin thickness.
pulp exposure. ◆◆ Type of restorative material used.
ii. Large spoon excavator in lateral wiping motion,
forces removal of infected dentin should be directed
7. Secondary Resistance and
laterally and not towards the center of carious lesion.
Caries are removed in a spiraling fashion, beginning Retention Forms
with the most superficial caries at the outer lateral This step is needed in complex and compound tooth
wall. As hard dentin is reached laterally, it is followed preparations where added preparation features are used to
to the central area. improve the resistance and retention form of the prepared
iii. Use of smart prep burs: Smart burs are round burs tooth. These can be done by adding:
used at a speed of 500–800 rpm. Their hardness is ◆◆ Mechanical features.
greater than infected dentin but lesser than normal ◆◆ Conditioning procedures.
Mechanical Features
many mechanical features are added in the tooth
preparation to provide additional retention and resistance
form.
These can be:
1. Retention grooves: Retention grooves are placed on
axiofacial and axiolingual line angles from gingival
floor to occlusal surface. These are prepared with the
help of no.1/4 round but just inside the dentin. Table
8.3 enlists type of tooth preparation and location of
retention grooves.
Table 8.3: Location of retention grooves for different tooth
preparations.
Fig. 8.26: Secondary retention in the form of amalgam pins to
Type of tooth preparation Location of retention grooves
increase the retention of the restoration.
Class II preparation Proximal wall, at the axiofacial and
axiolingual line angles
Class III preparation Axiogingival line angle or 6. Skirts: Skirts are prepared for providing additional
axiofaciogingival point angle and retention in cast restorations by increasing the total
lingual dovetail surface area of preparation. Skirts can be prepared
Class V preparation Axioincisal and axiogingival line angle on one or all four sides of the preparation using flame
shaped bur.
2. Coves: Coves are small conical depressions prepared 7. Amalgam pins: Amalgam pins are vertical posts of
in the proximal walls of class II preparations at amalgam anchored in dentin. Dentin chamber is
axiofacial and axiolingual line angles thus resisting prepared by using inverted cone bur on the gingival
the proximal displacement of restoration. floor 0.5 mm into dentin with 1–2 mm depth and 0.5–1
3. Slots or internal boxes: These are 1.0–1.5 mm deep mm width (Fig. 8.26).
box-like grooves prepared in dentin to increase the
surface area. These are prepared in occlusal box,
Conditioning procedures
buccoaxial, linguoaxial and gingival walls (Fig. 8.25).
For cast restorations, these are prepared by using treatment of the pre paration walls by conditioning
tapered fissure bur to avoid undercuts and for procedures, etching, and bonding increases the adhesive
amalgam, these are prepared by using inverted cone property of tooth preparation. These procedures are
bur to create slight undercuts in dentin. done for glass ionomer cements, composites or ceramic
restorations.
8. Procedures for Finishing the

External Walls of the Tooth
Preparation
Definition
Finishing of tooth preparation walls is further development
of a specific cavosurface design and degree of smoothness
which produces maximum effectiveness of the restorative
material being used.
Fig. 8.25: Slot or internal box is given in cast restoration which
helps in retention of amalgam. Objectives
4. Locks: Locks are usually prepared for class II amalgam i. To have smooth marginal junction between resto
restorations for increasing resistance and retention ration and tooth surface.
form. ii. To provide maximum strength for both tooth and
5. Pins: Different types of pins of various shapes and restorative material at and near the margins.
sizes are used to provide additional retention in iii. To have smooth blending of restoration and tooth
amalgam, composite and cast restorations. surface at the margins.
9. Final Procedures: Cleaning,

Inspecting and Sealing
Final step in tooth preparation is cleansing of the
preparation. This includes the removal of debris, drying
of the preparation, and final inspection before placing
restorative materials.
◆◆ Cleaning of tooth preparation using warm water.
◆◆ Drying the tooth preparation using air, dry cotton
pellets.
◆◆ Sterilization of preparation walls using very mild
alcohol free disinfectant: Use of mild disinfectant in
tooth preparation serves the purpose of disinfection.
Fig. 8.27: At the margins, all the enamel walls should have
full length rods supported by dentin. CONCLUSION
While preparing the cavity, one should keep in mind all
the principles like outline form, resistance, and retention
Factors Affecting Type of Finishing Necessary form features according to type of cavity, properties of the
for External Walls tooth tissue and type of restorative material to be used. To
have success in restorative procedure, one should have
◆◆ Direction of enamel rods.
fundamental knowledge of all the principles of cavity
◆◆ Choice of restorative material.
preparation.
◆◆ Location of the margins.
To avoid fracture of the tooth structure at the margins, EXAMINER’S CHOICE QUESTIONS
all enamel walls should have full length of enamel rods
supported by sound dentin (Fig. 8.27). 1. Define tooth preparation. What are indications of
tooth preparation?
Features 2. Write fundamentals of tooth preparation.
1. Degree of Smoothness or Roughness of the Walls a. Primary resistance form.
b. Primary retention form.
This varies according to type of restorative material used.
c. Air abrasion/kinetic tooth preparation.
Smooth surface is indicated for cast metal restorations
d. Enameloplasty.
whereas roughness of the walls can be given in case
e. Secondary resistance and retention forms.
of amalgam, direct filling gold, and composite resin
f. Grooves and coves.
restorations.
g. Slots or internal boxes.
2. Design of Cavosurface Angle Viva questions
This also varies according to type of restorative material
1. Define tooth preparation.
used. For amalgam, 90° cavosurface angle or butt joint is
2. What are different types of tooth restorations?
recommended due to low edge strength of the material. For
3. Name of the external and internal wall in cavity
composite and cast metal restorations, bevel is indicated
preparation.
for better marginal sealing and better bonding.
4. Define cavosurface margin.
5. Define cavosurface angle.
Facts 6. What is line angle and point angle?
Noy’s structural requirements of finished tooth preparation: 7. How many line angle and point angle are there in
Tooth preparation should rest on sound dentin.
Class I and Class V cavity preparation?
Enamel rods of cavosurface angle should have their inner
8. Who gave the Class VI cavity design?
ends resting on sound dentin. 9. List all stages and steps of cavity preparation.
Outer ends of enamel rods of cavosurface angle should 10. What are the features of outline form and initial depth?
rest on sound dentin with their outer ends to be covered 11. What are the features of primary resistance form?
with restorative material. 12. What are the features of primary retention form?
Cavosurface angle should be properly trimmed or beveled 13. What are the features of convenience form?
so as to prevent harm to the tooth structure or restoration. 14. What are the features of secondary resistance and
retention form?
15. What is cavosurface angle for any given restoration? 2. Charbeneau GT. Principles and practice of operative dentistry,
16. What should be cavity depth for different restorative 3rd edition. Philadelphia: Lea and Febiger; 1988.
3. Charbeneau GT, Peyton FA. Some effects of cavity instrumen
materials?
tation on the adaptation of gold castings and amalgam. J
17. How will you check the convenience form of cavity Prosthet Dent. 1958;8(3):514-25.
preparation? 4. Fusayama T. Two layers of carious dentin; diagnosis and
18. What is isthmus? treatment. Oper Dent. 1979;4(2):63-70.
19. What should be the height of proximal box in Class II 5. Hosoda H, Fusayama T. A tooth substance saving restorative
technique. Int Dent J. 1984: 34(1):1-12.
cavity preparation? 6. Jokstad A, Mjor IA. Cavity designs for class II amalgam
20. What is minimum width of isthmus? restorations. A literature review and a suggested system for
evaluation. Acta Odontol Scand. 1987;45(4):257-73.
BIBLIOGRAPHY 7. Osborne JW, Summit JB. Extension for prevention: is it relevant
today? Am J Dent. 1998;11(4):189-96.
1. Ben-Amar A. Reduction of microleakage around new amalgam 8. Street EV. Effects of various instruments on enamel walls. J Am
restorations. J Am Dent Assoc. 1989;119(6):725-8. Dent Assoc. 1953;46(3):274-80.
Chapter
9
Patient Evaluation, Diagnosis and
Treatment Planning
Chapter Outline
Introduction Treatment Planning

Patient Evaluation Quadrant Dentistry
Clinical Evaluation Treatment Record/Documentation
INTRODUCTION History of Present Illness

Diagnosis is defined as utilization of scientific knowledge Once the patient completes information about his/her
for identifying a diseased process and to differentiate it chief complaint, a report is made which provides more
from other disease process. It is the procedure of accepting descriptive analysis about this initial information. It
a patient, recognizing that he/she has a problem, should include signs and symptoms, duration, intensity of
determining the cause of problem and developing a pain, relieving and exaggerating factors, etc.
treatment plan which would solve the problem. There are
various diagnostic tools of diagnosis. Out of all these, art Dental History
of listening is most important. It also establishes patient-
doctor rapport, understanding and trust. This helps to know any previous dental experience, and
Although diagnostic testing of some common past restorations. It also tells important information
complaints may produce classic results but sometimes regarding patient’s current dental problems. Frequency
tests may produce wrong results, which need to be carefully of dental care and perception of previous treatment may
interpreted by clinician. give indication of patient’s future behavior. It is crucial
to understand past experiences to provide optimal care
PATIENT EVALUATION in the future. Recent radiographs taken in past should
be evaluated so as to minimize unnecessary radiation
It is the first step for diagnosis of the patient. it is done exposure to the patient.
by gathering all information related to chief complaint
like recording general status of the patient, past, present
medical and dental history of the patient and to see
Medical History
attitude of the patient toward dental treatment. Following There are no medical conditions which specifically
steps are taken for evaluation of the patient: contraindicate operative treatment, but there are several
which require special care.
Chief Complaint
Systemic Health
It consists of information which promoted patient to visit
a clinician. It should be recorded in patient’s own words. Patients with valvular defects or heart murmurs are at
Patient should be encouraged to discuss aspects of current high risk for development of bacterial endocarditis after
problem, including onset, duration, symptoms and related surgical and dental procedures, therefore, prophylactic
factors. antibiotic coverage should be given to such patients before
Patient Evaluation, Diagnosis and Treatment Planning 111
initiating dental treatment. A screening test should be Intraoral Examination
done to evaluate the status of the diseased person. For this,
blood pressure and the patient’s pulse should be recorded. 1. Soft Tissue Examination
It includes visual examination and palpation of buccal
Communicable Diseases mucosa, buccal vestibule, hard and soft palate, tongue and
Before initiating any treatment, the clinician should check floor of mouth.
for presence of any communicable disease like herpes
simplex, mumps, tuberculosis, chicken pox, etc. Patient 2. Hard Tissue Examination
should also be asked about other diseases like Hepatitis-B, i. Evaluation of caries
AIDS, etc. Dental caries is diagnosed by the following:
◆◆ Visual changes in tooth surface (Fig. 9.1).
Allergies or Medication ◆◆ Tactile sensation while using explorer.
Clinician must be informed about any allergy related ◆◆ Radiography—definite radiolucency indicating a break
to patient. For example, if the patient is allergic to local in the continuity of enamel is carious enamel (Fig. 9.2).
anesthetic during dental treatment, he/she may go in the ◆◆ Transillumination: A translucency producing a charac
state of anaphylactic shock. Allergic reactions may occur teristic shadow on the proximal surface indicates
in the form of itching, rashes, swellings, gingivitis, ulcers, presence of caries.
etc.
Physiological Changes Associated with Aging

Physiological changes associated with aging should be
examined properly and should not be confused with the
pathological changes. Changes in oral cavity occurring due
to aging are attrition, abrasion, extrinsic stain, diminished
salivary flow and gingival recession.
Social Status of the Patient

Social status of the patient is evaluated to know his
attitudes, expectations, priorities, education, and habits.
This helps in planning the line of treatment according to
expectations of the patient.
CLINICAL EVALUATION Fig. 9.1: Clinical phogotraph showing multiple carious teeth.
Clinical evaluation is done by examining complete

extraoral and intraoral structures of oral cavity in following
steps:
Extraoral Examination
One should check for general built and gait. Local extraoral
examination should begin while clinician is taking patient’s
dental history by observing the facial features. One should
look for facial asymmetry (may indicate odontogenic
origin or systemic ailment), skin lesions, any asymmetrical
movement of the joint, swelling of lymph nodes, etc.
Vital Signs
Check for blood pressure (normal range is 120/80 mm
of Hg), pulse rate (normal 60–80/minute), respiration
(normal is 16–18/minute), and temperature (normal is
37°C). Fig. 9.2: Radiograph showing caries in first molar.
ii. Evaluation of existing restorations (Fig. 9.3) Hereditary conditions like hypodontia, microdontia,
Evaluation should be done to know the present condition amelogenesis imperfecta, dentinogenesis imperfecta
of the restoration. It can be done by visual, tactile and should be examined.
clinical examination using radiographs. On clinical
evaluation of restorations, the following conditions may iV. Examination of periodontium
be observed: Check gingival color, contour and consistency as these
i. Proximal overhangs: Proximal restoration is evaluated are important indices of periodontal health. Determine
by moving the explorer back and forth across it. If the the depth of gingival sulcus around each tooth, mobility,
explorer stops at the junction and then moves onto presence of bifurcation or trifurcation involvement,
the restoration, an overhang is present. This should be gingival recession to check long-term prognosis of the
corrected, as it can result in the inflammation of the tooth.
adjacent soft tissues. V. Radiograph
ii. Marginal gap or ditching: It is the deterioration of the Radiograph is one of the most important tools in
restoration-tooth interface on occlusal surfaces as a making a diagnosis. Without radiograph, case selection,
result of wear or fracture. Shallow ditching less than 0.5
diagnosis and treatment would be impossible as it
mm deep usually requires patchwork repair. If ditch is
helps in examination of oral structure that would
too deep, restoration should be completely replaced.
otherwise be unseen by naked eye. Radiographs help to
iii. Amalgam blues: These are the discolored areas seen
diagnose tooth related problems like caries, fractures,
through the enamel in teeth. The bluish hue results
root canal treatment or any previous restorations,
either from leaching of corrosion products of amalgam
into dentinal tubules or from color of underlying abnormal appearance of pulpal or periradicular tissues,
amalgam as seen through translucent enamel. periodontal diseases and the general bone pattern
iv. Voids: These also occur at the margins of amalgam (Fig. 9.4). Sometimes the normal anatomic landmarks
restorations. If the void is at least 0.3 mm deep and is like maxillary antrum, foramina, tori, inferior alveolar
located in the gingival one-third of the tooth crown, canal, etc. may be confused with endodontic pathologies
then the restoration should be replaced. which may result in wrong diagnosis and thus improper
v. Fracture line: A fracture line that occurs in the isthmus treatment.
region generally indicates fractured restoration which Indications of use of radiographs
needs replacement. ◆◆ Deep carious lesion.
vi. Recurrent caries at the margin of the restoration also ◆◆ Large restoration.
indicates repair or replacement of the restoration.
◆◆ History of pain.
III. Clinical examination of noncarious lesions ◆◆ History of trauma.
Check thoroughly tooth wear, chemical erosion, abrasion, ◆◆ History of root canal treatment.
abfraction, attrition, developmental defects like enamel ◆◆ Presence of sinus/fistula.
hypoplasia, hypomineralization, fluorosis, tetracycline ◆◆ Unusual tooth morphology.
staining, etc. ◆◆ Missing teeth with unknown reason.
Fig. 9.3: Clinical photograph showing multiple amalgam Fig. 9.4: An OPG showing showing carious, missing, root canal
restoration. treated and filled teeth.
Patient Evaluation, Diagnosis and Treatment Planning 113
VI. Study casts and lateral excursive movements should be checked
Study casts are used as adjunct to develop the proper properly by articulating study casts.
treatment plan (Fig. 9.5). Study casts help in study of the
following: TREATMENT PLANNING
◆◆ To educate the patient.
◆◆ To evaluate occlusal relationship. Treatment planning consists of the following phases:
◆◆ To analyze tilted or extruded teeth.
◆◆ To check presence of plunger cusps or wear facets. 1. Urgent Phase
In urgent phase, treatment mainly aims at providing the
relief from symptoms, for example, incision and drainage
of an abscess with severe pain and swelling, endodontic
treatment of a case of acute irreversible pulpitis, etc.
2. Control Phase
In this phase, the treatment involves halting the progress
of primary disease, i.e. caries or periodontal problem by
removing etiological factors. Finally, the patient is made
to understand the disease and its treatment which further
increases his/her compliance to the treatment. This
approach is beneficial for the long-term prevention of the
dental caries and periodontal disease.
Fig. 9.5: Study models help to evaluate the occlusal relationship,
presence of wear facets, tilted or extruded teeth and to educate the
patient. 3. Holding Phase
It comes between control phase and the definitive phase.
VII. Occlusion Examination (Fig. 9.6) Thus, holding phase is a time between control phase and
Through occlusal examination, one can identify the definitive phase that allows time for healing and analysis
signs of occlusal trauma such as enamel cracks, tooth of inflammation. During this phase, patient is advised
mobility and other occlusal abnormalities. During home care habits and motivated for further treatment.
occlusal examination, one should check presence of The initial treatment is re-evaluated before the definitive
supraerupted teeth, spacing, fractured teeth and marginal treatment.
ridge discrepancies. Teeth are examined for abnormal
wear patterns, such as bruxism or parafunctional habits 4. Definitive Phase
in addition to unfavorable occlusal relationships such
The definitive phase may involve many procedures such
as plunger cusp, which may result in food impaction.
as endodontic, orthodontic, periodontic, oral surgical and
Dynamic relationship of teeth during forward, backward
operative procedures prior to further treatment.
5. Maintenance Phase
In maintenance phase, regular recall and examination of
patient is done. This helps in prevention of the recurrence
of the disease and maintenance of the previous treatment
results. Recall visits for patients can vary from patient-
to-patient, for example, patients who are at high-risk for
dental caries should be examined more frequently than
the patients at low risk for dental caries.
QUADRANT DENTISTRY
Quadrant dentistry is treating multiple teeth in a quadrant
during one visit (Fig. 9.7). It is is beneficial to both patients
and dental offices due to following reasons:
Fig. 9.6: Photograph showing deep bite and occlusal relationship 1. It calls for fewer appointments and less time off from
of teeth. work.
diagnosis, and treatment planning for providing optimal

treatment to the patient except in case of dental emergency
which requires immediate intervention. Examination,
diagnosis and treatment planning are very challenging
if done thoroughly and properly with the patient’s best
interest in mind.
EXAMINER’S CHOICE QUESTIONS

1. Discuss patient assessment, diagnosis and treatment
Fig. 9.7: Quadrant dentistry is treating multiple teeth in a quadrant planning in operative dentistry.
during one visit. 2. Write short notes on:
a. Treatment planning in operative dentistry.
b. Radiographs in operative dentistry.
2. It reduces discomfort and stress. Anxious patients face
c. Intraoral examination in diagnostic process.
fewer visits, fewer injections, etc.
3. It becomes cost effective to dentist by maximizing time, viva QUESTIONS
decreasing cost, and less stress.
4. There are fewer patient queries overtime. 1. What is marginal gap/ditching?
5. It increases quality of care. For example, management of 2. What is amalgam blue?
interproximal contacts, occlusal forces, and aesthetics 3. What are indications of use of radiographs?
become more predictable if quadrant dentistry is 4. What is treatment planning?
performed rather than treating one tooth at a time. 5. Discuss the phases of treatment planning.
6. What do you mean by quadrant dentistry and why it is
TREATMENT RECORD/DOCUMENTATION beneficial?
7. What are benefits of maintaining treatment records/
All the activities from the initial treatment plan to final documentation?
treatment like examination, diagnosis and final treatment 8. How many phases are there in treatment planning?
should be maintained in the form of record. Maintenance
of the records also becomes a legal document in support BIBLIOGRAPHY
of a particular action a dentist may take while rendering
1. Charbeneau GT. Examination, Diagnosis and Treatment
a treatment. This record must be dated with the headings
Planning. In: Principles and Practice of Operative Dentistry. 3rd
made chronologically. edition. Mumbai: Varghese Publishing House; 1989. pp. 19-41.
Record keeping system should have following features: 2. Kidd EA, Smith BG, Pickard HM. Making Clinical Decisions.
1. Allow quick and easy data entry and retrieval. In: Pickard’s Manual of Operative Dentistry (Oxford Medical
2. Should be comprehensive. Publication), 7th edition. Oxford: Oxford University Press; 1996.
pp. 28-48.
3. Should be easily expandable. 3. Sanger RG, Boone ME. Problem-oriented dental record
4. Should be economical. system—an alternative. In: Wood NK (Ed). Treatment Planning.
5. Should be educational by reinforcing diagnostic, treat A Pragmatic Approach. St Louis: Mosby; 1978. pp. 323.
ment planning, and patient management principles. 4. Shugars DA, Shugars DC. Patient Assessment, Examination
and Diagnosis, and Treatment Planning. In: Roberson TM,
Heymann HO, Swift EJ (Eds). Sturdevant’s art and science of
CONCLUSION operative dentistry, 4th edition. St. Louis: Mosby; 2002. pp.
389-428.
Proper diagnosis and treatment planning play a critical role 5. Whitehead SA, Wilson NH. Restorative decision-making
in quality of dental care. One should follow the meticulous behavior with magnification. Quintessence Int. 1992;23(10):
detailed step by step approach of clinical examination, 667-71.
Chapter
10
Patient and Operator Position
Chapter Outline
Introduction Four Handed Dentistry

Operating Stool Zones of Working Area/Activity
Considerations for Dentists While Treating Patients Visibility
Dental Chair Positions
INTRODUCTION
The patient and operator positions are important for the
benefits of both individuals. A patient, who is comfortably
seated in dental chair with right posture is going to
experience less muscular strain, less fatigue and is more
cooperative during the treatment. The same is the case
with operator. If operator maintains proper position and
posture during treatment, the operator is less likely to
get strained, fatigued, and be more efficient and has less
chances of getting musculoskeletal disorders. Most of the
restorative dental procedures can be completed while
sitting.
Following points should be kept in mind in relation to
dental chair:
◆◆ It should be able to provide comfort to the patient and Fig. 10.1: Operating stool.
total body support during working.
◆◆ Headrest of chair should be attached for supporting
patient’s chin and reducing strain on chin muscles. ◆◆ Have casters for mobility and easy movement.
◆◆ It should be able to provide maximum working area to ◆◆ Be sturdy and well balanced.
the operator. ◆◆ Have a seat which is well padded with cushion.
◆◆ It should be placed at the convenient location with ◆◆ Have adjustable backrest to provide full support to the
adjustable control switches. dentist.
◆◆ Foot switches are preferred to improve infection
control. CONSIDERATIONS FOR DENTISTS WHILE
treating patients
Operating Stool 1. Dentist should not sacrifice good operating posture as
Many types of operating stools are commercially available it will decrease visibility, accessibility and efficiency.
(Fig. 10.1). An operating stool should have following 2. Dentist should sit on the middle of the chair cushion
features like it should: rather than edges.
A B
Figs. 10.2A and B: Incorrect and correct operator posture while performing dental procedures.
3. Back should be straight. Head should be erect and

should not be bent or drooping (Figs. 10.2A and B).
4. Hip should sit at an angle of 90° with the thighs parallel
to the floor.
5. Heels of the feet should touch the floor. When working
in 11 O’clock or 12 O’clock position, feet should be
spread apart so that legs and the chair base form a
tripod which creates the stable position. Avoid placing
legs behind patient’s chair.
6. Elbow should be close to the sides and at the level of
patient’s mouth.
7. Forearm while working should be parallel to the floor.
8. Maintain proper working distance during dental
procedure. This will result in increased cooperation
and confidence from the patient. When the patient
is properly positioned, the dentist’s eyes should be
14–16 inches from the treatment site (Fig. 10.3).
Fig. 10.3: Distance considerations while working on a patient.
9. Avoid/minimize body contact with patient. Operator
should not rest forearms on the patient’s shoulders
16. While working on mandibular arch:
and hands on the face of the patient.
•• Back of chair should be almost parallel to the floor.
10. Patient’s head can be rotated backward or forward
•• mandibular occlusal surface should be oriented
or from side to side for operator’s ease and visibility 45° to the floor.
while doing work. •• Chin should face slightly downward.
11. Dentist should not use patient’s chest as an instrument
tray.
DENTAL CHAIR POSITIONS
12. Operator should keep left hand free during most of
dental procedures for retraction using mouth mirrors. There are four general chair positions, viz; upright, reclined
13. Operator should keep changing position if procedure at 45°, supine and Trendelenburg.
is of long duration to decrease the muscle strain and
fatigue. Upright Position
14. The assistant should sit in an erect position with feet
This is the initial position of chair from which further
firmly placed on the foot-support ring at the base of
adjustments are made (Fig. 10.4A). This position is
the assistant chair. Stool height of assistant should be
mainly used for initial patient seating, consultation and
4–6 inches above the dentist’s eye level.
conclusion of treatment.
15. While working on maxillary arch:
•• Back of chair should be slightly 45° to the floor.
•• maxillary occlusal surfaces should be perpendi
Reclined at 45°
cular to the floor. Here, the chair is reclined at 45° (Fig. 10.4B). this position
•• Chin should face slightly upward. is preferred while working for mandibular teeth. Patient
Patient and Operator Position 117
should have chin down position and mandibular occlusal Four Handed Dentistry
surfaces, almost at 45° to the floor for optimal working on
mandibular teeth. It is an ergonomically sound way to practice dentistry
using the skills of dental assistant while including work
Supine simplification techniques.
The term “Four handed dentistry” was first recorded in
In this, chair position is such that patient’s head, knees and conference on training dental students to use their chair
feet are approximately at the same level (Fig. 10.4C). This side assistants in 1960. Since then, this term has been
position is preferred while working for maxillary teeth.
extensively used. Four handed dentistry allows the dentist
Patient should have chin up position for optimal access of
and assistant to function as a team in seated position with
maxillary teeth.
minimum strain and maximum efficiency. Prerequisites to
practice four handed dentistry:
Trendelenburg Position i. Equipment is ergonomically designed to minimize
This is the primary position to manage a dental emergency the unnecessary movement.
position. In this, the head of patient is below the level of feet ii. Dentist, assistant and patient should be comfortably
to allow perfusion of blood to head and other vital organs to seated.
recover from dental emergencies (Fig. 10.4D). iii. Dentist assigns all legally delegable duties to qualified
assistant as per state’s guidelines.
iv. Treatment of patient should be planned in advance in
logical sequence.
v. Use preset trays which have minimum number of
instruments for use, placed in sequence from left to
right or top to bottom as preferred.
Zones of Working Area/activity

A B Working area is divided into four zones (Fig. 10.5).
1. Operator’s zone.
2. Assistant’s zone.
3. Static zone.
4. Instrument exchange zone.
C
1. Operator’s Zone
Accurate operating positions are essential while doing
restorative work so as to increase the efficiency and to
D
decrease physical strain.
Level of teeth being treated should be same as that
Figs. 10.4A to D: (A) Upright position; (B) Reclined at 45°; (C) Supine; of operator’s elbow. For better understanding, sitting
(D) Trendelenburg position.
positions of operator are related to a clock. In this clock
Fig. 10.5: Schematic representation of zones of working area for right and left handed operator.
concept, an imaginary circle is drawn over the dental chair, ◆◆ Working areas include:
keeping the patient’s head at center of the circle. Then the •• Palatal and incisal (occlusal) surfaces of maxillary
numbering to circle is given similar to that of a clock with teeth.
top of the circle as 12 O’clock. •• Mandibular teeth (direct vision).
Accordingly, the operator’s positions (right handed IV. Direct rear position (12 O’clock)
operator) can be 7 O’clock, 9 O’clock, 11 O’clock, and 12 ◆◆ Dentist sits directly behind the patient and looks down
O’clock and for left handed operator, it can be 5 O’clock, 3 over the patient’s head during procedure.
O’clock and 1 O’clock (Fig. 10.6). ◆◆ This position has limited application.
◆◆ Working areas are lingual surfaces of mandibular teeth.
I. Right front position (7 O’clock):
◆◆ It helps in examination of the patient. Preferred Operator Positions
◆◆ To increase the ease and visibility, the patient’s head
◆◆ Right-handed operator—preferred positions
may be turned toward the operator. ◆◆ Left-handed operator—preferred positions
◆◆ Working areas include: ◆◆ Right front or 7 O’clock Left front or 5 O’clock
•• Mandibular anterior teeth. ◆◆ Right or 9 O’clock Left or 3 O’clock
•• Mandibular right posterior teeth. ◆◆ Right rear or 11 O’clock Left rear or 1 O’clock
•• Maxillary anterior teeth.
II. Right position (9 O’clock) 2. Assistant’s Zone
◆◆ In this position, dentist sits exactly right to the patient. Efficient exchange of instruments between the operator
◆◆ Working areas include: and the dental assistant is fundamental to have an
•• Facial surfaces of maxillary and mandibular right efficient and stress free dental practice. All instruments
posterior teeth. and materials are located in the assistant’s zone. Transfer
•• Occlusal surfaces of mandibular right posterior of instrument between the operator and assistant should
teeth. occur in exchange zone which is below the patient’s chin
III. Right rear position (11 O’clock) and several inches above the patient’s chest.
◆◆ In this position, dentist sits behind and slightly to the
right of the patient and the left arm is positioned around 3. Static Zone
patient’s head.
◆◆ This is preferred position for most of the dental It is a nontraffic area where other equipment can be
procedures. placed. When an object or material is heavy or dangerous,
◆◆ Most areas of mouth are accessible from this position if held near the patient’s face, it should be passed through
either using direct or indirect vision the static zone.
Instrument Exchange
Ideally, the instrument transfer is accomplished with a
minimum of motion involving movement only of fingers,
wrist, and elbow. Assistant should be ready when dentist
gives the signal to pass the next instrument and receives
the used one in a smooth motion. Instruments should be
arranged in an orderly fashion for comfortable exchange.
As a rule, the instruments should be set from left to right,
in the sequence in which they are to be used. After use,
they should be returned to their original position in case
they need to be reused.
Visibility
Visibility of working area is prerequisite for successful
dental procedure. It includes both lightening and
magnification.
Lightening
Fig. 10.6: For right handed perator, positions can be 7 O’clock, 9
O’clock, 11 O’clock, and 12 O’clock and for left handed operator, it is 5 Most of the dental chairs come with overhead light which
O’clock, 3 O’clock and 1 O’clock. help to optimally visualize the working area. To avoid
Patient and Operator Position 119
shadowing, this overhead light should be positioned practice. Adopting newer techniques, armamentarium
parallel to the operator’s line of sight. to have light parallel and work strategies can prevent detrimental changes of
to clinician’s line of sight, the light should be slightly musculoskeletal system.
behind and to one side of operator’s head.
Nowadays, head mounted lights have become popular. EXAMINER’S CHOICE QUESTIONs
Head mounted light can be either worn over the head
separately from operator’s eyewear or can be fixed to its 1. Discuss in short about zones of working area.
frame. Head mounted light provides high intensity light 2. What are the different operator positions for right-
with more accuracy to a focussed area when compared to handed dental surgeon?
chair mounted light. 3. What is four handed dentistry?
Magnification Viva questions

Another important aspect of the restorative procedure 1. What is four handed dentistry?
for increasing efficiency and visibility is magnification of 2. Name the preferred positions for right-hand operator
working area. commonly used magnification devices are: while doing dental procedure.
◆◆ Loupes. 3. Name the preferred positions for left-hand operator
◆◆ Surgical telescopes. while doing dental procedure.
◆◆ Bifocal eyeglasses. 4. What should be patient position during syncope?
5. What are zones of working area?
6. What should be distance of patient’s mouth to dentist?
Advantages 7. What is operators zone?
◆◆ Increase in the visibility of the working area. 8. What is static zone?
◆◆ Minute and delicate procedures can be easily carried
out. BIBLIOGRAPHY
◆◆ Increase in the operator’s efficiency and success
1. Chasteen, JE. The Four-handed Dentistry in Clinical Practice. St.
outcome.
Louis: CV Mosby Company; 1978.
◆◆ Helps in getting good posture as using magnification 2. Fish DR, Morris-Allen DM. Musculoskeletal disorders in
maintains a constant working distance. dentists. NY State Dent J. 1998;64(4):44-8.
◆◆ Provides protection to eye from injury. 3. Four-handed dentistry manual, 6th edition, Birmingham;
University of Alabama; 1990.
4. Graham C. Ergonomics in dentistry, Part 2. Dent Today.
CONCLUSION 2002;21(5):106-9.
5. Goldstep F. Dental ergonomics: basic steps to optimum health.
Musculoskeletal disorders result in loss of work efficiency Academy of Dental Therapeutics and Dentistry; 2004. p. 57.
among dental surgeons which can be prevented by 6. Rundcrantz BL, Johnsson B, Moritz U. Cervical pain and
adopting ergonomics in dentistry. Applying ergonomics discomfort among dentists. Epidemiological, clinical and
in dentistry provides safety benefits to clinicians and therapeutic aspects. Part 1. A survey of pain and discomfort.
Swed Dent J. 1990;14(2):71-80.
improves work performance without putting at risk 7. Valachi B, Valachi K. Preventing musculoskeletal disorders
their own health. One of the main goals of ergonomics in clinical dentistry: strategies to address the mechanisms
in dentistry is to minimize the amount of physical and leading to musculoskeletal disorders. J Am Dent Assoc.
mental stress that sometimes occurs day to day in a dental 2003;134(12):1604-12.
Chapter
11
Isolation of Operating Field
Chapter Outline
Introduction Methods of Moisture Control

Components of Oral Environment Need to be Controlled During Isolation with Rubber Dam
Operative Procedures Pharmacological Means
Advantages of Moisture Control Gingival Tissue Management
INTRODUCTION Operator-related factors

An effective isolation of the teeth from tongue, soft tissues, i. A dry and clean operating field
gingival fluid, and saliva can prove crucial to have safe ii. Infection control by minimizing aerosol production
and successful restorative procedure. Isolation of teeth iii. Increased accessibility to operative site
improves efficiency of the treatment and provides comfort iv. Improved properties of dental materials, hence better
to the patient. Many means of isolation are present like results are obtained
rubber dam, cotton rolls, low and high evacuator systems, v. Protection of the patient and operator
chemical methods, etc, each having its advantages and vi. Improved visibility of the working field
vii. Less fogging of the dental mirror
disadvantages. In restorative dentistry, rubber dam is
viii. Prevents contamination of tooth preparation
considered as standard of care during restorative dentistry.
ix. Hemorrhage from gingiva does not enter operative
site.
Components of oral environment
need to be controlled during methods of moisture control
operative procedures 1. Direct methods:
◆◆ Saliva i. Rubber dam
◆◆ Moving organs: ii. Absorbent materials (cotton rolls and cellulose
•• Tongue wafers)
•• Mandible iii. Low-volume evacuator
◆◆ Lips and cheek iv. High-volume evacuator
◆◆ Gingival tissue v. Air-water syringe
◆◆ Buccal and lingual vestibular spaces. vi. Throat shield
vii. Cheek retractor
viii. Mouth prop.
Advantages of moisture control 2. Pharmacological methods:
i. Antisialagogues
Patient-related Factors
ii. Antianxiety drugs
i. Provides comfort to patient iii. Muscle relaxants.
ii. Protects patients from aspiration of foreign bodies 3. Methods used for gingival tissue management:
iii. Protects patient’s soft tissues like tongue and cheeks i. Mechanical
by retracting them from operating field. ii. Chemomechanical
Isolation of Operating Field 121
iii. Chemical Rubber dam accessories:
iv. Surgical ◆◆ Lubricant/petroleum jelly
v. Recent advences. ◆◆ Dental floss
◆◆ Rubber dam napkin.
Isolation with Rubber Dam
Single tooth isolation Multiple teeth isolation
Rubber dam was introduced by Sanford Christie Class I and V restoration Bleaching
Barnum, a New York dentist, in 1864. Rubber dam can be Direct and indirect pulp capping Class II restoration
defined as a flat thin sheet of latex/nonlatex that is held by
Pulpotomy Multiple restorations
a clamp and frame which is perforated to show the tooth/
teeth to protrude through the perforations while all other Pulpectomy/endodontic Quadrant dentistry
teeth are covered and protected by sheet. procedure
Rubber Dam Sheet

Advantages of using a Rubber Dam
◆◆ Rubber dam sheet is normally available in size 5 × 5 or
i. It helps in improving accessibility and visibility of the
6 × 6 sq. inches in light and dark colors (Fig. 11.1). Dark
working area
colors are preferred (green or black) for good contrast.
ii. It gives a clean and dry aseptic field while working
iii. It protects the lips, cheeks, and tongue by keeping ◆◆ Sheet has dry and shiny sides. Dull side faces the
them out of the way occlusal surface of isolated teeth because it is less
iv. It acts as raincoat for the teeth reflective than shiny surface.
v. It helps to avoid unnecessary contamination, thereby ◆◆ It is available in three thicknesses: light, medium, and
infection control heavy. Thicker dam is effective in retracting the tissues
vi. It protects the patient from aspiration of instruments and is more resistant to tearing. These are preferred for
and medicaments isolating class V cavities with cervical retainer. Thinner
vii. It helps in keeping teeth, saliva free while performing dam can easily pass through the contacts easier, so
endodontic treatment, so tooth does not get conta especially helpful in cases of tight contacts. Middle
minated by bacteria present in saliva grade is usually preferred as thin is more prone to
viii. It improves the efficiency of the treatment tearing and heavier one is more difficult to apply.
ix. It potentially improves the properties of dental ◆◆ Latex-free dam is necessary as the number of patients is
materials increasing with latex allergy.
x. It provides protection to patient and dentist. ◆◆ Flexi dam is latex-free dam of standard thickness with
no rubber smell.
Disadvantages of using a Rubber Dam
Thickness of rubber dam sheet
i. Insecured clamps can be swallowed or aspirated
ii. Careless placing and removal of rubber dam can Thin 0.15 mm
damage oral mucosa Medium 0.20 mm
iii. Time-consuming and expensive Heavy 0.25 mm
iv. Since it blocks off oral airway, it is difficult to use in Extra heavy 0.30 mm
patient with temporary nasal congestion.
Special heavy 0.35 mm
Contraindications of use of Rubber Dam

i. Asthmatic patients with breathing problems
ii. Mouth breathers
iii. Extremely malpositioned tooth
iv. Teeth which are not fully erupted to support the
retainer.
Rubber dam equipments:
◆◆ Rubber dam sheet
◆◆ Rubber dam clamps
◆◆ Rubber dam forceps
◆◆ Rubber dam frame
◆◆ Rubber dam punch
◆◆ Rubber dam template Fig. 11.1: Different colors of rubber dam sheets.
A B
Figs. 11.3A and B: Photograph showing winged and wingless clamp.
Fig. 11.2: Different shapes and sizes of rubber dam clamps.

2. On the basis of material used:
i. Metallic
ii. Nonmetallic/plastic.
Rubber Dam Clamps i. Metallic: Traditionally, clamps have been made from
tempered carbon steel and stainless steel. Problem
◆◆ Rubber dam clamps to hold the rubber dam onto
with using metallic clamps is that they appear
the tooth are available in different shapes and sizes
radiopaque on radiograph, thereby overlapping the
(Fig. 11.2).
structures.
◆◆ Clamps mainly serve two functions:
ii. Nonmetallic/plastic: Nonmetallic is made from poly
1. They anchor the rubber dam to the tooth
carbonate plastic (Fig. 11.4). These are radiolucent
2. Help in retracting the gingiva.
but they are bulky, so do not easily fit the teeth.
Classification of Rubber Dam Clamps
Retainer number and their applications
1. On the basis of jaw design:
Retainer number Application
i. Bland
ii. Retentive. W2 Small premolars
i. Bland clamps: W4 Most of premolars
•• Bland clamps are usually identified by the jaws, W56 Most of molars
which are flat and point directly toward each other. W7 Mandibular molars
•• In these clamps, flat jaws usually grasp the tooth at
W8 Maxillary molars
or above the gingival margin.
•• They can be used in fully erupted tooth where W27 Terminal mandibular molar
cervical constriction prevents clamp from slipping
off the tooth.
ii. Retentive clamps:
•• These clamps have jaws which are directed
gingivally and grasp the teeth more gingivally.
•• Jaws of clamps should have a four-point contact
and should not extend beyond mesial and distal
line angles of the tooth. If not placed properly, it
results in rocking and tilting of the clamp.
Both bland and retentive can be divided into winged
and wingless types (Figs. 11.3A and B).
◆◆ Winged: These have anterior and lateral wings which
provide extra retention of rubber dam. But these
interfere with placement of matrix band retainers and
wedges.
◆◆ Wingless: They have no wings. Here, retainer is first
placed on the tooth and then dam is stretched over the
clamp onto the tooth. Fig. 11.4: Plastic rubber dam clamp.
◆◆ Modern frames have sharp pins which easily grip the
dam. These are mainly designed with the pins that slope
backward.
◆◆ Rubber dam frames are available in either metal
or plastic. Plastic frames have advantage of being
radiolucent.
Rubber dam frames serve following purposes:

Support the edges of rubber dam
Retract the soft tissues
Improve accessibility to the isolated teeth.
Rubber Dam Punch

◆◆ Rubber dam punch is used to make the holes in the
rubber sheet through which the teeth can be isolated
Fig. 11.5: Rubber dam forceps. (Fig. 11.7).
◆◆ Working end is designed with a plunger on one side and
Rubber Dam Forceps a wheel on the other side. This wheel has different sized
holes on the flat surface facing the plunger.
◆◆ Rubber dam forceps is used to carry the clamp to the ◆◆ Punch must produce a clean cut hole every time.
tooth. ◆◆ If rubber dam punch is not cutting cleanly and leaving
◆◆ When the handles of forceps are compressed together, behind a tag of rubber, the dam will often split as it is
its two working ends move apart (Fig. 11.5). stretched out.
◆◆ Working end has small projections that fit into two
corresponding holes of the rubber dam clamp.
Rubber Dam Template
◆◆ Area between working end and the handle has a sliding
lock device which locks the handles in positions while ◆◆ It is an inked rubber stamp which helps in marking
the clinician moves the clamp around the tooth. the dots on the sheet according to position of the tooth
◆◆ It should be taken care that forceps do not have deep (Figs. 11.8A and B).
grooves at their tips or they become very difficult to ◆◆ Holes should be punched according to arch and
remove once the clamp is in place. missing teeth.
Rubber Dam Frame Rubber Dam Accessories

◆◆ Rubber dam frame supports the edges of rubber dam i. Lubricant
(Figs. 11.6A to C). ◆◆ It is applied on the undersurface of dam in the area
◆◆ Frames have been improved dramatically since their of punched holes to facilitate the passing of the dam
old style with the huge “butterflies”. through the proximal contacts.
A B C
Figs. 11.6A to C: Different types of rubber dam frames. (A) Ash pattern—most suitable for children; (B) Svenska N-O frame; (C) Young’s
holder—U-shaped metal frame with small metal projections for securing borders of the rubber dam.
◆◆ Petroleum-based lubricant should be avoided because

it is difficult to remove and can interfere bonding
procedures. Thus, water-soluble lubricant like soap
slurry should be preferred as a lubricant.
ii. Dental Floss

It is usually required for testing interdental contacts. Floss
is tied to the clamp to prevent its accidental aspiration
(Fig. 11.9).
iii. Wedjets
Wedjet cord is made up of natural latex to stabilize the dam
with little chances of tissue trauma (Fig. 11.10).
iv. Modeling Compound

Fig. 11.7: Working end of rubber dam punch has plunger on one
side and wheel with different sized holes on the other side. It is used to secure and stabilize the retainer to the tooth. In
some cases, they can be used as retainer instead of clamps.
Fig. 11.8A: Rubber dam template with position of teeth marked on it Fig. 11.9: Floss prevents accidental aspiration of the rubber dam
for punching holes on rubber dam sheet accordingly. clamp.
Fig. 11.8B: Schematic representation of rubber dam punch holes;

smaller holes for anterior teeth, medium for premolars, and larger ones
for molars. Fig. 11.10: Photograph showing wedjet rubber dam cord.
v. Rubber Dam Napkin ◆◆ Off-center, prepunched hole customizes fit to any
quadrant—add more holes if desired.
This is a sheet of absorbent materials usually placed
between the rubber sheet and soft tissues (Fig. 11.11). It
2. Hat Dam
absorbs saliva from corner of patient’s mouth.
It is a clear plastic form which is shaped like a hat without
the top. It is trimmed and fitted around the tooth which
cannot be clamped.
3. Handi Dam
◆◆ This is preframed rubber dam eliminates the need for
traditional frame
◆◆ Handi dam is easy to place and saves time of both
patient and doctor
◆◆ It allows an easy access to oral cavity during the
procedure.
4. Optra Dam
It is an anatomically shaped rubber dam for isolation.
It is made up of flexible latex. For use, intraoral ring is
Fig. 11.11: Photograph showing rubber dam napkin. positioned in gingivobuccal fold and outer ring remains
outside the mouth (Fig. 11.13). Dam is secured around
Recent Modifications in the Designs of the teeth by fitting septum of dam interproximally and in
the sulcus using dental floss.
Rubber Dam
1. Insta-Dam
Salient Features of Insta-dam
◆◆ It is natural latex dam with prepunched hole and
built-in frame (Fig. 11.12).
◆◆ Its compact design is just the right size to fit outside the
patient’s lips.
◆◆ It is made up of stretchable and tear-resistant, medium
gauge latex material.
◆◆ Radiographs may be taken without removing the dam.
◆◆ Built-in flexible nylon frame eliminates bulky frames
and sterilization.
Fig. 11.13: Optra dam is anatomical dam with flexible 3D design.
5. Liquid Dam
It is a resinous material which is applied on gingival aspect
of the teeth especially before bleaching, microabrasion,
sandblasting, etc. (Figs. 11.14A to C).
Placement of Rubber Dam

Before placement of rubber dam, the following procedures
should be done:
◆◆ Thorough prophylaxis of the oral cavity
◆◆ Check contacts with dental floss
◆◆ Check for any rough contact areas
◆◆ Anesthetize the gingiva if required
Fig. 11.12: Insta-dam with prepunched hole and built-in frame. ◆◆ Rinse and dry the operated field.
A B C
Figs. 11.14A to C: Liquid rubber dam: (A) Resinous material; and (B and C) Applied on gingival aspect of the teeth and cured to protect gingiva
especially before bleaching, microabrasion, sandblasting, etc.
Methods of Rubber Dam Placement ◆◆ Stretching of the rubber dam over the clamps can be
done in the following sequence:
Method I: Clamp placed before rubber dam (Figs. 11.15A •• Stretch the rubber dam sheet over the clamp
to C): •• Then stretch the sheet over the buccal surface and
◆◆ Select an appropriate clamp according to the tooth size allow to settle into place beneath buccal contour
◆◆ Tie a floss to clamp bow and place clamp onto the tooth •• Finally, the sheet is carried to palatal/lingual side
◆◆ Larger holes are required in this technique as rubber and released.
dam has to be stretched over the clamp. Usually, two or This method is mainly used in posterior teeth in both
three overlapping holes are made. adults and children except third molar.
A B
C
Figs. 11.15A to C: Placement of rubber dam: (A) Placing clamp on selected tooth; (B) Stretching rubber dam sheet over clamp;
and (C) After complete stretching, tooth is isolated.
Method II: Placement of rubber dam and clamp together Management of Difficult Cases
(Figs. 11.16A to C):
◆◆ Select an appropriate clamp according to tooth anatomy 1. Malpositioned Teeth
◆◆ Tie a floss around the clamp and check the stability To manage these cases, the following modifications are
◆◆ Punch the hole in rubber dam sheet done:
◆◆ Clamp is held with clamp forceps and its wings are ◆◆ Adjust the spacing between the holes
inserted into punched hole ◆◆ In tilted teeth, estimate the position of root center at
◆◆ Both clamp and rubber dam are carried to the oral gingival margin rather than the tip of the crown
cavity and clamp is tensed to stretch the hole ◆◆ Another approach is to make a customized cardboard
◆◆ Both clamp and rubber dam is advanced over the template
crown. First, jaw of clamp is tilted to the lingual side to ◆◆ Tight broad contact areas can be managed by:
lie on the gingival margin of lingual side •• Use of wedges to open the contact temporarily for
◆◆ After this, jaw of the clamp is positioned on buccal side passing the rubber sheet
◆◆ After seating the clamp, again check stability of clamp •• Use of lubricant.
◆◆ Remove the forceps from the clamp
◆◆ Now release the rubber sheet from wings to lie around
2. Extensive Loss of Coronal Tissue
the cervical margin of the tooth.
When sound tooth margin is at or below the gingival
Method III: Split dam technique:
margin because of decay or fracture, the rubber dam
This method is split dam technique in which rubber dam
application becomes difficult. In such cases, to isolate the
is placed to isolate the tooth without the use of rubber
tooth:
dam clamp. In this technique, two overlapping holes are
◆◆ Use retentive clamps
punched in the dam. The dam is stretched over the tooth to
◆◆ Punch a bigger hole in the rubber dam sheet so that it
be treated and over the adjacent tooth on each side. Edge
can be stretched to involve more teeth, including the
of rubber dam is carefully teased through the contacts of
tooth to be treated
distal side of adjacent teeth.
◆◆ In some cases, the modification of gingival margin can
Indications of split dam technique
be tried so as to provide supragingival preparation
To isolate anterior teeth margin. This can be accomplished by gingivectomy or
When there is insufficient crown structure the flap surgery.
When isolation of teeth with porcelain crown is required. In
such cases, placement of rubber dam clamp over the crown 3. Leakage
margins can damage the cervical porcelain
Dam is placed without using clamp ◆◆ Sometimes leakage is seen through the rubber dam
Here, two overlapping holes are punched and dam is because of the accidental tears or holes. Such leaking
stretched over the tooth to be treated and adjacent tooth gaps can be sealed using cavity, periodontal packs,
on each side.
liquid rubber dam, rubber dam adhesives, or Oraseal.
A B C
Figs. 11.16A to C: (A) Punch hole in the rubber dam sheet according to selected tooth; (B) Clamp and its wings are inserted in the punched
hole; and (C) Carry both clamp and rubber dam over the crown and seat it.
Table 11.1: Commonly encountered problems during application of ◆◆ If a fragment of the rubber dam is found missing,
rubber dam. inspect interproximal area because pieces of the rubber
Problem Consequences Correction dam left under the free gingiva can result in gingival
irritation.
• Improper • Wrinkling of dam • Proper placement
distance • Interference in of holes by
between holes accessibility accurate use of Absorbents (Cotton Roll and Cellulose Wafers)
−− Excessive • Overstretching of rubber dam punch
distance dam and template Cotton rolls, pellets, gauze, and cellulose wafers absorbents
between • Tearing of dam are helpful for short period of isolation, for example, in
holes • Poor fit examination, polishing, pit, and fissure sealant placement
−− Too short
(Fig. 11.17). Absorbents play an essential role in isolation
distance
between of the teeth especially when rubber dam application is not
holes possible.
• Off-center arch • Obstructs • Folding of extra ◆◆ Cotton rolls are placed in buccal or lingual sulcus
form breathing dam material especially where salivary gland ducts exit so that they
• Makes patient under the nose and can absorb saliva.
uncomfortable proper punching of ◆◆ Maxillary teeth are isolated by placing a cotton roll in
holes
the buccal vestibule. Mandibular teeth are isolated by
• Torn rubber dam • Leakage • Replacement of placing a small-sized cotton roll in the buccal vestibule
• Improper dam
isolation • Use of cavit,
and a larger-sized cotton roll in lingual vestibule.
periodontal packs, ◆◆ Cellulose wafers are used in addition to cotton rolls
or liquid rubber and are placed in the buccal sulcus to retract the cheek.
dam They are used to absorb saliva and other fluids for short
periods of time, for example, during examination,
fissure sealants, and polishing.
◆◆ For sealing the larger gaps, the rubber dam adhesives in ◆◆ Other methods of moisture control, for example, saliva
combination with orabase can be tried. ejector may be positioned, after the cotton rolls or
◆◆ If leakage persists despite of these efforts, the rubber cellulose wafers are in place.
dam sheet should be replaced with new one. ◆◆ One should take care while removing cotton rolls or
•• Depending upon the clinical condition, isolation of cellulose wafers that they should be moist, to prevent
single or multiple teeth can be done with the help of inadvertent removal of the epithelium.
rubber dam. Table 11.1 entails problems commonly
encountered during application of rubber dam. Advantages
◆◆ Effective to control small amounts of moisture for
Removal of Rubber Dam short-time periods
◆◆ Before the rubber dam is removed, use the water syringe ◆◆ Retract soft tissues at same time.
and high-volume evacuator to flush out all debris that
collected during the procedure.
◆◆ Cut away tied thread from the neck of the teeth. Stretch
the rubber dam facially and pull the septal rubber away
from the gingival tissue and the tooth.
◆◆ Protect the underlying soft tissue by placing a fingertip
beneath the septum.
◆◆ Free the dam from the interproximal space, but leave
the rubber dam over the anterior and posterior anchor
teeth.
◆◆ Use the clamp forceps to remove the clamp.
◆◆ Once the retainer is removed, release the dam from
the anchor tooth and remove the dam and frame
simultaneously.
◆◆ Wipe the patient’s mouth, lips, and chin with a tissue
or gauze to prevent saliva from getting on the patient’s
face.
◆◆ Check for any missing fragment after procedure. Fig. 11.17: Cotton rolls and gauze pieces.
Disadvantages Precautions to be Taken While Using Saliva Ejector
◆◆ Provide only short-term moisture control ◆◆ Sides of saliva ejector should not rub against surface of
◆◆ Ineffective if high volume of fluid is present mouth to avoid injury.
◆◆ Shallow sulci and hyperactive tongue may make ◆◆ When rubber dam is used, always make a hole so that
placement and retention difficult. ejector can pass through the dam instead of placing it
under the dam.
Low-Volume Evacuator ◆◆ Always protect floor of mouth beneath the ejector using
cotton rolls or gauze piece to avoid tissue injury.
Low-volume evacuation is basically done using saliva
ejectors (Fig. 11.18). Saliva ejector is best used to remove
small amounts of moisture and saliva collected in the High-Volume Evacuator
oral cavity during clinical procedure. It can be used in It is used to remove water from airotor and large particulate
conjunction with other methods of moisture control. Tip matter with high suction speed (Fig. 11.19). It also helps
of saliva ejector should be smooth to prevent any tissue in retracting cheek and tongue. Tip used in high-volume
injury. To avoid any interference with working, it can be evacuator can be made up of plastic or stainless steel.
bent to place in the required area of mouth. Saliva ejector
with flexible plastic tubing and protective flange provides
an added advantage of retraction of tongue.
Fig. 11.19: High-volume evacuator.
Advantages
Fig. 11.18: Low-volume evacuator: Saliva ejectors.
It facilitates fast removal of:
◆◆ Large particulate matter
Advantages ◆◆ Water from high speed drills
◆◆ Air-water spray
◆◆ Economical ◆◆ Since clean field is achieved in less time, quadrant
◆◆ Easy to use dentistry is made easy
◆◆ Can be held by patient ◆◆ Added advantage of double-ended aspiration tip is that
◆◆ Can be placed under rubber dam if by chance one end gets clogged, another end can
◆◆ Some have flanges attached which help in retraction of keep on aspirating.
tongue and floor of mouth.
Disadvantages Air-Water Syringe

By air-water syringe, air can directed towards the tooth or
◆◆ Hyperactive tongue can make its placement difficult
soft tissues to dry them during examination or operative
◆◆ Low-volume aspirators do not remove solids well
procedures (Fig. 11.20).
◆◆ If used inappropriately, it can be uncomfortable for
patient
◆◆ May cause soft tissue damage by sucking in soft tissues
Advantage
into the tip. Easy to use.
Fig. 11.20: Three way syringe. Fig. 11.21: Cheek retractor.
Disadvantages
◆◆ Can dehydrate dentin and cause pain and discomfort
to patient
◆◆ Not effective if there are large volume of moisture
◆◆ Does not remove the moisture from oral cavity, it can
just transfer moisture from one tooth to the next.
Throat Shield
Throat shield is especially important when the maxillary
tooth is being treated. In this, an unfolded gauze sponge is
stretched over the tongue and posterior part of the mouth.
Fig. 11.22: Mouth prop.
It is useful in recovering a restoration (inlay or crown), if it
is dropped in the oral cavity. site, placed between mandibular and maxillary teeth. A
mouth prop should have following features:
Advantages ◆◆ It should be easily positioned in the mouth without any
discomfort
◆◆ Avoids aspiration of restorations
◆◆ It should be easily and readily removable by clinician or
◆◆ Economical
the patient in case of an emergency
◆◆ Easy to use.
◆◆ It should be either disposable or sterilizable
◆◆ It should be adaptable to all mouths.
Disadvantage
Not well-tolerated by some patients as it can cause gagging. Advantages
◆◆ Offers muscle relaxation to patient
Cheek Retractor ◆◆ Provides sufficient mouth opening for long durations
Cheek retractor is used to expand the mouth opening ◆◆ Easily positioned and removed.
more in the vertical rather than horizontal direction
(Fig. 11.21). This makes them ideal for use when working Pharmacological means
on the gingival border of upper and lower front teeth and In this method, drugs are usually used to reduce the
for the adjustment of orthodontic bands. salivation. Commonly used drugs are antisialagogues,
antianxiety drugs, muscle relaxants, and sedatives, etc.
Mouth Prop
1. Antisialagogues
Mouth prop should establish and maintain suitable mouth
opening, thus help in tooth preparation of posterior teeth In this, anticholinergic agents like atropine are used half
(Fig. 11.22). It is placed on the side opposite to treatment an hour before procedure to reduce the salivation. But it
should be avoided in nursing mothers and patients with field. Isolation of operating field and moisture control
cardiovascular problems. increases the quality of the treatment, safety of patient
as well as operator. Though many methods are employed
2. Antianxiety Agents and Sedatives for isolation, rubber dam is considered as gold standard
for isolation. For different clinical situations, appropriate
Antianxiety drugs and sedatives like diazepam and
isolation method can be used so as to have clean and clear
barbiturates are used in apprehensive patients 24
operating field.
hours before appointment. Since these drugs result in
psychological dependence, patient selection is done
carefully. Examiner’s Choice Questions
1. Write in detail about rubber dam isolation.
3. Muscle Relaxants 2. Write short notes on:
Muscle relaxants can also be used to reduce salivation. a. Chemical means of isolation in dentistry.
b. Insta-dam.
Advantages c. Recent advances in rubber dam.
These drugs control salivary flow in case of hypersalivation
when other methods are ineffective, help in relaxing the Viva Questions
patient.
1. What are different methods of moisture control?
Disadvantages 2. What are advantages of using rubber dam?
3. What are contraindications of use of rubber dam?
Side effects: Tachycardia, dilatation of pupils, urinary
4. What is flexi dam?
retention, and sweat gland inhibition can occur.
5. What are functions of rubber dam clamps?
6. Which retainer is used for terminal mandibular molar?
Gingival Tissue Management 7. Which retainer is used for maxillary molars?
Gingival tissue management means temporary eversion 8. What is function of rubber dam forcep?
or resection of gingiva away from tooth structure so in 9. What is purpose of using rubber dam frame?
order to have proper marginal finish of the restoration 10. What is insta-dam?
and good cervical cavosurface margin of the tooth 11. What is Hat dam?
preparation . Various methods for the soft tissue retraction 12. What is optra dam?
are mechanical, mechanical-chemical, surgical and newer 13. What is liquid dam?
methods. 14. What is split dam technique and their indications?
Mechanical methods include use of rubber dam sheets, 15. What is procedure of removing rubber dam?
cotton fibers, copper band, zinc oxide eugenol cement 16. name few drugs which are used to reduce the salivary
placed on cotton, gutta percha, gingival tissue retraction. flow.
In mechanical-chemical methods, gingival retraction
cord is treated with vasoconstrictors like epinephrine,
and coagulants like alum. Surgically, gingiva is managed Bibliography
by ginigitage or electrosurgery. Newer methods of gingival 1. Ballal NV, Saraswathi MV, Khandelwal D. Rubber dam
tissue management include laser gingivectomy, expasyl in endodontics: an overview of recent advances. IJCD.
injectable retraction method, magic foam and gingitrac 2015;6(4):320-30.
2. Cragg TK. The use of rubber dam in endodontics. J Can Dent
etc.
Assoc (Tor). 1972;38(10):376-7.
All the above mentioned methods have been discussed 3. Ito K, Funayama S, Katsura K, et al. Moistened techniques
in detail in Chapter 12. considered for patients’ comfort and operators’ ease in dental
treatment. Int J Oral Med Sci. 2012;11(2):85-9.
conclusion 4. Jacks ME. A laboratory comparison of evacuation devices on
aerosol reduction. J Dent Hyg. 2002;76(3):202-6.
To have optimal results of restorative dentistry, one 5. Knowles KI, Ibarrola JL, Ludlow MO, et al. Rubber latex allergy
should have proper control and isolation of the operative and the endodontic patient. J Endod. 1998;24(11):760-2.
Chapter
12
Gingival Tissue Management
Chapter Outline
Introduction Contraindications of Gingival Tissue Management

Definition Advantages
Indications of Gingival Tissue Management Methods of Gingival Tissue Management
INTRODUCTION ◆◆ To remove gingival polyp which may interfere with

cavity preparation and restoration
The aesthetics and longevity of restorations significantly ◆◆ To control gingival fluid and bleeding while dealing
depend on gingival and periodontal factors. Restorations with cervical margins of the cavity
placed in proximity to the soft tissues sometimes require ◆◆ To increase retention in case of poor crown root ratio.
consideration of subgingival margins, which if not taken
care of can lead to failure of restorations. Moreover,
Contraindications of gingival
adhesive restorations in cervical areas require isolation
from crevicular fluid. To manage the areas, the adjacent
tissue management
soft tissue needs to be retracted and displaced adequately ◆◆ Poor oral hygiene
without causing damage to the tissues. The success of the ◆◆ Presence of gingival disease
restorative procedure depends on harmony between the ◆◆ Gingival recession
restoration and the surrounding periodontal tissues. ◆◆ Bone loss.
Definition Advantages
Gingival tissue retraction is the deflection of marginal ◆◆ Better accessibility, visibility and ease of operation
◆◆ Control of gingival crevicular fluid and bleeding
gingiva away from the tooth. It is the procedure of
◆◆ Proper contouring, adaptation and setting of restorative
widening of gingival sulcus, retraction of gingiva from
materials
the tooth and deepening of gingival sulcus to expose the
◆◆ Better aesthetics due to improved angle of emergence
cervical portion of the tooth so as to have proper finish of
◆◆ Crown lengthening as per the clinical requirement.
the restoration.
METHODS OF GINGIVAL TISSUE
Indications of gingival tissue MANAGEMENT
management
There are various methods available which can be used for
◆◆ Presence of subgingival caries, fracture or finish line effective gingival tissue retraction. These methods are:
◆◆ To treat cervical abrasion, erosion or abfraction 1. Mechanical
◆◆ For aesthetics in final restoration in case of anterior 2. Chemomechanical
teeth 3. Chemical
◆◆ To accurately record the margins while taking an 4. Surgical.
impression 5. Recent advances.
Gingival Tissue Management 133
1. Mechanical Means iii. Wooden wedges (Fig. 12.3): They are used inter
dentally to displace the gingival tissue, thus helping in
These method are used, which mechanically displace the retraction.
gingiva both laterally and apically away from the tooth iv. Rolled cotton twills: Rotten cotton twills impregnated
surface. with ZoE are mechanically packed into gingival sulcus
Before using these methods following requirements for retraction.
should be fulfilled: v. Gingival retraction cords (Fig. 12.4): Different types
◆◆ Normal and healthy gingiva with good vascular supply. of retraction cords are available in the market, which
◆◆ Adequate zone of attached gingiva displace the gingiva both laterally and apically away
◆◆ Adequate amount of healthy bone without the sign of from the tooth surface.
tooth resorption.
Retraction cord can be of following types:
Methods for Mechanical Means a. According to configuration: Plain, twisted or braided
b. According to surface finish: Waxed or nonwaxed
i. Rubber dam (Fig. 12.1): Heavy and extra heavy rubber c. According to chemical treatment: Plain or impregnated
dam sheets provide an effect which is immediate. d. According to material: Cotton or synthetic
According to Gilmore, it is called gum compression e. According to number of strands: Single or double
rather than displacement. For additional retraction, f. According to thickness (Fig. 12.5):
Clamp No. 212 (cervical retainer) can also be used. i. Black #000 (extra small–used in anterior teeth with
ii. Copper band (Fig. 12.2): Copper band acts as a means minimum crevicular space)
of carrying impression material and thus gingival ii. Yellow #00 (small–used in anterior teeth with
retraction. But it can also cause gingival injuries. After minimum crevicular space)
selecting the copper band, it is filled with impression iii. Purple # 0 (used in premolars)
compound and seated on tooth and impression is iv. Blue #1 (used as secondary cord)
taken. Instead of impression compound, elastomeric v. Green #2 (used in molars)
impression material, gutta-percha or acrylic resin can vi. Red #3 (extra-large–used where tissue friability
also be used. permits)
Fig. 12.1: Rubber dam sheet along with isolation, provides Fig. 12.3: Placement of wooden wedge interproximally between
retraction of gingiva. 2nd premolar and 1st molar depress the gingiva.
Fig. 12.2: Diagrammatic representation of application Fig. 12.4: Gingival retraction cord displaces the gingiva apically
of copper band. exposes the prepared tooth margins.
Fig. 12.5: Types of gingival retraction cords according to thickness.
Placement and Removal of Retraction Cord Fig. 12.7: Procedure for placement of retraction cord.
1. Select the appropriate size of cord which can be
placed into gingival sulcus without causing any injury/
gentle pressure laterally against the tooth surface.
ischemia.
Avoid application of apical pressure as it may harm the
2. Take the length of cord so that it extends 1 mm beyond
junctional epithelium (Fig. 12.7).
the gingival width of the preparation or extends around
5. In single cord technique, a single cord is used for
the whole circumference of the tooth.
tooth with healthy gingival tissue. Here, a single
3. Use cord packing instrument for cord placement. Its
piece of retraction cord is packed into the gingival
working end should be thin enough to pack the cord
sulcus, followed by removal after adequate gingival
into the sulcus efficiently, but not sharp enough to
displacement has been achieved. It is indicated when
initiate bleeding from the sulcus wall or cause any
there is minimum or no bleeding from the gingival
perforation (Fig. 12.6).
sulcus, and the preparation margins on the tooth are
4. Packing of the retraction cord should be initiated from
either gingival or slightly subgingival.
the interproximal area using a periodontal probe and
6. In double cord technique, two retraction cords are
gentle pressure because interproximal gingival is thin
placed in the gingival sulcus. It is indicated when sulcus
and delicate, with minimal depth of gingival sulcus.
is very deep, margins of preparation are subgingival and
Thus, start pushing cord at axial area first, then in
hence require additional displacement of the gingival
lingual surface and finally in labial surface by applying
tissues. Here, a smaller diameter cord with hemostatic
agent is placed in depth for lateral tissue displacement
and controlling hemorrhage. Then, a larger diameter
cord is placed in the sulcus, causing further lateral
tissue displacement. The deeper placed cord stays in
place when the impression is made, after removal of the
top cord.
7. For better retention, leave the cord in place for 5–10
minutes.
8. Moisten the cord before removal. A dry cord may
adhere to epithelium and on removal it may cause its
abrasion.
9. Check for any pieces of retraction cord immediately
after its removal and remove if any, to avoid gingival
irritation.
Problems with retraction cord technique
◆◆ Technique sensitive procedure
Fig. 12.6: Cord packing instrument used for placement of gingival ◆◆ Risk of epithelial attachment injury
retraction cord. ◆◆ Painful procedure so may require anesthesia
(Courtesy: Hu-Freidy). ◆◆ May cause bleeding.
2. Chemicomechanical Methods are trichloroacetic acid and sulfuric acid. Trichloroacetic
acid is a crystalline substance which becomes liquid on
This is the most common and popular technique used for
exposure to air. Blade of instrument is dipped in TCA
gingival retraction and has been considered safe, also it
applied on gingival margin for 1 minute, and then washed
provides adequate amount of gingival tissue displacement.
thoroughly. It produces immediate hemostasis and control
In this, chemical can be used alone or in combination
of gingival fluid flow. but it is caustic in nature; can cause
with retraction cord for retraction of gingiva and control
of fluids seeping from gingival sulcus. Chemical used with soft tissue damage if accidently dropped on tissues.
cord are as follow:
4. Surgical Methods
I. Vasoconstrictors
Surgical methods include:
As the name indicates, these cause local vasoconstriction, i. Rotary curettage
reduce the blood supply and gingival fluid seepage. ii. Electrosurgery/surgical diathermy
Epinephrine and norepinephrine are used in this category. iii. Gingivectomy/gingivoplasty
These are not indicated in patients with hypertension, iv. Periodontal flap procedures.
cardiovascular disease and diabetes as these may cause
tachycardia, increase in blood pressure and anxiety.
i. Rotary Curettage/gingitage/Denttage
II. Astringents (Cause Tissue Contraction) This is troughing technique which is used to remove
As compared to vasoconstrictors, these chemicals are minimal amount of gingival epithelium during placement
considered to be safe and have no systemic effects. These of restorative margins subgingivally. This is usually done
chemicals coagulate blood and gingival fluid in the sulcus, with high speed handpiece and chamfer diamond bur
thus forms a surface layer which seals against blood and (Fig. 12.8). for this, there should be presence of adequate
fluid seepage. Commonly used agents are as astringents keratinized healthy gingiva, free of inflammation with
are Alum (100%), Aluminium chloride (15–25%), Tannic absence of bleeding on probing.
acid (15–25%) and Ferric sulfate (15–15.5%).
Disadvantages of rotary curettage are:
III. Tissue Coagulants ◆◆ Excessive bleeding
◆◆ Poor tactile sense, can damage gingiva if used
These chemicals or coagulants are not preferred because
of side effects. These agents usually act by coagulating incorrectly.
the surface layer of sulcular and gingival epithelium. Zinc
chloride (8%) and silver nitrate are used as in the tissue ii. Electrosurgery/Surgical Diathermy
coagulants. If applied for prolonged time, coagulants can Electrosurgical method is preferred when approach
cause ulceration, local necrosis, change in contour, size to working area is not obtained by more conservative
and position of free gingiva. methods. One of the main advantages of electrosurgical
method is minimal bleeding during surgery.
3. Chemical Means Principle
Chemical means is one of the oldest methods of retraction Electrosurgery unit is a high frequency oscillator which
of gingiva. Commonly used chemicals for this method uses a vacuum tube to deliver high frequency electric
Fig. 12.8: Rotary curettage technique.

current of at least 1.0 MHz. surgical electrode is similar to ◆◆ Rapid procedure

a probe, which can fit into electrosurgical handpiece and ◆◆ Causes atraumatic cutting of tissue
produce intense heat to vaporize the target tissue. Figures ◆◆ Sterilizes the wound.
12.9 and 12.10 are showing different cutting edge designs
Disadvantages
of electrodes and their actions.
◆◆ Unpleasant odor
Advantages ◆◆ Not suitable for thin gingiva
◆◆ Easier to obtain bloodless area ◆◆ Slight loss of crestal bone.
◆◆ Healing by primary intention
Actions by electrosurgery
Four types of actions can be done using electrosurgery:
1. Cutting: Cutting is commonly used action as it is precise
in nature and does not induce bleeding.
2. Coagulation: it causes surface coagulation of tissues,
fluid, and blood as more heat is used, but this overdose
can cause carbonization.
3. Fulguration: It uses greater heat and energy than
coagulation causing deeper tissue involvement and
more after effects.
4. Desiccation: It is the most dangerous among four
actions causing massive destruction of tissue.
Figs. 12.9A to E: Different types of cutting edges of electrodes. Rules for electrosurgery
◆◆ Proper isolation of working site. Avoid excessive drying
up of the tissues
◆◆ Use adequate current
◆◆ Use fully rectified, filtered current with minimum
energy output for cutting action on tissues.
◆◆ For cutting action, use unipolar electrode either
in probe or loop type with light touch, rapid and
intermittent strokes. Cut on the inner area of sulcus,
avoid touching the gingival crest area as it may result in
gingival recession.
◆◆ For coagulation action, use bulky unipolar electrode,
with partially rectified current. Place electrode close to
the tissue but avoid touching it to the tissue and metallic
restorations to prevent short circuit.
◆◆ For gingival retraction, use a straight or J shaped
electrode, position it parallel to long axis of the tooth
Fig. 12.10A: Straight knife electrode used for sulcular enlargement. and create a subgingival tissue trough 0.3–0.5 mm
beneath the margin (Fig. 12.11).
◆◆ Always clean electrode tips with alcohol sponge after
energy use.
Fig. 12.11: For gingival retraction, position the electrode parallel to

long axis of the tooth and create a subgingival tissue trough 0.3–0.5
Fig. 12.10B: Long loop electrode used to remove gingiva. mm beneath the margin.
5. Recent Advances of Gingival Tissue
Management
Recent advances in gingival tissue management include
use of Lasers, Expasyl technique (noncord technique),
GingiTrac, Magic foam cord.
i. Lasers
When compared to other retraction techniques, diode
lasers with wavelength of 980 nm and neodymium:
yttrium-aluminium-garnet (Nd:YAG) lasers with wave-
length of 1.064 nm are less aggressive, cause less bleeding
and less gingival recession postoperatively.
ii. Expasyl (Noncord Technique) (Fig. 12.12)
It is chemomechanical technique of sulcus opening. It
consists of white clay to ensure consistency of paste for
Fig. 12.13: GingiTrac.
mechanical action and aluminium chloride for chemical
action. Expasyl paste is injected into sulcus exerting a
nondamaging pressure of 0.1 N/mm. it is safe, quick, easy
method without risk of contamination.
Fig. 12.14: Magic FoamCord: Apply it around the preparation and

place Compercap anatomic and hold it for 3–5 minutes by antagonist
tooth. This causes expansion of magic foam cord in sulcus causing its
Fig. 12.12: Expasyl technique for sulcus opening. retraction.
iii. GingiTrac (Fig. 12.13)

gingiTrac is a vinyl polysiloxane material with aluminium Conclusion
sulfate as astringent in it. GingiTrac is injected into sulcus
around the tooth and GingiCap on which patient bites The gingival margin of restorations should be taken care so
with medium force. It sets in 2 minutes, ready for removal. as to have optimal results of restoration. Gingival margin
It leaves dry sulcus with no residue. of restoration is critical because the margin directly affects
the periodontal health of teeth and the slightest marginal
iv. Magic FoamCord (Compercap from Coltene) inconsistency may become a harbor for growth of bacterial
It is nonhemostatic gingival tissue retraction system plaque. Thus, the clinician should make an effort to utilize
consisting of vinyl polysiloxane material. Apply Magic different methods and products available for retraction of
FoamCord around the preparation by syringing. Place gingival tissues in various clinical scenarios. The effort put
Compercap Anatomic and hold it for 3–5 minutes by into the appropriate retraction of gingival tissues pays off
antagonist tooth (Fig. 12.14). Due to the counter pressure in terms of longevity of restorations, better margins, and
of the Compercap Anatomic, the expansion of the Magic aesthetics.
FoamCord occurs in the sulcus. After proper setting,
remove the Compercap Anatomic and Magic FoamCord Examiner’s Choice Questions
in one piece. It is quick, easy nontraumatic method for
gingival retraction. 1. Write in detail about gingival tissue management.
2. Write short notes on: 9. What is single cord and double cord technique for
a. Gingival tissue retraction gingival retraction?
b. Chemomechanical methods of gingival tissue
management Bibliography
c. Surgical methods of gingival tissue management
1. Baba NZ, Goodacre CJ, Jekki R, et al. Gingival displacement
d. Recent advances in gingival tissue management. for impression making in fixed prosthodontics: contemporary
principles, materials, and techniques. Dent Clin North Am.
2014;58(1):45-68.
Viva questions 2. Brass GA. Gingival retraction for Class V restorations. J Prosthet
Dent. 1965;15(6):1109-14.
1. What are indications of gingival tissue management?
3. Drucker H, Wolcott RB. Gingival tissue management with Class
2. What are contraindications of gingival tissue V restorations. J Amer Acad Gold Foil Oper. 1970;13(1):34-8.
management? 4. Fischer DE. Tissue management: a new solution to an old
3. What are different methods for gingival tissue problem. Gen Dent. 1987;35(3):178-82.
5. Gilmore HW, Lund MR. Operative dentistry, 2nd edition. St.
management? Louis, CV Mosby Co.; 1973.
4. What are different chemicomechanical methods for 6. Markley MR. Amalgam restorations for Class V cavities. J Am
gingival tissue management? Dent Assoc. 1955;50(3):301-9.
7. Ruel J, Schuessler PJ, Malament K, et al. Effect of retraction
5. What are different surgical methods used for gingival procedures on the periodontium in humans. J Prosthet Dent.
tissue management? 1980;44(5):508-15.
6. What do you mean by rotary curettage/gingitage/ 8. Sorensen JA, Doherty FM, Newman MG, et al. Gingival
denttage? enhancement in fixed prosthodontics. Part I: Clinical findings.
J Prosthet Dent. 1991;65():100-7.
7. What is GingiTrac? 9. Walford P. Design principles for Class II preparations. Oral
8. What is Magic FoamCord? Health. 2012;102:60.
Chapter
13
Infection Control in Operative Dentistry
Chapter Outline
Introduction Instrument Processing Procedures/Decontamination Cycle

Rationale for Infection Control Sterilization of Dental Handpiece
Objective of Infection Control Disinfection
Universal Precautions Sterilization of Dental Unit Waterlines
Classification of Instruments Infection Control Checklist
INTRODUCTION Definitions
Dental professionals are exposed to wide variety of micro Cleaning: It is the process that physically removes contamination
organisms in the blood and saliva of patients, making but does not necessarily destroy microorganisms. It is a
infection control procedures important. Common goal prerequisite before decontamination by disinfection or
of infection control is to eliminate or reduce the number sterilization of instruments since organic material prevents
of microbes from being transferred from one person to contact with microbes, inactivates disinfectants.
another. Disinfection: It is the process of using an agent that destroys
germs or other harmful microbes or inactivates them, usually
referred to chemicals that kill the growing forms (vegetative
Rationale for Infection Control forms) but not the resistant spores of bacteria.
Deposition of organisms in the tissues and their growth Antisepsis: It is the destruction of pathogenic microorganisms
resulting in a host reaction is called an infection. Number existing in their vegetative state on living tissue.
of organisms required to cause an infection is termed as Sterilization: Sterilization involves any process, physical, or
the infective dose. chemical that will destroy all forms of life, including bacterial,
Factors affecting infective dose are: fungi, spores, and viruses.
◆◆ Virulence of the organism Aseptic technique: It is the method that prevents contamination
◆◆ Susceptibility of the host of wounds and other sites by ensuring that only sterile objects
and fluids come into contact with them, and that the risks of air-
◆◆ Age, drug therapy, or pre-existing disease, etc. Micro
borne contamination are minimized.
organisms can spread from one person to another
Antiseptic: It is a chemical applied to living tissues, such as skin
via direct contact (by touching soft tissues or teeth of
or mucous membrane to reduce the number of microorganisms’
patients), indirect contact (injuries with contaminated present, by inhibiting their activity or by destruction.
sharp instruments, needlestick injuries, or contact with
Disinfectant: It is a chemical substance that causes disinfection.
contaminated equipment and surfaces), and droplet It is used on nonvital objects to kill surface vegetative pathogenic
infection (by large particle droplets spatter which is organisms, but not necessarily spore forms or viruses.
transmitted by close contact).
Objective of Infection Control neck and long sleeves to protect the arms from splash and
spatter.
The main objective of infection control is elimination
or reduction in spread of infection from all types of
II. Face mask
microorganisms.
A surgical mask that covers both the nose and mouth
Universal Precautions should be worn by the clinician during procedures. Though
face masks do not provide complete microbiological
1. Personal hygiene protection, they prevent the splatter from contaminating
the face. Mask with 95% filtration efficiency for particles
the dentist and team should follow the proper hygiene
3–5 µm in diameter should be worn.
protocol to avoid cross infection. Any cuts if present should
not be touched.
III. Head Cap
2. Personal Protection Equipment (PPE)/ Hairs should be properly tied and covered with a head cap.
Barrier Technique
IV. Protective Eyewear
Use of barrier technique is very important, which includes
gown, face mask, protective eyewear, and gloves (Fig. Eyewear protects the eyes from injury and from microbes
13.1). Protective clothing should be made of fluid-resistant such as hepatitis B virus, which can be transmitted through
material and should not be worn out of the office for any conjunctiva. Eyewear should be clear, antifog, distortion
reason. These should be washed in hot water (70–158°F) or free, close fitting and shielded. Face shield: chin length
cool water containing 50–150 ppm of chlorine. plastic face shield can be worn as alternate to protective
eyewear.
I. Protective gown
V. Gloves
Protective gown should be worn to prevent contamination
of normal clothing and protect the skin of the clinician Gloves should be worn to prevent contamination of
from exposure to blood and body substances. Gown can hands when touching mucous membranes, blood, saliva,
be reusable or disposable for use. It should have a high and to reduce the chances of transmission of infected
Fig. 13.1: Personal protective equipment showing mouth mask, gloves, eyewear, head cap.
Infection Control in Operative Dentistry 141
Fig. 13.2: Showing the technique of handwashing.
microorganisms from clinician to patient. Gloves should against hepatitis B, tuberculosis, varicella, measles,
be of good quality and well-fitted. Gloves should be rubella, etc.
disposed after the activity for which they were used.
Classification of Instruments
VI. overgloves
Centers for Disease Control and Prevention (CDC)
These are inexpensive, clear plastic gloves which can be classified the instrument into critical, semicritical, and
put over the treatment gloves while handling drawers, noncritical depending on the potential risk of infection
cabinets, making entries, etc. during the use of these instruments. This classification of
instruments is also referred to as Spaulding classification,
3. Hand hygiene given by Spaulding in 1968 (Table 13.1).
Hand hygiene significantly reduces potential pathogens Table 13.1: Classification of instrument sterilization (Spaulding
on the hands and is considered the single most critical classification).
measure for reducing the risk of transmitting organisms Method of
to patients and dentists. Hand cleansers containing Category Definition Examples sterilization
mild antiseptic like 3% PCMX (parachlorometaxylenol), Critical Where Needles, Heat
triclosan, or chlorhexidine control transient pathogens instruments enter scalpels, sterilization/
and suppress overgrowth of skin bacteria. or penetrate surgical burs, single use
into sterile endodontic
Handwashing instructions (Fig. 13.2) tissue, cavity, or instruments
◆◆ Wet hands with warm water. bloodstream
◆◆ Apply adequate amount of soap to achieve lather. Semicritical Which contact • Amalgam Heat
◆◆ Rub vigorously for a minimum of 15 seconds, covering intact mucosa or condenser sterilization
all surfaces of hands and fingers. Pay particular attention nonintact skin • Dental
handpieces
to finger tips, between fingers, backs of hands, and base • Mouth
of thumbs, which are the most commonly missed areas. mirror
◆◆ Rinse well with running water. • Saliva
◆◆ Dry thoroughly with a disposable paper towel. ejectors,
suction tips
4. Immunization Noncritical Environmental • Light Disinfection

surfaces not switches
All members of the dental team (who are exposed to blood touched during • Dental chair
treatment
or blood-contaminated articles) should be vaccinated
Instrument Processing Procedures/

Decontamination Cycle
Instrument processing is the collection of procedures
which prepare the contaminated instruments for reuse.
For complete sterilization process, instruments should be
processed correctly and carefully (Flowchart 13.1).
Flowchart 13.1: Instrument processing cycle.
Fig. 13.3: Ultrasonic cleaner.
3. Control of Corrosion by Lubrication

For rust-prone instruments, use dry hot air oven/chemical
vapour sterilization instead of autoclave. Use rust inhibitor
(2% sodium nitrite) spray on the instruments.
4. Packaging
It maintains the sterility of instruments after the
sterilization. Packaging materials can be self-sealing,
1. Presoaking (Holding) paper-plastic, and peel-pouches.
Sterilization method and packaging material have been
For this, place loose instruments in a holding solution shown in Table 13.2.
(neutral pH detergents/water) for 30 minutes. It facilitates
Table 13.2: Sterilization method and packaging material.
cleaning process by preventing the debris from drying so
as to reduce chances of contamination. Sterilization method Packaging material
Autoclave • Paper or plastic peel-pouches, wrapped
cassettes
2. Cleaning • Plastic tubing (made up of nylon)
Cleaning reduces the bioburden, i.e., microorganisms, • Thin clothes (thick clothes absorb too
much heat)
blood, saliva, and other materials. Methods used for • Sterilization paper (paper wrap)
cleaning:
Chemical vapour • Paper or plastic pouches
• Sterilization paper
i. Manual Scrubbing
Dry heat • Sterilization paper (paper wrap)
It is one of the most effective methods for removing debris, • Nylon plastic tubing (indicated for dry heat)
• Wrapped cassettes
if performed properly. Brush delicately all the surfaces of
instruments while submerged in cleaning solution using
long-handled stiff nylon brush to keep the scrubbing hand
5. Methods of Sterilization
away from sharp instrument surfaces. Sterilization is the process by which an object, surface,
or medium is freed of all microorganisms either in the
ii. Ultrasonic Cleaning (Fig. 13.3) vegetative or spore state.
It is an excellent cleaning method as it reduces direct Though there are many ways of sterilization, the following four
handling of instruments. Ultrasonic energy generated in methods are accepted methods in dental practice:
the ultrasonic cleaner produces billions of tiny bubbles 1. Moist/steam heat sterilization
which, further collapse and create high turbulence at the 2. Dry heat sterilization
surface of the instrument. This turbulence dislodges the 3. Chemical vapour pressure sterilization
4. Ethylene oxide (ETOX) sterilization.
debris. Instruments are kept for 5–10 minutes.
Moist/Steam Heat Sterilization/Autoclave Sterilization cycles for autoclaves have been shown in
Table 13.3.
Autoclave provides the most efficient and reliable method
of sterilization for all dental instruments. It involves heating Table 13.3: Sterilization cycles for autoclaves.
water to generate steam in a closed chamber resulting in Temperature
moist heat that rapidly kills microorganisms (Fig. 13.4). Cycle Pressure (psi) (°C) Time (minutes)
Saturated steam under pressure is the most efficient, Standard 15 121 15
quickest, safest, and effective method of sterilization
Flash 30 134 3–10
because:
◆◆ It has high penetrating power
Advantages of autoclaving
◆◆ It gives up a large amount of heat (latent heat) to the
Time efficient
surface with which it comes into contact and on which Good penetration
it condenses as water. The results are consistently good and reliable
The instruments can be wrapped prior to sterilization.
Packaging of Instruments for Autoclaving Disadvantages of autoclaving
Blunting and corrosion of sharp instruments
◆◆ For packaging of autoclaving instruments, one should Damage to rubber goods
use porous covering to permit steam to penetrate Corrosion of carbon steel instruments.
through and reach the instruments. For example, fabric
or sealed paper or cloth pouches and paper-wrapped Dry Heat Sterilization/Hot Air Oven
cassettes (Fig. 13.5).
Dry heat utilizes the hot air which has very little or no
water vapours in it to sterilize the instruments.
Hot air oven utilizes radiating dry heat for sterilization
as this type of energy does not penetrate materials easily.
So, long periods of exposure to high temperature are
usually required. In conventional type of hot air oven, air
circulates by gravity flow, thus it is also known as Gravity
convection.
Packaging of Instruments for Dry Heat

Dry heat ovens usually achieve temperature above 320°F
(160°C). The packaging or wrapping material used should
be able to withstand high temperature; otherwise, it may
get charred. Acceptable materials for packaging are paper
and plastic bags, wrapped cassettes, and aluminium foil.
Unacceptable materials are plastic and paper bags which
are not able to withstand dry heat temperature. Packs
Fig. 13.4: Autoclave for moist heat sterilization.
of instruments should be placed ≥1 cm apart for air to
circulate in the chamber.
Temperature (°C) 160 190

Time (minutes) 60–120 6–12
Mechanism of Action
◆◆ Dry heat kills microorganisms by protein denaturation,
coagulation, and oxidation.
◆◆ Instruments that can be sterilized in dry hot oven
are glassware such as pipettes, flasks, scissors, glass
syringes, carbon steel instruments, and burs. Dry heat
does not corrode sharp instrument surfaces. Also, it
does not erode glassware surfaces.
◆◆ Before placing in the oven, the glassware must be dried.
The oven must be allowed to cool slowly for about
2 hours as the glassware may crack due to sudden or
Fig. 13.5: Cloth pouches for instrument wrapping. uneven cooling.
Advantages of dry heat sterilization oxide (ETOX) is a highly penetrative, noncorrosive gas
◆◆ No corrosion is seen in carbon steel instruments and above 10.8°C with a cidal action against bacteria, spores,
burs. and viruses.
◆◆ Maintains the sharpness of cutting instruments.
◆◆ Effective and safe for sterilization of metal instrument Mechanism of Action
and mirrors. It destroys microorganisms by alkylation and causes
◆◆ Low cost of equipment. denaturation of nucleic acids of microorganisms. The
◆◆ Instruments are dry after cycle. duration that the gas should be in contact with the material
◆◆ Industrial forced draft types usually provide a larger to be sterilized depends on temperature, humidity,
capacity at reasonable price. pressure, and the amount of material.
◆◆ Rapid cycles are possible at higher temperatures.
Disadvantages of dry heat sterilization Advantages
It leaves no residue
◆◆ A long cycle is required because of poor heat conduction
Good penetration power
and poor penetrating capacity.
Can be used at a low temperature
◆◆ High temperature may damage heat-sensitive items
Suited for heat-sensitive articles, for example, plastic,
such as rubber or plastic goods. rubber.
◆◆ Instruments must be thoroughly dried before placing
them for sterilization.
◆◆ Not suitable for handpieces. Disadvantages
◆◆ Cannot sterilize liquids. High cost of the equipment
Toxicity of the gas
Chemical Vapour Sterilization/Chemiclave Explosive and inflammable.
Sterilization by chemical vapour under pressure is known

as chemical vapour sterilization. Here, formaldehyde Monitoring of Sterilization
and alcohol formulation is heated in a closed chamber,
Monitoring of instruments must be conducted through
producing hot vapours that kill microorganisms.
a combination of mechanical, chemical, and biological
Temperature, pressure, and time required for completion
means, which evaluate both the sterilizing conditions and
of one cycle are 270°F (132°C) at 20 psi for 30 minutes.
the procedure’s effectiveness.
I. Mechanical indicators are the gauges on the sterilizer
Contents of Chemical Solution for cycle time, temperature, and pressure. Mechanical
◆◆ Active ingredient—0.23% formaldehyde indicators must be checked and recorded for each
◆◆ Other ingredient—72.38% ethanol + acetone + water load.
and other alcohols. II. Chemical indicators use sensitive chemicals to
assess physical conditions during the sterilization
Mechanism of Action process. For example, when a heat-sensitive tape
is applied to the outside of a package, rapid change
◆◆ Coagulation of protein
in color indicates that the package has undergone a
◆◆ Cell membrane disruption
sterilization cycle, although it does not guarantee that
◆◆ Removal of free sulfhydryl groups
sterilization has been achieved.
◆◆ Substrate competition.
III. Biological indicators are the most accepted means
Advantage for monitoring of sterilization because they assess
Eliminates corrosion of carbon steel instruments, burs and the effectiveness of sterilization in killing the most
pliers. resistant microorganisms. For example, Geobacillus
Disadvantages stearothermophilus (formerly known as Bacillus
The instruments or items which are sensitive to elevated stearothermophilus) and Bacillus subtilis spores
temperature are damaged. demonstrate a high resistance towards steam
Sterilization of linen, textiles, fabric, or paper towels is not
sterilization and are therefore used as biological
recommended.
Dry instruments should be loaded in the chamber. indicators that monitor the sterilization process.
Ethylene Oxide Sterilization 6. Storage of Processed Instruments

This sterilization method is best used for sterilizing After sterilization, instruments should be stored in an
complex instruments and delicate materials. Ethylene enclosed space like closed or covered cabinets. Date
should be mentioned on storage packets because dating and to expel excess oil to prevent coagulation during
helps in assessing shelf life of sterilization. Packages autoclaving. Place a bur in the chuck and run the
containing sterile instruments should be inspected before handpiece for 20 seconds and then pack the handpiece
use to verify barrier integrity and dryness. If packaging in paper/plastic bag to maintain sterility.
is compromised, the instruments should be cleaned, ◆◆ Dental motors and attachments require higher viscosity
packaged, and sterilized again. oil than a high-speed spray. One or two drops of oil in
Table 13.4 summarizes different sterilization methods the drive airline are all that is necessary. Run the motor
used in operative dentistry. to distribute the oil. Wipe away excess oil with a paper
towel. It is very important to take latch angles apart for
proper lubrication. At least once a day, unscrew the
STERILIZATION OF DENTAL HANDPIECE
head from the sheath and remove the transmission
Sterilization of dental handpiece is equally important gear for cleaning and oiling.
as any other dental instrument. “No handpiece should
be used on more than one patient without being Method of Sterilization
autoclaved between patients.” Barrier protection and
wiping down with a disinfectant does not assure no cross Handpieces should be sterilized by autoclave and chemical
contamination. methods.
According to Centers for Disease Control (CDC), the
following guidelines represent a general approach to Sterilization of Dental burs
handpiece sterilization and maintenance.
i. Diamond and carbide burs: After use, place the
◆◆ Clean the surface of handpiece using mild detergent burs in 0.2% glutaraldehyde and sodium phenate
for 30 seconds to remove contaminants. Alcohol or any (sporicidin) for at least 10 minutes. Then clean
chemical solution should never be used as a cleaning the burs using bur brush or ultrasonic cleaner and
agent as it can dehydrate spores and increase resistance sterilize by autoclaving. Burs should be protected
to sterilization. from rust by submerging them in 2% sodium nitrite
◆◆ Dry off the handpiece to prevent the corrosion. solution.
◆◆ Lubricate the handpiece using lubricating spray oil into ii. Steel burs: Steel burs may get damaged by autoclaving,
the drive airline. Run the handpiece to expel excess so these should be used using chemical vapour
oil to evenly distribute the oil through the bearings, sterilizer or glass bead sterilizer.
Table 13.4: Showing different methods of sterilization.

Method of sterilization Sterilizing conditions Advantages Disadvantages
Dry heat • Hot air oven • 160°C for 60–120 • No corrosion • Poor penetration of dry heat
• Rapid heat transfer minutes • Instruments are dry after • Long cycle of sterilization
• 190°C for 6–12 minutes cycle • Damage to rubber and plastic
• Low cost of equipment • Higher temperature may damage the
instruments
Moist heat • Autoclaving • 121°C at 15 psi for 15 • Better penetration of moist • Dulling and corrosion of sharp
• Flash autoclaving minutes heat instruments
• 134°C at 30 psi for 3–10 • Rapid and effective • Damage to plastic and rubber
minutes method of sterilization • Instruments need to be air dried at the
• Does not destroy cotton or end of cycle
cloth products
• Used for most of
instruments
Chemical Chemical vapour 132°C at 20 psi for 30 • Short sterilization cycle • Requires adequate ventilation
pressure sterilization minutes • Lack of corrosion of • Instruments should be dried before
instrument sterilization
• Effective method • May emit offensive vapour smell
• Chemical vapors can damage
sensitive instruments
Chemical Ethylene oxide • Good penetration • Expensive
sterilization • Nontoxic • Explosive and inflammable
• Heat-sensitive articles can • Toxicity of gas
be sterilized
Disinfection STERILIZATION OF DENTAL UNIT

It is the term used for destruction of all pathogenic WATERLINES
organisms, such as vegetative forms of bacteria, myco Water samples from the Dental Unit Waterlines (DUWLs)
bacteria, fungi, and viruses, but not bacterial endospores. contain large numbers of organisms in the range 104−106
colony-forming units (cfu)/mL. DUWLs have a number
Methods of Disinfection of characteristics that promote biofilm growth unless they
are regularly cleaned and disinfected. Because of high
1. Boiling Water surface area, slow flow rate, water in the DUWL can be
Mechanical cleaning with hot water provides an excellent stagnant for long periods of time. Biofilms develop rapidly
quality of disinfection for a wide variety of purposes. It in such systems within 8 hours, forming a mature bacterial
destroys many microorganisms, but not spores. For this, community within 6 days that is capable of shedding
instruments are completely submerged in boiling water at 104−106 (cfu)/mL if left untreated.
98°C to 100°C for 10 minutes.
Recommendations for Care of Waterlines
2. Formaldehyde The recommendations of DUWL sterilization state “Drain
It is broad-spectrum antimicrobial agent, but has limited down, clean, flush and disinfect all system components,
sporicidal activity. Formaldehyde is used for large heat- pipework and bottles twice daily, at the start and finish of
sensitive equipment such as ventilators and suction each day”.
pumps excluding rubber and some plastics. It is not Following measures should be used for sterilization
preferred because of its pungent odor and long hours of of Dental Unit Waterlines
contact for cidal action. 1. Daily flushing to reduce water stagnation: All DUWLs
should be flushed for two minutes at the beginning of
3. Glutaraldehyde each day, before starting the treatment, and at the end
of the day. One should check malodor, cloudiness and
It is toxic, irritant, and allergenic, provides high-level bad taste indicate microbial contamination.
disinfection. It is active against most vegetative bacteria, 2. Antiretraction valves: All DUWLs should be fitted
fungi, and bacterial spores and commonly used for heat- with check valves (nonretractable devices), to prevent
sensitive materials. A solution of 2% glutaraldehyde (Cidex) suck-back (backflow) of contaminants.
requires immersion of 20 minutes for disinfection and 6–10 3. Disinfectant systems: Various disinfectants like
hours of immersion for sterilization. It can be safely used hydrogen peroxide, silver ions, tetrasodium EDTA,
on metal instruments, rubber, plastics, and porcelain. chlorhexidine formulations, iodine, quaternary
ammoniums and chlorine dioxide. Sodium
4. Iodophors hypochlorite is popular for disinfecting DUWLs but it
These are used for surgical scrub, soaps and surface can cause corrosion of handpieces.
antisepsis. Iodine is complexed with organic surface-active 4. Use filters: Filters may be installed between the
agents such as polyvinylpyrrolidone (Betadine, Isodine). waterline and the dental handpiece to remove
Their activity is dependent on the release of iodine from microorganisms as the water is delivered to the
the complex. These compounds are effective against most patient.
bacteria, spores, viruses, and fungi. 5. Water purification system: Water purification
systems treat the water coming into the dental unit.
They kill or remove microorganisms by methods such
5. Sodium Hypochlorite
as filtration, electrolyzed water or ultraviolet light.
It can be used as disinfectant for noncritical items. 1.5% One advantage of these methods is that they may
solution of sodium hypochlorite is applied for 10–30 delay biofilm formation on waterlines or synergize other
minutes for surface disinfection. It is effective against methods mentioned above.
bacteria and viruses. Sterile water and autoclavable DUWL systems can be
used for delivery of quality water.
6. Ethanol and Isopropyl Alcohol
These have antibacterial activity, but not effective against Infection Control Checklist
spores and viruses. To have maximum effectiveness, Infection Control during the Pretreatment
alcohol must have a 10-minute contact with the organisms.
Instruments made of carbon steel should not be soaked in
Period
alcoholic solutions, as they are corrosive to carbon steel. 1. Use disposable items whenever possible.
2. Ensure before treatment that all equipment have been 4. After disposing of blood and suctioned fluids, use
sterilized properly. 0.5% chlorine solution to disinfect the dental unit
3. Remove avoidable items from the operatory area collection bottle. Keep the solution in the bottle for
to facilitate a thorough cleaning following each ≥10 minutes.
patient. 5. Clean the operatory area and disinfect all the items
4. Identify those items that will become contaminated not protected by barriers.
during treatment, for example, light handles, X-ray 6. Remove the tray with all instruments to sterilization
unit heads, tray tables. Disinfect them when the area separate from the operatory area.
procedure is complete. 7. Never pick up instruments in bulk because this
5. Review patient records before initiating treatment. increases the risk of cuts or punctures. Clean the
6. Preplan the materials needed during treatment to instruments manually or in an ultrasonic cleaner.
avoid opening of the cabinets and drawers once the 8. Sterilize the handpieces whenever possible. In general,
work is started. handpiece should be autoclaved, but the handpiece
7. Use separate sterilized bur blocks for each procedure that cannot be heat sterilized should be disinfected
to eliminate the contamination of other, unneeded by the use of chemicals. Clean the handpiece with a
burs. detergent and water to remove any debris and sterilize
8. Always keep rubber dam kit ready in the tray. it.
9. Follow manufacturer’s directions for care of DUWLs. 9. Waste that is contaminated with blood or saliva should
10. Clinician should be prepared before initiating the be placed in sturdy leak proof bags.
procedure; this includes the use of personal protective 10. Handle sharps items carefully.
equipment (gown, eyewear, masks, and gloves) and 11. Remove personal protective equipment after cleanup.
hand hygiene. Utility gloves should be washed with soap before
11. Update patient’s medical history. removal.
12. At the end, thoroughly wash hands.
Chairside Infection Control
1. Treat all patients as potentially infectious. Conclusion
2. Take special precautions while handling syringes and The dental operatory is a potential source of infection and
needles. cross infection. To protect dental clinician and patient
3. Use a rubber dam whenever possible. from cross infection, proper barrier protection and asepsis
4. Use high-volume aspiration. achieved via sterilization and disinfection are of utmost
5. Ensure good ventilation of the operatory area. importance. among various methods of sterilization
6. Be careful while receiving, handling, or passing sharp available, one must choose the sterilization method so that
instruments. it does not damage the dental instruments and materials.
7. Do not touch unprotected switches, handles and other All dental personal must be educated and trained in these
equipment once gloves have been contaminated. protocols to provide better care to patients.
8. Avoid touching drawers or cabinets, once gloves have Environment cannot be achieved without an efficient
been contaminated. When it becomes necessary to coordination within the dental team (dentists and
do so, ask your assistant to do this or use another assistants).
barrier, such as overglove to grasp the handle or According to our findings, only an appropriate workflow
remove the contaminated gloves and wash hands
relationship between dentists, assistants, dental stations,
before touching the drawer and then reglove for
and stored material can guarantee the maximum efficiency
patient treatment.
in terms of operative time, if the highest standard of
instrument and operative environment sterility and
Infection Control during the Post-treatment disinfection are to be maintained.
Period
1. Remove the contaminated gloves used during examiner’s choice Questions
treatment, wash hands and put on a pair of utility 1. Define sterilization and disinfection. Explain
gloves before beginning the cleanup. streilization of airrotor and dental burs.
2. Continue to wear protective eyewear, mask, and gown 2. What are recommendations for sterilization of dental
during cleanup. unit water lines?
3. Dispose blood and suctioned fluids which have been 3. Write short notes on:
collected in the collection bottles during treatment. i. Autoclave.
ii. Asepsis in operative dentistry. 13. What is mechanism of action of dry heat?
iii. ETOX sterilization. 14. Which bacterial spores are used for monitoring of
autoclaving?
viva questions 15. How will you sterilize handpiece?
1. What are various transmissible diseases to dental
surgeon? Bibliography
2. Discuss different methods of infection control. 1. Condrin AK. Disinfection and sterilization in dentistry. Tex
3. What are personal barrier techniques? Dent J. 2014;131(8):604-8.
4. What is asepsis? 2. Crawford JJ, Whitacre RJ, Middaugh DG. Current status
5. How do we do surface asepsis? of sterilization instruments, devices, and methods for the
6. What is chemiclav? dental office. Council on Dental Materials, Instruments, and
7. What is recommended temperature and pressure for Equipment. J Am Dent Assoc. 1981;102:683-9.
3. Gyorfi A, Fazekas A. Significance of infection control in
autoclave?
dentistry: a review. Fogorv Sz. 2007;100(4):141-52.
8. Define sterilization. 4. Miller CH. Cleaning, sterilization and disinfection: basics
9. Define disinfection. of microbial killing for infection control. J Am Dent Assoc.
10. Give examples of critical, semicritical and non-critical 1993;124:48-56.
items. 5. Miller CH. Sterilization and disinfection: what every dentist
11. What do you mean by ETOX? needs to know. J Am Dent Assoc. 1992;123:46-54.
12. Why autoclaving is considered one of the effective 6. Rutala WA, Weber DJ. Disinfection, sterilization, and antisepsis:
method of sterilization? an overview. Am J Infect Control. 2016;44(5):e1-6.
Chapter
14
Pain Management in Operative Dentistry
Chapter Outline
Introduction Pain Management Protocol

Definition Recent Advances in Local Anesthesia
Method of Control of Pain in Restorative Dentistry Other Methods of Pain Control
Introduction iii. Use of cooling methods so as to avoid heating of tooth

iv. To prevent desiccation of the dentin
Many patients enter in dental office in such a state of v. Local anesthesia
nervousness or agitation that they even find taking of vi. Other methods of pain control
radiographs almost unbearable. Some of them who vii. Newer methods of pain control.
outwardly appear normal, may also be suffering from
severe inner apprehension. A kind, supportive and
PAIN MANAGEMENT PROTOCOL
understanding attitude together with suggestion for the
control of such feelings will be greatly appreciated and i. Preoperative oral NSAID, preferably given one hour
usually yield acceptable response. before initiating the treatment.
A variety of techniques for management of anxiety ii. Local anesthesia for pain control during operative
are available. Together these techniques are termed as procedure.
spectrum of pain and anxiety control. They represent a wide iii. To continue oral NSAIDs as per patient requirements.
range from non-drug technique to general anesthesia.
1. Local Anesthesia
DEFINITION It is defined as a loss of sensation in a circumscribed area
of the body caused by depression of excitation in nerve
According to International Association for the Study of
endings or an inhibition of the conduction.
Pain (IASP), “Pain is an unpleasant emotional experience
in general, pit and fissure sealant procedures do not
associated with actual or potential tissue damage or
require local anesthesia, but management of moderate
described in terms of such damage”.
to deep caries require administration of local anesthesia.
According to Monheim, “pain is an unpleasant
Apart from pain relief, local anesthesia causes increase in
emotional experience usually initiated by noxious stimulus
patient cooperation and reduction in salivary flow, thus
and transmitted over a specialized neural network to CNS increases operator’s efficiency.
where it is interpreted as such”.
Following Factors should be Kept in Mind Prior to
Method Of Control Of Pain In Administration of Local Anesthesia
Restorative Dentistry 1. Age: In very young and extremely old people, lesser
i. Gaining confidence of the patient to reduce fear of therapeutic dose should be given.
pain and anxiety 2. Allergy: Since it is life-threatening in most of the cases,
ii. Use of sharp instruments used with skill and proper history about allergy should be taken before
confidence administering local anesthesia.
3. Pregnancy: It is better to use minimum amount of local Techniques of Local Anesthesia for Maxillary and
aesthetic drugs especially during pregnancy. Mandibular Teeth (Fig. 14.1)
4. Thyroid disease: Since patients with uncontrolled
hyper thyroidism show increased response to the i. Topical anesthesia: It is applied on mucosa of
vasoconstrictor present in local anesthetics, therefore, selected site after drying it. It is effective in reducing
in such cases, local anesthesia solutions without the discomfort of initial prick of needle into the
adrenaline should be used. mucosa. Topical anesthesia is available in form of gel,
5. Hepatic dysfunction: In hepatic dysfunction, the liquid or spray.
biotransformation cannot take place properly, resulting ii. supraperiosteal infiltration: it is local infiltration
in higher levels of local anesthetic solution in the blood. where anesthetic is deposited near the nerve endings
So, in such cases low doses of local aesthetic should be in operating site. This is commonly given in maxillary
administered. teeth.
Composition of a local anesthetic agent: iii. Regional nerve block: It is nerve block where
◆◆ Local anesthetic—lidocaine/lignocaine anesthetic solution is deposited near nerve trunk at a
◆◆ Vasoconstrictor—epinephrine distance from operating site. It is commonly used in
◆◆ Preservative for vasoconstrictor—sodium metabisulfite mandibular teeth.
◆◆ Isotonic solution—sodium chloride
◆◆ Preservative—methylparaben Mandibular Additional
◆◆ Distilled water acts as vehicle. Maxillary anesthesia anesthesia procedures
• Anterior and • Inferior alveolar • Supraperiosteal
addition of vasoconstrictor causes:
middle superior nerve block injection
i. Delay in absorption of local anesthetic from the site alveolar nerve • Long buccal nerve • Intraligamentary
ii. Reduction in bleeding from the operating field block block injection
iii. Prolong action of local anesthetic agent • Posterior superior • Mental nerve • Intrapulpal
iv. Reduction in systemic toxicity. alveolar nerve block anesthesia
Among amide- and ester-based local anesthetics, amide block
based local anesthetics are commonly used because they • Greater palatine
produce less allergic reaction. Commonly used local nerve block
anesthetics are 2% lidocaine with or without adrenalin, 0.5% • Nasopalatine
bupivacaine with adrenalin, etc. nerve block
Fig. 14.1: Techniques of Local anesthesia administration for maxillary and mandibular teeth.
Pain Management in Operative Dentistry 151
Precautions to be Taken while Administration
of Local Anesthesia
◆◆ Patient should be in supine position as it favors good
blood supply and pressure to brain. Clean the site of
injection with a sterile cotton pellet before injecting the
local anesthesia.
◆◆ Before injecting local anesthesia, aspirate a little
amount in the syringe to avoid chances of injecting
solution in the blood vessels.
◆◆ Do not inject local anesthesia into the inflamed and
infected tissues as local anesthesia does not work
properly due to acidic medium of inflamed tissues. Fig. 14.2: Schematic representation of local anesthesia with
◆◆ Always use disposable needle and syringe in every injection and without needle.
patient. Needle should remain covered with cap till its
use. 3. WAND System of Local Anesthesia (Fig. 14.3)
◆◆ To make injection a painless procedure, temperature of WAND local anesthesia system is computer-automated
the local anesthesia solution should be brought to body injection system which allows precise delivery of anesthesia
temperature. at a constant flow rate despite varying tissue resistance. In
◆◆ Inject local anesthesia solution slowly not more than this, topical anesthetic is first applied to freeze the mucosa
1 ml per minute and in small increments to provide and then a tiny needle is introduced through the already
enough time for tissue diffusion of the solution. numb tissue to anesthetize the surrounding area.
◆◆ Needle should be continuously inserted inside till
the periosteum or bone is felt by slight increase in Advantages Disadvantages
resistance of the needle movement. The needle is • Reduced pain and anxiety • Expensive
slightly withdrawn and here the remaining solution is • More rapid onset of • Longer injection time
injected. anesthesia • System does require some
◆◆ Patient should be carefully watched during and after • More accurate than standard time to get accustomed too.
aspirating syringe • System is operated by foot-
local anesthesia for about half an hour for delayed pedal control and anesthetic
reactions, if any. cartridge is not directly
visible
Recent Advances in Local
Anesthesia
To make local anesthesia more comfortable and less
traumatic, following advances have been made:
1. Needle-free anesthesia
2. Intraoral lignocaine patch
3. WAND system of local anesthesia
4. Comfort control syringe
5. TENS local anesthesia
6. Electronic dental anesthesia (EDA)
1. Needle-free Anesthesia
This needle-free injection system uses high-pressure, i.e.
it uses the narrow jet of the injected liquid instead of a
hypodermic needle to penetrate the mucosa (Fig. 14.2).
Fig. 14.3: WAND system of local anesthesia.
2. Intraoral Lignocaine Patch
4. Comfort Control Syringe (CCS) (Fig. 14.4)
It is used for topical anesthesia. It contains 10% or 20%
lidocaine. It is placed on buccal mucosa of maxillary It is an electronic, preprogrammed delivery system for local
and mandibular premolar 2 mm apical to mucogingival anesthesia that dispenses the anesthetic in a slower, more
junction. controlled and more consistent manner than traditional
the A-delta and C-fibers. This prevents descendent motor

activity (tightening up).
Technique
◆◆ Clean and dry the area over the coronoid notch area
◆◆ Apply electrode patches
◆◆ Attach electrode leads from patch to TENS unit
◆◆ Adjust the timer
◆◆ Adjust the controls to high bandwidth and high
frequency
◆◆ Slowly adjust the amplitude so that patient feels a gentle
pulsing sensation
◆◆ Proceed with dental procedure in usual manner
◆◆ At the completion of the procedure, disconnect the
leads and remove the electrode patches from the
Fig. 14.4: Comfort control syringe (CCS).
patient.
manual syringe. Comfort control syringe has two-stage 6. Electronic Dental Anesthesia (EDA) (Fig. 14.6)
delivery system in which injection begins at a very slow
rate to decrease the discomfort associated with rapid Electronic dental anesthesia developed in mid-1960s for
injection. After ten seconds, CCS automatically increases management of acute pain, but the use of electricity as
injection rate for the technique which has been selected. therapeutic modality is not new in the field of medical and
dental sciences.
During the first phase of injection, • Longer injection time
Indications
anesthetic solution is delivered at • Cost of the unit is ◆◆ Patients allergic to local anesthesia
very slow rate. This minimizes the expensive
pressure, tissue trauma, and patient
◆◆ Patient having needle phobia.
discomfort.
Contraindications
5. Transcutaneous Electrical Nerve Stimulation ◆◆ In patients with cardiac pacemakers
(TENS) (Fig. 14.5) ◆◆ Pregnant patients
◆◆ In patients with neurological disorders such as epilepsy,
This is noninvasive technique in which a low-voltage stroke, etc.
electrical current is delivered through wires from a power ◆◆ Young and very old patients.
unit to electrodes located on the skin.
Mechanism of Action Mechanism of EDA
It is based on Gate’s control theory, which states that This is explained on the basis of Gate control’s theory. In
stimulating input from large pain conducting nerve fibers this, higher frequency is used which causes the patient to
closes the gate on nociceptive sensory phenomena from experience a sensation described as throbbing or pulsing.
Fig. 14.5: Transcutaneous electrical nerve stimulation (TENS). Fig. 14.6: Electronic dental anesthesia (EDA).
Pain Management in Operative Dentistry 153
It also causes stimulation of larger diameter nerve fibers be used to improve the level of patient cooperation by
(A-fibers) which is usually responsible for touch, pressure increasing confidence itself.
and temperature.
These large diameter fibers (A-fibers) are said to inhibit Conclusion
the central transmission of effects of smaller nerve fibers
(A-delta and C-fibers) which, in turn, are stimulated Pain is a diagnostic challenge. A dentist should be aware
during drilling at high speed and curettage. So, when no of the physiologic and psychological aspects of pain and
impulse reaches the central nervous system, there would anxiety as it applies to the patient. Adequate clinical
be no pain. assessment and diagnosis can help in managing the
pain in operative procedures. Various methods of pain
Advantages Disadvantages management are present to handle pain during operative
• No fear of needle • Expensive
procedures; these should be applied as per patient
• No fear for injection of drugs • Technique sensitive— requirements so as to have optimal results and maximum
• No residual anesthetic effect requires training comfort.
after the completion of
procedure EXAMINER’S CHOICE QUESTIONs
1. What are different ways of pain control in dentistry?
other methods of pain control Write short note on local anesthetics.
2. Write short note on methods of pain management in
1. Premedication using antianxiety drugs: Benzo operative dentistry other than local anesthesia.
diazepines, including diazepam and midazolam have 3. Write a short note on recent advances in local
sedative and selective anxiolytic effects and wide anesthesia.
margin of safety. Thus these drugs are widely used
to calm the patient by prescribing them before the
VIVA questions
treatment. Commonly used drugs for anxiety control
are diazepam (2–10 mg), alprazolam (0.25–0.5 mg) one 1. What are advantages of using vasoconstrictor in the
hour before treatment. local anesthetic solution?
2. Inhalation sedation: Conscious sedation is a technique 2. What are different techniques of local anesthesia?
in which the use of a drug produces a state of depression 3. What is WAND system of local anesthesia?
of the central nervous system (CNS) enabling treatment 4. What is comfort control syringe?
to be carried out, but during which verbal contact 5. What is principle of TENS?
with the patient is maintained throughout the period 6. What is EDA?
of sedation. Conscious sedation retains the patient’s 7. What is conscious sedation?
ability to maintain a patent airway independently 8. What are methods of pain control other than LA?
and continuously. Mixture of nitrous oxide (N2O) and
oxygen is used as inhalational anesthetic agent. It is an bibliography
anxiolytic/analgesic agent that causes CNS depression 1. Nustein J, Reader A, Nist R, et al. Anesthetic efficacy of the
and muscle relaxation with hardly any effect on the supplemental intraosseous injection of 2% lidocaine with
respiratory system. 1:100,000 epinephrine in irreversible pulpitis. J Endod.
1998;24:487-91.
3. Hypnosis: Hypnosis is widely and often successfully
2. Reynolds DC. Pain control in the dental office. Dent Clin North
used in a variety of clinical situations to modify Am. 1971;15:319-25.
patients’ thinking, behavior, and perception. It is one of 3. Small EW. Preoperative sedation in dentistry. Dent Clin North
the method to help the anxious patient relax and can Am. 1970;14(4):769-81.
Chapter
15
Matricing
Chapter Outline
Introduction T-shaped Matrix Band

Matricing S-shaped Matrix Band
Parts of Matrix Aluminium or Copper Collars
Functions of a Matrix Transparent Crown Forms Matrices
Ideal Requirements of a Matrix Window Matrix
Classification Anatomic Matrix
Ivory Matrix Holder (Retainer) No. 1 Clear Plastic Matrix Strips
Ivory Matrix Band Retainer No. 8 Aluminium Foil Incisor Corner Matrix
Tofflemire Universal Matrix Band Retainer (Designed by Dr BR Preformed Transparent Cervical Matrix
Tofflemire) Matrix Retainerless System
Steele’s Siqveland Self-adjusting Matrix Holder for Tapering Recent Advances in Matrix Systems for Class ii Composite
Teeth Restorations
Compound Supported Matrix Sectional Matrices and Contact Rings
INTRODUCTION
Teeth and periodontium are designed in such a manner
that mutually they contribute to their own health and
support. Proper form and alignment of teeth protect
periodontium. A breach in the continuity of normal tooth
form of teeth gives rise to periodontal pathology.
Consequences of not restoring proximal areas (Fig. 15.1)
◆◆ Food impaction leading to recurrent caries
◆◆ Change in occlusion and intercuspal relations
◆◆ Rotation and drifting of teeth
◆◆ Trauma to the periodontium.
MATRICING
Restoration of a tooth requires great clinical expertise so Fig. 15.1: Arrow showing faulty restoration in interproximal area. It
as to reproduce the original contacts and contours of the favors food lodgement resulting in periodontal disease, secondary
caries, etc.
tooth. In case of large missing wall of the tooth, support
has to be provided while placing and condensing the
restorative material. Usually, a metallic strip serves this which forms the temporary walls is held in its place by
function and is known as the matrix band. Matrix band means of a matrix band retainer.
Matricing 155
Viva Voce
6. Height and contour: Matrix band should not extend
more than 2 mm beyond the occlusogingival height of
Matricing: It is the procedure by which a temporary wall the crown of tooth.
is built opposite to the axial wall, surrounding the tooth 7. Ease of application and removal: Matrix band should
structure which has been lost during the tooth preparation.
be such that it can be applied and removed easily.
Matrix: It is an instrument which is used to hold the
restoration within the tooth while it is setting.
8. Sterilization: It should be easy to sterilize.
9. Inexpensive: It should be inexpensive.
Parts of Matrix CLASSIFICATION

Retainer According to Method of Retention
It holds the band in desired position and shape. Retainer I. Mechanically retained, e.g. Ivory matrix retainers
can be a mechanical device, floss, metal ring or impression no. 1 and 8, Tofflemire universal dental matrix band
compound. retainer.
II. Self-retained, e.g. copper or stainless steel bands,
Band Automatrix.
◆◆ It is a piece of metal or polymeric material, intended
to give support and form to the restoration during its According to its Preparation
insertion and setting. i. Mechanical matrix, e.g. Ivory matrix retainers no.1
◆◆ Commonly used materials for bands are: and 8, Tofflemire matrices
•• Stainless steel ii. Anatomic/custom-made matrix, e.g. compound
•• Polyacetate supported matrix.
•• Cellulose acetate
•• Cellulose nitrate.
◆◆ Matrix band should extend 2 mm above the marginal According to Transparency
ridge height and 1 mm below gingival margin of the i. Transparent matrices, e.g. cellophane, celluloid.
preparation. ii. Nontransparent matrices, e.g. stainless steel.
◆◆ Bands are usually available as strips of around 0.001 to
0.002 inch (0.05 mm and 0.038 mm) in thickness and According to the Type of Band Material
0.18 inch, 0.25 inch or 0.31 inches width.
i. Stainless steel
Functions of a matrix ii. Copper band
iii. Cellophane
i. To confine the restoration while it is setting. iv. Mylar.
ii. To establish optimal contacts and contours for the
restoration. According to the Tooth Preparation for
iii. To provide optimal surface texture for restoration.
Which they are used
iv. To prevent gingival overhangs of the restoration.
Table 15.1 enlists various matrices used according to the
Ideal Requirements of a matrix type of tooth preparation.
To achieve an optimal restoration, matrix band should

Ivory Matrix Holder (Retainer) No. 1
have following requirements:
1. Rigidity: Matrix band should be rigid enough so as Ivory matrix holder number 1 is most commonly used
to withstand the pressure of condensation applied matrix band holder for unilateral class II tooth preparations.
during restoration, placement and maintains its shape Matrix holder has a claw at one end with two flat semicircle
during hardening. arms having a pointed projection at the end (Fig. 15.2). On
2. Adaptability: Matrix band should be able to match to other end of matrix band holder, there is a screw which on
almost any size and shape of tooth. rotating clockwise brings ends of both claws closer to each
3. Easy to use: Band should be simple in design so that it other. Band used with this matrix has one margin slightly
does not cause any difficulty to the patient, or hindrance projected in its middle part. This projected margin is kept
to the operator during restoration of the tooth. towards the gingiva on the side of tooth preparation.
4. It should be able to displace the gingiva and rubber Keeping the matrix band around the tooth, the screw of the
dam for ease in working. retainer is tightened so that the band perfectly fits around
5. Nonreactive: It should be inert to the tissues and the tooth. After this, wedge is placed which also helps in
restorative material. further adaptation of the matrix band to the tooth.
Table 15.1: Classification of matrices according to the type of tooth Advantages

preparation.
◆◆ Economical
Types of preparation Matrices and retainers
◆◆ Used for restoring class II tooth preparations
• Class I with buccal or • Double banded Tofflemire matrix ◆◆ Can be sterilized.
lingual extension (Bartons matrix)
• Class II tooth preparation • Ivory matrix number 1 Disadvantages
• Nystrom’s retainer
• Ivory matrix number 8 ◆◆ Cumbersome to apply and remove.
• Class II mesio- • Tofflemire matrix ◆◆ Not used commonly nowadays.
occlusodistal (MOD) • Steele’s Siqveland self-adjusting
tooth preparation matrix, Copper band matrix Ivory Matrix Band Retainer No. 8
• Anatomical matrix band
• “T” shaped matrix band Ivory matrix band retainer holds the matrix band that
• Retainerless automatrix encircles the tooth to provide missing walls on both
• Class III tooth preparation • ”S” shaped matrix band proximal sides. The matrix band is made up of thin sheet
• Cellophane matrix strips of metal so that it can pass through the contact area of
• Mylar strips the unprepared proximal side of the tooth (Fig. 15.3).
• Class IV tooth • Cellophane strips circumference of the band can be adjusted using the
preparation • Aluminium foil screw present in the matrix band retainer.
• Transparent crown form
• Class V tooth preparation • Custom made plastic matrix Indications
• Window matrix
• Tin foil matrix ◆◆ Unilateral or bilateral class II preparations (MOD)
• S-shaped matrix ◆◆ Class II compound tooth preparations having more
• Anatomic matrix than two missing walls.
• Aluminium or copper collars
• Direct tooth colored • Cellophane matrices Advantages
and other complex • Anatomic matrices
preparations • Aluminium or copper collars ◆◆ Economical
• Transparent plastic crown forms ◆◆ Used for restoring class II tooth preparations
◆◆ Can be sterilized.
Indication Disadvantages
For unilateral class II tooth preparations, especially when ◆◆ Cumbersome to apply and remove.
the contact on the unprepared side is very tight. ◆◆ Not used commonly nowadays.
Fig. 15.2: Ivory No. 1 matrix retainer and band. Fig. 15.3: Ivory No. 8 matrix retainer and bands.
Matricing 157
Tofflemire Universal Matrix
Band Retainer (designed by Dr BR
Tofflemire)
It is also well known as “universal” matrix because it can
be used in all types of tooth preparations of posterior
teeth. Matrix band is fitted onto the retainer and then
fitted loosely over the tooth, which then can be tightened
in position by means of the screw.
Parts of Tofflemire Retainer (Fig. 15.4)

1. Head
It has slot for positioning of matrix. It is U-shaped with two
slots in open side. Open side of the head should be held
Fig. 15.5B: Slots of head should always be directed gingivally.
facing gingivally when the band is placed around the tooth
(Figs. 15.5A and B). Head can be straight or angulated
with respect to rest of retainer (Fig. 15.6).
◆◆ Straight:
•• Head of matrix system is straight
•• Placed only from buccal side.
◆◆ Contra-angle:
•• Head is angulated
•• Placed either from buccal or lingual side.
Fig. 15.6: Types of head of a tofflemire retainer.
2. Locking Vise
Fig. 15.4: Parts of Tofflemire retainer. It has a diagonal slot. This portion is located near the head
for placing band in the retainer and helps in positioning of
band around the tooth.
3. Pointed Spindle
Pointed spindle is used to adjust the distance between
head and locking vise and to adjust the size of loop of
matrix band.
4. Large Knurled Nut

It is also known as rotating spindle. It helps in adjusting the
size of loop of matrix band against the tooth.
5. Small Knurled Nut

It helps in tightening the band to retainer by turning it
Fig. 15.5A: Slots should not be directed occlusally clockwise.
Tofflemire matrix is available in two sizes: •• Straight—used near anterior teeth

1.Standard—used in permanent dentition •• Left/Right—used mostly in posterior areas of oral
2.Small—used in primary dentition. cavity.
◆◆ Turn the small knurled nut clockwise to tighten the
Types of bands used in Tofflemire Retainer band to the retainer.
◆◆ After securing the band tightly to the retainer, position
Two types of bands are usually used:
the band around the tooth to be restored.
◆◆ For final adaptation of matrix band to the tooth,
1. Flat Bands tighten the large knurled nut (Fig. 15.8D) by turning it
Flat bands are available in two thicknesses, 0.0020 inches clockwise.
and 0.0015 inches. These need to be contoured using ◆◆ Check the contour of matrix, sometimes burnisher may
burnisher or spoon excavator before placing in retainer. be used from prepared cavity wall to adapt the band for
Three shapes of flat bands are available (Fig. 15.7). optimal contour.
a. No. 1 or universal band ◆◆ Place wedge.
b. No. 2 or MOD band: It has two extensions projecting
at gingival edge. It is commonly used in molars
Procedure for Removal of Tofflemire Retainer
c. No. 3: Similar to No. 2 band in design but narrower and Band
than No. 2. This is usually accomplished in two steps:
1. Removal of retainer
2. Precontoured Bands 2. Removal of band.
They are also available but less commonly used. While Removal of Retainer
removing these bands, band should be rotated in such a
way that its trailing end should not fracture the restoration. Turn the small knurled knot counter clockwise to free the
band from the retainer. While rotating the smaller knurled
Placement of Tofflemire Retainer and Band knot, hold the larger nut. Keep the index finger on occlusal
surface of tooth to stabilize the band.
◆◆ First open the large knurled nut by turning it counter
clockwise so that locking vise is at least ¼ inches from Removal of Band
the head (Fig. 15.8A). Support the occlusal surface of the restoration. While
◆◆ Hold the knurled nut (large) with one hand, open removing the band, hold a condenser against the marginal
the small knurled nut in opposite direction (counter ridge of the restoration. Do not pull band in occlusal
clockwise) for clearance of diagonal slot for reception direction rather move the band in facial or lingual direction.
of matrix band (Fig. 15.8B).
◆◆ Bring the two ends of matrix band together to form Indications of Tofflemire Matrix
loop. One side of loop has larger diameter which should
◆◆ Class I tooth preparations with buccal or lingual
be placed occlusally, other side has smaller diameter,
extensions
which should be placed gingivally for better adaptation
◆◆ Unilateral or bilateral class II MOD tooth preparations
to cervical area. This loop can be projected in following
◆◆ Class II compound tooth preparations having more
ways as given in Figure 15.8C. than two missing walls.
Advantages
◆◆ Easy to use
◆◆ Sturdy and stable in nature
◆◆ Provides good contact and contours
◆◆ Can be easily removed
◆◆ Can be sterilized.
◆◆ Can be used both from facial as well as lingual side
◆◆ Economical.
Disadvantages
◆◆ Cannot be used in badly broken teeth or extensive class
Fig. 15.7: Three types of Tofflemire bands. II restorations.
Matricing 159
A B
D E
Figs. 15.8 A to E: Placement of Tofflemire retainer: (A) Open the large knurled nut by turning it counter clockwise so that locking vise is at least
¼ inches from the head; (B) Hold large knurled nut with one hand, open the small knurled nut in opposite direction so as to receive matrix band;
(C) Bring the two ends of matrix band together to form loop. This loop can project in straight, left or right; (D) Turn the small knurled nut clockwise
to tighten the band to the retainer; (E) Position the band around the tooth to be restored.
◆◆ Does not offer optimal contour and contact for posterior

resin restorations.
Modification in Tofflemire Retainer

Omni Matrix
It is preassembled Tofflemire retainer for one time use (Fig.
15.9).
It is available with band thickness of 0.0010 inch and
0.0015 inch.
Advantage
Takes less time to use.
Disadvantage
Expensive. Fig. 15.9: Omni matrix.
Steele’s Siqveland Self-adjusting Advantages

Matrix Holder for Tapering Teeth ◆◆ Can adapt to tooth contour properly
It is especially used when there is a significant difference ◆◆ Due to Steele’s Siqveland self-adjusting matrix holder
between the diameters of the cervical and occlusal anatomic adaptation of the band is possible without the
one-third of the tooth. This matrix retainer can give two help of wedges.
different diameters at the two ends of the matrix band. It is
based on the principle of a movable slide which holds and Compound Supported Matrix
tightens the band in the required position (Fig. 15.10).
It was described by Sweeney. Here band is contoured with
a burnisher to achieve optimal facial, lingual, and proximal
Indication contours of the tooth.
All types of compound and complex tooth preparations in
posterior teeth. Materials Used
◆◆ Matrix band of 0.30 inches width(8mm) and 0.002 inch
(0.05 mm) thickness
◆◆ Impression compound or low fusing compounds.
Procedure for Placement of Anatomical Matrix

Band (Figs. 15.11A to F)
◆◆ Cut a sufficient length of matrix band so that it covers
one-third of facial and lingual surface along with
proximal tooth preparation
◆◆ Contour the band with burnisher in back and forth
motion to achieve desired proximal as well as facial and
lingual contours of the tooth
Fig. 15.10: Steele’s Siqveland self-adjusting matrix holder for
◆◆ Heat one end of impression compound over flame for 5
tapering teeth. to 10 seconds. When compound starts drooping, carry
A B C
D E F
Figs. 15.11A to F: Steps for placement of anatomical matrix band: ( A and B) Cut the matrix band so as to cover facial and lingual surface along
with proximal tooth preparation; (C) Contour the band with burnisher to achieve desired contour of tooth; (D) Place the band in the place; (E)
Place wedge; (F) Take warm impression compound with dampened glove fingers and adapt it around the tooth to further stabilize the band.
Matricing 161
it with dampened glove fingers and adapt it around the
tooth
◆◆ Recontour the band by pressing the warmed instrument A
to inside of matrix to soften the compound
◆◆ To remove the matrix, compound can be broken with
explorer or carver and strip can be removed.
B
Indications
◆◆ Restoration of class II proximal tooth preparation
involving one proximal surface or both
◆◆ Complex restorations, e.g. pin amalgam restorations.
Advantages
C
◆◆ Provides better contact and contour in restoring class II
tooth preparations Figs. 15.12A to C: Procedure for placement of T-shaped matrix band.
◆◆ Highly rigid and stable than other matrix systems
◆◆ Recontouring can be easily done after compound
placement. S-shaped Matrix Band
S-shaped matrix band is used for restoring distal part of
Disadvantage canine and premolar. In this, stainless steel matrix band is
Time consuming. taken and twisted like “S” with the help of a mouth mirror
handle. The contoured strip is placed interproximally over
T-shaped Matrix Band the facial surface of tooth and lingual surface of bicuspid
(Figs. 15.13A to D). To increase its stability, wedge and
This is preformed brass, copper or stainless steel matrix impression compound can be used.
bands without a retainer. In this band, the long arm of the
T surrounds the tooth and overlaps the short arm of the
Indications
T (Figs. 15.12A to C). Band is adapted according to tooth
shape and size. Wedges and impression compound may ◆◆ For class III restoration on the distal part of canine.
be used to provide further stability to the band. ◆◆ Class II slot restorations.
Indication Advantage
Unilateral or bilateral class II MOD tooth preparations. Offers optimal contour for distal part of canine.
Advantages Disadvantage
◆◆ Simple to use Cumbersome to apply and remove.
◆◆ Economical
◆◆ Rapid and easy to apply. Aluminium or Copper Collars
Copper bands are cylindrical in shape, which are available
Disadvantage in different sizes of 1–20 according to gingival third of
Not stable in nature. buccal and lingual surfaces (Figs. 15.14A and B). Size
A B C D
Figs. 15.13 A to D: Procedure for placement of S-shaped matrix band.
A B
Figs. 15.14A and B: (A) Aluminium or copper collars; (B) Schematic representation of copper band matrix in place.
number 1 is 4 mm and size number 20 is 12 mm. Band is Indications

selected according to diameter of crown and it is softened
◆◆ For bilateral class IV preparations
by heating to redness in a flame and quenching in alcohol.
◆◆ For oblique fractures of anterior teeth.
After this, band is adapted according to gingival contour
of tooth, keeping 1–2 mm of band surface beyond the
preparation margins. Once the band is seated, wedges Advantages
are used to stabilize the band. Compound is applied on ◆◆ Simple and easy to use
external surface for further stabilization of band. It should ◆◆ Offers better contours.
be left in place till the amalgam is initially set. Band is
removed by sectioning in next appointment. Disadvantages
◆◆ Time consuming
Indications
◆◆ Expensive.
◆◆ Badly broken teeth
◆◆ Complex amalgam restoration Window Matrix
◆◆ Class V preparations.
It is modified Tofflemire matrix or copper band matrix.
In this, contra-angle Tofflemire retainer is applied at the
Advantage
side of tooth which does not have preparation, e.g. lingual
Offers better contours. surface. a window is cut in band slightly smaller than
outline of the cavity (Figs. 15.15A and B). Wedges are
Disadvantages placed interproximally to stabilize the band. after band is
stabilized, amalgam is condensed and contoured through
◆◆ Cannot be used with resin restorations window.
◆◆ Time consuming.
Anatomic Matrix
Transparent Crown Forms Matrices
In this, prepare a study model for affected teeth together
These are “Stock” plastic crowns which can be contoured with at least one intact adjacent tooth on each side.
according to tooth shape and size. After selecting Restore the area on study model by heat resistant material
appropriate crown form, it is trimmed to fit 1 mm beyond the like plaster, resin, plasticine, etc. Make a plastic template
preparation margins. When composite restoration is loaded for restored tooth on model using combination of heat and
in this crown form, it is positioned over the prepared tooth suction. Heat is used to soften the template material and
and cured. After restoration is completed, this crown form is suction is used to draw the material on the study model
cut with the help of burs for its removal. For unilateral class (Fig. 15.16).
IV, the plastic crown is cut incisogingivally to use one-half of ◆◆ Trim and finish the template. Template should seat on
the crown according to the side of restoration. at least one unprepared tooth on each side.
Matricing 163
A B
Figs. 15.15A and B: Window matrix.
Fig. 15.16: Procedure of placement of anatomic matrix.
◆◆ Place restorative material into the preparation and

partially filled matrix or template over it and cure it.
Fig. 15.17: Clear (Mylar) matrix strips.
Indication
Indication
Class IV preparation and obliquely fractured teeth.
For class III and IV tooth colored restorations.
Advantage
Advantages
Produce better contours.
◆◆ Simple and easy to use
◆◆ Economical.
Disadvantage
Time consuming. Disadvantage
Lack of stability.
Clear Plastic Matrix Strips
These are transparent matrix strips used for tooth colored For Class III Direct Composite Restorations
restorations because they allow light to be transmitted
during polymerization of composite restorations (Fig. Take the mylar strip of sufficient length to cover labial and
15.17). lingual surfaces of the tooth. Place it and burnish it using
handle of a tweezer. Stabilize it further by using wedge.
Types
For Class Iii Preparation in Contact with
◆◆ Celluloid (Cellulose nitrate) strips are used for silicate
Each Other
cements
◆◆ Cellophane (Cellulose acetate) strips are used for resins In this, fold the mylar strip with one end slightly longer
◆◆ Mylar strips used for composite and silicate restorations. than other so as to facilitate their separation after insertion
of strip between the teeth. Flatten the strip loop to make Preformed Transparent Cervical
T-shape using a finger. After the material is compacted, Matrix
fold each side of the strip towards the setting material and
support it with thumb of hand. This matrix is used for light cure resin material or for
resin modified glass ionomer cement. The matrix is held
For Class Iv Preparations in place while the restoration is setting (Figs. 15.19A
and B).
For this, fold the mylar strip at an angle to form L-shape.
Seal it using a plastic cement. one side of strip should be Indications
equal to length of the tooth and other side should be equal
to width of the tooth. Class V restorations with composite resin or resin modified
Adapt the strip to the tooth. Make sure that angle formed glass ionomer cement.
by fold of the strip should approximate the normal corner
of the tooth. Advantage
Fill the cavity with slightly excess material and bring Provides good contour to the restorations.
one end of strip across proximal surface of the filled tooth.
similarly, complete the incisal restoration by folding Disadvantage
the strip over incisal edge. Support the mylar strip using
thumb. Expensive.
Aluminium Foil Incisor Corner

Matrix
These are stock metallic matrices which are shaped
according to proximoincisal corner and surfaces of
anterior teeth.
Technique
◆◆ Select an appropriate size of matrix according to size A B
and shape of the tooth. Figs. 15.19A and B: Clear cervical matrices.
◆◆ Trim it gingivally to match it with gingival contour and (Courtesy: Cure-Thru)
cover the gingival margin of the preparation.
◆◆ Using thumb and index finger adapt it and fit it
Matrix Retainerless System
according to mesiodistal and labiolingual dimension of
the tooth. This matrix system can be adjusted according to tooth
◆◆ Keeping space for matrix band, loosely place the wedge. shape and size.
◆◆ Partially fill the preparation and corners of the matrix
and apply this matrix over partially filled tooth. Components (Fig. 15.20)
◆◆ Tighten the wedge and remove excess material (Fig.
15.18). AutoMatrix Bands
Bands are available in different sizes, and come in
preformed and disposable form. Width of band can be
3/16th inch, 1/4th inch or 5/6th inch. Thickness of bands
varies from 0.0015 to 0.002 inch. Matrix is adapted over the
tooth with clip on the buccal aspect.
Automate II Mechanical Device

To tighten the band, an automate II mechanical device is
used.
Shielded Nippers
Once restoration is complete, the band is cut with the help
Fig. 15.18: Aluminium foil incisor corner matrix. of cutting pliers.
Matricing 165
and contour, gingival adaptation of composite, etc. If
a composite restoration is used with traditional matrix
system, it may not lead to a successful restoration. Use of
Tofflemire matrix and band with composite can cause flat
proximal contour, occlusal shift of contact area closer to
the marginal ridge, resulting in larger gingival embrasure,
consequently food impaction and gingival inflammation.
This leads to development of circumferential transparent
matrices with light-reflective wedges. But, due to more
thickness of clear matrices, they were not flexible enough
for proper adaptation in posterior teeth and posed difficulty
in wedge adaptation with these matrices. To solve these
problems, contact forming instruments, ceramic inserts,
Fig. 15.20: Components of retainerless automatrix system. and light tips were developed.
(Courtesy: Dentsply)
i. Contact Forming Instruments (Fig. 15.21)

Placement of Automatrix
These instruments are designed to form optimal contacts
◆◆ Select appropriate band according to the tooth with posterior composites by pushing the matrix toward
◆◆ Adjust circumference of the band, place it around the contact area during polymerization. For example,
the tooth and tighten it using automate tightening Contact Pro and Optra contact.
device
◆◆ Place wedge interproximally to adapt the band gingivally ii. Ceramic Inserts
◆◆ Stabilize the band using impression compound.
Prefabricated ceramic inserts (like Beta Quartz) are formed
Removal of Automatrix from a silica-based glass composite. When ceramic inserts
are heated, they crystallize to form a ceramic. These are
◆◆ Use shielded nippers, to cut autolock loop treated with silane-coupling agents for better bonding
◆◆ Separate the band into two halves using explorer and with composite. Use of these inserts with composite
remove the band in two directions, i.e. facially and results in optimal gingival margin adaptation and tight
occlusally. contact. But it was difficult to achieve optimal contour and
occlusal anatomy with these inserts, so their use was not
Indications much promoted.
◆◆ In tilted and partially erupted teeth
◆◆ For complex amalgam restorations iii. Light Tips
◆◆ In patients who cannot tolerate retainers.
Class II composites restorations show poor gingival floor
adaptation because of more distance of curing light from
Advantages
gingival margin and polymerization shrinkage resulting
◆◆ Simple to use
◆◆ Convenient
◆◆ Takes less time to apply
◆◆ No interference from retainer, therefore, better
visibility.
Disadvantages
◆◆ Unable to develop optimal contacts and contours
◆◆ Expensive
◆◆ Difficult to burnish because bands are flat.
Recent advances in matrix systems

for class ii composite restorations
Nowadays, posterior composite resin restorations are
replacing the amalgam restorations, but before their use
one should be clear of few aspects like proximal contact Fig. 15.21: Contact forming instrument.
in gap between composite and gingival margin. To solve BiTine rings are available in round and oval or elongated
these problems, light tips were introduced. These are shapes suitable for posterior region.
plastic tips which focus the light closer to the gingival The advantages of the sectional matrices and rings
margin, thus improving the polymerization and adaptation include natural contours for better control of contact areas
of the Problems with these tips were their large size for and embrasures, ease of placement, better visualization of
conservative preparations and prone to breakage. the operative field, and more comfort for the dentist and
patient.
Sectional Matrices and Contact Rings Steps of Application
◆◆ To place the round BiTine ring, grasp it at its widest
To solve above problems, sectional matrices and contact
diameter with a rubber dam forceps, place the ring with
rings were introduced for composite restorations. The first
one tine in each interproximal space from buccal to
contoured sectional matrix was introduced by Meyer in
lingual adjacent to the surface to be restored.
1985.
◆◆ To place the elongated BiTine II ring, grasp it so that the
rubber dam forceps engages the ring in the “u-shaped”
Principle of Contact Rings depressions above the prongs.
Basically, the ring works by providing mild tooth ◆◆ Place it around the tooth. The ring may also be used to
separation. When the ring is expanded and its beaks are provide the necessary separation when applied before
placed between the contacting teeth, its spring action the preparation is initiated.
applies equal and opposite force against the teeth. It results ◆◆ Complete cavity preparation, once the preparation is
in tooth separation, after which the composite increments complete, remove the ring.
are placed and cured. Finally, the ring is removed and ◆◆ Select the sectional matrix according to size of tooth
teeth are brought back into contact. This results in tight and cavity. Finger roll the matrix to the approximate
contacts after ring is removed. tooth circumference. Grasp the matrix so that the notch
Nowadays many ring systems are availble. according to is toward the occlusal for the standard matrix, the dot
their evolution, rings can be classified as first and second toward the occlusal for the Mini-matrix and the longer
generation systems. flap toward the apex for the Plus matrix, with a forcep or
cotton pliers. Place this band adjacent to the space to be
I. First-generation Contact Ring Systems restored from the occlusal approach.
◆◆ Close the gingival margin by placing an anatomic
include Palodent BiTine, Contact matrix and wooden wedge. Lightly burnish the matrix against the
Composi-Tight adjacent tooth, both buccally and lingually to further
adapt it to form proper contours.
i. Palodent BiTine (Figs. 15.22A to C)
◆◆ Place restorative material, allow material to reach
This was the first system that was available. The Palodent initial set. Accomplish the gross contouring with matrix
system employs a spring steel BiTine ring and sectional in place.
matrices for placement of restorations in the posterior ◆◆ Remove ring, wedge and sectional matrices. Finish
region. Sectional matrices are available in three sizes contouring and verify appropriate proximal contact
suitable for use with all posterior restorative materials. formation.
A B C
Figs. 15.22A to C: Palodent BiTine.
(Courtesy: Dentsply).
Matricing 167
ii. Contact Matrix thicknesses and sizes depending on the manufacturer for
flash free, perfectly contoured restorations.
These rings have rectangular tines which are converging
and hence are more retentive. They provide optimum Advantages of sectional matrices and contact rings:
separation (0.38 mm). ◆◆ Ease of use and good visibility
◆◆ Good gingival adaptation of the restoration
iii. Composi-Tight Matrix (Fig. 15.23) ◆◆ Formation of optimal contact, contour and embrasures
In this system, two separate rings are available for premolar ◆◆ No need for prewedging.
and molar teeth. The rings separate the teeth to help create Disadvantages of first generation contact rings
tighter contacts but not as tight as with contact matrix. ◆◆ In case of wide proximal box, ring displacement occurs.
Steps of application ◆◆ In case of MOD, ring stacking that is placing one ring
◆◆ Select the band matching the height of tooth, curl it over the other is a problem (Fig. 15.25).
with fingers to conform the contours of tooth. ◆◆ Since contact rings are made of stainless steel, their
◆◆ Place a finger on to prevent dislodgement and seal the repeated use and sterilization make them lose their
gingival margin. springiness.
◆◆ Open the ring with forceps and place it over wedge
seating it as far gingivally as possible. II. Second-generation rings
iv. Precontoured Sectional Matrix Bands (Fig. 15.24) These have been introduced to overcome the problems of
first generation ring system. These are Composi-Tight 3D
All these systems are based on precontoured sectional dead soft face ring system and V3 ring system.
soft metal matrices which are available in different shapes,
i. Composi-Tight 3D Soft Face Ring
These have benefits of original orange 3D ring along
with enhanced soft face technology and dynamic tip
angle. It has two styles of rings to create the required
tooth separation and band adaptation for a tight, natural
contact. The Soft Face 3D Ring combined with the thin
tine G-Ring provide incredible flexibility providing
predictable, tight and anatomically accurate contacts
(Fig. 15.26).
ii. V3 Ring Sectional Matrix System (Fig. 15.27)

It was developed by Dr Simon McDonald in 2008. V3
Fig. 15.23: Composi-Tight matrix Ring Sectional Matrix System has three components:
(Courtesy: Garrison Dental).
Fig. 15.25: Schematic representation of ring stacking in case of an

MOD preparation.
Fig. 15.24: Different sizes of precontoured sectional matrix bands. (Courtesy: Garrison Dental)
Fig. 15.26: Composi-Tight 3D soft face ring. Fig. 15.28: Fender wedges for tooth separation.
(Courtesy: Garrison Dental).
buccally or lingually. It is available in four color-coded

sizes of x-small (purple), small (orange), medium (green)
and large (yellow).
Conclusion
Reconstruction of natural proximal contact and contour
is of utmost importance to have functional harmony.
When a class II restoration is performed, obtaining a
strong and proximal contact area prevents food impaction
and periodontal disease, dental caries and migration of
teeth. Tofflemire and other traditional systems produces
good contours and contacts for use with amalgam and
can also be employed for insertion of composite resin,
but more recently developed matrix systems have proven
more clinically efficacious, especially for the attainment of
Fig. 15.27: V3 Ring sectional matrix system. interproximal contacts and anatomically correct contours
for protection of the periodontal complex. To achieve ideal
contacts and contours with Class II composite restorations,
The V3 ring, a separator ring with V-shaped autoclavable one needs to understand the proximal integrity. The
tines, V3 matrix and Wave-Wedge. The V3 Ring is made of dentist should select the right method according to needs
nickel-titanium alloy, which provides increased tension of individual case.
to establish a sound contact area. The tines are reinforced
glass fiber and are designed to match buccal and lingual EXAMINER’S CHOICE QUESTIONs
contours of posterior teeth to prevent the ring from
collapsing into preparations with wide proximal boxes. 1. Define matricing. What are objectives of matricing?
The Wave-Wedge is plastic with flexible wings and a hollow 2. Write short note on matrices and retainers used in
underside to accommodate the gingival papilla. operative dentistry.
3. Write in short about the classification of matrices.
Fender Wedges (Fig. 15.28) 4. Recent advances in matrix system for class II
composite restorations.
These were developed for protection and separation 5. Write short notes on:
during tooth preparation. Fender wedge is a combination a. Tofflemire retainer.
of a steel plate and a plastic wedge. When it is placed b. Elliot separator.
into the interdental space, it provides protection to the c. Anatomical matrix band.
adjacent tooth and gingiva, separates the teeth, making d. Matrices and retainers.
the application of matrix easy. It can be placed either e. Palodent BiTine system.
Matricing 169
VIVA QUESTIONS BIBLIOGRAPHY
1. What are ideal requirements of a matrix? 1. Blalock JS. A tofflemire time saving tip. Oper Dent. 2003;28:345.
2. Brackett MG, Contreras S, Contreras R, et al. Restoration of
2. Classify matrices.
proximal contact in direct class II resin composites. Oper Dent.
3. What are different parts of a matrix system? 2006;31(1):155-6.
4. What are dimensions of a matrix band? 3. Chan DC. Custom matrix adaptation with elastic cords. Oper
5. Discuss materials used as matrices. Dent. 2001;26(4):419-22.
6. What is Barton’s technique? 4. Cunningham PJ. Matrices for amalgam restorations. Aust Dent J.
7. What are Fender wedges? 1968;13(2):139-42.
5. El-Badrawy WA, Leung BW, El-Mowafy O, et al. Evaluation of
8. What is Palodent Bitine system? proximal contacts of posterior composite restorations with 4
9. What is other name of tofflemire matrix retainer? placement techniques. J Can Dent Assoc. 2003;69(3):162-7.
10. What are AutoMatrix? 6. Kampouropoulos D, Paximada C, Loukidis M, et al. The
11. What are various types of matrix retainers? influence of matrix type on the proximal contact in class II resin
12. Who designed the Tofflemire Universal matrix band composite restorations. Oper Dent. 2010;35(4):454-62.
7. Kaplan I, Schuman NJ. Selecting a matrix for class II amalgam
retainer? restoration. J Prosthet Dent. 1986;56(1):25-31.
13. Name the types of band used in tofflemire retainer. 8. Kucey BK. Matrices in metal ceramics. J Prosthet Dent.
14. Discuss the removal of Tofflemire retainer and band. 1990;63(1):32-7.
15. What is compound supported matrix and their 9. Loomans BA, Opdam NJ, Roeters FJ, et al. A randomized clinical
indications. trial on proximal contacts of posterior composites. J Dent
2006;34(4):292-7.
16. What is T-shaped matrix band? 10. Lopes GC, Ferreira Rde S, Baratieri LN, et al. Direct posterior
17. What are aluminium and copper collar and their resin composite restorations: New techniques and clinical
indications? possibilities. Case reports. Quintessence Int. 2002;33(5):337-46.
18. What is anatomic matrix and their indications? 11. Medlock JW, Re GJ. Contoured mylar matrices. J Prosthet Dent.
19. What is matrix retainerless system? 1984;51(3):364-5.
12. Meyer A. Proposed criteria for matrices. J Can Dent Assoc.
20. What are recent advances in matrix system for Class II 1987;53(11):851-3.
composite restorations? 13. Qualtrough AJ, Wilson NH. Matrices: their development and in
21. What are contact rings? clinical practice. Dent Update. 1992;19(7):284-6.
Chapter
16
Separation of Teeth
Chapter Outline
Introduction Rapid or Immediate Tooth Separation

Reason for Tooth Separation Slow or Delayed Separation
Methods of Tooth Separation
INTRODUCTION Methods of Tooth Separation

During diagnosis and restorative procedures, separation of Two methods used for tooth separation are:
teeth is required for increasing convenience and preventing A. Rapid or immediate separation.
trauma to adjacent hard and soft tissues. Moreover, if B. Slow or delayed separation.
properly done, one can achieve final restoration with
optimal contact and contour which further enhances the Rapid or Immediate Tooth
health of teeth and their supporting structures. Separation
Definition Rapid separation is most frequently used method in which
Separation of teeth is defined as the process of separating tooth separation can be achieved in very short span of
the involved teeth slightly away from each other or time.
bringing them closer to each other and/or changing their
spatial position in one or more dimensions. Advantages
◆◆ More useful and advantageous than slow separators
Reason for Tooth Separation ◆◆ Quicker than slow separators
◆◆ More predictable.
Following are reasons for tooth separation:
1. Examination: For examination of initial proximal Disadvantages
caries which is usually not seen on the radiograph.
2. Preparation of teeth: For providing accessibility to It may cause damage to periodontal ligament (PDL).
proximal area during preparation of class II and class
III tooth preparations. Principles used in Rapid Separation
3. Polishing of restorations: Tooth separation helps in 1. Wedge principle.
providing accessibility to the proximal area of class II 2. Traction principle.
and class III tooth preparations.
4. Matrix placement: Matrix can be placed easily by
creating space in class II preparation. Wedge Principle
5. Removal of foreign bodies: Foreign bodies and objects A pointed, wedge-shaped mechanical device is inserted
forced interproximally can be removed using tooth beneath the contact area of teeth to produce the separation,
separation. e.g. Elliot separator and wedges.
Separation of Teeth 171
Elliot Separator (Fig. 16.1) 4. Provide close adaptability in cervical portions of the
proximal restorations, thereby help in achieving correct
It is also known as “Crab claw” separator because of its contour and shape at cervical area.
design. It is a mechanical device consisting of bow and 5. Help in retracting and depressing the interproximal
two holding jaws. Two holding jaws are positioned gingival gingival area, thus help in minimizing trauma to soft
to contact area without damaging the interproximal area tissue.
(Fig. 16.2). Clockwise rotation of tightening screw moves 6. Help in depressing rubber dam in interproximal area.
the contacting teeth. The separation should not be more
than thickness of PDL, i.e. 0.2 to 0.5 mm.
Types of Wedges
Wedges 1. Wooden wedges (Fig. 16.3): Wooden wedges are
commonly made from soft wood like pine or hard wood
Wedges are devices used for rapid tooth separation during like oak. These can be medicated also. These are most
tooth preparation and restoration. commonly used and preferred as they can be easily
trimmed and can adapt well in gingival embrasure.
Advantages Wooden wedges absorb water and swell to provide
1. Provide space to compensate for thickness of matrix stabilization to matrix band. These are available in two
band. shapes.
2. Help in stabilization of retainer and matrix during i. Triangular wedge: It is most commonly used type
condensation of area. of wedge. It has two parts; apex and the base. Apex
3. Prevent gingival overhang of restoration. of the wedge usually lies towards contact area
and base lies in contact with gingiva. This helps
in stabilization and retraction of gingiva. It is used
in tooth preparations with deep gingival margins
(Fig. 16.4A).
ii. Round wedge: It is made from wooden tooth picks
by trimming the apical portion. It has uniform
shape and is preferred in conservative class II tooth
preparations (Fig. 16.4B).
2. Plastic wedges (Fig. 16.5A): Though commercially
available but they are not much preferred because:
•• Trimming is difficult
•• Adaptability is difficult in some cases.
Types of plastic wedge:
1. Normal wedges: They are similar to the wooden
wedges in shape and use.
2. Wave-shaped wedges (Fig. 16.5B): Their curved
shape helps in easy placement and proper seal of
Fig. 16.1: Elliot or crab claw separator.
Fig. 16.2: Placement of Elliot separator. Fig. 16.3: Wooden wedges.

Table 16.1: Different types of wedges with their indications.

Type of wedge Indications
Round wooden Conservative class II preparations
Triangular wooden Preparation with deep gingival margin
Plastic wooden Preparation with deep gingival margin
Light transmitting wedge Cervical portion of class II composite
restoration
Wedging Techniques
Fig. 16.4A: Triangular wedge is used for preparation with Prewedging
deep gingival margins.
Prewedging is the procedure of placing the wedge between
interproximal surfaces of two adjacent teeth prior to
cutting a cavity involving a proximal wall.
Purpose of prewedging is to achieve some tooth
separation such that after restoration the teeth will return
to their original position and a more positive tooth contact
can be achieved.
Placement of Wedges
1. Select the appropriate wedge as per requirement.
2. Length of the wedge should be in the range of 1–1.2 cm
so that it does not irritate tongue or cheek.
Fig. 16.4B: Round wedge is used in conservative class II 3. Wedge should be placed beneath the contact area in
tooth preparation.
the gingival embrasure.
4. Wedge is usually placed from lingual embrasure area as
buccal and lingual embrasures without impinging it is wider than buccal area. But if irritates tongue; it can
gingiva. Wave-shaped wedges are available in three placed from buccal side.
different sizes, i.e. small (white), medium (pink) and 5. Wedge should be firm and stable during restorative
large (violet) color. procedure.
3. Light transmitting wedges (Fig. 16.5C): As the
name indicates, these are transparent wedges with Modified Wedging Techniques
light reflecting core. These are designed for use in
cervical area of class II composite resin restoration i. Double wedging
ii. Piggyback wedging.
because these help in reducing the polymerization
iii. Wedge wedging.
shrinkage because of light transmission. But they
have disadvantage of having difficulty in adaptation
with transparent matrices.
i. Double Wedging
Table 16.1 shows different types of wedges and their In this technique, two wedges are used; one from buccal
indications. embrasure and another from lingual embrasure for
A B C
Figs. 16.5A to C: (A) Plastic wedges; (B) Wave-shaped wedges; (C) Light transmitting wedges.
Fig. 16.6: In double wedging technique, two wedges are used, one Fig. 16.7: In piggyback wedging technique, larger wedge is placed
for buccal embrasure and another from lingual embrasure. as normal, other smaller wedge is placed over the larger one.
better adaptation of matrix band at cervical area of tooth

(Fig. 16.6). This technique is used when there is:
a. Spacing between adjacent teeth where single wedge is
not sufficient
b. Wide proximal box in buccolingual dimension.
ii. Piggyback Wedging

In this technique two wedges are used; one (larger) wedge
is placed as used normally, while the other smaller wedge
is piggy backed over larger one (Fig. 16.7). It is indicated in
cases of shallow proximal box with gingival recession where
a single wedge lies much apically to the gingival margin,
this technique provides closer adaptation and contour of
the matrix band.
Fig. 16.8A: In wedge wedging technique, one wedge is placed as
Wedge Wedging normal, another wedge is placed between the wedge and matrix band
at right angle to the first wedge.
In this technique, two wedges are used; one wedge is placed
as normal, and another wedge is placed between the wedge
and matrix band at right angle to first wedge (Fig. 16.8A).
Wedge wedging technique is primarily indicated while
treating mesial aspect of maxillary first premolar because
of presence of flutes in root near the gingival area (Figs.
16.8B and C), where placing a single wedge may leave
open margins gingivally. this technique helps to close this
opening.
Separation by Traction Principle

This type of principle always uses mechanical devices B C
which engage the proximal area of the tooth with holding Figs. 16.8B and C: Wedge wedging technique for restoring mesial
arms, separation of teeth occur by moving the holding aspect of maxillary 1st premolar.
arms apart from each other. Following devices are based on
traction principle: area. A “Wrench” system is used for turning the threaded
i. Ferrier double bow separator bars, this helps in causing separation.
ii. Noninterfering true separator.
Advantages
◆◆ Stabilization of the separation throughout the
i. Ferrier Double Bow Separator (Fig. 16.9)
procedure.
As the name indicates, it has two bows. Each bow engages ◆◆ Separation is achieved at expense of both contacting
the proximal surface of the tooth just gingival to contact teeth rather than one tooth.
Fig. 16.9: Ferrier double bow separator. Fig. 16.10: Separating rubber ring/band placed interproximally for
tooth seperation.
ii. Noninterfering True Separator 2. Rubber Dam Sheet

As the name indicates, it is noninterfering type rapid In this, a small piece of heavy or extra-heavy rubber dam
separator. It is used where continuous stabilized separation sheet is placed in contact area between the teeth. Separation
is required. of teeth occurs due to thickness of sheets. it may take 1 hour
Advantages to 24 hours for tooth separation. if pain occurs, dental floss
◆◆ Separation can be increased or decreased after may be used to remove rubber dam sheet.
stabilization
◆◆ Noninterfering in nature. 3. Ligature Wire/Copper Wire (Fig. 16.11)
In this technique, an orthodontic wire is passed beneath the
Slow or Delayed Separation contact area to form a loop around contact area. twisted
In this separation, teeth are slowly and gradually shifted ends are then bent into buccal or lingual embrasure to
apart by inserting material between the teeth. This prevent impingement on soft tissues. Tightening of wire
separation usually takes long time, i.e. from several days loop is done by twisting two ends together. By this method,
to weeks. separation is usually achieved in 2 to 3 days. though
tightening causes increase in the separation, but it should
Indication not be more than 0.5 mm. this is effective method, though
maximum amount of separation is equivalent to thickness
Tilted, drifted, and rotated teeth in which rapid separation
of wire.
is not useful.
Advantage
One of the main advantages of slow tooth separation is
that tooth repositioning occurs without damage to PDL
fibers.
Disadvantages
◆◆ May require many visits.
Methods for Achieving Slow Separation

1. Separating Rubber Ring/Band
Separating rubber band stretched and placed inter
proximally between the two teeth to achieve separation. It
may take 2 to 3 days to 1 week (Fig. 16.10). Fig. 16.11: Ligature wire/copper wire.
examiner’s choice Questions
1. Explain tooth separation in detail.
2. Wedges and wedging techniques.
a. Modified wedging technique.
b. Elliot separator
c. Ferrier double bow separator
d. Double wedging technique.
e. Piggyback wedging technique.
viva questions
1. Which are two methods used for tooth seperation?
2. What is rapid or immediate tooth seperation and what
are their advantages and disadvantages?
Fig. 16.12: Gutta-percha stick. 3. What are principles used in rapid seperation?
4. What are different types of wedges?
4. Gutta-percha Stick (Fig. 16.12) 5. What is light transmitting wedge?
6. Describe double wedging.
Gutta-percha stick is softened with heat and packed into
proximal area for tooth separation which takes 1–2 weeks. It
7. Describe piggyback wedging.
is indicated for tooth preparation of adjoining teeth. 8. What are advantages of using Ferrier double bow
seperator?
5. Oversized Temporary Crowns 9. What do you mean by slow or delayed seperation?
10. What are methods of acheiving slow seperation?
In this, acrylic resin is periodically added in the mesial and
distal contact area of temporary crowns to increase the
separation. It should not be added more than 0.5 mm per
Bibliography
visit. 1. Al-Hamdan KS. Prevalence of overhang interproximal amalgam
restorations. Pakistan Oral Dent J. 2008;28:245-7.
6. Fixed Orthodontic Appliances 2. Brackett MG, Contreras S, Contreras R, et al. Restoration of
proximal contact in direct Class II resin composites. Operat
It is indicated only in cases where extensive repositioning Dentistr. 2005;31 1:155-6.
of teeth is required. It is the most predictable and effective 3. Eli I, Weiss, E, Kozlovsky A, et al. Wedges in restorative
method. dentistry: Principles and applications. J Oral Rehab. 1991;
18(3):257-64.
4. Keogh TP, Bertolotti RL. Creating tight, anatomically correct
CONCLUSION interproximal contacts. Dent Clin North Am. 2001;45(1):83-102.
5. Terry DA. Restoring the interproximal zone using the proximal
Separation of teeth is required for diagnosis, during cavity
adaptation technique—Part 2. Compend Contin Educ Dent.
preparation, restoration and finishing and polishing 2005;26(1):11-2, 15-6.
procedures. One should know the methods, indications, 6. Varlan CM, Dimitriu BA, Bodnar DC, et al. Contemporary
and contraindications of slow and rapid tooth separation approach for re-establishment of proximal contacts in
so as to achieve optimal separation in required time direct class II resin composite restorations. Timisoara Med J.
without damaging the supporting periodontal tissues. 2008;58(3-4):236-43.
Chapter
17
Pulp Protection
Chapter Outline
Introduction Cavity Liners

Pulpal Irritants Base
Effect of Caries on Dental Pulp Guidelines of Using Liners, Bases, and Varnishes for Different
Effect of Tooth Preparation on Dental Pulp Restorative Materials
Importance of Remaining Dentin Thickness Management of Shallow, Moderate, and Deep Caries
Need for Pulp Protection Management of Deep Carious Lesion
Materials Used for Pulp Protection Prevention of Pulpal Damage Due to Operative Procedure
Cavity Sealers
Introduction 3. Iatrogenic
One of the main goals of operative dentistry is to preserve ◆◆ Thermal changes generated during cutting and resto
the health of dental pulp. Normal pulp is a coherent soft rative procedures, bleaching, microleakage occurring
tissue, dependent on its normal hard dentin shell for along the restorations, electrosurgical procedures, laser
protection and hence, once exposed, extremely sensitive to beam, etc.
contact and temperature. Pulp can get irritated by various ◆◆ Orthodontic movement
restorative materials and dental procedures. To protect the ◆◆ Periodontal curettage
pulp from various irritants, various pulp protective agents ◆◆ Periapical curettage.
are used.
4. Idiopathic
Pulpal irritants ◆◆ Aging
Pulpal irritants can be: ◆◆ Resorption: Internal or external.
1. Bacterial effect of caries on dental pulp

Most common cause for pulpal irritation are bacteria or Pulp gets affected by caries directly or indirectly from
their byproducts which may enter pulp through caries, the bacteria, acids, and other toxic substances which
accidental exposure, fracture, extension of infection from penetrate through the dentinal tubules. Depending upon
gingival sulcus, periodontal pocket, and anachoresis. the caries progression, pulp shows different types of
defense mechanisms.
2. Traumatic The following defense reactions take place in a carious
tooth to protect the pulp:
It can be:
◆◆ Acute trauma like fracture, luxation, or avulsion of
Decrease in Dentin Permeability
tooth.
◆◆ Chronic trauma including parafunctional habits like It is the first and the fastest defense to caries in the form of
bruxism. dentin sclerosis. In this, there is increase in deposition of
Pulp Protection 177
mineral crystals in dentinal tubules causing narrowing of 4. Speed of Rotation
the tubules and thus decrease in permeability of dentin.
Ultrahigh speed should be used for removal of enamel and
superficial dentin. A speed of 3,000–30,000 rpm without
Tertiary Dentin Formation
coolant can cause pulpal damage.
Formation of tertiary dentin occurs in response to mild-
to-moderate carious lesion. Here, acidic products of 5. Nature of Cutting Instrument
carious process degrade the dentin matrix and release
bioactive molecules which resume their role of dentin Use of worn off and dull instruments can cause vibration
formation. and reduced cutting efficiency. This further encourages
More intense injury leads to odontoblast death which the clinician to apply excessive operating pressure, which
is followed by formation of reparative dentin. Here, results in increased temperature leading to thermal injury
healing takes place by progenitor cells of pulpal origin to pulp.
which differentiate to odontoblast-like cells. These cells
cause reparative dentin formation. Rate of reparative 6. Use of Coolants
dentin formation is related to rate of carious attack. More
reparative dentin is formed in response to slow chronic Water spray is considered as the ideal coolant. In deep
caries than acute caries. cavities, cotton pellet instead of air blast should be
used to dry the prepared cavity because air blast can
EFFECT OF TOOTH PREPARATION ON cause desiccation of dentin which can damage the
DENTAL PULP odontoblasts.
Pulpal inflammation resulting from the operative

procedures is often termed as dentistogenic pulpitis.
importance of Remaining Dentin
During tooth preparation, pulpal reaction depends on Thickness
following factors: Remaining dentin thickness (RDT) is the dentin present
between floor of the tooth preparation and pulp chamber.
1. Pressure It has been shown in many studies that dentin is the best
Pressure of instrumentation causes aspiration of insulator and protector to pulp. Thus, conserving as much
odontoblasts or nerve endings from pulp tissues into as remaining dentin during cavity preparation should
the dentinal tubules. This disturbs the metabolism of be the main goal. As the thickness of remaining dentin
odontoblasts leading to their complete degeneration and decreases, chances of pulp injury increase (Fig. 17.1 and
disintegration. Instrumentation pressure should not be Table 17.1). Stanley et al. suggested that the remaining
>4 oz when using high speed and 12 oz when using low dentin under the cavity preparation should be at least 2
speed. mm thick to guarantee protection of the pulp. As the tooth
preparation approaches closer to the pulp, a thick liner or
2. Heat Production a base is used to augment dentin to the proper thickness
If pulp temperature is elevated by 11°F, destructive reaction range. Thus, the remaining dentin thickness determines
occurs. “Heat” is a function of: the choice of material for pulp protection.
◆◆ RPM, more the RPM greater is the heat production
◆◆ Pressure: It is directly proportional to heat generation
◆◆ Surface area of contact: The more the contact between
tooth structure and revolving tool, greater is the heat
generation
◆◆ Desiccation: It causes aspiration of odontoblasts into
tubules. Subsequent disturbances in their metabolism
may lead to the complete degeneration of odontoblasts.
3. Vibrations
Vibrations are an indication of eccentricity in instruments.
Higher the amplitude, more destructive is the pulp Fig. 17.1: As the remaining dentin thickness decreases, the pulp
response. response increases.
Table 17.1: Importance of remaining dentin thickness and effect of Cavity Sealers
toxic substances.
these are the materials which provide a protective coating
Remaining dentin thickness Effect of toxic substance
to the walls of prepared cavity. these are applied on
0.5 mm 25% preparation walls to seal the tooth restoration interface.
1 mm 10% Materials used as cavity sealers are varnish and bonding
2 mm Minimal or nil agents.
Varnish (Fig. 17.3)

NEED FOR Pulp protection
varnish is a natural gum like copal, rosin, or a synthetic
Pulp needs protection against various irritants like resin dissolved in an organic solvent like alcohol, acetone,
(Fig. 17.2): or ether. When applied on the tooth surface, the organic
1. Thermal protection against temperature changes solvent evaporates leaving behind a protective film which
2. Electrical protection against galvanic currents seals the dentinal tubules and reduces leakage around
3. Mechanical protection during various restorative the restoration. Thickness of varnish is 2–5 µm. Varnish
procedures should have thin viscosity. If it is too viscous, it would not
4. As medication to allow pulp recovery in deep carious properly wet the cavity, allowing microleakage to occur
lesions between varnish and tooth. Varnish does not provide any
5. Chemical protection from toxic components thermal insulation.
6. Protection from microleakage interface between tooth
and the restoration.
Mode of Application
Materials Used for Pulp Protection Minimum two coatings are required using a small cotton
pledget or brush for sufficient wetting of cavity walls, floors,
Different types of materials are used for pulp protection. and margins of cavity preparation. As the initial layer dries,
These materials help to: it leaves small pinholes, and the second coating fills in the
◆◆ Insulate the pulp voids to produce a more continuous coating. thickness of
◆◆ Protect the pulp in case of deep carious lesion this film is 5–25 µm depending on type of solvent used
◆◆ Act as barriers to microleakage and number of applications done.
◆◆ Prevent bacteria and toxins from affecting the pulp.
Advantages of applying varnish
i. In case of amalgam restoration, varnish improves
Classification of Pulp Protective Agents the sealing ability of the amalgam, until corrosion
1. cavity sealers: products are formed
i. Varnish ii. Reduces postoperative sensitivity by preventing
ii. Resin bonding agents microleakage
2. liners iii. Prevents discoloration of tooth by preventing
3. bases. migration of ions into the dentin.
Fig. 17.2: Pulp protective agents provide chemical, mechanical,

thermal and electrical protection to the pulp. Fig. 17.3: Varnish.
Pulp Protection 179
Contraindications It is placed directly over the deepest part of preparation.
Though it is protective agent but it does not have obtundent
◆◆ Under glass ionomers, varnish is not used as it interferes
properties and is not strong enough to provide sufficient
with bonding of tooth to glass ionomer cement
support to the restoration under heavy occlusal forces, so
◆◆ With restorative resins, varnish is not used because
a strong base material is used to cover it. It can be applied
varnish liners dissolve in monomer of resin and
using an instrument which is shaped like a probe with a
interferes with polymerization of resins
small ball on the end. Cement is applied only on halfway
◆◆ Under indirect ceramic and resin composite restorations.
of the ball, if it is applied more than terminal half of ball,
material runs down the shaft toward the handle.
Resin Bonding Agent
Resin bonding agent is commonly used under composite II. Glass Ionomer Cement
restorations. For application, cotton tip applicator is used
It is used as liner under composite resins to reduce
to apply bonding agent on all areas of prepared tooth.
the microleakage. its main advantages are being
Indications: chemically adhesive, anticariogenic, low solubility, and
◆◆ To seal dentinal tubules biocompatible in nature. Its problem is sensitivity to
◆◆ for indirect restorations like inlays, veneers to bond the moisture contamination.
restoration to tooth.
Base
Cavity Liners
Base is applied in thicker layers to provide thermal
Liner provides a thin barrier of 0.5 mm which protects the protection for the pulp and to supplement mechanical
pulp tissue along with providing therapeutic benefit. This support for restoration by distributing local stresses
means a liner provides physical barrier and therapeutic
from restoration to underlying dentin (Fig. 17.5). it also
effect to pulp. Liner does not act as thermal insulator. it is
provides support during condensation of amalgam if
applied only to the dentin walls near to pulp (Fig. 17.4).
remaining dentin thickness is less.
Materials used as a Liner
Mode of Application
Earlier, zinc oxide eugenol liners were frequently used but
nowadays, commonly used liners are calcium hydroxide After having optimal consistency, a small sesame seed
and glass ionomer. size of base is attached to tip of explorer and carried in the
prepared cavity, and applied on pulpal floor and axial wall.
I. Calcium Hydroxide With the help of ultra small cotton pellet held with cotton
Calcium hydroxide is usually available as an aqueous plier, pat the material and adapt it to the floor of the cavity.
suspension, as powder, or as paste. Paste form is most
commonly used because it is easily applied and hardens Materials used as Base (Figs. 17.6A to E)
rapidly. It protects pulp from chemical irritation by its
i. Zinc Oxide Eugenol
sealing ability, stimulating production of reparative
and secondary dentin. It is compatible with all types of It has been used since ages due to its anodyne effect
restorative materials. and bacteriostatic nature and but contraindicated under
Fig. 17.4: Liner is placed beneath the base, it provides therapeutic Fig. 17.5: Application of liner, base and varnish in
effect to the pulp. deep cavity preparation.
A B C
D E
Figs. 17.6A to E: Different materials used as base under the restoration.
composite restorations as it interferes with polymerization v. Resin Modified Glass Ionomer Cements
reaction.
Resin modified glass ionomer cement was introduced to
ii. Zinc Phosphate Cement overcome problem of water sensitivity of conventional
glass ionomer cements.
It has been used for past 100 years. it is fast setting, has
satisfactory mechanical properties, and low solubility
with excellent thermal insulation but it does not adhere to guidelines OF USING LINERS, BASES,
dentin and has high acidity which irritates the pulp tissue. AND VARNISHES for different
iii. Polycarboxylate Cement restorative materials
It chemically bonds to tooth structure, biocompatible, and Best base is always the healthy sound dentin overlying
has moderate strength. the pulp. So, do not remove the healthy tooth structure to
provide space for base. Use base as build up and block out
iv. Glass Ionomer Cement for cemented restorations. Therefore, avoid removing the
It is most commonly used liner and base because of its healthy tooth structure in an attempt to provide space for
anticariogenic property, adhesion to tooth structure, and a base. Table 17.2 shows the methods of pulp protection
biocompatible nature. with different restorative materials.
Table 17.2: Methods of pulp protection with different restorative materials.

Moderately deep (RDT >
Types of restoration Shallow (RDT > 2.0 mm) 0.5–2 mm) Deep (RDT < 0.5 mm)
1. Silver amalgam Varnish, dentin bonding agent (DBA) Base Calcium hydroxide as liner and base
2. Glass ionomer cement Not required Not required Calcium hydroxide as liner
3. Composite resins Dentin bonding agent Dentin bonding agent Calcium hydroxide as liner followed by glass
ionomer as base
4. Cast gold restorations Luting cement Base and luting cement Calcium hydroxide as liner, base, and luting cement
5. Ceramic inlays and DBA and resin cement DBA and resin cement Calcium hydroxide as liner, GIC as base, DBA and
onlays resin cement
Pulp Protection 181
Management of shallow, moderate, Clinical Technique
and deep caries
In shallow or moderate carious lesion, the caries may not
reach inner one-half or one-fourth of the dentin. In these
lesions, to protect pulp, varnish and base are applied, over
which final restoration is done.
Management of Deep Carious Lesion

The main aim in management of deep caries management
is to maintain the health of pulp tissue which has been
compromised by caries, trauma, or operative procedures.
Objective of managing deep caries is to stimulate formation
of reparative dentin to retain the tooth as functional
unit. Deep carious lesions can be managed by following
procedures:
I. Indirect Pulp Capping (IPC)

Indirect pulp capping is a procedure performed in a tooth Prognosis: Prognosis is good in young patients due to good
with deep carious lesion adjacent to the pulp. In this vascularity and presence of large volume of pulp tissue. In
procedure, caries near the pulp is left in place to avoid pulp older patients, pulp response is less due to degenerative
exposure and is covered with a biocompatible material changes.
(Fig. 17.7).
II. Stepwise Excavation/Serial Excavation/
Rationale
Gradual Caries Excavation
◆◆ Decalcification of the dentin precedes bacterial
It is a two-step excavation procedure, advocated by
invasion within the dentin
Magnusson and Sundell (1977) and then modified by
◆◆ Removal of outer carious dentin removes majority of
Bjorndal (1997). This procedure is less invasive and
bacteria reducing further decalcification of deeper
decreases the chances of pulp exposure. The main
dentin
difference is that the indirect pulp capping procedure
◆◆ Sealing the lesion to allow the pulp to generate
almost completely removes the affected dentin and
reparative dentin.
re-entry is not made (one-step procedure), while stepwise
Objectives excavation procedure does remove as much caries as
possible in the first visit, but rather changes the lesion’s
◆◆ Arrests carious process cariogenic environment and activity which is removed on
◆◆ Promotes dentinal sclerosis and formation of re-entry of lesion at different intervals.
reactionary dentin
◆◆ Remineralization of carious dentin while preserving Two stepwise excavation approach is recommended due
pulp vitality. to following reasons:
i. It avoids unintentional pulp exposure
Indications ii. It gives opportunity to remove slow progressive lesion
◆◆ Deep carious lesion near the pulp tissue but not in slightly infected, discolored, and demineralized
involving it dentin before placing final restoration.
◆◆ No history of spontaneous toothache or history of mild iii. Dentist gets time to evaluate the tooth and caries
discomfort from chemical and thermal stimuli activity
◆◆ No tenderness to percussion. iv. In second sitting, it becomes easier to remove dry
carious dentin.
Contraindications
◆◆ Presence of pulp exposure Rationale of Stepwise Excavation
◆◆ Radiographic evidence of pulp pathology Concept of stepwise excavation is based on the fact that
◆◆ History of spontaneous toothache progression of caries is dependent on continuous supply
◆◆ Tooth sensitive to percussion of substrate. If supply of sugar substrate is stopped,
◆◆ Mobility present. bacteria are no longer able to metabolize and their
A B C
Figs. 17.7A to C: Schematic representation of indirect pulp capping. (A) Indirect pulp capping is done in cases when carious lesion is quite close
to the pulp; (B) Placement of calcium hydroxide and zinc oxide eugenol dressing after excavation of soft caries; and (C) Permanent restoration
of tooth.
number reduce and activity of lesion slows down. So, in III. Direct Pulp Capping
this method, carious lesion is sealed from oral cavity using
hard restorative material. Moreover, following sealing Direct pulp capping (DPC) involves the placement of
caries into the tooth, the carious dentin becomes dry, biocompatible material over the site of pulp exposure to
harder, and darker in color. As a result, there is shrinkage maintain vitality and promote healing.
of the tissue leaving a void beneath the restoration. The
final excavation is done because it is more convenient Rationale
to excavate the harder, darker caries than the soft yellow
To encourage young and healthy pulp to initiate a dentin
demineralized dentin.
bridge and forms a wall over the exposure site.
Indications
Indications
◆◆ Deep carious lesion
◆◆ No history of spontaneous pulpal pain ◆◆ Small pinpoint (<1 mm) mechanical exposure of pulp
◆◆ No radiographic evidence of periapical lesion surrounded by sound dentin during tooth preparation
◆◆ Positive pulp vitality to all tests. ◆◆ Traumatic injury (<24 hours) with pinpoint exposure
◆◆ No or minimal bleeding at the exposure site.
Clinical Technique
Contraindications
◆◆ Carious or wide pulp exposure
◆◆ Spontaneous and nocturnal toothache
◆◆ Uncontrolled bleeding at the exposure site
◆◆ Radiographic evidence of pulp pathology
◆◆ Excessive tooth mobility.
Clinical Procedure
Flowchart 17.1 and Figure 17.8 shows the clinical
procedure of direct pulp capping.
Prognosis
If exposure is mechanical, <1 mm, without bacterial contam
ination in young patient, the prognosis is good. If exposure is
carious, >1 mm, in old patient, the prognosis is bad.
Pulp Protection 183
Flowchart 17.1: Direct pulp capping. ◆◆ Should stimulate reparative dentin formation
◆◆ Should be radiopaque in nature
◆◆ Should be able to resist the forces under restoration.
Materials used for Pulp Capping (Figs. 17.9A to C)

A. Calcium hydroxide
B. Mineral trioxide aggregate (MTA)
C. Biodentine
D. BioAggregate
A. Calcium hydroxide: It was introduced by Hermann
in 1920. It is most commonly used for pulp capping
because, along with blocking the dentinal tubules, it
helps in neutralizing the attack of inorganic acids from
restorative materials.
Calcium hydroxide has a high alkaline pH of 12.5 which
is responsible for its antibacterial activity and its ability
to form hard tissue. Though calcium ions from calcium
Ideal Requirements of a Pulp Capping Agent hydroxide do not directly contribute to formation of
Cohen and Combe gave the following requirements of an hard tissue, they stimulate the repair process.
ideal pulp capping agent: B. Mineral trioxide aggregate (MTA): It was developed
◆◆ Should maintain pulp vitality by Torabinejad in 1993. It contains tricalcium silicate,
◆◆ Should be bactericidal or bacteriostatic in nature dicalcium silicate, tricalcium aluminate, bismuth
◆◆ Should be able to provide bacterial seal oxide, calcium sulfate, and tetracalcium aluminoferrite.
Fig. 17.8: Schematic representation of direct pulp capping.
A B C
Figs. 17.9A to C: Materials used for pulp capping: (A) Dycal (Courtesy: Dentsply); (B) MTA (Courtesy: Dentsply);
(C) Biodentine (Courtesy: Septodont).
pH of MTA is 12.5 and sets in a moist environment Irritant/procedure Methods to prevent pulpal injury
(hydrophilic in nature). It produces hard-setting Tooth • Effective cooling
nonresorbable surface and low solubility. preparation • High-speed ratio
Advantages: • Intermittent cutting
•• Excellent biocompatibility
Restorative Use material after considering physical and
•• Sets in presence of moisture material biological properties according to tooth
•• More radiopaque than calcium hydroxide preparation
•• Bacteriostatic in nature due to high pH
Marginal leakage • Pulp protection using liners and bases
•• Excellent sealing ability. • Use of bonding agents
Disadvantages:
While placing Avoid application of excessive forces of
•• Difficult handling characteristics
restoration restoration
•• Long setting time (2 hours 45 minutes)
•• Expensive. While polishing Effective cooling to avoid heat generation
C. Biodentine Its powder consists of tricalcium silicate, during polishing
dicalcium silicate, calcium carbonate, and zirconium Irritants to dentin Avoid application of any irritant, desiccant on
oxide. Liquid consists of hydrosoluble polymer and freshly cut dentin
calcium chloride. Biodentine is both a dentin substitute
base and a cement for maintaining pulp vitality and conclusion
stimulating hard tissue formation. Figures 17.10A to G
show the direct pulp capping using biodentin as pulp Dental pulp can be injured by caries, during operative
capping agent. procedures and during restoration. It needs to be protected
D. BioAggregate: It consists of bioceramic nanoparticles. from various irritants. Though sound and healthy dentin is
Its powder and liquid are mixed to form a thick paste- the best pulp protective agent, but use of varnish, liner, and/
like consistency for use. or base is indicated beneath the restorations to protect it
from chemical, mechanical, and thermal injuries. In deep
Prevention of Pulpal Damage Due to carious lesions, there are chances of pulp exposure while
Operative Procedure removal of the caries. The main aim in management of
deep caries is to avoid removing all the infected tissue, and
To preserve integrity of the pulp, the following measures to inactivate or arrest the lesion by changing cariogenic
should be taken: environment, placing pulp protective/therapeutic agent,
A B C D
E F G
Figs. 17.10A to G: (A) Preoperative radiograph showing deep carious lesion in relation to mandibular 1st molar; (B) Pin point exposure following
caries excavation; (C) Biodentine used for direct pulp capping; (D) Biodentine placed on exposed pulp; (E) Interim restoration placed using glass
ionomer cement; (F) Six months follow up radiograph showing dentin bridge formation; (G) Permanent restoration using composite.
(Courtesy: Pranav Nayyar).
Pulp Protection 185
and enhancing the defense mechanisms of the dentin- 11. What is indirect pulp capping?
pulp complex. 12. What are indications and contraindications of indirect
pulp capping?
EXAMINER’S CHOICE QUESTIONs 13. What is difference between stepwise excavation and
indirect pulp capping?
1. What are effects of tooth preparation on pulp?
2. Write in detail about management of deep carious
bibliography
lesions.
3. Write short notes on: 1. Accorinte ML, Holland R, Reis A, et al. Evaluation of mineral
a. Remaining dentin thickness. trioxide aggregate and calcium hydroxide cement as pulp
capping agents in human teeth. J Endod. 2008;34:1-6.
b. Pulp protection in deep carious lesion. 2. Alleman DS, Magne P. A systematic approach to deep caries
c. Role of liner and base. removal end points: the peripheral seal concept in adhesive
d. Materials used for pulp protection. dentistry. Quintessence Int. 2012;43:197-208.
e. Pulp protection in amalgam restoration. 3. Bergenholtz G. Inflammatory response of the dental pulp to
bacterial irritation. J Endod. 1981;7:100-4.
4. Brännström M, Lind PO. Pulpal response to early dental caries.
Viva Questions J Dent Res. 1965;44:1045-50.
1. What are effects of tooth preparation on dental pulp? 5. Fuks AB. Pulp therapy for the primary and young permanent
dentitions. Dent Clin North Am. 2000;44:571-96.
2. What is importance of remaining dentin thickness? 6. Fusayama T, Terachima S. Differentiation of two layers of
3. Discuss the materials used for pulp protection? carious dentin by staining. J Dent Res. 1972;51:866.
4. What are the advantages of applying varnish? 7. Mertz-Fairhurst EJ, Curtis JW, Ergle JW, et al. Ultraconservative
5. What is purpose of using liner? and cariostatic sealed restorations: results at year 10. J Am Dent
6. Name the materials used as liner. Assoc. 1998;129:55-66.
8. Ricketts D, Lamont T, Innes NP, et al. Operative caries
7. How to apply liner?
management in adults and children. Cochrane Database Syst
8. What is purpose of base? Rev. 2013;(3):CD003808.
9. Name commonly used materials as base. 9. Tziafus D, Smith AJ, Lesot H. Designing new treatment strategies
10. How will you manage a case of deep carious lesion? in vital pulp therapy. J Dent. 2000;28:77-92.
Chapter
18
Interim Restorations
Chapter Outline
introduction Materials
Objectives of Interim Restorations For Intracoronal Preparations
Requirements of Interim Restoration For Extracoronal Preparations
Purposes of Interim Restoration
introduction Requirements of interim

The word interim means established for the time being a restoration
permanent restoration is placed. Whatever the intended All intermediate restorations/provisional restorations
length of time of treatment, an interim restoration must be should:
able to maintain patient’s health. ◆◆ Have good marginal adaptation
Intermediary restorations are used during the interval ◆◆ Have optimal strength and durability
between the tooth preparation and fitting of a definitive ◆◆ Maintain physiologic contours and embrasures
restoration. They are temporarily used or inserted, ◆◆ Have smooth plaque resistant surface
cemented or filled until final restoration is permanently ◆◆ Be able to satisfy mechanical, biological, and aesthetic
inserted or cemented. criteria
◆◆ Be economical
Definition ◆◆ Have easy and quick manipulation, placement, and
removal
An interim restoration is a fixed or removable dental
◆◆ Be insoluble in oral fluids
prosthesis designed to enhance aesthetics, stabilization,
◆◆ Be dimensionally stable
and/or function for a limited period of time, after which
◆◆ Be sedative to pulp and periodontium
it has to be replaced by definitive restoration/prosthesis.
◆◆ Be aesthetically acceptable.
Objectives of interim restorations Purposes of interim restoration

An interim restoration should be able to: ◆◆ Protects the pulp by sealing and insulating the prepared
◆◆ Maintain aesthetics tooth from the oral environment
◆◆ Act as space maintainer ◆◆ Sedative for hyperactive pulp due to tooth preparation
◆◆ Allow the tooth to function ◆◆ Maintains tooth position and prevents occlusal changes
◆◆ Act as a diagnostic tool to determine occlusion ◆◆ Acts as an indirect pulp cap as it creates a favorable
◆◆ Establish function and phonetics biological environment
◆◆ Allow the development of the gingival contour ◆◆ Protects the gingival tissue inflammation
◆◆ Seal and insulate the prepared tooth from the oral ◆◆ Protects the tooth structure weakened during tooth
environment, thereby protecting the underlying pulp preparation
◆◆ Prevent passive tooth eruption and mesial drift. ◆◆ Maintains the aesthetics.
Interim Restorations 187
MATERIALS ◆◆ Soften the gutta-percha stick over an alcohol lamp
slowly. Do not overheat it, as it can cause burning and
A. For intracoronal Preparation oxidation of its components.
1. Gutta-percha ◆◆ Place it in the preparation in bulk or as pieces and
2. Dental cements: condense it with ball burnisher.
i. Zinc oxide-eugenol and its modifications ◆◆ Remove the excess using warm instrument.
ii. Zinc phosphate cement ◆◆ Smoothen the surface using slightly warm instrument.
iii. Zinc silicophosphate cement
iv. Calcium hydroxide Advantages
v. Zinc polycarboxylate cement
◆◆ Compatibility allows it to easily adapt to preparation
vi. Glass ionomer cement.
walls
◆◆ Inertness of this material makes it nonreactive
B. For Extracoronal Preparations ◆◆ Dimensionally stable
Prefabricated crowns can be made from: ◆◆ Tissue tolerance
1. Tooth-colored polycarbonate crowns ◆◆ Radiopacity makes it easily recognizable on radiograph
2. Aluminium cylinder ◆◆ Plasticity on heating helps it to mold according to
3. Stainless steel crowns preparation walls.
4. Celluloid crowns
5. Indirect acrylic restorations. Disadvantages
◆◆ Lack of rigidity
For Intracoronal Preparations ◆◆ Easily displaced by pressure
◆◆ Lacks adhesive quality.
1. Gutta-Percha Stick (Fig. 18.1)
Gutta-percha is a dried coagulated extract which is derived 2. Dental Cements
from plants of Brazilian tree (Palaquium).
I. Zinc oxide-eugenol Cement (Fig. 18.2)
Zinc oxide-eugenol cement is one of the oldest used
cements. It has soothing action on pulpal tissues and
eugenol has topical anesthetic properties therefore, it
is also termed as an obtundent material. Though other
cements are also used for temporization, but zinc oxide-
eugenol cement is used most commonly because it is
much less irritating to the pulp and produces better
marginal seal than zinc phosphate.
Fig. 18.1: Gutta-percha stick.
Composition of Gutta-percha
◆◆ Matrix—gutta-percha 20% (organic)
◆◆ Filler—zinc oxide 66% (inorganic)
◆◆ Radio-opacifiers—heavy metal sulfates 11% (inorganic)
◆◆ Plasticizers—waxes or resins 3% (organic).
Manipulation
Fig. 18.2: Zinc oxide-eugenol.
◆◆ Moisten the walls of tooth preparation with a solvent. (Courtesy: Dentsply India).
Composition of zinc oxide-eugenol powder ◆◆ More powder can be incorporated to achieve standard
Sl. No Component Percentage % Purpose consistency
1. Zinc oxide (ZnO) 69.0% Reactive ◆◆ Decrease in setting time (if concentration is <70%).
ingredient
III. Polymer Reinforced Zinc Oxide-eugenol Cement
2. White rosin 29.3% Reduces
brittleness In this mixture, resin helps in improving strength,
3. Zinc stearate 1.0% Catalyst smoothness of the mixture, and decreases flow, solubility,
4. Zinc acetate (acts 0.7% Accelerator and brittleness of the cement.
as accelerator)
Composition of polymer reinforced zinc oxide-eugenol cement
Composition of liquid
Sl. No Component Percentage % Purpose
1. • Eugenol • 85.0% • Reactor
1. Zinc oxide 80% Reactive
2. • Olive oil • 15.0% • Plasticizer ingredient
2. Polymethyl– 20% Increases strength
Setting reaction of zinc oxide-eugenol cement:
methacrylate
◆◆ On mixing powder and liquid, the zinc oxide hydrolysis
3. Traces of zinc
and subsequent reaction take place between zinc
stearate, zinc acetate
hydroxide and eugenol to form a chelate, zinc
eugenolate. Composition of liquid
◆◆ First reaction: 1. Eugenol 85% Reactor
ZnO + H2O → Zn(OH)2 2. Acetic acid 15% Accelerator
◆◆ Second reaction:
Manipulation of zinc oxide-eugenol (ZOE) cement: ZOE
Zn(OH)2 + 2HE → ZnE2 + 2H2O cement is available as:
◆◆ Water is needed for the reaction and it is also a ◆◆ Powder and liquid system
byproduct of the reaction. So, reaction progresses more ◆◆ Paste-paste system.
rapidly in humid conditions. Manipulation of powder and liquid system (Fig. 18.3):
◆◆ Because zinc eugenolate rapidly hydrolyzes to form ◆◆ Powder is measured and dispensed with a scoop
free eugenol and zinc hydroxide, it is one of the most whereas liquid is dispensed as drops on glass slab.
soluble cements. To increase the strength of the set ◆◆ Powder is divided in main bulk increment, followed by
material, changes in composition can be made to the smaller increments.
powder and liquid. ◆◆ Start the mixing by incorporating half of the powder into
the liquid with a heavy folding motion and pressure.
II. Ethoxybenzoic Acid (EBA) Reinforced Cement ◆◆ When powder particles are wet with liquid, add the
◆◆ In this cement, EBA chelates with zinc forming zinc remaining powder to the mixture and continue to use a
benzoate. heavy folding motion to attain a putty consistency.
◆◆ Addition of fused quartz, alumina, and dicalcium ◆◆ For base, when mixing is done, bring the mixture
phosphate improves mechanical properties of cement. together and roll it. One should be able to pick up the
mixture without deformation.
Composition of ethoxybenzoic acid (EBA) reinforced cement
Sl. No. Component Percentage % Purpose
1. Zinc oxide (ZnO) 70% Reactive
ingredient
2. Alumina 30% Increases strength
3. Fused quartz and 30% Improve
calcium mechanical
properties
1. Eugenol 37.5% Fig. 18.3: Distribution of powder and liquid for manipulation
of ZOE cement.
2. Ortho- 62.5%
ethoxybenzoic acid Paste-paste system: In this, two pastes are dispensed in
equal lengths on paper pad. Two pastes have different
Effects of EBA on eugenol cement: colors, and mixing is done till a homogeneous color is
◆◆ Increase in compressive and tensile strength obtained.
Working time and setting time: Setting Reaction (Fig. 18.4)
◆◆ Higher the powder: liquid ratio, faster the material sets Setting reaction is a two-stage process. In first part, zinc
◆◆ Cooling of glass slab slows down the setting reaction oxide powder reacts with phosphoric acid to form zinc
◆◆ Setting time of this cement is long but since water phosphate and water. This zinc phosphate reacts with more
accelerates the setting reaction, it sets faster in mouth zinc oxide forming hopeite (hydrated zinc phosphate).
than outside. Aluminium prevents crystallization and permits the
formation of an amorphous cement.
• Least irritating cement (pH is • Highly soluble
7). Because of this, it is best • Low strength
known obtundent. • Long setting time
• Good short-term sealing • Low compressive strength
IV. Zinc Phosphate Cement

Zinc phosphate cement is one of the oldest and most
widely used cements. It was first introduced in 1878 and
still used today because of excellent clinical track record.
Its ADA specification number is 8.
Two Types
◆◆ Type I: Used for cementation. It forms the film thickness
of less than 25 µm.
◆◆ Type II: Used as base. It results in film thickness Fig. 18.4: Setting reaction of ZOE cement.
between 25 µm and 40 µm.
Manipulation of Cement
◆◆ Working time ~ 5 minutes
Composition of zinc phosphate cement
◆◆ Setting time ~ 2.5–8 minutes.
Sl. No. Component Percentage % Purpose Mixing on a cooled glass slab allows the heat produced
1. ZnO 90.2% main ingredient in the reaction to dissipate more easily and slow the
2. MgO 8.2% increases chemical reaction, thus increasing the working time. Care
compressive must be taken not to cool the slab below the dew point or
strength water condensation will form and affect the properties of
3. SiO2 1.4% aids in calcination the cement.
process Since setting reaction is an exothermic type, the heat
4. Bi2O3 0.1% imparts liberated while setting further accelerates the setting rate.
smoothness to the So, it is very important to dissipate the heat using chilled
mixed cement glass slab, mixing smaller increment for initial mixing of
5. Miscellaneous (BaO, 0.1% cement on large area of glass slab.
Ba2SO4, and CaO) ◆◆ Powder is divided into 5–8 increments of different sizes
6. All the ingredients (Fig. 18.5).
are sintered at
temperatures
between 1000°C and
1400°C into a cake
that is subsequently
ground into fine
powder
1. Phosphoric acid 38.2% Main reactive
ingredient
2. Water 36.0%
3. Aluminium or zinc 16.2% Fig. 18.5: Division of powder into 5–8 small increments. First two in-
phosphate crements are smaller in size so as to have slow neutralization of liquid
4. Zinc 7.1% Buffer and control the reaction. Middle increments are larger in size to satu-
rate the liquid and form bulk and finally smaller increments of powder
5. Aluminium 2.5% Buffer are added so as to achieve optimum consistency.
◆◆ First two increments are smaller in size so as to: silicate cement powder and 10% zinc phosphate cement
•• Achieve the slow neutralization of the liquid. powder.
•• Control the reaction by decreasing exothermic heat
of reaction. Composition
◆◆ Middle increments are larger in size: ◆◆ Powder contains an acid soluble silicate, zinc, and
•• To saturate the liquid to form zinc phosphate. magnesium oxides.
•• Because of presence of less amount of unreacted ◆◆ Liquid consists of phosphoric acid.
acid, this step is not affected by heat released from Properties of Zinc Silicophosphate Cements
the reaction. ◆◆ Translucent and more aesthetic than zinc phosphate
◆◆ In the end, the smaller increments of powder are cement
added so as to: ◆◆ Anticariogenic because of fluoride release from this
•• Achieve optimum consistency. cement
◆◆ While dispensing, the liquid bottle should be held ◆◆ Has sufficient strength and low solubility.
vertical and close to the powder. Repeated opening of
the liquid bottle or early dispensing of the liquid prior
to mixing should be avoided because evaporation of vi. Zinc Polycarboxylate Cement/Zinc Polyacrylate
liquid can result in changes in water/acid ratio which Cement (Fig. 18.6)
can further result in decrease in pH and an increase in It was one of the first chemically adhesive dental materials
viscosity of the mixed cement. If the liquid is cloudy or introduced in the 1960s. It bonds to tooth structure
crystals are present in the bottle, it should be discarded because of chelation reaction between carboxyl groups of
as the concentration of the acid has been changed and cement and calcium present in tooth structure.
it is no longer optimal. Its ADA specification number is 96.
◆◆ For base or temporary restoration, consistency should
be such that it can be rolled into a ball without sticking.
Mechanical Properties
◆◆ Strength depends on its powder to liquid ratio; zinc
phosphate cement achieves 75% of its ultimate strength
within 1 hour.
◆◆ Good compressive strength of cement is 104 MPa.
◆◆ Low tensile strength—5.5 MPa.
◆◆ Modulus of elasticity is 13.7 gigapascals. This high MOE
makes the cement quite stiff and resistant to elastic
deformation.
◆◆ Retention of cement by mechanical interlocking and
not by chemical interaction.
Biocompatibility
◆◆ Because of presence of phosphoric acid, acidity of Fig. 18.6: Zinc polycarboxylate cement.
cement is quite high (pH is 2.0) making it irritable to
pulp. Composition of zinc polycarboxylate cement/zinc polyacrylate
cement
• Long record of clinical • Low initial pH, irritant to pulp
acceptability • Lack of an adhesion to tooth 1. Zinc oxide 85–96% Main reactive
• High compressive strength structure ingredient
• Thin film thickness • Lack of anticariogenic effect 2. Stannous 4% improves the set,
• Soluble in water fluoride leaches fluoride—
anticariogenic
3. Magnesium 4–10% Preserves white color
v. Zinc Silicophosphate Cements oxide
It is hybrid cement which is combination of zinc 4. Silica 0–2% improves sintering
phosphate cement with silicate cement and is also process
known as silicophosphate cement. Most commonly used 5. Alumina <5% forms complexes with
cement is silicophosphate cement that consists of 90% acid
Composition of liquid 5. Biological considerations: pH of the liquid is 1.7 but

increases rapidly after mixing. Zinc polycarboxylate is
biocompatible because of the following reasons:
1. Polyacrylic 32–43% main ingredient
acid
•• Size of polyacrylic acid molecule is bigger, this makes
it difficult to enter into dentinal tubules.
2. Itaconic acid/ 32–43%
maleic acid •• pH of the cement rises more rapidly when compared
to that of zinc phosphate.
Manipulation of Zinc Polycarboxylate Cement:
◆◆ Liquid is dispensed just before mixing of the cement Advantages Disadvantages
as the loss of water from liquid can result in increase in • Adhesion to tooth structure • Short working time (2–3
its viscosity. While dispensing the liquid bottle should • Rapid rise in pH upon minutes)
be held vertical, so that liquid comes out under its own cementation • Does not resist plastic
weight. • Biocompatible deformation under high
masticatory stresses
◆◆ Mix first-half of powder to liquid to obtain the maximum
length of working time. Mixed cement should be
adapted to tooth till it is glossy in appearance. It shows For Extracoronal Preparations
presence of unreacted acid groups which are available
Various types of prefabricated crowns are available
for bonding.
(made of plastic or metal), along with self-cured or light-
Setting reaction cured resins for extracoronal preparations. Crown forms
When the zinc oxide and polyacrylic acid come into in anatomic shapes are most useful because of their
contact, a salt (zinc polyacrylate) matrix is formed only simulation to the tooth structure.
on the surface of the zinc oxide particles. Polyacrylic acid
chains cross-link through the zinc ions of the zinc oxide. Crown Forms
The set material has cores of zinc oxide within the zinc
polyacrylate matrix binding the unreacted zinc oxide cores Crown forms are indicated in the following cases:
together. ◆◆ Extensive carious lesions undermining the cusps
The mixed cement goes through a rubbery phase as it ◆◆ Failure to use other available restorative materials
is setting and it should not be disturbed during this phase ◆◆ Following pulpotomy or pulpectomy
because otherwise adhesive bond of the cement will be ◆◆ For fractured teeth.
ruptured. This can cause microleakage if cement is pulled
away from the tooth surface. The cement should not be Criteria of Using Crowns
disturbed until it can be removed cleanly from the margin ◆◆ Surface of crown should be smooth and polished
of a cemented restoration. ◆◆ Crown margins should be closely adapted to the tooth
Properties ◆◆ Contact with adjacent teeth should be proper
1. Working time and setting time: ◆◆ Crown should be in proper occlusion
•• Working time ~ 2.5 minutes ◆◆ Crown should facilitate the patient to adequately
•• Setting time ~ 6–9 minutes. maintain oral hygiene.
2. Adhesive to tooth structure:
Materials
•• Polyacrylic acid bonds with calcium ion via the
carboxyl group. Adhesion depends on the unreacted I. Preformed crowns: They are also called as proprietary
carboxyl group. shells. They are available in different sizes but for
3. Mechanical properties: proper fitting they need to be adjusted.
•• Compressive strength is less than zinc phosphate II. Cellulose acetate and polycarbonate crown forms:
cement ~ 55–67 MPa Crown is made up of soft, thin, and transparent
•• Tensile strength ~ 2.4–4.4 MPa material, available in diverse sizes and shapes. Due to
•• Low modulus and is, therefore, slightly more elastic their good aesthetics, they are commonly indicated in
and less likely to fracture under heavy load. While it anterior teeth. To place this crown, select the crown
appears thick after mixing, the cement is more fluid according to tooth, fill the crown with cold-cure resin,
and it exhibits shear thinning underload allowing and seat it on prepared tooth. Remove the excess
restorations to be seated completely under pressure. cement and adjust the occlusion.
4. Solubility: It is low in water. But in acidic environment Iii. Stainless steel crowns: These are commonly used for
with pH of less than 4.5, solubility increases. Reduction the posterior teeth. In this, select the crown according
in P:L ratio also increases solubility. to the gingival diameter.
IV. Aluminium shell crowns: These are commonly used Enumerate different materials used as interim
for posterior teeth. These are softer and weaker than restorations.
stainless steel crowns. 3. Write short notes on:
V. Acrylic restorations: These can be prepared by direct a. Materials used for interim restorations.
or indirect technique using polymethylmethacrylate, b. Temporary restorations for extracoronal
polyethylmethacrylate, bis-acryl composite, and preparations.
urethane dimethacrylate.
Polymethylmethacrylate has advantages of having viva Questions
high strength, good wear resistance, and aesthetics.
1. Define interim restoration.
Its disadvantages include polymerization shrinkage,
2. What is composition of ZOE cement?
exothermic heat produced during polymerization, and
3. What is composition of Ethoxybenzoic acid reinforced
free monomer release during setting. cement?
4. How to manipulate zinc phosphate cement?
Limitations of Temporization 5. What is composition of zinc phosphate cement?
◆◆ Poor marginal adaptation is commonly seen with 6. What is composition of zinc polycarboxylate cement?
temporary restorations. 7. What are properties of zinc polycarboxylate cement?
◆◆ In intermediate restoration, discoloration may take 8. What makes zinc polycarboxylate cement biompatible?
place in long duration restorations. 9. What are different forms of extracoronal preparation
◆◆ Poor strength of temporary crowns may fracture used for temporization?
in patients with bruxism or reduced interocclusal 10. What are problems faced with interim restorations?
clearance.
◆◆ Autopolymerizing resins may result in odor because of BIBLIOGRAPHY
food accumulation. 1. Gilles JA, Huget EF, Stone RC. Dimensional stability of
◆◆ Inadequate bonding between tooth and restoration temporary restoratives. Oral Surg Oral Med Oral Pathol.
1975;40(6):796-800.
may result in their failure.
2. Gilson TD, Myers GE. Clinical studies of dental cements. II.
Further investigation of two zinc oxide--eugenol cements for
CONCLUSION temporary restorations. J Dent Res. 1969;48(3):366-7.
3. Grieve AR. A study of dental cements. Br Dent J. 1969;127(9):
For the protection of pulp and to maintain the aesthetics 405-10.
and function, interim restorations are given. Various 4. Markowitz K, Moynihan M, Liu M, et al. Biologic properties of
types of cements in one form or the other have been used eugenol and zinc oxide-eugenol. A clinically oriented review.
Oral Surg Oral Med Oral Pathol. 1992;73(6):729-37.
since long, such as ZOE, zinc phosphate cement, zinc 5. Meryon SD, Johnson SG, Smith AJ. Eugenol release and the
polycarboxylate system, etc. For individual extracoronal cytotoxicity of different zinc oxide-eugenol combination. J
preparations, both anterior and posterior, prefabricated Dent. 1998;16(2):66-70.
crowns, and indirect acrylic restorations are used. 6. Norman RD, Swartz ML, Phillips RW, et al. Direct pH
determination of setting cements. The effects of prolonged
storage time, powder/liquid ratio, temperature, and dentin. J
EXAMINER’S CHOICE Questions Dent Res. 1966;45(4):1214-9.
7. Phillips RW, Swartz ML, Rhodes B. An evaluation of a carboxylate
1. What is the role of interim restorations? Enumerate adhesive cement. J Am Dent Assoc. 1970;81(6):1353-9.
different materials used as interim restorations. 8. Servais GE, Cartz L. Structure of zinc phosphate dental cement.
2. What are interim restorations? What are the J Dent Res. 1971;50(3):613-20.
requirements and purposes of interim restorations?
Chapter
19
Amalgam Restorations
Chapter Outline
Introduction Class I Cavity Preparation for Silver Amalgam

Definitions Class Ii Cavity Preparation for Amalgam Restoration
History of Dental Amalgam Class Iii Cavity Preparation for Amalgam Restoration
History of Dental Amalgam Class V Cavity Preparation
Classification Class Vi Cavity Preparation for Amalgam Restoration
Composition Steps for Amalgam Restoration
Types
Life of Amalgam Restorations
Setting Reaction/Amalgamation Reaction
Failures of Amalgam Restoration
Physical Properties
Indications of Silver Amalgam Reasons for Failure of Amalgam Restorations
Contraindications Mercury Hygiene
Advantages Is Dental Amalgam Safe?
Disadvantages Amalgam Wars
Recent Advances in Silver Amalgam Phase Down of Amalgam
INTRODUCTION Mineral Succedaneum” which was actually a mixture of

silver coins and mercury.
Dental amalgam is a dental filling material used to restore
the cavities. For more than 150 years, dental amalgam
has served as a safe, durable and affordable material in
Definitions
restorative dentistry.
Alloy
The American Dental Association (ADA) defines
dental amalgam as an alloy composed of mercury, silver, Alloy is a union of two or more metals.
tin, and copper along with other metallic elements added
to improve physical and mechanical properties. Amalgam
It is one of the most versatile restorative materials
Amalgam is an alloy of mercury with any other metal.
used in dentistry. It constitutes approximately 75% of all
restorative materials used by dentists.
Dental Amalgam
Dental amalgam was first used by the Chinese Su Kung
(659 AD) who mentioned its use as a mixture in the Material Dental amalgam is an alloy of mercury with silver, tin,
Medica. In Europe, Johannes Stokers, recommended and varying amounts of copper, zinc, and other minor
amalgam as a filling material. Major development in constituents.
amalgam was made in France. Traveau described a “silver
paste” filling material in 1826. He produced amalgam Dental Amalgam Alloys
by mixing the silver coins with mercury. In 1833, the Dental amalgam alloys are silver-tin alloys with varying
Crawcours brothers introduced to America their “Royal amounts of copper, zinc, and other metals.
History of Dental Amalgam 4. Based on the Presence of Alloyed Metals

Sl. No. Year Inventor Action i. Binary alloys: Contain two metals, i.e. silver and tin.
1. 1659 AD Su Kung Used mixture in Material Medica ii. Ternary alloys: Contain three metals, i.e. silver, tin,
and copper.
2. 1528 Johannes Described amalgam as a filling
Stokers material iii. Quaternary alloys: Contain four metals, i.e. silver,
tin, copper, and zinc.
3. 1818 Louis Nicolas Father of amalgam—invented
Regnart amalgam by addition of one Out of these, quaternary alloys are most acceptable.
tenth by weight of mercury to
another metal/metals 5. Based on Whether Alloy is Unicompositional
4. 1819 Joseph Bell Introduction of dental silver or Admixed
amalgam and also known as
“Bells Putty” i. single composition or unicompositional: each
5. 1826 Traveau Described “silver paste” filling particle of alloy has same chemical composition
material by mixing silver coins ii. Admixed alloys: these are physical blend of lathe-cut
with mercury and spherical particles.
6. 1833 Crawcours Introduced amalgam to US as
brothers Royal Mineral Succedaneum 6. Based on Presence or Absence of Noble Metals
7. 1895 GV Black Developed formula for modern
amalgam alloy 67% silver, 27% i. Noble metal alloys: Contain small amount of gold or
tin, 5% copper, 1% zinc platinum
1959 Dr Wilmer Recommended a 1:1 ratio of
ii. Non-noble metal alloys: Do not contain noble metals.
8.
Eames mercury to alloy, thus lowering
the 8:5 ratio of mercury to alloy 7. Generations of Dental Amalgam Based on
9. 1963 Innes and Development of high copper Addition of Noble Metals
Youdelis alloys (admixed type)
1st generation 3 parts silver and 1 part tin peritectic
10. 1971 Johnson Designed a spherical particle
alloy
2nd generation Silver, tin, copper (4%), and zinc
3rd generation Silver copper eutectic alloy added to
11. 1974 Asgar Single composition high copper
alloy
original alloy
4th generation Copper content increased to 29%
12. 1980 Showell Amalgapin
5th generation Indium added to mixture of silver, tin,
and copper
6th generation Noble metals added such as palladium.
Classification
1. Based on Shape of Particles COMPOSITION
i. Irregular: In this, shape of particles is irregular, and Amalgam consists of amalgam alloy and mercury.
may be in the shape of spindles or shavings. Amalgam alloy is composed of silver-tin alloy with varying
ii. Spherical: In this, shape of particle is spherical with amounts of copper, zinc, indium, and palladium (Fig.
smooth surface. 19.1). Dental amalgam alloys are mainly of two types, low
iii. Spheroidal: In this, shape of particle is spheroidal copper and high copper alloys (Table 19.1).
with irregular surface.
2. Based on Copper Content

i. Low copper alloy: Contains copper in range of 2 to
6%.
ii. High copper alloy: Contains copper in the range of 12
to 30%.
3. Based on Zinc Content

i. Zinc-containing alloys: In these, zinc is in range of
0.01–1%.
ii. Zinc-free alloys: Contain less than 0.01% of Zinc. Fig. 19.1: Constituents of amalgam alloy.
Amalgam Restorations 195
Table 19.1: Composition of amalgam alloys (percentage of elements by weight).
Alloy Silver% Tin% Copper% Zinc% Indium% Palladium%
1. Low copper 65–70 26–28 2–5 0–2 0 0
2. High copper
i. Admixed 40–70 26–30 13–30 0–1 0 0
ii. Unicompositional 40–60 0–30 13–30 0 0–1 0–1
Table 19.2 summarizes the differences between high Copper: It has the following effects on the properties of
and low copper amalgam alloys. amalgam:
In general, amalgam alloy consists of silver 40% ◆◆ Reduces tarnish and corrosion
(minimum), tin 32% (maximum), copper 30% (maximum), ◆◆ Reduces creep
zinc 2% (maximum), and traces of indium or palladium. ◆◆ Strengthening effect on the set amalgam
In preamalgamated alloys, 3% mercury is used, which ◆◆ Helps in uniform comminution of the alloy.
reacts more rapidly when mixed with silver-tin alloy.
Mercury used for dental amalgam is purified by Zinc: Its presence is not essential. It may vary from 0% to 2
distillation. % by weight. It has the following effects on the properties
of amalgam:
◆◆ Scavenges the available oxygen to impede oxidization
Effects of Constituent Metals on Properties of of Ag, Sn or Cu during alloy ingot manufacturing.
Amalgam ◆◆ If zinc-containing alloys are contaminated with moisture,
Silver: It has following effects on the properties of zinc gives rise to delayed or secondary expansion.
amalgam: Palladium (0–1% by weight): Improves the corrosion
◆◆ Increases strength resistance and the mechanical properties.
◆◆ Increases setting expansion
◆◆ Reduces setting time Indium (0–4% by weight): It decreases the evaporation of
mercury and the amount of mercury required to wet the
◆◆ Resists tarnish and corrosion
alloy particles.
◆◆ Decreases flow
◆◆ Gives silver color to amalgam.
TYPES
Tin: Tin helps in formation of a silver/tin compound (Ag/
Lathe-cut is made by cutting of alloy from a pre-
Sn). This is the gamma-phase, which readily undergoes an
homogenized ingot, which was heat treated at 420°C for
amalgamation reaction with mercury. Tin causes following many hours. Fillings are then reheated at 100°C for 1 hour
effects: for aging of the alloy.
◆◆ Increases setting time Spherical (spheroidal) alloy is formed when molten
◆◆ Retards the reaction alloy is sprayed into a column filled with inert gas; this
◆◆ Reduces strength, hardness, and setting expansion. molten metal solidifies as fine droplets of alloy.
Table 19.2: Difference between high copper and low copper alloys.
High copper alloys Low copper alloys
Copper content 12–30% <6%
Mercury required for amalgamation Less More
Setting reaction Fast setting Slow setting
Amalgamation speed and energy Require high speed and energy for Require less speed and low energy for
amalgamation since copper has low amalgamation
solubility in mercury
Dormant phase It is Cu6Sn5, i.e. η phase It is Ag2Hg3, i.e. γ1 phase
Tarnish and corrosion It is due to copper-rich phase, i.e. Cu6Sn5(η) It is due to gamma-2 phase, i.e. Sn8Hg(γ2)
Creep Less creep More creep
(<1%) (1–8%)
Compressive strength High (250–500 Mpa) Low (150–350 Mpa)
Dimensional change Less (1–9 µm/cm) More (10–20 µm/cm)
Admixed alloy is when different size or shape of Final phase formed is Cu6Sn5 (g). There is no Sn8Hg (g2)
amalgam powder particles are mixed together to increase phase.
filling efficiency. Table 19.3 shows different phases of silver amalgam
Single composition is that alloy in which every particle setting reaction.
of alloy is having same shape, size, and composition.
Table 19.3: Phases of silver amalgam.
Dispersion modified, high copper alloys are that, in
which high copper alloy is mixed with conventional alloy. Code Component
(γ) gamma Ag3Sn (Silver–tin phase) strongest phase
Setting Reaction/amalgamation (γ1) gamma 1 Ag2Hg3(Silver–mercury phase) noblest phase
reaction (γ2) gamma 2 Sn8Hg (Tin–mercury phase): Least resistant to
tarnish and corrosion and weakest phase
1. For Lathe-cut Low Copper Alloys
(e) epsilon Cu3Sn (Copper–tin phase)
On mixing amalgam alloy with mercury, the alloy particles (h) eta Cu6Sn5 (Copper–tin phase)
get dissolved in the mercury. Mercury reacts with alloy More corrosion resistant and stronger than
particles to form two products, i.e. the silver-mercury phase gamma-2 phase.
and tin-mercury phase. After this reaction, the unreacted
particles are embedded in the matrix of reaction products Structure of Set Amalgam
with mercury. The reaction is as follows: Set amalgam mass consists of unreacted alloy particles
Ag3Sn + Hg Ag2Hg3 + Sn8Hg + unreacted Ag3Sn surrounded by a matrix of the reaction products (Fig. 19.2).
(g) (g1) (g2) (g)
In lathe-cut low copper amalgams both g1 and g2 form
a continuous network. Since g2 phase is least corrosion-
resistant phase, its distribution in reaction product is
important.
2. For Admixed High Copper Alloys

For high copper alloys, the reaction is different. It occurs Fig. 19.2: Structure of amalgam.
in two phases. The initial reaction is similar to that of low
copper alloys, i.e. PHYSICAL PROPERTIES
(g) Ag3Sn + Ag-Cu + Hg (g1) Ag2Hg3 + (g2) Sn8Hg Dimensional Change
+ (g) unreacted Ag3Sn + Ag-Cu
Small amount of contraction occurs in first half an hour
Second phase of reaction involves the silver–copper after trituration because mercury diffuses into silver
phase (Ag-Cu). and tin, and the mix dissolves in the mercury. After this,
It reacts with g (Ag3Sn) and mercury to form Ag2Hg3, expansion occurs because of crystallization of new phases
(Figs. 19.3 and 19.4). According to American Dental
Sn8Hg and Cu6Sn5 phase. The mercury released from Sn8Hg
(g2 phase) reacts with silver to form Ag2Hg3 (g1) phase.
Sn8Hg + Ag-Cu Cu6Sn5 + Ag2Hg3 + Ag3Sn
(g2) (h) (g1) (g)
This reaction goes on. After one week, the g2 phase reacts
completely with eutectic and replaces all the g2 phase by g
and g1 phase.
3. Unicompositional High Copper Alloy

Difference in admix type and the unicompositional alloys
is that, in latter, the eutectic phase, i.e. Ag-Cu phase is
absent and the reaction is directly with silver, copper and
tin phases. In these, only silver reacts with mercury and
the tin remains bound to copper.
Ag3Sn + Cu3Sn + Hg Cu6Sn5 + Ag2Hg3
(g) (e) (h) (g1) Fig. 19.3: Dimensional changes in amalgam.
◆◆ Amalgam protrudes from the space and this chemical
stress leads to increase in creep.
Compressive Strength
◆◆ Strength of amalgam takes 24 hours to reach
A
maximum. In the 1st hour, only 40–60% of its maximum
compressive strength is achieved.
◆◆ According to ADA specification number 1, amalgam
should have minimum 1 hour compressive strength
of 11,600 psi (80 MPa). It has satisfactory compressive
strength of 310 MPa. After 7 days, high copper alloys
have more compressive strength than low copper alloys.
B ◆◆ Compressive strength of amalgam is seven times
Figs. 19.4A and B: Dimensional changes in amalgam. more than its tensile or shear strength making it
brittle material. Being a brittle material, it is weak in
thin sections, thus unsupported edges of restoration
Association (ADA) specification number 1, dimensional fracture frequently. To avoid this, a 90° butt joint angle
change should be limited to 20 microns/cm measured of amalgam is required at the margins.
between 5 minutes and 24 hours after trituration.
Factors affecting strength:
Factors Affecting Dimensional Changes of Amalgam ◆◆ Mercury is weakest phase; more is residual mercury,
weaker is the amalgam.
◆◆ Type of alloy being used, for example single composition ◆◆ Optimally done trituration increases strength
spherical alloys contract more than single composition ◆◆ More condensation force removes excess mercury, thus
lathe-cut or admixed alloys. improves strength
◆◆ Condensation technique, i.e. more the mercury is ◆◆ Presence of porosity decreases strength
removed from alloy, the more it will contract. ◆◆ Smaller is the particle size of alloy powder, more is the
◆◆ Trituration time: Over-trituration causes contraction. strength
◆◆ Presence of zinc: If zinc-containing amalgam comes ◆◆ Corrosion causes decrease in strength.
in contact with moisture, it can result in delayed
expansion or secondary expansion after 3–5 days of Plastic Deformation (Creep)
restoration. This occurs due to formation of zinc oxide
and hydrogen gas when zinc reacts with water. This ◆◆ Creep is time-dependent response of an already set
expansion can result in extrusion of restoration beyond material to stress in form of plastic deformation.
preparation margins and pulpal pain. ◆◆ It can be of two types depending on the stresses
involved, viz static and dynamic.
H2O + Zn ZnO2 + H2 ◆◆ By ADA specification number 1, creep is limited to 3%
in set amalgam.
◆◆ Creep occurs near melting temperature of a material.
Mercuroscopic Expansion
In amalgam, creep occurs because gamma-1 is a fine-
The term was given by Jorgenson. Expansion that occurs grained structure in which particles “slide” over each
due to reaction of mercury with alloy components is called other resulting in slipping of grain boundaries.
as mercuroscopic expansion or primary expansion. It is ◆◆ Creep is undesirable because it causes amalgam to flow
seen only in low copper amalgam. out over the margins resulting in marginal deterioration
Mechanism: Release of mercury from g2 phase during and fracture.
electrochemical corrosion results in additional formation
of phase on reaction with unreacted g phase, causing Factors Affecting Creep:
further expansion. ◆◆ Low copper alloys have higher creep than high copper
Causes: alloys because in high copper alloys, copper binds
◆◆ Increased Hg:alloy ratio with tin-forming eta-phase, this prevents formation
◆◆ Failure to squeeze out excess Hg of g2-phase. Crystals of e-phase interlock and prevent
◆◆ Inadequate condensation pressure. slippage at gamma-1 grain boundaries, resulting in
less creep.
Consequences of Mercuroscopic Expansion: ◆◆ Residual mercury is directly proportional to creep.
◆◆ It results in “ragged” edges forming small unsupported ◆◆ Increased condensation pressure reduces creep
ledges of amalgam which can fracture during function. because it reduces residual mercury level.
◆◆ Marginal areas show more creep because they have the gold. Therefore, such dissimilar restorations should not
higher levels of residual mercury. be placed in contact with each other.
◆◆ Delay between trituration and condensation increases
creep. Biocompatibility
Table 19.4 showing properties of high and low copper
amalgam alloys. Though there has been a great debate related to mercury
toxicity, if careful handling of mercury is taken, amalgam
Table 19.4: Properties of high and low copper amalgam alloys.
has proved to be a biocompatible material.
Type of Compressive Tensile strength
amalgam strength (MPa) Creep (%) (MPa) Thermal Conductivity
1 hour 7 days
Because of good thermal conductivity, amalgam can
Low copper 145 343 2.0 60 transmit temperature changes readily to the pulp.
Admixed 137 431 0.4 48 Therefore, it should be placed in tooth after adequate
Single 262 510 0.13 64 pulp protection like sealing dentinal tubules by applying
composition varnish to walls or placing base on pulpal floor.
Tarnish and Corrosion Coefficient of Thermal Expansion

Coefficient of thermal expansion of amalgam is three
Tarnish is the surface discoloration of metal or alteration
times more than that of dentin. This large difference is
of surface finish or luster.
responsible for microleakage.
Corrosion is actual deterioration of a metal by reaction
with its environment. Corrosion proceeds from outer
surface to interior of restoration making it porous and
Microleakage
spongy, thus it causes decrease in strength of restoration by Microleakage occurs when there is 2–20 micron wide gap
50%. advantage of corrosion is that, its by-products seal the between the amalgam and tooth structure. Following
preparation margin, resulting in self-sealing of amalgam. factors are responsible for microleakage in amalgam:
In both high and low copper amalgams, corrosion ◆◆ Poor condensation techniques that cause marginal voids
products are oxides and chlorides of tin. In high copper ◆◆ Lack of corrosion by-products, which are necessary for
alloys, corrosion is slower and limited because e-phase sealing of margins
is less susceptible to corrosion than g2-phase, which is ◆◆ High coefficient of thermal expansion of amalgam
responsible for corrosion in low copper alloys. ◆◆ Use of single composition spherical alloys which show
When amalgam comes in contact with dissimilar metal more leakage than lathe-cut or admixed alloys.
(gold restoration), amalgam undergoes galvanic corrosion Microleakage can lead to:
due to large difference in electromotive force of two materials ◆◆ Pulpal inflammation
(Fig. 19.5). It also causes release of mercury, which weakens ◆◆ Tooth discoloration
◆◆ Postoperative sensitivity.
INDICATIONS OF SILVER AMALGAM

1. Class I preparations:
In moderate to large class I preparations.
2. Class II preparations:
In class II preparations, especially if preparation is on root
surface and moisture control is difficult.
3. Class V preparations:
For restoration of class V lesions in which aesthetic is not
a problem, preparation is entirely on root surface and
isolation is difficult.
4. Class VI preparations:
Amalgam restoration is done to restore cusp tips.
5. Class III preparation:
Fig. 19.5: When amalgam comes in contact with gold restoration,
Use of amalgam is reserved for the distal surface of
galvanic corrosion occurs due to difference in electromotive force of two maxillary and mandibular canines, especially if there is
materials. minimal facial involvement and lesion is on root surface.
6. Postendodontic restoration: 7. Favorable Long-term Clinical Results
Amalgam is used as a postendodontic restoration to
restore the access cavity. Amalgam has shown long history of successful use.
7. In teeth with questionable prognosis as interim Disadvantages

restoration:
In teeth having no definitive pulpal prognosis, amalgam 1. Unaesthetic
is used as interim restoration before assessment of pulpal
Silver gray color of amalgam makes it unaesthetic.
status of the tooth and as foundation in cases of grossly
decayed teeth while planning for cast restoration.
2. Extensive Cavity Preparation
8. Tooth having fractured cusp:
It can be restored with the help of amalgam using pin and Since amalgam does not bond to the tooth structure, an
slot. extensive preparation is required to hold an amalgam
filling.
CONTRAINDICATIONS
1. When aesthetics is main concern:
3. Corrosion
Use of amalgam is avoided where aesthetics is the primary Amalgam fillings can corrode or tarnish over the time,
concern. causing discoloration of tooth.
2. Small class I and class II preparations:
These cases should be restored with composite rather than 4. Noninsulating
amalgam as former results in more conservative cavity
Being metallic restoration, it transmits thermal sensation
preparation.
to the pulp making it non-insulating.
3. Grossly decayed teeth:
In grossly decayed teeth, amalgam is not indicated because 5. Marginal Degradation
it does not reinforce the remaining tooth structure.
Marginal degradation is seen in low copper alloys.
Advantages
6. Lack of Reinforcement of Weakened Tooth
1. Ease of Manipulation
Structure
Amalgam is easier to manipulate and less technique
sensitive. It can be completed in one dental visit. Amalgam does not reinforce the weakened tooth struc-
ture as it does not form monoblock with remaining tooth
structure.
2. Self-sealing Ability
Corrosion products formed at interface of amalgam resto- 7. Brittle Material
ration and tooth, seal the amalgam against microleakage.
Amalgam also shows satisfactory marginal adaptation. Amalgam has poor tensile strength thus making it a brittle
material.
3. High Compressive Strength
8. Galvanism
Physical characteristics of amalgam are comparable to
enamel and dentin. Results in galvanic current in association with gold
restoration or even in same restoration with non-uniform
4. Biocompatible condensation.
Amalgam is a biocompatible material.
9. Oral lichen Planus
5. Good Wear Resistance It is also seen with amalgam restoration.
Because of good wear resistance, amalgam can be used in
patients with moderate–to-heavy occlusal loads. RECENT ADVANCES IN SILVER AMALGAM
6. Economical 1. Mercury-free Direct Filling Alloy
Cost of amalgam is much less than composites, ceramics, The American Dental Association, in combination
and cast restorations. with National Institute on Standard and Technology
(ADA-NIST) patented a mercury-free direct filling alloy

which is based on Ag-coated Ag-Sn particles that can
be self-welded by compaction to create a restoration. To
keep the surface of alloy particles clean, a fluoroboric acid
solution is used. These alloys can be condensed in the
same manner as direct-filling gold restoration.
Disadvantages:
◆◆ Poor adaptation to preparation walls
◆◆ Material hardens and becomes brittle during
condensation
◆◆ Presence of internal voids.
2. Low Mercury Alloy

In this approach, alloy particles are carefully selected so
that they can be packed well. This reduces the need of
mercury for amalgamation around 15–25%. However, the Fig. 19.6: Bonding mechanism of bonded amalgam.
clinical properties of these alloys are not yet known.
◆◆ Remove all the carious portion and unsupported enamel
rods.
3. Bonded Amalgam System ◆◆ In deep preparation, protect the pulp with suitable liner
One of major disadvantages of the amalgam is that it does and base.
not adhere to the preparation walls. To conquer this problem, ◆◆ Place matrix and wedges properly.
bonded amalgam was developed. In this, dentin bonding ◆◆ Etch the enamel and dentin walls of the preparation
system is used along with a viscous resin liner which physically with 37%phosphoric acid gel for 15–20 seconds. Wash
mixes with amalgam and forms a micromechanical union to and dry the preparation.
increase amalgam’s retention to tooth structure. ◆◆ Apply adhesive primer to the conditioned dentin and
Amalgam is hydrophobic, and tooth is hydrophilic, then evenly apply dentin bonding agent.
to achieve optimal wetting, bonding systems must have ◆◆ Before the bonding agent gets dried, condense freshly
dual properties. For this, monomer molecule having triturated high copper amalgam into the preparation.
hydrophilic and hydrophobic ends are used, for example ◆◆ Carve, finish, and polish the final restoration as usual.
4-methacryloxyethyl trimellitic anhydride (4-META).
Advantages
Indications of Bonding
◆◆ Adequate dentin sealing
◆◆ When remaining tooth structure is weak ◆◆ Increased resistance form
◆◆ In extensively carious teeth where it acts as cost- ◆◆ Increased retention
effective alternative for cast metal and metal ceramic ◆◆ Conservative cavity preparation
restorations ◆◆ Improved marginal seal
◆◆ In deep bite cases, where short clinical crown is present, ◆◆ Elimination of use of retention pins and other modes
and pin retained restoration is not possible. of retention
◆◆ As core for foundation of cast crown restoration. ◆◆ Reduction in microleakage, secondary caries, and post
operative sensitivity
Bonding Mechanism (Fig. 19.6) ◆◆ Cost-effective for extensively carious tooth
Bonded amalgam is retained by micromechanical means ◆◆ Can be done in single appointment.
in which resin tags are incorporated into amalgam at the
interface. The bonding interface consists of tooth-adhesive
Disadvantages
resin—amalgam components, i.e. bonding is produced by ◆◆ Reduction in bond strength over years because of
condensing the plastic amalgam mass into a plastic–resin repeated thermocycling in the oral cavity
layer, producing micro-retentive areas within the resin, ◆◆ Technique-sensitive system: Amalgam must be
after resin has polymerized. condensed over wet adhesive resin
◆◆ More expensive than nonbonded amalgam restoration.
Technique of Placing Bonded Amalgam
◆◆ Isolate the tooth with rubber dam. 4. Gallium Amalgam
◆◆ Do the conservative preparation, i.e. conventional To conquer the harmful effects of mercury, gallium metal
retention and resistance forms are not strictly followed. which has second lowest melting point (next to mercury)
has been tried. This is triturated with high copper amalgam ◆◆ Setting time is less than silver–mercury amalgam,
alloy to produce material similar to amalgam. therefore, can be finished and polished after one hour.
◆◆ Most of the physical and mechanical properties of gallium
Composition alloy are similar to high copper–mercury amalgam.
◆◆ Powder:
Disadvantages
•• Silver (Ag) – 60%
•• Tin (Sn) – 25% ◆◆ Corrosion resistance of gallium amalgam is very low.
•• Copper (Cu) – 12% ◆◆ Handling of gallium alloy is difficult because it has
•• Palladium (Pd) – 3% tendency to stick to the instruments.
◆◆ Liquid: ◆◆ Extremely technique sensitive, any moisture contami
•• Gallium (Ga) – 65% nation during placement results in alloy expansion.
•• Indium (In) – 20% ◆◆ Shows expansion after setting. Excessive expansion can
•• Tin (Sn) – 15% produce stresses sufficient to crack the tooth.
Setting Reaction Clinical Tip

Reaction between powder AgSn particles and liquid This sticking problem of gallium amalgam can be reduced
gallium results into formation of AgGa phase and a pure by adding a drop of absolute alcohol to the mix before
tin phase. trituration. Alcohol slowly evaporates and thus does not
AgSn + Ga→AgGa + Sn adversely affect the properties of the amalgam.
Properties of Gallium Amalgam Restorations 5. Consolidated Silver Alloy

i. Compressive strength: Compressive strength is It is a recently introduced amalgam developed at the
almost similar to high copper amalgam National Institute of Standards and Technology. It uses
ii. Setting expansion: In initial stages, controlled fluoroboric acid solution for keeping the surface of
expansion occurs, but if contaminated, uncontrolled silver alloy particles clean. Alloy is condensed in the
expansion can result. This excessive expansion can preparation similar to direct filling gold. Limitation
cause cuspal fracture and postoperative sensitivity. of using this material is that alloy hardens due to
repeated burnishing. This makes it difficult to compact
Creep value in preparation. For good adaptation of material and to
In gallium alloys, creep value is less. avoid voids in the final restoration, an excessive force is
required for compaction.
Microleakage
6. Indium Liquid Alloy Containing Alloy Powder
Gallium amalgam has very high wetting ability, hence the
final restoration is highly resistant to microleakage.
and Binary Mercury
Powell et al (1989) found significant decrease in mercury
Time Consuming required for amalgamation when pure medium was added
to disperse phase in high copper alloy triturated with
Since their handling is difficult because of being sticky,
mercury. This was marketed as Indisperse and Indiloy.
it takes more time for condensation and matrix band
Amalgam prepared with indium rapidly forms indium
has to be removed very carefully to avoid fracture of
oxide and tin oxide, which reduces mercury release.
restoration.
However long-term clinical performance of such alloys
needs further evaluation.
Expensive
Gallium amalgam is about 16 times costlier than the silver– 7. Fluoridated Amalgam
mercury amalgam.
Fluoride has been added in amalgam due to commonly
seen recurrent caries associated with amalgam
Advantages restorations. Fluoride is released from amalgam by two
◆◆ Gallium amalgam can be manipulated with same possible mechanisms:
instruments used for silver amalgam i. Dilution of salt crystals which are in contact with
◆◆ Creep resistance complies with ISO requirements. cavity walls.
◆◆ Gallium amalgam expands after trituration, it provides ii. By corrosion, which releases fluoride present in
better marginal seal than silver amalgam. amalgam mass.
By this fluoride present in amalgam can increase

fluoride content in plaque and saliva subsequently
affecting remineralization.
Thus fluoridated amalgam acts as “slow-release device”
8. Resin-coated Amalgam
To overcome the problems of microleakage, a coating of
unfilled resin over restoration margins and enamel is
applied after etching the enamel. Though resin may wear
away, it delays the microleakage until corrosion products
begin to form at tooth restoration interface.
Class I Cavity preparation for

silver amalgam Fig. 19.8: Dimensions of bur number 245 for cavity preparation.
Initial Cavity Preparation
5. While working towards mesial and distal surface,
1. Outline form orient the bur toward respective marginal ridge. This
Outline form means extending the preparation margins to results in slight divergence of mesial and distal walls,
the place they will occupy in the final preparation, avoid which helps to provide dentinal support for marginal
ending preparation margins in high-stress areas like cusp ridges (Fig. 19.9D).
tip and crest of the ridges, and placing the margins on 6. Isthmus width should not be more than one-fourth of
sound tooth structure (Fig. 19.7). intercuspal distance.
7. Deep pit and fissure defects less than 0.5 mm apart
should be included in outline form.
8. External outline form should have smooth curves,
straight lines, and rounded angles. All unsupported
and demineralized enamel should be removed.
9. Enameloplasty is done whenever required to remove
sharp and irregular enamel margins by “rounding”
or “saucering”, thereby converting these into self-
cleansable areas. Enameloplasty should not extend the
outline form.
Fig. 19.7: Outline form for a class I cavity preparation.
2. Primary Resistance Form
Steps:
1. Take number 245 bur for cavity preparation. Its Primary resistance is achieved by having following features
dimensions help in guiding ideal cavity preparation, in the preparation:
i.e. depth of cavity preparation, 1.5 mm (half the 1. Box-shaped preparation with flat floors: This helps
the tooth to resist occlusal masticatory forces without
length of bur, i.e. 3 mm), to preserve marginal ridge
fracture. Though floor should be flat, but it should also
of width 1.6–2 mm (double the width of bur, i.e.
follow the contour of occlusal surface.
0.8 mm), rounded internal line angles, and convergent
2. Minimum occlusal depth of 1.5 mm, to provide
external walls (due to pear shape with rounded adequate thickness of amalgam.
corners of the bur) (Fig. 19.8). 3. Cavosurface angle of 90° (Fig. 19.9E)
2. Using number 245 bur oriented parallel to the long 4. Restricting the extension of external walls so as to have
axis of tooth, make a punch cut in carious lesion (Fig. strong marginal ridge areas with sufficient dentin
19.9A). support.
3. Maintain the initial depth of 1.5 mm from central 5. Maintaining minimal width of cavity which is not
fissure at least 0.2–0.5 mm in dentin. While more than 1/4th of intercuspal distance.
maintaining the same depth and bur orientation, 6. Keeping the pulpal floor 0.2 mm in dentin
move the bur to include defective pits and fissures 7. Inclusion of all the weakened tooth structure.
(Figs. 19.9B and C). 8. Rounding off all the internal line and point angles.
4. Extend the margin mesially and distally but do not 9. Circumventing of cusps should be done for
involve marginal ridges. These walls should have preserving cuspal strength and achieving a smooth,
dovetail shape to provide retention to the restoration. free flowing outline form.
A B C D E
F G H I
Figs. 19.9A to I: Steps of class I cavity preparation.
3. Primary Retention Form In the large preparations with soft caries, the removal of
carious dentin is done with spoon excavator or slow-speed
Primary retention for amalgam is provided by following
round bur. In this, stepped or two-level pulpal floor is
features:
made, i.e. only portion of tooth which is affected by caries
◆◆ Occlusal convergence (about 2–5%) of buccal and
is removed, leaving the remaining floor untouched (Figs.
lingual walls (Fig. 19.9F)
19.9G and H).
◆◆ Occlusal dovetail.
4. Convenience Form Protection of Pulp, if needed

Convenience form is provided by having sufficient width Use of pulp protective materials depends upon following
of the preparation so as to have ease of accessibility and factors:
instrumentation. ◆◆ Base is not required in shallow preparations (1.5-2.0
mm deep). In these cases, only varnish is used.
Final Cavity Preparation ◆◆ In a deep preparation, a base is placed in the deepest
part in the thickness of 0.5–0.75 mm, so as to protect
Removal of Remaining Carious Dentin pulp (Fig. 19.9I).
In this, remaining caries, old restorative material, and Be sure that no trace of the base material remains on
adjacent deep pits and fissures are removed and involved enamel walls of preparation, as this would eventually
in the preparation. dissolve in the oral fluids leaving a gap between the
restoration and the tooth resulting in microleakage and

recurrent caries.
Finishing of the Enamel Walls and Margins

Finishing of walls and margins is guided by the knowledge
of dental histology. At this stage, all unsupported enamel
is removed. Cavosurface angle should be made 90° butt
joint type. This provides bulk to restoration, which in turn,
provides maximum strength.
Final Cleaning and Inspection of the Preparation

Final stage of cavity preparation is to clean the preparation
thoroughly with water and air spray. Then dry it with moist
air and inspect it for final approval.
Fig. 19.11: During lingual extension, inclined the bur facially so as to
Cavity preparation on Occlusal Surface with establish the axial wall of lingual portion.
Buccal or Lingual Extension (Fig. 19.10)
a. For buccal or palatal extension, slight modification is c. Conventional preparation on occlusal surface of
required maxillary first molar (Fig. 19.12C).
b. To prepare the lingual surface, hold the bur parallel to d. Conventional preparation on occlusal surface of
lingual surface mandibular first molar (Fig. 19.12D).
e. Conservative preparation on occlusal surface of
mandibular first premolar (Fig. 19.12E).
f. Conventional preparation on occlusal surface of
mandibular premolar (Fig. 19.12F).
Class II Cavity preparation for

Amalgam Restoration
Initial Cavity Preparation
1. Outline form
Fig. 19.10: Photograph showing class I amalgam preparation Outline form for occlusal portion follows the same
with buccal extension.
principles as given for pit and fissure lesions except
c. Inclined the bur facially so as to establish the axial wall that external outline is extended proximally towards
of lingual portion (Fig. 19.11) defective proximal surface. For description, a mesio-
d. Axial wall should follow the contour of lingual surface occlusal preparation on mandibular second premolar is
of tooth and it should be 0.2 mm in the dentin considered.
e. Make a box shaped preparation with parallel mesial or
distal walls i. Establishing the Occlusal Step
f. Round off the axiopulpal line angle. if additional
retention is required, using no. 1/4 or 169 bur, place ◆◆ Using high-speed bur, make a punch cut in the
grooves into mesioaxial and distoaxial line angles pit closest to the involved proximal surface. Keep
g. Accomplish the final tooth preparation by removal of long axis of the bur parallel to the long axis of the
remaining caries and pulp protection. finally inspect tooth and maintain the initial depth of 1.5–2.0 mm
the prepared cavity for amalgam restoration. (Fig. 19.13A).
◆◆ Extend the outline to include the central fissure while
Cavity preparations on Occlusal Surfaces of maintaining uniformity in depth of pulpal floor (Fig.
19.13B).
Different Teeth (Figs. 19.12A to F)
◆◆ Make isthmus width as narrow as possible, not more
a. Cavity preparation on maxillary incisors (Fig. 19.12A). than one-fourth of the intercuspal distance. Give slight
b. Conservative preparation on occlusal surface of occlusal convergence to facial, lingual, and proximal
maxillary first molar (Fig. 19.12B). walls to provide retention for amalgam. A dovetail
A B C
D E F
Figs. 19.12A to F: Cavity preparations on occlusal surfaces of different teeth.
is provided in the distal pit area to prevent mesial small chisel or enamel hatchet. Proximal margins should
displacement of the restoration. Consider enameloplasty have a cavosurface angle of 90° and when completed,
wherever required to conserve tooth structure. the walls of the proximal box should converge occlusally
(Fig. 19.13F). Flatten the gingival floor so that masticatory
ii. Extending Occlusal Step Proximally forces are distributed equally. Flattening of gingival floor
is done using enamel hatchet. Ideal width of gingival seat
While maintaining established pulpal depth, extend the
ranges from 0.6 mm to 0.8 mm for premolars and 0.8 mm to
preparation toward proximal surface of tooth, ending 0.8
1.0 mm for molars. It consists of 2/3rd of dentin and 1/3rd
mm short of cutting through mesial marginal ridge (Fig.
of enamel. Ideal clearance of facial and lingual margins of
19.13C). Proximal cutting should be sufficiently deep
the proximal box should be 0.2–0.5 mm from the adjacent
into the dentin (0.5–0.6 mm) so that retentive locks are
tooth (Fig. 19.13G).
prepared into axiolingual and axiofacial line angles.
iii. Preparation of Proximal Box 2. Primary Resistance Form

Widen the preparation faciolingually to just clear the This can be obtained by incorporating the following
contact areas. Proximal cut is diverged gingivally. It results features in the preparation:
in greater faciolingual dimension at gingival surface i. Providing enough depth of cavity to have sufficient
than occlusal surface. It provides good retention and bulk of amalgam
conservation of marginal ridge (Fig. 19.13D). Keep a small ii. Flat pulpal and gingival floor
slice of enamel at the contact area to prevent accidental iii. Cavosurface angle of 90°
damage to adjacent tooth (Fig. 19.13E). If there is any iv. Maintaining minimal width of the preparation so as to
doubt that accidental damage to the adjacent tooth can preserve tooth structure
occur, use a metal matrix band interdentally. Fracture v. Rounding the internal line and point angle
the slice of enamel in the region of the contact area with a vi. Cusp capping for preserving cuspal strength.
A B C
D E F G
H I J K
L M
Figs. 19.13A to M: Steps of class II cavity preparation for amalgam restoration: (A) Keep long axis of bur parallel to the long axis of the tooth and
maintain the initial depth of 1.5–2.0 mm; (B) Extend the outline to include the central fissure maintaining uniformity in depth of pulpal floor;
(C) Extend the preparation toward proximal surface of tooth; (D) Diverge the proximal cut gingivally, resulting in greater faciolingual dimension
at gingival surface than occlusal surface; (E) Keep a small slice of enamel at the contact area to prevent damage to adjacent tooth; (F) Make
proximal cavosurface angle of 90° and proximal box converge occlusally; (G) Clearance of facial and lingual margins of the proximal box should
be 0.2–0.5 mm from the adjacent tooth; (H) Occlusal convergence of buccal and lingual walls; (I) Rounding of axiopulpal line angle to reduce
stress concentration and increase bulk of amalgam; (J) Retention locks at axiofacial and axiolingual line angles; (K) Providing pulp protection;
(L and M) Beveling of gingival cavosurface angle for removing unsupported enamel rods.
3. Primary Retention Form ◆◆ Make cavosurface angle 90° butt joint to provide bulk
to restoration, which in turn, provides maximum
Retention is achieved by following features:
strength.
◆◆ Occlusal convergence (about 2–5%) of buccal and
◆◆ The final stage of cavity preparation is to clean the
lingual walls (Fig. 19.13H) preparation thoroughly with water and air spray. Then
◆◆ Occlusal dovetail. dry it with moist air.
Final Cavity Preparation Reverse Curve

I. Removal of Remaining Caries or Old Restorative In class II preparations, extension of proximal area is
Materials important for elimination of caries and breaking proximal
During final preparation, remove debris and examine for contacts. But in teeth with broader contacts, reversed
correction of all cavosurface angles and margins. Remove S-shaped curve is given to both widen the box yet remove
remaining caries, old restorative material, and adjacent less tooth structure. Reverse curve is given to the proximal
deep pit and fissure involved in the preparation. In the walls by curving them inward toward the contact area (Fig.
19.14). If excessive flare is given in these teeth, proximal
large preparations with soft caries, the removal of carious
walls will end past the axial angle of tooth through the
dentin is done with spoon excavator or slow-speed round
cusps resulting in weakening of tooth structure and
bur. In this, stepped or two-level pulpal floor is made, i.e.
fracture of restoration. Therefore, this S-shaped curve
only portion of tooth which is affected by caries is removed,
helps in increasing the resistance form of tooth and the
leaving the remaining preparation dentin untouched.
amalgam restoration.
II. Secondary Retention and Resistance Form

Secondary resistance and retention is achieved by:
i. Limit the extensions of external walls.
ii. Rounding of axiopulpal line angle: This reduces stress
concentration and increases bulk of amalgam at that
area (Fig. 19.13I).
iii. Providing retention locks at axiofacial and axiolingual
line angles using 169 L bur, 0.2 mm into dentin (Fig.
19.13J).
iv. Placing retention grooves on axiofacial and axiolingual
line angles with number 1/4 round bur or 1/8 bur.
The grooves should extend in the proximal walls just Fig. 19.14: Reverse curve is given to the proximal walls by curving
inside the DEJ and not the corners of the box. them inward towards the contact area to both widen the box yet
v. Circumferential slot 0.5–1.0 mm deep inside DEJ remove the less tooth structure.
prepared by using number 33½ inverted cone bur.
vi. Using pins like cemented, friction lock or threaded Advantages
pins. ◆◆ Conserves the sound tooth structure
vii. Amalgapins. ◆◆ Preserves the triangular ridge of the affected cusp
◆◆ Flare of the proximal wall leaves the tangent to that
III. Pulp Protection outer tooth surface at 90° angle, this further increases
the resistance form.
Use pulp protective materials on pulpal floor and axial
wall (Fig. 19.13K).
Factors Affecting Class II Preparation Design
IV. Finishing of Enamel Walls and Margins Modifications in class II cavity preparation are made
depending upon the following factors:
Finally finishing of walls and margins is done by removing
all unsupported enamel. Beveling of enamel portion of
1. Extent of Caries
gingival wall is done with the help of gingival margin
trimmer. This helps to have full-length enamel rods at the In extensive caries, complex amalgam restorations and
gingival margin (Figs. 19.13L and M). Gingival cavosurface full coverage restorations are indicated. In small proximal
bevel is not indicated if gingival margin is placed gingival caries, instead of making ideal class II preparation, only
to cementoenamel junction (CEJ) proximal box can do.
2. Aesthetic Requirement 1. Slot Preparation

In maxillary premolars, for aesthetics reasons, minimal Indications of slot preparation:
facial extension is done so as to display less amalgam. ◆◆ Proximal root caries in geriatric patients with gingival
recession
3. Relationship with Adjacent Tooth ◆◆ When adjacent tooth is missing
If adjacent tooth is missing, slot preparations are made for ◆◆ When isolation is difficult in treating cervical one-third
treating proximal caries. root caries.
Design features: It is similar to class V cavity preparation.
4. Requirements for Abutment Teeth for Partial Dentures Preparation is approached from facial aspect. It is done
with round bur number 2 or number 4 to a limited depth
Here modifications are done for providing retention to axially, i.e. 0.75–1.25 mm (Fig. 19.16). When occlusal mar-
the prosthesis without compromising class II amalgam gins are in enamel, make them 0.5 mm in dentin. Prepare
restoration. 90° cavosurface margins, give retention grooves at axio-oc-
clusal and axiogingival line angles 0.2 mm inside the DEJ.
5. Rotated Teeth
Here preparation is modified according to contact with
adjacent tooth.
Modifications in Class II Design

Following modifications can be made in class II design
(Fig. 19.15):
1. Slot preparation
2. Simple box preparation
3. Aesthetic considerations
4. Rotated teeth
5. Unusual outline form
6. Conservative preparation for mandibular first premolar
and maxillary molar
7. Adjoining restoration Fig. 19.16: Schematic representation of slot
8. Modification for abutment teeth. preparation for amalgam.
2. Simple Box Preparation

Indications of simple box preparation:
◆◆ Small proximal caries, not involving the occlusal surface
◆◆ Proximal surface caries with narrow proximal contact
◆◆ Proximal caries in attrited teeth.
Design features (Fig. 19.17): Prepare proximal box with
minimum facial and lingual extensions. For retention,
facial and lingual walls are converged and locks of 0.5
mm depth gingivally and 0.3 mm occlusally are made
in extensive proximal boxes. Retentive grooves are not
indicated in conservative small proximal boxes.
3. Aesthetic Considerations
To avoid unaesthetic display of amalgam in mesio-occlusal
preparation of maxillary first premolar restoration, the
facial wall of proximal box is prepared straight, parallel
to long axis of the tooth rather than gingivally divergent.
By doing this, unaesthetic display of amalgam at facio-
Fig. 19.15: Modifications in class II design. gingival corner of tooth can be avoided.
Fig. 19.17: Proximal box for amalgam restoration. Fig. 19.18: Conservative preparation for molar.
4. For Rotated Teeth

Design features: They are similar as that of normally
aligned teeth except that preparation depends on area of
tooth which is in contact with adjacent tooth. Depending
on angle of rotation, the proximal box is displayed facially
or lingually.
5. Unusual Outline Form

If fissures are separated by 0.5 mm or more, restore the
tooth with individual amalgam restorations. Until or
unless fissure is emanating from occlusal surface, dovetail
is not required.
6. Conservative Preparation for Maxillary First Molar

and Mandibular First Premolar
Conservative design in these teeth helps in the preservation
of oblique ridge or the transverse ridge which protects the Fig. 19.19: Due to inclination of mandibular first premolar, bur should
cuspal strength. be tilted to avoid exposure of facial pulp horn.
Design features: For maxillary first molar, mesio-occlusal
and disto-occlusal preparations are made independently
without involving oblique ridge (Fig. 19.18). without weakening the margins of previous restoration.
Oblique ridge in preparation is included if: The intersecting margins of two restoration should be
◆◆ Ridge is undermined by caries perpendicular to each other (Figs. 19.20A and B).
◆◆ Distance between MO preparation and DO preparation If a tooth has continuous class II and class V preparations,
is less than 0.5 mm then prepare and restore class II lesion before class V to
◆◆ Ridge is crossed by deep fissure. facilitate the ease of condensation.
For mandibular first premolar, transverse ridge is not
involved in proximal preparation. Because of high facial 8. Modification for Abutment Teeth
pulp horn, pulpal floor should have facial inclination to
For abutment tooth, additional extension is required
avoid exposure of buccal pulp horn (Fig. 19.19).
if rest seat is planned for partial denture. For abutment
teeth, facial and lingual walls are extended more for
7. Adjoining Restoration providing space for rest seat (Fig. 19.21). Also pulpal
If proximo-occlusal restoration is already present and a floor is deepened 0.5 mm more in the area of rest seat so
new restoration is required adjoining it, then care should as to provide sufficient thickness for the amalgam (Fig.
be taken while preparing the tooth for second restoration 19.22).
A B
A B
Figs. 19.20A and B: (A) If restoration is already present, the intersection

margins of two restorations should be perpendicular to each other; (B)
If Class II and V preparation are required, then prepare and restore the
Class II cavity before Class V to conserve the tooth structure and have
ease of condensation.
C D
Figs. 19.23A to D: Steps of cusp capping for amalgam.
Cusp capping increases resistance form of the tooth.

Cusp reduction should result in uniform amalgam
thickness of 1.5–2.0 mm, though thicker amount is required
for functional cusps. For cavity preparation, take number
245 bur parallel to cuspal inclines and make depth cuts
of 1.5–2 mm depth. Reduce the cusps along mesiodistal
inclines. Reduced cusp should meet the unprepared cusp
at 90° cavosurface angle so as to have adequate bulk of the
amalgam and edge strength. Since cusp capping reduces
amount of vertical preparation wall height, therefore
Fig. 19.21: For abutment teeth, extend facial and lingual walls to
provide space for rest seat. it is indicated to give secondary retentive features like
retention locks, slots, etc.
Class III Cavity preparation for

Amalgam Restoration
Since amalgam is not aesthetic restoration, it is not
indicated for proximal surface of incisors and mesial
surface of canines. Amalgam for class III restoration
is indicated in the distal surface of maxillary and
mandibular canines especially, if:
◆◆ Caries do not undermine distal slopes of canines
◆◆ Labial axial angle is intact
◆◆ Sufficient tooth structure is present after removal of
caries
◆◆ Restoration which is not subjected to occlusal forces.
Fig. 19.22: Deepening of the pulpal floor for sufficient

thickness of amalgam.
Initial Cavity preparation
◆◆ Outline form includes only proximal surface. Shape of
9. Cusp Capping (Figs. 19.23A to D)
preparation is like a triangle with round corners. Labial
Cusp capping with amalgam is indicated if there is: side of triangle conforms more to the anatomy than
◆◆ Faciolingual width of the cavity is more than 2/3rd of with lingual side.
intercuspal distance. ◆◆ A punch cut is made using number 2 round bur on
◆◆ Undermining of cusp by caries. distolingual marginal ridge. Preliminary shaping of
◆◆ Lingual dovetail is required for large preparations. It
is prepared only after completion of proximal portion
because otherwise tooth structure needed for isthmus
between proximal portion and dovetail might be
removed when the proximal outline form is prepared.
◆◆ Finishing of external walls is done to remove all
unsupported enamel and to make cavosurface angle
90°. For rounding of junctions between different
retentive grooves, angle former or GMT can be used.
Class V Cavity preparation

Class V lesion is present on the gingival third of facial and
lingual surfaces of all teeth. Amalgam is not indicated for
anterior teeth, except when aesthetics is less important
A B and moisture control is difficult.
Figs. 19.24A and B: Class III tooth preparation: (A) Initial cavity
preparation for Class III amalgam; (B) Final cavity preparation with Initial Cavity Preparation
retention groove.
◆◆ Outline form is dictated by extension of caries. Outline
resembles kidney or bean shape.
preparation is completed with inverted cone bur with ◆◆ Preparation is started by keeping the bur perpendicular
long axis of bur keeping perpendicular to the lingual to long axis of tooth (Fig. 19.25A).
surface of the tooth. Depth of bur should be 0.5 mm ◆◆ Initial axial wall depth is maintained 0.5 mm into the
into the dentin. Outline form is completed when facial, dentin. Axial wall depth at the occlusal wall should
gingival, and lingual walls are prepared. be more than at the gingival wall. This will result in a
◆◆ Cavosurface angle should be about 90° at all margins curved axial wall which conforms the contour of tooth.
(Fig. 19.24A). ◆◆ Extend the preparation incisally, gingivally, mesially,
and distally till the cavosurface margins are placed on
Final Cavity Preparation sound tooth structure (Fig. 19.25B).
◆◆ Removal of any remaining infected dentin is done using Final Cavity Preparation
a slow-speed round bur or spoon excavator. ◆◆ Remove any remaining caries using a round bur.
◆◆ Pulp protection is provided by using base or liner on ◆◆ For retention, give grooves incisally and gingivally
axial wall. along axioincisal and axiogingival line angles using a
◆◆ Resistance form is achieved by butt joint, rounded number 1/4th round bur, groove is prepared 0.2 mm
internal angles, and sufficient bulk of amalgam. into the dentin having depth of 0.25 mm.
◆◆ Retention is obtained by placing retention groove with ◆◆ Use hoe and chisel to finish the mesial, distal, and
a small round bur in the axiofaciogingival point angle gingival walls.
and lingual dovetail (Fig. 19.24B). Finally, clean and inspect the cavity (Fig. 19.25C).
A B C
Figs. 19.25A to C: Cavity preparation for class V amalgam restoration: (A) Start the preparation by keeping bur perpendicular to long axis of
tooth; (B) Extend the preparation incisally, gingivally, mesially and distally till the cavosurface margins are placed on sound tooth structure; (C)
Class V cavity preparation.
Class VI Cavity preparation for For this, triple distilled pure mercury having bright, mirror-
Amalgam Restoration like surface should be used. According to ADA specification
number 6, it should not leave any residue while pouring.
Class VI cavity preparation involves restoration of incisal
edge of anterior teeth or the cusp tip of posterior teeth 3. Mercury-alloy Ratio
(Fig. 19.26). Mercury-alloy ratio should be according to type of alloy
Indications of restoration of class VI lesions with used. Eames preferred 1:1 ratio of alloy/mercury for best
amalgam: results. Generally, it is 5:8 or 5:7 ratio. Lathe-cut amalgam
◆◆ In teeth where, enamel is lost due to excessive wear alloys require more (45%) of mercury to wet than the
and the underlying dentin becomes carious, commonly spherical alloys (40%).
seen in geriatric patients. ◆◆ If mercury content is more than required amount,
◆◆ Hypoplastic cusp tips as these are more prone to caries. resultant mix will be weaker. If mercury is less, it may not
sufficiently wet the alloy particles. Nowadays, capsules
with preproportioned amounts of alloy and mercury are
preferred. Here, alloy and mercury are separated by a
membrane which is ruptured by manual compression
of the capsule or amalgamator (Fig. 19.27).
Fig. 19.26: Class VI cavity preparation for amalgam restoration.
Steps of Cavity Preparation

◆◆ Penetrate enamel with a small-tapered fissure bur
extending to the depth of 1.5 mm.
◆◆ Prepare a 90° cavosurface margin on enamel.
◆◆ Make small undercuts along the internal line angles to
provide retention.
STEPS for amalgam restoration Fig. 19.27: Amalgam capsule.
1. Selection of Amalgam Alloy

Following factors are considered while selecting an alloy 4. Trituration
for restoration: Purpose of trituration is to remove oxide layers from alloy
◆◆ Type of alloy: particles so as to coat each alloy particle with mercury,
•• High copper or low copper alloys resulting in a homogeneous mass for condensation.
•• Zinc-free or zinc-containing alloys Trituration can be done by hand or mechanical means.
•• Size and shape of the particles. Mechanical method is done with the help of automatic
In general, admixed or unicompositional high copper amalgamator (Fig. 19.28A) and hand method of trituration
alloys are preferred due to superior properties. Lathe-cut
is done with the mortar and pestle (Fig. 19.28B).
low copper alloys are not used due to their poor properties.
Mechanical amalgamators take less mixing time, produce
Normally zinc-containing alloys are preferred because
uniform mix, and reduce chance of mercury spilling in the
zinc makes the amalgam mass more plastic and workable
dental office.
but if it is difficult to control moisture, it is preferred to use
zinc-free alloy to avoid delayed expansion. Objectives of trituration
2. Mercury Objectives of trituration are to:
◆◆ Achieve a workable mass of amalgam within minimum
Mercury forms 50% of dental amalgam mass by weight. The time
chemical properties of elemental mercury allow it to react and ◆◆ Increase direct contact between particle and mercury
bind together the amalgam alloy particles to form amalgam. by removing oxides from powder alloy particles
A B C
Figs. 19.29A to C: (A) Normal triturated is shiny homogenous mass

with plastic consistency; (B) Overtriturated mix is shiny and hard
due to premature setting of amalgam; (C) Undertriturated mix is dry,
A crumbly and dull in appearance.
can be done manually or mechanically. By hand, it can be

done by squeezing the freshly mixed amalgam collected
in the chamois skin. Mulling should not be done by bare
hands as it can be contaminated by moisture. Mechanical
mulling is done in the amalgamator by triturating it for 2–3
seconds.
6. Application of Matrix Band

This step is done in case one or more walls of tooth are
missing. For example, class II, class I with extension, class
V, and complex amalgam restorations.
B 7. Insertion of Amalgam
Figs. 19.28A and B: (A) Amalgamator; (B) mortar and pestle. Use amalgam carrier to carry amalgam alloy into the
preparation. Place first increment of amalgam in the
◆◆ Reduce particle size of powder so that fast and complete deepest proximal part of preparation and condense it
amalgamation can occur with flat surface of condenser. After it, add next increment
◆◆ Help in dissolving the particles of powder in mercury and again condense it. When level of amalgam reaches
◆◆ Reduce the amount of gamma-1 and gamma-2. preparation margins, continue the packing of preparation
Time for which the trituration is done, speed, and force to allow an excess to build up for better finishing.
applied for trituration, affect the quality of trituration.
Trituration can produce following three types of mixes 8. Condensation
(Figs. 19.29A to C):
i. Normal triturated mix: This is a shiny mix which is Condensation is process of compaction of amalgam into
plastic in consistency, appears as homogeneous mass prepared cavity until dense mass of amalgam is formed in
and convenient to handle. the preparation. Condensation is done by using different
ii. Over-triturated mix: This mix is “warm”, shiny, and shapes of condensers like round, elliptical, trapezoid,
hard due to premature setting of amalgam. This mix is and parallelogram. Working end of condenser should be
difficult to condense in prepared cavity. serrated so as to avoid slipping away of amalgam while
iii. Under-triturated mix: This mix is dry and crumbly manipulation.
which is very weak and dull in appearance and difficult Start condensation soon after trituration otherwise it
to manipulate. becomes difficult to adapt the amalgam to cavity walls.
Condensation should be continued till cavity is overfilled.
For spherical alloys, condenser with large tip should
5. Mulling
be used with ranging between 2–4 lbs. If more force is
Mulling is continuation of trituration so as to make the applied, spherical particles tend to get pushed to the side
mix homogenous and cohesive. Mulling of the amalgam creating a punch throughout the amalgam mass.
For admixed amalgam, condenser with smaller tip is 11. Checking the Occlusion
used with force ranging from 5 lbs to10 lbs.
Since amalgam has not gained full strength at this stage, tell
the patient to gently contact upper and lower teeth without
Objectives of Condensation (Table 19.5)
applying pressure. Place an articulating paper and check
1. Reduces residual mercury in amalgam mass by for “high points” marked on the restoration during centric
bringing excess mercury on the surface of restoration. and eccentric movement. These marked areas are carved
2. Adapts the amalgam to cavity walls. using spoon excavator or cleoid–discoid carver.
3. Compacts amalgam thus reduces voids in the
restoration. 12. Postcarve Burnishing
Table 19.5: Choice of condenser depending upon type of amalgam It is done after completion of carving with the help of
alloy. small-sized burnishers using light strokes to improve the
Type of alloy Type of condenser smoothness with shiny appearance. It helps in reducing
Lathe-cut alloy Small condenser the surface roughness produced by carving. In high
Admixed alloy Small condenser
copper amalgam restoration, postcarve burnishing has no
significant effect on the clinical performance but in low
Spherical alloy Large condenser
copper amalgam, postcarve burnishing produces denser
amalgam at the margins.
9. Precarve Burnishing
Objectives
Precarve burnishing is done soon after condensation
when amalgam is overfilled. It is burnished immediately ◆◆ Reduces number of voids on surface of restoration
using large round or egg-shaped burnisher applying firm ◆◆ Produces denser amalgam at margins
and gentle strokes moving from amalgam to tooth surface ◆◆ Improves marginal seal
for 10–15 seconds. ◆◆ Increases surface hardness
Objectives of precarve burnishing: ◆◆ Decreases rate of corrosion.
◆◆ Improves the marginal integrity of restoration.
◆◆ Shapes the restoration according to contours and 13. Finishing and Polishing
curvatures of the tooth. Finishing an amalgam restorations involves removal of
◆◆ Helps in reducing the mercuric content of amalgam. marginal irregularities, defining anatomical contours,
and smoothening the surface roughness of restoration.
10. Carving Polishing is done to achieve a smooth and shiny luster on
surface of amalgam restoration. Finishing and polishing
Carving is anatomic sculpturing of amalgam restoration.
should be done after 24 hours of placement of amalgam
It is done to produce anatomical contours and functional
restoration. Premature finishing and polishing will
occlusion for the restoration. Amalgam should not be
interfere with crystalline structure of hardening amalgam,
carved until it is sufficiently firm. For adequate carving, it
is preferable to overpack the preparation and then carve resulting in weakening of the restoration. Polishing may
it to the margins. Commonly used carvers are Hollenback not be essential for restorations with high copper alloys
carver, Frahm’s carver (diamond-shaped) and cleoid– because they have a tendency of self-polishing.
discoid carver.
Advantages of Polishing
Objectives of carving are to achieve restoration with:
◆◆ No over- and underhangs ◆◆ Improves marginal adaptation of restoration by
◆◆ Proper size, location, and good interproximal contact removing flash
◆◆ Adequate marginal ridges ◆◆ Reduces tarnish and corrosion
◆◆ Optimal occlusal anatomy and contours •• Polished surface is plaque resistant
◆◆ Adequate embrasures. •• Polished surface is smoother and easier to clean
In proximal cavity preparation, carving should be •• Prevention of recurrent decay
started while matrix band is still in place. Define occlusal •• Prevention of amalgam deterioration
embrasure of marginal ridge by removing excess amalgam •• Maintenance of periodontal health.
using carver 45° to the matrix. Then, create triangular fossa
using cleoid–discoid carver. After this, do the occlusal Steps for Finishing and Polishing of Amalgam
carving, keeping the carver blade parallel to cuspal 1. Identify the high spots which appears burnished shiny
inclines. Perform the remaining carving after removal area on the surface of restoration. Establish proper
of wedge and matrix. Remove amalgam flash and refine occlusion with steel finishing bur by running it lightly
proximal contours using Hollenback carver. on the surface.
2. Use series of abrasive points working with gentle touch
and constant movement on restoration surface. Take
care to avoid overheating the amalgam. Amalgam
surface must not be heated above 140°F (60°C) by
polishing procedure. If temperature rises above 60°C,
more mercury is released which may cause corrosion
and fracture at the margins.
3. Polish the surface by using progressively finer abrasive
agents. For polishing amalgam, pumice is mixed with
tin oxide slurry and used with rubber cup or wheel
brush. Continue to polish the amalgam until tin oxide
begins to dry and high luster is achieved. An optimally
polished amalgam has smooth surface with mirror-
like shine. It is plaque resistant, and less prone to
tarnish and corrosion.
Fig. 19.31: Proximal overhang.
life of amalgam restorations
Since 1860, amalgam has been the most widely used
restorative material in posterior teeth. Studies have shown 2. Proximal Overhangs (Fig. 19.31)
that life of a properly manipulated and restored silver
proximal overhangs can be detected radiographically
amalgam restoration is about 10–12 years. With time,
and clinically. Overhang is confirmed by tearing of a floss
the restoration may show some changes such as tarnish,
when passed through it. Overhangs lead to gingival and
corrosion, recurrent marginal caries, discoloration of
periodontal problems because of food impaction.
teeth, fracture of restoration or tooth, and ultimately
loss of restoration. Clinical failure is the point at which a
restoration is no longer serviceable or when it poses risks, 3. Improper Marginal Ridges
if not replaced. Marginal ridge of a restoration should be at the same level
as that of adjacent tooth. If there is incompatible marginal
Failures of Amalgam Restoration ridge, it leads to improper embrasure form, food impaction
and periodontal disease. Such restorations need to be
1. Marginal Ditching (Fig. 19.30) replaced.
marginal ditching is breakdown of amalgam at the margins
due to fracture or poor seal because of improper cavity 4. Poor Anatomic Contours
margins. If ditching is shallow less than 0.5 mm, it is not
Amalgam restoration with inadequate embrasure form,
a sign of failure because sealing property of amalgam can
improper marginal ridges, and flat contours need to be
improve the marginal seal. But if ditching is deep, it can
replaced (Fig. 19.32).
result in secondary caries.
Fig. 19.30: Marginal ditching of amalgam. Fig. 19.32: Poor anatomic contour of amalgam restoration.
5. Voids 9. Secondary or Recurrent Caries

Voids occur because of improper condensation of Secondary caries can occur where gaps or fractures are
amalgam. Voids can result in secondary caries and such present in amalgam restorations. These can be confirmed
restorations need replacement or repair. by clinical or radiographic examination (Fig. 19.34). These
restorations need to be replaced.
6. Fracture of Tooth of Restoration
Fracture of tooth or restoration can occur because of lack
of resistance and retention form. Such restorations need to
be replaced (Figs. 19.33A and B).
7. Poor Occlusal Contacts

poor occlusal anatomy can result in improper functioning.
Such restorations need replacement.
8. Improper Proximal Contacts

While treatment of proximal surface lesion, restoration
of optimal contact should be achieved so as to avoid food
lodgment and secondary caries. improper contact in
form of open contact leads to food impaction and further
periodontal problem. Such restorations need to be replaced.
Fig. 19.34: Faulty restoration leading to secondary caries.
10. Amalgam Blues

It is display of bluish hue through a thin layer of enamel.
Amalgam blues occur due to leaching of products into
dentinal tubules or due to color of underlying amalgam
visible through the thin layer enamel. It can result in loss
of aesthetics and needs replacement.
11. Fracture Lines

Fractures lines present on occlusal surface especially in
isthmus region need replacement of restoration.
A Reasons for Failure of amalgam

restorations
Reasons for failure of amalgam restorations can be divided
under the following headings:
1. Improper case selection
2. Improper cavity preparation
3. Faulty amalgam manipulation
4. Defective matrix adaptation
5. Post-restorative failures.
1. Improper Case Selection

For long-term success of the amalgam restorations, careful
selection of case is very important. Since amalgam requires
sufficient sound tooth structure to provide sufficient
B resistance and retention form, selecting teeth with
Figs. 19.33A and B: photograph showing fracture of extensive loss of tooth structure and undermined enamel,
amalgam restoration. parafunctional habits like bruxism and heavy masticatory
forces can result in restoration failure. Amalgam should be iv. Curved Pulpal Floor
placed in small-to-moderate-sized carious lesions.
Flat pulpal floor of the preparation provides resistance
form. Curved pulpal floor of cavity preparation creates
2. Improper Cavity preparation wedging effect, which can result in tooth fracture.
It is one of the major causes for failure of amalgam
restoration. An ideal preparation for amalgam should v. Lack of Butt Joint at Cavosurface Angle
have butt joint cavosurface angle, convergent walls, flat Cavosurface angle should be a butt joint. If cavosurface
pulpal and gingival floors, rounded line and point angles, angle is acute, enamel margins may fracture under load.
and 1.5–2.0 mm depth to provide sufficient bulk to the If cavosurface angle is obtuse, marginal amalgam may
restoration (Fig. 19.35). Following defects during cavity fracture under masticatory stresses.
preparation can cause amalgam failures.
vi. Unsupported Enamel Rods
i. Inadequate Occlusal and Proximal Box Extension Presence of unsupported enamel rods can result in
One should involve all susceptible pits and fissures fracture of tooth and restoration. These should be removed
in the preparation margins. Insufficient extension to by making the butt joint cavosurface angle and beveling of
include adjacent deep pits and fissures increases chances gingival floor.
for secondary/recurrent caries. Similarly, if walls of
proximal box of class II preparation are not extended vii. Wide and Narrow Isthmus
into embrasures, they become less amenable to cleaning Isthmus wider than 1/3rd of intercuspal distance
resulting in secondary caries. compromises the resistance form because restoration is
subjected to more occlusal forces.
ii. Overextended Cavity preparation Isthmus narrower than rest of cavity can compromise
the retention of restoration.
Width of isthmus should be less than 1/4th of intercuspal
distance. If the faciolingual width of the preparation is viii. Sharp Axiopulpal Line Angle
more than 2/3rd of intercuspal distance, cusp capping
should be considered. If amalgam is to be used for capping, Sharp axiopulpal line angle can result in stress concen
it should be at least 2 mm thick over the functional cusp tration in this area, resulting in restoration fracture.
and 1.5 mm over nonfunctional cusp to prevent its fracture
under masticatory load. ix. Incomplete Removal of Defective Enamel
Incomplete removal of defective enamel can result in
iii. Shallow Cavity Preparation fracture of the restoration under masticatory load.
Minimum depth of preparation should be 1.5–2 mm so
as to provide bulk to restoration which can prevent its x. Extensive Mesiodistal extension
fracture under masticatory load. Cavity preparation lesser
Overextensive mesiodistal preparation undermines the
than 1.5 mm in depth can fracture the restoration.
marginal ridge enamel which may result in tooth fracture.
xi. Lack of Occlusal Convergence

Lack of occlusal convergence compromises the retention
form resulting in amalgam failure.
3. Faulty Amalgam Manipulation

i. Selection of Alloy
High copper alloys should be chosen because of their
superior properties than low copper lathe-cut alloys.
Low copper alloys have low strength, high creep, and are
more prone to tarnish and corrosion. Zinc in amalgam
helps to make amalgam which is plastic, workable, and
less susceptible to oxidation, so zinc-containing amalgam
should be preferred. But moisture contamination in these
Fig. 19.35: Features for retention and resistance form of amalgam. results in delayed expansion causing pain and fracture of
restoration. In case where isolation of operative field is 5. Post-restorative Failures

difficult, zinc-free amalgam should be selected.
Post-restorative Pain
ii. Incorrect Mercury-Alloy Ratio It can occur because of the following reasons:
Ideally, mercury content in amalgam should be between i. High points in amalgam restoration can result in
43% and 50%. If its more than 55%, it causes decrease apical periodontitis or fracture of the filling or tooth
in compressive strength, increased flow, and increased and pain.
susceptibility to tarnish and corrosion. ii. Delayed expansion in zinc-containing alloys. It can
cause fracture of restoration or tooth and pain.
iii. Galvanism due to presence of dissimilar adjacent
iii. Contamination during Manipulation
metal restoration.
While manipulation, if zinc-containing amalgam gets iv. Inadequate pulp protection leads to conduction
contaminated with moisture, marginal failure, post of heat. Varnish is applied on walls to avoid leakage
operative pain, and weakening of restoration can occur around restoration which may cause postoperative
due to delayed expansion. sensitivity.
iv. Improper Condensation Premature Fracture of Restoration

Purpose of condensation is to adapt amalgam to If patient bites on the restoration soon after its placement
preparation walls and to express excess mercury from and before final setting of amalgam takes place, restoration
amalgam. Amalgam mix should be condensed within may fracture. Therefore, postoperative instructions must
3 minutes of its trituration. If it is delayed, it becomes be clearly explained to the patient.
difficult to condense the amalgam. Poor condensation can
result in voids and poor strength of the restoration.
MERCURY HYGIENE
Mercury is main component in amalgam restorations
v. Over and undercarving and also used in medicines to cure skin problems, in
antibacterial ointment and laxatives.
Overcarving of deep pits and fissures results in reduced
thickness of amalgam; this can cause fracture of the
restoration. Undercarving results in high points in the History of Conflicts Regarding Amalgam Use
restoration which can cause trauma from occlusion. 1920 (First Amalgam war)—war between the dentists
This trauma can further cause pain and fracture of the using gold foil and dental amalgam.
restoration. 1980 Dr Hal Huggins—amalgam responsible for cardio
vascular and nervous problems.
vi. Faulty Finishing and Polishing 1991 National Institute of Health–National Institute
Excessive heat production during polishing may result in for Dental Research (NIH–NIDR) Food and
pulpal trauma. Heavy pressure applied during polishing Drug Administration (FDA), and several experts
results in spur-like overhangs, which fracture under concluded that amalgam is not considered as a
mastication causing leaky margins and secondary caries. significant health hazard.
Improper polishing results in rough surface which is
prone to tarnish, corrosion, pitting, plaque accumulation, Forms of Mercury
and gingival irritation. To reduce these while polishing, Mercury exists in three chemical forms:
temperature at the surface should be maintained below
1. Elemental mercury: It is highly volatile form existing
65°C. Excessive heat production can be minimized by
in liquid/vapour form. It can be inhaled and absorbed
using adequate coolant and applying very light pressure
into lungs (80%) and GIT (0.01%). Most common form
during polishing.
of entry in human body during amalgam restoration
can occur due to accidental spillage of mercury in
4. Defective Matrix Adaptation dental office.
Matrix should be properly contoured according to the 2. Inorganic mercury: It is mined as inorganic sulfide
tooth type and stabilized using a wedge. If wedge is ore and exists mainly in liquid form. It is potentially
not used, excess material can go into gingiva and thus toxic and irritating in nature. Its main route of entry is
irritate the periodontium. If matrix band is removed through lungs (80%).
prematurely before the restoration is set, it may fracture 3. Organic mercury: It mainly exists in the form of
the restoration. methyl mercury. Its main route of entry is absorption
via GIT (95–98%). Methyl mercury is present in salt, 4. Insertion and Condensation of Amalgam
vegetables, grains, tuna fish, and sword fish. It is very
◆◆ After mixing, the unhardened mixture releases
toxic in nature.
mercury vapours in air and causes air pollution. Proper
ventilation of the area should be done.
Mercury Exposure in Dental Office ◆◆ Proper aseptic techniques such as use of mouth masks,
gloves, and protective eyeglasses should be done.
In the dental office, mercury exposure can occur from the
◆◆ Avoid direct exposure of mercury with skin.
following sources:
◆◆ Use rubber dam to isolate the tooth.
◆◆ Storage of amalgam raw materials for use
◆◆ Use high-volume evacuation system to control the
◆◆ Mixed but unset amalgam during trituration, insertion,
mercury level in air.
and intraoral hardening
◆◆ Amalgam scrap containing insufficient alloy for consu
ming mercury completely 5. Polishing of Amalgam
◆◆ Finishing and polishing of restoration Polishing should be done with coolant to decrease heat
◆◆ Removal of old restoration. and vapours present in atmosphere.
Steps to Reduce Mercury Exposure in 6. Disposal of Scrap Amalgam

the Dental Clinic Scrap amalgam during insertion and condensation should
be carefully collected and stored under water, glycerin or
1. Designing of Office spent X-ray fixer solution in tightly capped jar. Mercury-
Office should be designed so as to reduce mercury contaminated cotton rolls should be stored in a tightly
contamination. Following points are to be kept in mind capped plastic container for separate disposal.
while designing: Spent X-ray fixer is preferred for storage of amalgam
i. Proper ventilation of the dental office scrap because it is a source of both silver and sulfide ions
ii. Avoid carpeting/floor coverings in dental office as which react with mercury present in scrap amalgam to
there is no way of removing mercury from the carpet form solid product and decrease the mercury vapour
pressure.
2. Storage of Mercury
7. Disposal of Mercury-contaminated Waste
Storage of mercury is considered difficult because it is
very mobile and has high diffusion rate. It can penetrate Disposal of spent capsules, mercury-contaminated
in extremely fine spaces. Therefore, one should take care cotton rolls and paper napkins should be done properly.
while storage of mercury is concerned. For example: These items should be disposed in tightly closed plastic
i. Precapsulated alloys should be preferred for avoiding container/plastic bag which can be placed into sanitary
mercury spill. landfill for disposal.
ii. If bulk mercury is purchased, store it in tight container
with tight lid in closed cabinets. 8. Removal of Old Amalgam Restorations
iii. Location of storage should be near the window/ Certain points should be kept in mind while removing
exhaust vent. amalgam restoration:
◆◆ Rubber dam and high-volume evacuator should be
3. Trituration of Amalgam used to decrease mercury vapour.
i. Use precapsulated alloy in amalgamator ◆◆ Water coolant should be used during the procedure
ii. Avoid manual mixing to avoid spilling because when rotary instruments are used without
iii. High vibrations during mixing can create aerosols of water, it increases the temperature of restoration and
liquid droplets and these vapours may extend up to increases the mercury vapours in that area.
6–12 ft from the amalgamator. So, to minimize the
risk, small covers are used over the amalgamator to 9. Cleaning of Mercury-contaminated Instruments
contain the aerosol in that area Clean the mercury-contaminated instrument used during
iv. Airflow should be reasonably high in dental office to insertion, finishing and polishing, and during removal of
minimize air contamination. restoration as amalgam material left on the instrument
v. Avoid direct exposure of the mercury with skin as it surface, heated during sterilization can release mercury
may cause hypersensitivity reactions. vapour in atmosphere.
10. Monitoring of Mercury Vapours Factors Affecting Toxic Effects of Mercury

The accepted threshold limit for exposure to mercury ◆◆ Amount of exposure
vapour for a 40-hour work per week is 50 μg/m3 (given by ◆◆ Length of exposure
OSHA). ◆◆ Location of mercury accumulation in body
Periodical monitoring of mercury vapour in dental ◆◆ Amount of accumulated mercury
office should be done and carefully recorded. ◆◆ Overall health of the patient (for detoxification).
Dental Mercury Hygiene Recommendations Acute Mercury Poisoning

in Dental Office It occurs when there is sudden exposure of high levels of
mercury, especially from elemental mercury or organic
◆◆ Follow aseptic technique, i.e. wear protective clothing,
mercury. It results in immediate and severe symptoms
protective masks, gloves, and glasses to prevent
requiring urgent medical attention.
exposure to mercury vapours.
◆◆ Dental personnel involved in handling of mercury
and dental amalgam products should follow mercury Levels of Mercury Toxicity
hygiene practice. ◆◆ At level of 4 µg: This level is attributed as the upper
◆◆ Dentists and dental assistants should have knowledge limit in urine when extensive restoration of amalgam is
of amalgam disposal and its handling. present in patient’s mouth.
◆◆ Ventilation of the working space should be there, to ◆◆ At level 0–25 µg: No known health hazards are detected.
reduce mercury levels in the atmosphere. ◆◆ At level 25–100 µg: Decreased response on tests done
◆◆ Periodically check the working area to analyze the for brain conduction. Decreased response related to
mercury vapour pressure using dosimeter badges. verbal skills.
◆◆ Avoid carpet/floor coverings in dental office; floor ◆◆ 100–500 µg: Mild-to-moderate effects can be seen:
coverings should be easy to clean, nonabsorbent, and •• Irritability • Memory loss
seamless. •• Depression • Tremors
◆◆ Mercury should be stored in unbreakable closed •• Nervous system disturbances.
container in isolated area. ◆◆ 500–1,000 µg: Pronounced symptoms:
◆◆ Use precapsulated alloy for mixing. •• Inflammation of kidney
◆◆ Instead of manual/hand mixing, use amalgamator with •• Tremors and pronounced nervous system disturbances
completely enclosed arm. •• Swollen gums.
◆◆ Polish amalgam restoration under coolant to decrease
the mercury vapour pressure.
IS DENTAL AMALGAM SAFE?
◆◆ Avoid direct contact of mercury with skin.
◆◆ Use high-volume evacuation and rubber dam during Amalgams are still widely used by the dental profession
insertion, condensation, and polishing of restoration. in most parts of the world. Some countries like Sweden,
◆◆ Store scrap amalgam in water, glycerin or spent fixer Canada, Germany, and UK have either banned or
solution in closed container. imposed serious limitations on amalgam usage. In
◆◆ Precapsulated alloys and mercury-contaminated cotton the 1990s, several governments evaluated the effects
rolls should be disposed in closed plastic container. of dental amalgam and concluded that the most likely
◆◆ Clean the spilled mercury using trap bottles or freshly health effects would be due to hypersensitivity or
mixed amalgam. allergy. Chewing gum, particularly nicotine, along with
◆◆ Remove professional clothing, gloves, and masks before amalgam, seem to pose the greatest risk of increasing
leaving operating area. exposure. However, the World Health Organization states
mercury levels in biomarkers such as urine, blood, or
hair do not represent levels in critical organs and tissues.
Mercury Toxicity
The American Dental Association Council on Scientific
Mercury toxicity is mainly seen because of chronic Affairs has concluded that both amalgam and composite
exposure of mercury, which can be in form of food, materials are considered safe and effective for tooth
restorations or other sources. Since too many factors are restoration.
involved, it takes time for symptoms to appear. Usually The accepted threshold limit for exposure to mercury
mercury gradually accumulates in the body over a period vapour for a 40-hour work per week is 50 mg/m3 (given by
of time, contributing to chronic mercury poisoning. OSHA).
Amalgam wars literature due to its appearance, environmental hazard,
and alleged toxicity. Dental treatment should ensure that
In 1850, American dentists who used amalgam were dental restorative materials continue to be used in a safe
threatened with malpractice actions by dentists who did
and effective manner for the patient, while respecting the
not. This became known as the “amalgam wars”.
environment.
First Amalgam War

Definition
In 1845, the American Society of Dental Surgeons
restricted the use of all filling materials other than gold as Phase down of dental amalgam is a task to reduce the use
toxic, thereby starting the “First Amalgam War”. However, of dental amalgam through increased prevention, health
this policy was reconsidered in 1850 and after studying promotion, and research on advanced restorative materials
composition and properties of amalgam, its use was and techniques simultaneously have the adequate clinical
promoted by F Flagg, and final approval of its clinical use performance.
came from GV Black. Improved handling and performance Minamata Convention on Mercury is a global agreement
of amalgam blocked the criticism of amalgam as an inferior to protect human health and the environment from the
restorative material and inspired its use. adverse effects of mercury. Controlling the anthropogenic
releases of mercury throughout its lifecycle has been a
Second Amalgam War key factor in shaping the undertakings in convention. It
In mid 1920s, a German dentist, A Stock started the “Second is named after the Japanese city of Minamata, which had
Amalgam War”. He said, mercury from dental amalgam can a severe and prolonged incidence of mercury poisoning
get absorbed leading to health problems. He also showed after industrial wastewater from a chemical factory was
his concerns over the health of dentists. For this, Charite discharged into Minamata Bay. The wastewater contained
Hospital in Berlin formed a committee to investigate methylmercury, which bioaccumulated in fish and
amalgam toxicity. Findings of the committee showed no shellfish in the bay. Local people who consumed seafood
reason to restrict the newer silver-tin amalgams. from Minamata Bay became very sick, and many died or
were left severely disabled.
Third Amalgam War On November 6, 2013 the United States signed the
Minamata Convention on Mercury. The Convention
“Third Amalgam War”, began in 1980 by seminars of
entered into force in 2017, and the first conference of the
Dr Huggins who found that mercury released from
participants took place from 24th September, 2017 to 29th
dental amalgam was responsible for affecting human
September, 2017 in Geneva, Switzerland; by April 2018, 91
cardiovascular and nervous system. He also found that
countries have joined the convention.
removal of amalgam restorations can cure multiple
sclerosis and Alzheimer’s disease of the patients. But The decision to “phase down” and not to “phase out” use
research in United States and other First World Countries of dental amalgam by 2020 was taken to allow smooth
showed no such relation of amalgam and health. transition toward amalgam-free dentistry. Minamata
convention identified the use of cost-effective and
Current Status of Amalgam Wars durable mercury-free materials to reduce the use of
amalgam. It also encouraged dental schools to educate
Amalgam war continues to fume today. Some states
and train dental students on the use of mercury-free
have appointed holistic dentists to dental boards for new
dental restorations. For this, emphasis is given on minimal
policies. American council on health and science has said
it a serious problem. Pesently a congressional bill in United invasive dentistry. A restorative dentist should consider
State House of Representatives has been introduced to ban preventive and ultraconservative cavity preparations as
the use of dental amalgam fillings. the first line of treatment. This paradigm shift prevents
unnecessary destruction of sound tooth structure to
place amalgam restorations. Now, amalgam is no longer
Phase Down of Amalgam the first choice among clinicians, students, or patients.
Dental amalgam is a clinically well-proven and successful Time spent to teach amalgam will continue to fall, or
restorative material. For more than 150 years, dental cease by the next decade. Even in post-amalgam era,
amalgam was, and in many countries, continues to be the the dentists would still adhere to guidelines of mercury
mainstay of operative dentistry treatments. However, the hygiene while removing old amalgam restorations or
use of dental amalgam is one of several sources of mercury preparing amalgam foundations for crowns and fixed
pollution. Amalgam use has been criticized in the dental partial dentures.
Table 19.6 shows set of strategic interventions of includes dental amalgam. In the European Union, though
Minamata convention on mercury. dental amalgam is the second largest product that uses
mercury, but they stated that after 1st July 2018, dental
Table 19.6: Intervention of Minamata convention on mercury.
amalgam shall not be used in deciduous teeth, children
Nine measures to phase down the use of dental amalgam: less than 15 years of age, pregnant or breastfeeding
i. Setting national objectives aiming at dental caries prevention women, except if it is necessary on the basis of specific
and health promotion, thereby minimizing the need for dental medical needs of the patient.
restoration
ii. Setting national objectives aiming at minimizing its use Main Principles on Phase Down of
iii. Promoting the use of cost-effective and clinically effective Amalgam Action
mercury-free alternatives for dental restoration
1. Manage
iv. Promoting research and development of quality mercury-free
materials for dental restoration Dentist should know safe handling and disposal
v. Encouraging representative professional organizations and of amalgam. This can be improved by training at
dental schools to educate and train dental professionals undergraduate level and by continuing dental education
and students on the use of mercury-free dental restoration programs. For disposal of amalgam, follow strict norms of
alternatives and on promoting best management practices mercury disposal should be followed.
vi. Discouraging insurance policies and programs that favor
dental amalgam use over mercury-free dental restoration
2. Replace
vii. Encouraging insurance policies and programs that favor
the use of quality alternatives to dental amalgam for dental In an attempt to replace the amalgam to mercury-free
restoration dental material, government should introduce new
viii. Restricting the use of dental amalgam to its encapsulated form
technology which suits to the dentist perspective and is
in best interest, and benefits of patient. The new materials
ix. Promoting the use of best environmental practices in should be easily accessible, costeffective, and show equal
dental facilities to reduce releases of mercury and mercury
compounds to water and land.
efficacy as amalgam.
Source: Minamata Convention, Annexure A, Part II4.

3. Reduce
FDI and Phase Down of Amalgam To reduce the use of amalgam, there should be programs
and strategies to spread public health awareness, tell risk
FDI in collaboration with other National Dental factors of amalgam, and implement the policies for use of
Associations support the World Health Organization in mercury-free materials.
the phase down of dental amalgam use by increasing the
importance on prevention and research into alternative Challenges of a Phase Down
treatment options.
FDI supports the following practices in the phase down Measuring and understanding the risk of use of amalgam
of dental amalgam: is critical so as to have significant sustainable reduction of
◆◆ Increased importance on disease prevention and amalgam use. Following challenges are faced to amalgam
health promotion phase down:
◆◆ Increased research on mercury-free materials ◆◆ Questions about performance and cost of mercury-free
◆◆ Use of best environmental management practices for materials
amalgam waste ◆◆ Objections from the dentists not wanting to use new
◆◆ Avoiding the use of amalgam especially in small, materials, techniques, investing in new equipment, etc.
conservative lesions in young patients and in patients ◆◆ Lack of awareness on preventive and conservative
with special medical conditions, like severe renal treatment methods
disease or allergy to amalgam or lichenoid contact ◆◆ Lack of skills may reduce the optimal use and benefits
lesions in the oral mucosa. of mercury-free dental materials
◆◆ Impacts of toxicity of mercury on environment have
not been fully demonstrated. WHO urged for more
Actions Taken quality studies and systemic reviews on evidences
Several countries have implemented actions to phase on ecotoxicology of mercury so as to develop quality
down the use of dental amalgam. Norway began phasing mercury-free materials as an alternative to amalgam.
down of amalgam in late 1990s and since 2008 has ◆◆ Lack of global tracking system on sources of mercury
implemented a general ban on mercury products that for dental use.
◆◆ Low- and middle-income countries face challenges in d. Reverse curve.
encouraging the use of mercury-free materials. In rural e. Mercury toxicity.
settings, due to lack of electricity and water, optimal f. Failure of amalgam restorations.
benefits of resin-based composites cannot be obtained, g. Steps of amalgam restoration.
because it is more temperature sensitive and technique
sensitive during placement than dental amalgam. VIVA QUESTIONS
◆◆ As compared to amalgam, composite-focused training
for undergraduates is challenging. While using amalgam, 1. Define dental amalgam.
one needs to take care of few things that affect the 2. What are the advantages and disadvantages of dental
final outcomes, whereas while using composite, many amalgam alloys?
things like cavity preparation method, etching method, 3. How do you classify dental amalgam alloy?
duration, concentration, the bonding techniques, and 4. What is the composition of dental amalgam alloy and
type and method of placement of composite play a role of individual ingredient?
major role for final success of restoration. 5. What are the different phases in silver amalgam?
6. What is mercuroscopic expansion?
conclusion 7. What is creep?
8. What do you understand by term corrosion?
Amalgam restorations have served the profession 9. What is delayed (secondary) expansion?
well and may continue to do so in the years to come. 10. What are indications and contraindications of
The use of amalgam can be continued as a material amalgam?
of choice if aesthetics is not a concern. A successful 11. What is purpose of trituration?
amalgam restoration depends on the proper trituration, 12. What are signs of good mix amalgam?
condensation, carving and finishing of amalgam. Although 13. Why amalgam is a brittle material?
small amounts of mercury release from amalgam is known 14. What is mulling?
to occur, it does not cause any major health problems. 15. What are recent advances in dental amalgam?
Although there are other alternatives to amalgam, they 16. What do you understand by the term self-sealing?
can not match amalgam’s longevity, ease of manipulation 17. What is the main advantage of high copper dental
and versatility. But, recently phase down of amalgam amalgam over low copper dental amalgam?
of amalgam is a major concern. We are shifting from 18. What are objectives of pre-carve and post-carve
traditional restorative dentistry to minimally intervention burnishing?
dentistry, where phase down of the use of dental amalgam 19. When should the polishing of amalgam be done after
can become a catalyst to renew and revitalize the dentistry. restoration?
20. What are the different types and causes of failure in
EXAMINER’S CHOICE Questions amalgam restoration?
1. Define and classify amalgam. What is the role of each 21. What is Eames technique?
constituent in amalgam alloy? 22. What are different forms of mercury?
2. Explain in detail the steps of cavity preparation for 23. How can we dispose off scrap amalgam?
class II amalgam restoration. 24. What is reverse curve and what is its significance?
3. What are different reasons for failure of amalgam 25. What is the amount of threshold limit for exposure to
restorations? mercury vapour?
4. Enumerate the steps of cavity preparation. How would 26. What is gallium amalgam?
you obtain resistance and retention form in class II 27. What are advantages and disadvantages of gallium
cavity for amalgam restoration? amalgam?
5. Write in detail about the delayed expansion of silver 28. What is primary resistance form. Discuss its features
amalgam. in class I amalgam preparation.
6. Write short note on unicompositional alloys. 29. What are reasons for failure of amalgam restorations?
7. Write short note on amalgam alloy. 30. What steps should be taken to reduce mercury
8. Describe causes and treatment of pain in a teeth after exposure in dental clinic?
placing a restoration. 31. How will you achieve primary resistance form in Class
9. Write short notes on: II amalgam cavity preparation?
a. Indications and contraindications of amalgam 32. What is slot preparation?
restoration. 33. What is simple box preparation and what are its
b. Bonded amalgam. indications?
c. Gallium amalgam. 34. What are indications of cusp-capping?
BIBLIOGRAPHY 9. Lindemuth JS, Hagge MS, Broome JS, et al. Effect of restoration
size on fracture resistance of bonded amalgam restorations.
1. Ben-Amar A, Liberman R, Rothkoff, et al. Long term sealing Oper Dent. 2000;25(3):177-81.
properties of Amalgam bond under amalgam restorations. Am J 10. Osborne JW, Summitt JB. Extension for prevention: is it relevant
Dent. 1994;7(3):141-3. today? Am J Dent. 1998;11(4):189-96.
2. Ben-Amar A, Cardash HS, Judes H. The sealing of the tooth/ 11. FDI World Dental Federation (1997). FDI Policy Statement/
amalgam interface by corrosion products. J Oral Rehabil. WHO Consensus Statement on Dental Amalgam. [online]
1995;22(2):101-4. Available from https://www.fdiworlddental.org/sites/default/
3. Berry TG, Summitt JB, Chung AK, et al. Amalgam at the new files/media/documents/WHO-consensus-statement-on-dental-
millennium. J Am Dent Assoc. 1998;129(11):1547-56. amalgam-1997.pdf. [Last accessed September 2019].
4. Bouschor CF, Martin JR. A review of concepts of silver amalgam 12. Plasmans PJ, Creugers NH, Mulder J, et al. Long-term survival of
retention. J Prosthet Dent. 1976;36(5):532-7. extensive amalgam restorations. J Dent Res. 1998;77(3):453-60.
5. Cowan R. Amalgam repair--a clinical technique. J Prosthet 13. Vrijhoef MM, Letzel H. Creep versus marginal fracture of
Dent. 1983;49(1):49-51. amalgam restorations. J Oral Rehabil. 1986;13(4):299-303.
6. Duncalf WV, Wilson NH. Adaptation and condensation 14. United Nations Environment Programme (2013). Minamata
of amalgam restoration in Class II preparation of convention agreed by nations. 0 [Online] Available from
conventional and conservative design. Quintessence Int. https://www.unenvironment.org/news-and-stories/press-
1992;23(7):499-504. release/minamata-convention-agreed-nations. [Last accessed
7. Elderton RJ. Cavo-surface angles, amalgam margin angles and September 2019].
occlusal cavity preparations. Br Dent J. 1984;156(9):319-24. 15. FDI World Dental Federation. FDI policy statement on dental
8. Görücü J, Tiritoglu M, Ozgünaltay G, et al. Effects of preparation amalgam and the Minamata Convention on Mercury: adopted
designs and adhesive systems on retention of class II amalgam by the FDI General Assembly: 13 September 2014, New Delhi,
restorations. J Prosthet Dent. 1997;78(3):250-4. India. Int Dent J. 2014;64:295-6.
Chapter
20
Pin-retained Restorations
Chapter Outline
Introduction Types of Pins

Definition Principles and Techniques of Pin Placement
Advantages Factors Affecting Retention of Pins in Dentin and Amalgam
Disadvantages Pins and Stresses
Indications Complications of Pin-retained Restorations
Contraindications Other Means of Retention in Complex Amalgam Restorations
Introduction 4. Cost factor: Pin amalgam restoration is relatively

inexpensive as compared to cast restoration.
Most of the teeth can be restored using amalgam or
composites. But when the preparation size is very large
due to caries or other reason and the remaining tooth Disadvantages
structure is very less, it becomes difficult to achieve 1. Dentin fracture: Use of pins in teeth, where less dentin
optimal resistance and retention form. In such cases, is present, produces stresses in dentin in form of craze
dentin lock and slots are prepared in the dentin. But when lines or cracks.
these retentive features are insufficient to provide desired 2. Strength of amalgam: Compressive strength is not
retention, pin-supported restorations are used where pins increased by use of pins, but there is decrease in tensile
support the restorative materials and resist their dislodge and transverse strength of amalgam.
ment in severely damaged teeth. 3. Perforations: Using bur or pin in wrong direction can
cause pulpal exposure or perforation of external tooth
Definition surface.
A pin-retained restoration is defined as any restoration 4. Microleakage: If pin ends appear on or near to the
which requires the placement of pins in dentin in order surface of the restoration, it may result in microleakage
to provide sufficient retention and resistance form to the around the pins.
restoration. 5. Tooth anatomy: Sometimes, it is difficult to achieve
optimal contours and occlusal contacts with these
Advantages restorations.
1. Conservation of tooth material: Pin amalgam resto Indications

ration is more conservative than tooth preparation for
cast restoration. 1. Extensive tooth loss: In teeth with extensive tooth loss
2. Resistance and retention form: Use of pin increases where conventional restoration may fracture, pins are
resistance and retention of the restoration. indicated.
3. Number of appointments: One appointment is 2. As a foundation for indirect restorations: Pin-retained
required for pin-retained restoration whereas for cast restoration may be used as foundation for indirect
restoration, at least two appointments are required. restorations like crowns or onlays.
3. Time period: Pin-retained restorations are restorations ii. Wrought Precious Metal Pins
of choice for patients who cannot come for multiple
times (debilitated and aged patients). Surface of these pins is roughened by means of threaded or
knurled patterns. Commonly used pins are alloys of gold,
4. Economics: It is economical as compared to expensive platinum, palladium, or platinum-indium. In this, pins are
indirect cast gold restorations. placed in the pinholes and included in the wax pattern.
5. Questionable prognosis: In teeth with questionable These pins are 20–30% more retentive than smooth cast
prognosis (pulpal or periodontal), pin-retained resto pins.
rations are used as interim restorations till their
prognosis is confirmed.
2. Direct Pins/Nonparallel Pins
6. As core buildup after endodontic treatment: When
little remaining tooth structure is present, tooth is direct pins are inserted directly into dentin over which
strengthened by pin amalgam before placing full restoration is done. These are commonly made of stainless
coverage restoration. steel. Other materials can be silver, titanium, stainless
steel with gold plating, etc. These pins are also known as
Contraindications nonparallel pins because they can be inserted directly into
dentin and need not be parallel.
◆◆ When patient has occlusal problems
◆◆ When aesthetics is concerned, complex amalgam Direct pins are of following types (Fig. 20.1)
restorations are contraindicated
◆◆ In posterior teeth where accessibility and isolation for i. Cemented Pins
pin placement are difficult. Cemented pins were introduced by Dr Miles Markley
in 1958 for having better retention in large amalgam
Types of pins restorations. For these pins, the prepared pinholes should
be 0.025–0.05 mm larger than the diameter of pin. This
difference in diameter provides space for cementing
media. Pins are available in various diameters ranging
from 0.018” to 0.030” with the corresponding pinholes
of 0.020–0.032 inches. depth of hole in dentin for pin
insertion should be 3–4 mm.
Indications:
◆◆ In cases where least stresses or crazing is desired, e.g.
endodontically treated teeth.
◆◆ When bulk of dentin to hold the pin is less.
◆◆ When dentin has lost its elasticity because of
dehydration or sclerosis.
Advantages and disadvantages of cemented pins

1. Indirect Pins/Parallel Pins Advantages Disadvantages
Indirect pins are smaller in size when compared to their • Cemented pins are 0.001– • Provide less retention
pinholes and they constitute an integral part of a cast 0.002 inches smaller than • It is difficult to locate the
restoration. These pins are also known as the parallel pins their pinholes. Thus, these pinhole after cement
can be seated to the full has been placed in it for
because they are placed parallel to each other and to path depth of the hole cementation
of insertion of restoration. • Since these are passively • A poorly cemented pin
retained in the dentin, they can be dislodged while
Two types of pins are used in the parallel pin technique: do not generate stresses in manipulating the restorative
surrounding dentin material
i. Cast Gold Pins • Cement present between the • Require more time for the
pin and the tooth decreases mixing and hardening of
These pins have a smooth surface. For making restoration the chances of microleakage cement
using parallel pins, place the nylon bristles or plastic pins
in pinholes. over this, build restoration in conventional ii. Friction-locked pins
form with a blue inlay wax. Invest whole assembly and
cast it with pins forming an integral part of the cast Friction-locked pins were introduced by Dr Goldstein
restoration. in 1966. These pins are 0.001” larger than their pinholes,
Pin-retained Restorations 227
Fig. 20.1: Types of direct pin.
hence utilize the elasticity of dentin for retention. They are Indications:
2–3 times more retentive than the cemented pins. ◆◆ In vital teeth
Indications: ◆◆ When maximum retention is desired
◆◆ Vital teeth ◆◆ When sufficient amount of dentin is available to
◆◆ Periodontally sound teeth surround the pins.
◆◆ When direct access is possible so that the tapping force
can be applied parallel to the long axis of the pin Advantages and disadvantages of self-threading pins
◆◆ When sufficient amount of dentin is available to
surround the pin.
• Superior retention • Generate great stresses in dentin
Advantages and disadvantages of friction locked pins • Require less depth for • Pin may fail to seat completely.
placement • If pin is forced into pinhole, it may
• Require no cementing strip the sides of dentin resulting
• Cementing media is not • Length of pin cannot be medium in loose fit.
required adjusted after pin insertion • Microleakage occurs if overlying
• Pins attain stability from • Bending or contouring of the restoration leaks.
the moment they are pin after it has been placed into
placed pinhole further generate stresses
• Better retention than the • Stresses in dentin may result in Table 20.1 summarizes the comparison of direct
cemented pins form of craze lines pins in diameter of pinhole, depth of pin in dentin and
• Pin may not reach full depth of amalgam.
channel because of gouging
• Microleakage occurs if the
Table 20.1: Comparison of direct pins in diameter of pinhole, depth
overlying restoration leaks
of pin in dentin and amalgam.
Pin depth in Pin depth in

iii. Self-threading pin Types of pin Diameter of pinhole dentin amalgam
Self-threading pins were introduced by Going in 1966. Cemented pin 0.025–0.05 mm 3–4 mm 2 mm
These are 0.0015”–0.004” larger than their pinholes. larger than
Elastic property of dentin allows insertion of a threaded diameter of pin
pin into a hole of a smaller diameter. Pins are retained Friction locked 0.025 mm smaller 3 mm 2–3 mm
due to mechanical grasp of threads into dentin. These pin than diameter of
are available in stainless steel or titanium but can be gold pin
plated to increase their passivity. Self-threading 0.03–0.1 mm 2 mm 2 mm
Currently, threaded pins are most popular among the pin (0.004–0.015
three pin systems because of their ease and rapidity of inches) smaller
insertion and maximum retention offered. They are 3–6 than diameter of
pin
times more retentive than the cemented pins.
Thread Mate System (TMS) the handpiece chuck. After placement, pin can be
reversed one-fourth to decrease the dentinal stress.
It is considered as the most widely used among self- ii. Self-shearing pin (Fig. 20.3B): Self-shearing pin
threading pins (Fig. 20.2). is designed such that on reaching the bottom of the
Types of pins in thread mate system pinhole, the head separates automatically at the shear
line, leaving a portion of it to project from the dentin.
Pin type Size (Inches/mm) color code Shearing occurs when there is resistance to turning
Minuta 0.015/0.38 Pink because pin insertion is torque limited.
Minikin 0.019/0.48 Red iii. Two-in-one design (Fig. 20.3C): Length of two-in-one
Minim 0.024/0.61 Silver pin is approximately 8–9 mm with two pins of equal
lengths. One pin is peripheral pin and second pin is
Regular 0.031/0.78 Gold
wrench attachment pin. These two pins join each other
at a joint. This joint marks the shear line for peripheral
pin. When peripheral pin fixes to floor of pinhole,
it shears off at connecting joint leaving behind the
wrench attachment pin along with its attachment.
This pin can be reused for another pin channels.
iv. Link series (Fig. 20.3D): Disposable latch head
design has a plastic sheath/head designed to fit in
a slow speed contra-angle handpiece. Pin appears
to lie freely in the plastic sheath. This helps in self-
alignment as pin engages the pinhole. When pin
reaches bottom of the pinhole, there is resistance
which causes separation of head from the pin at the
shear line. Plastic sheath is then discarded.
v. Link Plus series (Fig. 20.3E): Link Plus series shows
great reduction in stresses in dentin because of
Fig. 20.2: Types of pins. presence of sharper threads and tapered tip which
readily fits in pinhole.
1. Minuta: Minuta is smallest in size among these self-
threaded pins. It is too small to provide retention in the
tooth. So, it is rarely used nowadays.
2. Minikin: Minikin pin is considered as the pin of choice
because of less dentin crazing, better retention, and
lesser chances of pulp and periodontal involvement.
3. Minim pin: This pin is also preferred in some cases,
depending upon the availability of dentin because it
provides less dentinal crazing as compared to regular
pins. It is also used in cases where pinholes for Minikin
get overprepared.
4. Regular: Regular is largest diameter pin among Thread
Mate System pins. It is rarely used because of more
amount of stress and crazing produced around pins
and more chances of pulp or periodontal involvement.
All of the abovementioned pins are available in the
following designs: A B C D E
◆◆ Standard
Figs. 20.3A to E: Types of pins.
◆◆ Self-shearing
◆◆ Two-in-one Advantages of Thread Mate System Plus:
◆◆ Link series ◆◆ Multipurpose designs
◆◆ Link Plus series. ◆◆ Wide variety of pin sizes
i. Standard pin (Fig. 20.3A): Standard pin is a full ◆◆ Good retention
length pin, i.e. 7 mm long which can be cut to the ◆◆ Color-coding system for easy identification and use
required length after placement. Pin provides a ◆◆ Gold plating for good surface finish and also for
flat head for engagement with hand wrench or reducing corrosion.
Principles and Techniques of Pin v. Location of Pin Placement: Following factors should
Placement be considered while selecting location of pins:
A. Knowledge of normal pulp anatomy to avoid
1. Cavity Preparation for Pin Amalgam pulpal exposure or external tooth perforations.
Restorations Avoid placing the pins directly under occlusal
loads as this may weaken the amalgam.
General principle for cavity preparation for pin-retained
B. Pinhole should be at least 0.5 mm away from
restoration should follow the basic steps like:
vertical wall of tooth for optimal condensation
•• Carry out the tooth preparation by excavating carious
of amalgam. Pinhole should be placed in
dentin and removing weakened tooth structure.
cervical one-third of posterior teeth near
•• Prepare facial and lingual walls parallel, pulpal and
line angles, 1.5 mm away from external tooth
gingival walls perpendicular to the axial wall. surface and 1 mm away from dentinoenamel
•• Make dovetails, grooves, and boxes wherever junction (Fig. 20.4).
required. C. Pinholes should be located on a flat surface,
•• Reduce the cusp 1.5–2 mm with shoulder margin. which should be perpendicular to the direction
of pinhole. When more than two pinholes are
2. Pulp protection planned, they should be placed at different levels
After final preparation, in deep preparations, apply to prevent stresses in same transverse plane of
calcium hydroxide liner followed by glass ionomer base the tooth.
for pulp protection. For shallow preparations, apply D. If two or more pins are to be placed, interpin
varnish. distance should be 3–5 mm to lower levels of
stresses in dentin and manipulate the amalgam
3. Preparation of pinhole around pins.
E. There should be at least 1 mm of sound dentin
Now prepare the pinholes in the axial wall of the around circumference of the pin.
preparation to provide adequate space for amalgam F. There should be at least 1 mm of dentin between
condensation around pins. pulp and the pin to avoid pulpal damage.
G. Intermittent radiographic monitoring should be
Factors Affecting Pinhole Preparation done constantly while preparing and placing the
i. Pin size: Increase in diameter of pin offers more pins.
retention but large-sized pins can result in more
stresses in dentin. Selection of pin size depends upon
amount of dentin present and amount of retention
required.
ii. Number of Pins: Rule of one pin per missing cusp
and one pin per missing axial line angle should be
followed. unnecessary use of pins causes stresses
in tooth, voids in restoration, decrease in available
interpin dentin, and decrease in strength of amalgam
restoration.
iii. Interpin Distance: Interpin distance should be such
that it prevents stress concentration in dentin and Fig. 20.4: Pinhole should be placed near line angles, 1.5 mm from
allows space for compaction of restorative material external tooth surface and 1 mm from dentinoenamel junction.
between pins. Interpin distance depends upon size
and type of pins. For cemented pins, it is 2 mm; for Tables 20.2 and 20.3 summarize the sites for
friction lock, it is 4 mm; and for threaded pins, it is 5 pin placements in maxillary and mandibular teeth,
mm. respectively.
iv. Length of Pin into Dentin and Amalgam: Pin
extension of 2 mm into dentin and amalgam provides
4. Technique of Preparation of Pinhole
maximum required retention. Extension more than 2
mm is avoided, so as to preserve the strength of dentin i. Pinholes are prepared using twist drills (Fig. 20.5).
and restoration. To prevent overextension of pins, use Commonly used drill for pinhole preparation is Kodex
depth-limiting drills, or pin bender to reduce length of drill. Drill is made of high-speed steel that is swaged
pins. into aluminium shank. Drill performs cutting when
Table 20.2: Pin placement for maxillary teeth.

Tooth Site for placing pin Areas to be avoided
Central and i. Gingival floor close i. Middle of lingual
lateral incisor to proximolabial and gingival floor
proximolingual floor ii. Incisal with
ii. Middle of labial insufficient depth
gingival floor
iii. incisal with
minimum 2 mm of
depth
Canine i. Close to labial and Gingival pin close to
lingual proximal part groove or concavity
of tooth
ii. incisal, close to
incisal angle
First and Close to proximobuccal • Middle of gingival
second and lingual corner of floor buccally and Fig. 20.5: Twist drills.
premolars the tooth lingually
• Mesiogingival floor
First and Gingival floor close • Gingival floor mesial
second molars to distolingual part of to buccal part of
tooth tooth
• Any part of gingival
floor occlusal to
furcation
Third molar Because of variable
anatomy, pin is placed
after radiographic
evaluation
Table 20.3: Pin placement for mandibular teeth.

A B
Areas to be
Tooth Site for placing pin avoided Figs. 20.6A and B: (A) Direct the drill towards desired location of
pin placement; (B) Move it in one axis and one direction with slight
Central and Because of less thickness – pressure for pin hole preparation.
lateral incisor of depth, pins are avoided
except in teeth where pulp
chamber is very much
ii. Mark the point where pin is supposed to be placed.
reduced Penetrate a small round bur (No. 1/4) at low speed up
to half of its diameter. This will make pilot hole or lead
Canine Same as maxillary canine Same as
maxillary canine
hole which allows accurate positioning of twist drill.
iii. Direct the drill towards desired location of pin place
First and second Close to labial and lingual Middle of
ment (Fig. 20.6A). Drill should be kept continuously
premolars proximal part of the tooth gingival floor
buccally and moving only in one axis and one direction from the
lingually time of insertion till removal to avoid fracture of the
drill in the pinhole and overcutting.
First and second • Distolingual portion of Mesiobuccal
molar gingival floor corner of gingival iv. While cutting dentin, apply slight pressure (Fig.
• Distobuccal and floor 20.6B). During drilling, avoid slanting of the
mesiolingual part of handpiece, or allowing the drill to rotate more at the
gingival floor bottom of the pinhole as this may result in a large
Third molar Because of variable hole. After pin preparation is complete, confirm the
anatomy, pin is placed depth using omni-depth gauge and take a radiograph.
after radiographic
evaluation 5. Insertion of Pin
rotated clockwise at slow speed. Suggested speed for Pins can be inserted in the prepared pinholes either
drilling is 300–500 rpm to 1,000 rpm. Omni-depth using conventional latch type contra-angle micromotor
gauge is used to measure accurate depth of pinhole. handpiece or using TMS hand wrenches.
Conventional micromotor handpiece is used for of tooth. Marginal ridge must be at the same height as the
disposable head pins like Link series and Link Plus designs. adjacent marginal ridge.
In this, attach pin to handpiece insert it into pinhole. As
it reaches the bottom of pinhole, it feels slight resistance, 10. Removal of the Matrix
and then shears it off from plastic sleeve.
Avoid premature removal of matrix band as it can result
TMS hand wrench is used for standard pins. Here, attach
in fracture of the restoration. If Tofflemire is being used,
the pin to hand wrench and move it clockwise in pinhole.
separate the band from retainer and take out the band
Once the pin reaches bottom of pinhole, give quarter to
without disturbing the set restoration.
half-turn rotation to pin to minimize dentinal stresses.
If copper band matrix is used, a groove is made on facial
Now, disengage the hand wrench from pin.
and lingual surfaces of the band. These sectioned parts are
removed carefully.
6. Length Control for Pins If AutoMatrix is used, cut the Auto-Lock loop using
A pin should engage minimum of 2 mm in dentin and 2 shielded nippers. Remove the band in oblique direction.
mm in amalgam restoration. If length is longer than this,
bending or trimming of pin should be done before placing 11. Finishing and Polishing Procedure
cemented pins. In case of friction lock and threaded
Objective of polishing is refinement of the margins,
pins, extra length of pin should be cut using no. 169L
development of the contour, and smoothening of
bur running at high speed perpendicular to the pin. To
the surface. Polishing must be done after 24 hours of
avoid loosening of pin, it should be stabilized using small
restoration placement. Round steel finishing bur or small
hemostat.
wheel diamond is used to contour the occlusal restoration.
If pin bending is required, it should be done using TMS
Silica or aluminium oxide is applied by prophylactic cup to
bending tool to bring the pin at the level of restoration.
polish the surface.
7. Matrix Placement
FACTORS AFFECTING RETENTION OF PINS
In general, Tofflemire retainer and band is used. For IN dentin AND amalgam
optimal contour, two matrix bands are used. One band
surrounds circumferentially, and second band is placed 1. Pin Type
to have buccal and facial contour. It is stabilized by using
softened impression compound between band and open Order of retention offered by different pin systems is:
part of Tofflemire retainer. ◆◆ Self-threaded pins > friction locked pins > cemented pins.
When Tofflemire matrix cannot be used, impression ◆◆ Among cemented pins, serrated pins are more retentive
compound-supported copper band matrix or AutoMatrix, than smooth surface pins.
which is a retainerless matrix system, can also be used.
2. Pin Number
8. Placement of Amalgam Within limits, increase in number of pins increases the
Spherical or admixed high copper alloy is preferred for retention. Ideally, there should be one pin per missing
restoration of these teeth because of high early compressive cusp and one pin for each missing line angle. Pin retention
strength and excellent clinical performance. Spherical is directly proportional to bulk of material around the
alloys have higher early strength and can be condensed pin. Overuse of pins cause decrease in amount of dentin
quicker with less pressure when compared with admixed available, decrease amalgam strength, and thus increase
alloys. But admixed alloys are preferred for proximal in fracture.
contacts because of their condensability and long working
time which allows sufficient time for condensation, matrix
3. Interpin Distance
removal, and carving of the restoration. Placing pins close to each other increases retention. But
Pack and condense the amalgam restoration around minimum interpin distance should be 2 mm; if distance is
pins first and then all step areas and proximal box area. lesser than 2 mm, pin retention is reduced because of the
Each increment of amalgam is properly condensed less amount of material present in between the pins and
to produce a flat surface. Amalgam must be properly increase in residual stresses in dentin (Fig. 20.7).
condensed around the pins.
4. Pin Diameter
9. Carving of Amalgam
Within limits, retention is directly proportional to diameter
Remove excess of amalgam from the occlusal surface. of pin. For example, retention doubles when diameter of
Use discoid and hollenback carver to develop anatomy pin increases from 0.0155 to 0.0190. However, overzealous
9. Cementing Agents
Zinc phosphate and glass ionomer cement are more
retentive than zinc oxide-eugenol cement. Application of
varnish reduces the retention of pins.
10. Type of Dentin

Young resilient primary dentin offers more retention than
secondary dentin or tertiary dentin. Stress tolerance of
different types of dentin in decreasing order is:
Fig. 20.7: Lesser interpin distance generates more Secondary dentin > sclerosed dentin > tertiary dentin >
stresses and cracks in dentin. calcific barrier
increase in diameter may decrease amount of dentin and Pins and Stresses
thus weaken the tooth. Pins, Stresses, and Tooth
5. Pin Depth in Dentin Stresses are seen maximum with use of friction locked
and threaded pins in dentin. Stresses are developed since
Minimum 2 mm of pin should be present in dentin. Within
pins are inserted into channels 0.001–0.004 smaller than
limits, increasing the depth of pin in dentin increases the
retention (Fig. 20.8). Overzealous increase of pin length in diameter of pins. If stresses exceed dentin’s plastic limit,
dentin may induce stresses in dentin and may cause pulp craze lines or cracks are seen.
exposure. Threaded pins show only apical stresses whereas
friction-locked pins act as wedges, which result in lateral
stresses, cracked tooth syndrome, gross fractures, loose
restorations, etc.
Cemented pins are shown to induce the least stresses,
threaded pins induce intermediate stresses, and friction
locked pins induce the maximum stresses.
Pins, Stresses, and Restorative Material

Pins did not strengthen or reinforce a restoration but aid
in retention of restoration. Neither compressive strength
nor transverse/tensile strength of amalgam is improved
because of stress concentrations around the pins and
cleavage planes setup in the restoration by the arrangement
of pins. Pins are likely to reduce the strength of amalgam
Fig. 20.8: Overzealous increase of pin depth in dentin induces because of absence of any chemical union between the pin
stresses in dentin. and restorative material at the interface.
6. Pin Depth in Amalgam complications of pin-retained

restorations
If pin is placed more than 2 mm in amalgam, it may cause
fracture of the restoration. 1. Failure of Pin-retained Restorations
7. Surface Characteristics i. Within the restoration: Restoration may fracture
because of improper condensation, trituration, or
Number of serrations present on pin surface affects its
manipulation (Fig. 20.9A).
retention. Serrated pins are more retentive than smooth
ii. Within pin: Pin fracture may occur because of
pins.
improper pin placement technique (Fig. 20.9B).
Pin fracture can occur in the following conditions:
8. Pin Orientation
•• During bending or if turned more than required in
Pins placed in nonparallel orientation have more retention the pinhole
than pins placed in parallel orientation. •• Excessive force is applied while its placement
A B C D E
Figs. 20.9A to E: (A) Fracture within the restoration; (B) Fracture within the pin; (C) Fracture at pin-restoration interface;
(D) Fracture at pin tooth interface; (E) Fracture within the tooth.
•• Pin is rotated despite being fully seated in the 4. Pulpal Penetration and Periodontal
pinhole. Perforation
Removal of broken pins and drills is difficult. It is
best to choose another site about 1.5 mm away from Pin placement can also result in pulp and periodontal
the previous site and leave the broken pin as if it perforation (Figs. 20.11A and B). Perforation is indicated
is not interfering in occlusion or condensation of by sudden bleeding while operating the drill.
amalgam.
iii. At pin-restoration interface: Restoration may pull
away from pin because of corrosion products at
pin-restoration interface (Fig. 20.9C).
iv. At pin tooth interface: Pin may separate along with
restoration because of improper pin tooth joint
(Fig. 20.9D). Failure at pin-dentin interface is more
common than at pin-restoration interface.
v. Within tooth: Dentinal fracture (Fig. 20.9E) can occur
because of concentration of internal stresses because
of improper selection of pin according to dentin type.
2. Broken drills (Fig. 20.10)

Drill can break in the following conditions:
◆◆ Stresses are applied laterally during drilling
◆◆ Dull drills are used
Fig. 20.10: Broken drill.
◆◆ Drill is stopped while entering or exiting from the tooth.
3. Loose Pins
Loose pins can occur in the following conditions:
◆◆ Repeated insertion and removal of drill during pin
preparation
◆◆ Pin drill is rotated more than required
◆◆ Pinhole is too large
◆◆ Manufacturer’s discrepancy, i.e. poor quality control
between pin drill and pin size
◆◆ Pin failed to be driven in the pinhole resulting in
stripped out or chipping of dentin or enamel.
To stabilize the pin, following can be done:
◆◆ Cement the existing pin in place A B
◆◆ Drill another hole of the same diameter 1.5 mm away Figs. 20.11A and B: (A) Pulpal penetration; and (B) Periodontal
from the present hole and insert the same pin. perforation while placement of a pin.
Penetration or perforation can be verified by radiograph.

If pulpal penetration occurs, and tooth is asymptomatic
with very little bleeding, do direct pulp capping and
prepare a fresh hole. If tooth has extensive restorations
or caries, root canal treatment should be done in case of
pulpal exposure.
If periodontal perforation occurs occlusal to the
gingival attachment, pin can be cut off and merged with
tooth surface and then prepare a cast restoration. Another
method is to remove the pin, enlarge pinhole, and restore
it with amalgam. If perforation occurs apically, expose the
area surgically, remove the bone, enlarge the pinhole, and
restore it with amalgam or with gold foil if possible.
5. Heat Generation
Excessive heat generation causes damage to pulp. Excessive Fig. 20.13: Preparation of a cove.
heat can be reduced by using 2.0 depth-limiting drill and
the smallest possible pin. Cove (Fig. 20.13)
Cove is prepared by using No. 1/4 bur. Coves may also be
6. Microleakage used in preparation using slots.
Microleakage around cemented pins occurs around whole
circumference. In case of threaded and friction-locked Lock (Fig. 20.14)
pins, it is semilunar in shape.
Lock is a groove placed in longitudinal plane. It is 0.2–0.3
mm wide and 0.5 mm deep into the dentin. It is usually
other means of retention in prepared with 169L tapered fissure bur in teeth with
complex Amalgam restorations sufficient crown height.
Though pins have been used as retentive devices in complex
amalgam restorations, in recent years, the emphasis has
shifted from creating adequate retention form to providing
adequate resistance form. In this, several mechanical
features are incorporated during cavity preparation like
slots, coves, grooves, amalgapins, etc.
Slot (Fig. 20.12)

Slot is a groove which is placed in the horizontal plane
in dentin. Slot is indicated especially in short teeth. It
has 1.0–1.5 mm of depth in occlusal or gingival floor. It is
prepared by using No. 33 1/2 inverted cone bur.
Fig. 20.14: Lock preparation.
Amalgapin (Fig. 20.15)

Concept of amalgapin was given by Shavell in 1980 to allow
amalgam to act as retentive pins. Amalgapins are vertical
posts of amalgam anchored in dentin. Pits prepared in
dentin are shallow and little wider than pinholes. These
are called “dentin chambers”. Post formed by amalgam
Fig. 20.12: Slot preparation. in dentin chamber is called “amalgapin”. Dentin chamber
is prepared by using inverted cone bur on gingival floor Conclusion
0.5 mm in dentin with 1–2 mm depth and 0.5–1 mm
width. Amalgapins increase the retention and resistance There are many modes of increasing retention and
of complete restoration. They also increase the bulk of resistance form in complex amalgam restorations like pins,
amalgam. slots, coves, grooves, amalgam pins, etc. Each feature has
its own indications and contraindications. Amalgam pins
and slots are indicated in teeth with short clinical crowns
and in cusps that have been reduced 2–3 mm for coverage
with amalgam.
When the vertical pins are placed in teeth with
sufficient crown height, they provide excellent retention
and resistance form. Pins should be placed at least 0.5 mm
inside the dentinoenamel junction, and should extend
minimum of 2 mm in dentin and 2 mm in restoration.
However, there are inherent risks involved with pin
placement like crazing of tooth structure, perforation into
the pulp or periodontium, and weakening of the amalgam
Fig. 20.15: Preparation of amalgam pin.
restoration over the pins.
If aesthetic appearance is a factor, horizontal pins may
Horizontal Pin be used to reinforce the tooth structure.
Pins, amalgapins, slots, and boxes may be used
It was described by Burgess. Horizontal pin should be
independently in many clinical situations. However, the
placed 0.5–1.00 mm from DEJ. It should not be placed too
effectiveness of these resistance and retention features can
close to the surface of amalgam restoration.
be maximized when used in combination.
Amalgam Foundation
EXAMINER’S CHOICE Questions
It is defined as a silver amalgam restorations using pin
retention that is to be reduced to provide a core for 1. What are indications and contraindications of
subsequent cast restoration. It is indicated for a tooth that pin-retained restorations? Explain different pin types.
is severely broken down and lacks resistance and retention 2. Explain in detail the factors affecting retention pins in
form needed for an indirect restoration. tooth structure and restorative material.
Principles of outline form dictate more conservative 3. What are different causes of failure of pin-retained
preparations for a pin amalgam foundation than for a restorations?
pin amalgam restoration. Margins need not be extended 4. Write short notes on:
to self-cleansing areas. However, for a pin amalgam a. TMS pins.
foundation, cavosurface angles can range from 45° to 135° b. Pin design.
as they are not subjected to direct occlusal forces. c. Principles of pin placement.
pin amalgam foundations rely on secondary preparation
retention features (pins, slots, coves, and proximal VIVA questions
retention locks). Minikin size of the pins should be used for
1. What are indications and contraindications of pin
the purpose of foundation (Figs. 20.16A and B).
retained restorations?
2. What are advantages and disadvantages of
pin-retained restorations?
3. What are different types of pins?
4. Which pin is the most retentive?
5. Which pin generates more stress in dentin?
6. What are different causes of failures of pin retained
restorations?
7. What is difference between slot and lock?
8. What are the factors which affect pin location in
A B pin-retained restorations?
Figs. 20.16A and B: Amalgam foundation in 9. What are the factors affecting retention of pins in tooth
pin-retained restoration. structure?
10. What are the factors affecting retention of pins in bibliography

restorative material?
11. Define pin retained restoration. 1. Abraham GC, Baum L. Intentional implantation of pins into the
dental pulp. J South Calif Dent Assoc. 1972;40(10):914-20.
12. What are differences between cement, friction lock 2. Burgess JO. Horizontal pins: a study of tooth reinforcement. J
and threaded pins? Prosthet Dent. 1985;53(3):317-22.
13. Where are threaded pins used? 3. Caputo AA, Standlee JP. Pins and posts—why, when and how.
14. What is TMS? Dent Clin North Am. 1976;20(2):299-311.
15. What are sizes of TMS pins? 4. Cecconi BT, Asgar K. Pins in amalgam: a study of reinforcement.
J Prosthet Dent. 1971;26(2):159-69.
16. What should be interpin distance? 5. Collard EW, Caputo AA, Standlee JP. Rationale for pin-retained
17. What should be length of threaded pins in amalgam amalgam restorations. Dent Clin North Am. 1970;14(1):43-51.
and dentin? 6. Dawson PE. Pin-retained amalgam. Dent Clin North Am.
18. How does pin number affect retention? 1970;14(1):63-71.
19. What is order of retention of pins? 7. Eames WB, Solly MJ. Five threaded pins compared for insertion
and retention. Oper Dent. 1980;5(2):66-71.
20. Name different failures occurring in pin-retained 8. Evans JR, Wetz JH. The pin-amalgam restoration. Part 1. A
restorations. review. J Prosthet Dent. 1977;37(1):37-41.
21. Where are slots given? 9. Going RE. Pin-retained amalgam. J Am Dent Assoc.
22. How do place slot? 1966;73(2):619-24.
23. What is amalgam foundation? 10. Goldstein PM. Retention pins are friction locked without use of
cement. J Am Dent Assoc. 1966;73(5):1103-6.
24. What are dentin chambers? 11. Robbins JW, Burgess JO, Summitt JB. Retention and resistance
25. How do you prepare locks? features for complex amalgam restorations. J Am Dent Assoc.
26. What is amalgapin? 1989;118(4):437-42.
Chapter
21
Direct Filling Gold
Chapter Outline
Introduction Principles of Tooth Preparations

Properties of Gold Class I Tooth Preparation
Advantages of Direct Filling Gold Restorations Class Ii Tooth Preparation
Disadvantages of Direct Filling Restoration Class IiI Tooth Preparation
Indications of Direct Filling Gold Restoration Class IV Tooth Preparation
Contraindications Compaction of Direct Filling Gold
Types of Gold Steps of Direct Filling Gold Restoration
Storage of Gold Future of Gold in Dentistry
Degassing/Annealing
Introduction 6. Hardness in bulk form——Brinell hardness number

(BHN) is 25 which rises to 75 during condensation
Gold is one of the oldest dental materials used for (cold working).
restoration of teeth. Use of gold in restorations remains 7. Gold is the noblest of all metals. It does not react with
considerable today, however, due to presence of alter air, water and does not undergo tarnish and corrosion
native materials available in dentistry, there is choice in oral environment.
for a replacement of old discolored fillings. In spite of 8. Tensile strength is 19,000 psi which rises to 32,000 psi
these restorative materials, direct filling gold restoration on cold working.
still forms one of the best available restorative material, 9. Coefficient of thermal expansion (14.4 × 10–6/°C) is
especially if: almost similar to that of tooth.
◆◆ It is used only where indicated. 10. Gold has high thermal conductivity.
◆◆ Proper manipulation is done. 11. Gold can be cold welded at room temperature. When
◆◆ Clinician has skill of using it.
two clean pieces of gold are pressed firmly, they get
If done properly, direct gold restoration lasts for a
welded together.
lifetime, because of outstanding biocompatibility of gold
12. Density of pure gold is 19.3 g/cm3, while when
in oral environment and its excellent marginal integrity.
compacted, because of voids, it reduces to 16.5 g/cm3.
Properties of Gold Advantages of Direct filling Gold

1. Cohesiveness, this property depends on purity of gold. Restorations
Best gold for restorations is about 999 parts in 1,000
parts of pure gold. 1. Gold foil restorations can last for a long-time if
2. Softness during manipulation. correctly done.
3. Malleability (Gold be reduced by beating to 1/250,000 2. Resilience of dentin and the adaptability of gold allow
of an inch in thickness). an almost perfect seal between the tooth structure and
4. Ductility (One grain of pure gold may be drawn into a gold.
wire nearly five hundred feet long). 3. Malleability of gold makes it possible to add gold in
5. Rich yellow in color with strong metallic luster. very small amounts that are building up the filling.
4. Being a noble metal, gold does not tarnish and corrode. ii. Class II preparations with minimal proximal caries of
5. Coefficient of thermal expansion is close to dentin, premolars and on mesial surface of molars
so shows no shrinkage or expansion when placed in iii. Class III preparations of all teeth especially when
preparation. aesthetics is not important
6. No cementing medium is required for restoration. iv. Class V preparations of all teeth
7. Gold can withstand compressive forces even in thin v. Class VI preparations of teeth where high occlusal
layers, hence bulk is not required for strength. stress is not present.
8. It does not cause tooth discoloration because of good
adaptation to the preparation margins and walls. 2. Erosion
9. Direct gold restoration is insoluble in oral fluids.
Direct filling gold restorations are indicated for small
10. If properly polished, the gold surface is plaque
erosions on all the surfaces of premolars, canines, and
repulsive. incisors, where aesthetics concern is limited.
11. Polish and smoothness lasts longer when compared
with other restorative materials.
12. Direct gold restoration can be completed in one 3. Repair of Margins
appointment. It is used to repair endodontic openings in gold crowns or
for gold crown margins, onlays and inlays.
Disadvantages of Direct filling
restoration 4. Hypoplastic Defects
1. Technique sensitive, for optimal restoration, great Direct gold is used for hypoplastic areas or other defects
skill, patience and time are required. on the facial or lingual areas.
2. Improper placement of gold foil can damage the pulp
or periodontal tissues. Contraindications
3. Welding technique, with or without a mallet, can
cause pulpal trauma. 1. Young Patients
4. Because of high thermal conductivity of gold, large Direct gold restoration is contraindicated in young patients
restoration can increase sensitivity. because:
5. Large restoration is very difficult to finish and polish. ◆◆ It is time consuming
6. Gold restorations are very expensive because of its ◆◆ Periodontal membranes and alveolar processes do not
high cost and work involved. offer resistance to hand pressure and mallet blows,
7. Multiple restorations are hectic because it is time necessary to ensure a well-condensed mass of gold.
consuming.
8. It cannot be placed when aesthetics is required. 2. Limited Accessibility
9. Gold is indicated only when lesion is small in size and
present in nonstress bearing areas. Limited accessibility makes manipulation of gold difficult
10. If gold and amalgam fillings are right next to each so defies its use.
other, “galvanic shock” can occur. It happens when
interactions between the metals and saliva result 3. Large Size of the Lesion
in electric current. This can result in discomfort to If large size of lesion/defect is present, direct filling gold is
patient. contraindicated because restoration would be exposed to
heavy masticatory forces and would take more time and
Indications of Direct filling gold efforts for manipulation.
restoration
According to Stibbs, smaller the lesion, greater will 4. Deep Carious Lesion
be indication because of more need for conservative In deep carious lesion where remaining dentin thickness
permanent restorations. is less than 1 mm, direct filling gold restoration is
contraindicated.
1. For Class I, II, III, V, and VI Cavities
Direct filling gold restorations are indicated for incipient 5. Poor Periodontal Condition
or early lesions, small in size and present in nonstress gold is not indicated in patients suffering from periodontal
bearing areas like: disease with considerable loss of alveolar process and
i. Small class I preparations of all teeth supporting tissues.
Direct Filling Gold 239
6. Temperament of Patient v. Corrugated gold foil
vi. Laminated gold foil.
Some anxious patients are unable to tolerate continuous
blow of the mallet, direct gold restoration should not be
used in them.
I. Sheets
Gold foil is made by beating pure gold into thin sheets of
7. Handicapped Patient size 10 × 10 cm (4 × 4 inch). Thickness of gold foil is 1.5
µm. Gold foil sheets are bound in form of books, one book
Since these restorations are time consuming, they should contains 12 sheets, each sheet with dimensions of 4” × 4”.
not be used in such patients. Book of gold, either 1/8 or 1/10 of an ounce is ruled off and
sizes are cut with the help of scissors. Book is divided into
8. Aesthetics such sizes that represent 1/2, 1/4, 1/8, 1/16, 1/32, 1/64,
If aesthetics is of prime importance, direct gold restoration and 1/128 of sheet of gold that weighs 4 grains (Fig. 21.1).
is not indicated. No. 3 gold foil weighs 3 g, No. 2 gold foil weighs 2 g, No. 4
gold foil weighs 4 g, and so on. Since size of 4 × 4 inch foil
9. Heavy Occlusal Stresses is too large for its use in preparation, before insertion into
the tooth preparation, it is cut, rolled into ropes, cylinders
Since gold cannot withstand heavy occlusal forces, it
or pellets.
should be avoided in stress-bearing areas.
10. Prognosis of the Tooth

It should not be used when expected functional period of
the tooth is not more than two years.
Types of Gold
Direct filling gold is classified as following (Flowchart 21.1).
1. Gold Foil/Fibrous Gold

Gold foil or fibrous gold is one of the oldest forms. Dental
foil (Number 4) is six times thicker (0.6 µm) than gold
leaf, which is used for ornaments (0.1 µm thick). Gold is
available in several types:
i. Sheets
ii. Gold foil cylinder
iii. Gold pellets
iv. Platinized gold foil Fig. 21.1: Gold sheets.
Flowchart 21.1: Classification of direct filling gold.

II. Gold Foil Cylinder VI. Laminated Gold Foil

To make cylinder, one end of the No. 4 foil is held with Laminated gold foil is manufactured by combining 2–3
an instrument and rolled again and again until the other gold foils together. It is based on the concept that a gold
end is reached. Foil is rolled into 1/2, 1/4, 1/8th width foil is usually formed from ingot with pattern of crystals
(Fig. 21.2). running in specific direction. When two or more gold foils
with crystals running in different directions are combined
III. Gold Pellets together, laminated gold foil is formed. It is more resistant
To make gold pellets, a piece of foil is placed in the to applied forces.
palm and each end is folded towards the center. This
incompletely formed pellet is transferred between thumb 2. Crystalline Gold or Electrolytic Precipitate
and index finger to form pellet (Fig. 21.3) Rolled pellets
can be stored in a gold foil box with cotton dipped in 18% It is electrolytically precipitated type of gold, i.e. produced
ammonia (to prevent the formation of oxide layer on the by electrodeposition.
pellets).
Types of Crystalline Gold
IV. Platinized Gold Foil
It is made up by placing a sheet of platinum between two i. Crystalline, Sponge, or Mat Gold
sheets of gold foil and then hammering till thickness of To prepare mat gold, pure gold is sintered in oven, which
no 4 gold foil is obtained. Platinum content in foil is 15%. helps to hold the crystalline gold together. Then gold is
Platinum increases hardness and wear resistance of the heated slightly below the melting point so that partial
restoration. This allows its use in areas of high occlusal fusion occurs, resulting in a spongy structure of loosely
forces.. aligned crystals. These crystals are about 0.1 mm long
dendritic or fern-like in shape. These crystals adapt very
V. Corrugated Gold Foil/Carbonized Gold Foil nicely to the preparation walls. It is mainly used for building
It was first observed by a dental dealer in great Chicago fire of internal restoration because it can be easily compacted
of 1871. Corrugated gold foil is made by putting thin sheets and adapted to retentive portions of the preparation.
of paper between gold foil sheets and igniting them. Paper Problem with mat gold is that it is difficult to handle, shows
in between the gold foil gets burnt and charred leading to voids, surface pitting, does not form a homogeneous mass
corrugated appearance of gold foil. and has rough finishing.
Fig. 21.2: Gold foil cylinder is made by rolling No. 4 gold foil in 12,14 and 18th width.
Fig. 21.3: To make gold pellet, place a piece of foil in the palm, fold each end towards the center and then roll it between
thumb and index finger to form pellet.
ii. Mat Foil 2. Semicohesive Form of Gold
Mat foil is formed by placing the mat gold between number This gold foil is coated with protective film of ammonia
3 or 4 gold foil and then sintering just below melting gas which prevents the absorption of other gases and
point of gold. It is then cut into strips of different sizes. prevents premature cohesion of sheets. This film can be
Advantage of using gold sheets is that gold sheets hold the easily removed by degassing to restore cohesive nature
crystalline gold together when it is placed and compacted of gold. This type of gold is called semicohesive form of
into prepared tooth. Since, mat gold foil is highly cohesive gold.
and readily adaptable than other types of foil, it is ideally
recommended for building internal bulk of class I and V 3. Noncohesive Form of Gold
restorations.
This form of gold loses its cohesive property because of
absorption of contaminants like sulfur, phosphorus and
iii. Electralloy RV iron on the surface which cannot be removed by heating.
Noncohesive forms have lesser strength and hardness as
RV stands for RV Williams who developed this gold. In
compared to cohesive forms.
this, calcium (0.1%) is added to increase hardness and
strength of the gold. Electralloy on compaction produces
the hardest direct filling gold surface.
Degassing/Annealing
degassing is the process of heating direct filling gold to
remove surface contaminants. It is especially done for
3. Powdered Gold or Gold-dent or noncohesive gold, in which an ammonia layer is placed as
Granular Gold a protective coating to prevent other gases and their oxides
Commercially available pellets of powdered gold wrapped from contaminating the gold and to prevent clumping of
in gold foil are known as “Goldent”. In this, individual pellets.
particles or granules of 15 µm particle size are gathered Degassing methods can be done in two ways:
into irregular shape of size 1–3 mm. Atomized particles are
difficult to manipulate, these are mixed with organic wax 1. Heating on Alcohol Flame
matrix cut into pieces and wrapped in No. 2 or No. 3 foil. It can be done in two ways:
Before compaction, matrix is burnt away so that only pure
gold is left. Powdered gold does not require very sharp line i. Bulk Method
angles and point angles in preparation because they are En masse gold is placed on the mica tray and then heated
difficult to handle. over open gas or alcohol flame. The tray is heated until the
gold pellets achieve the temperature of 650–700°C.
STORAGE OF Gold Advantages
◆◆ Takes less time
Ideally, the gold foil should be free from surface
◆◆ Convenient.
contaminants to place it in prepared tooth. But it is
difficult to maintain cohesive form of gold because Disadvantages
gases like carbonic acid, phosphoric acid and hydrogen ◆◆ Sticking of gold pieces
sulfide get accumulated on its surface during storage. ◆◆ Unused gold may be left and it can be wasted due to
This contamination of gold interferes with cohesive contamination
nature of gold. The cohesive nature of gold can be ◆◆ Risk of overheating.
maintained by proper storage or by heating it before ii. Piece Method
placing it into the prepared surface.
Gold foil is held with an instrument and heated over clean
blue flame of absolute or 90% ethyl alcohol. Temperature
1. Cohesive Form of Gold of the flame is about 1300°F. Heating is done until the gold
It is that form of the gold which is free from any surface becomes dull red for 3–5 seconds.
contaminants and can be placed into the prepared cavity. Advantages
Since gold can attract gases to its surface, it can prevent ◆◆ Less wastage
cohesion of gold particle. So, the manufacturer supplies the ◆◆ Desired size of piece can be selected.
foil free of surface contaminants and therefore inherently Disadvantage
cohesive, this type is referred to as cohesive foil. Time consuming.
2. Electric Annealer
In electric annealing, temperature is maintained 343°C
(640°F)–371°C (700°F). It is mainly used for powdered
gold to burn away wax. heating time depends on size
and configuration of gold, for example 15–20 seconds for
powdered gold, 1–2 seconds for electrolytic gold.
Hazards during Degassing

Fig. 21.4 : Class I tooth preparation for gold restoration.
A. Overheating
Overheating can result in:
◆◆ Contamination from tray iv. Pulpal floor is 0.5 mm deep into dentin.
◆◆ Melting of metal v. Cavosurface margins are beveled (0.2 mm in width)
◆◆ Adhesion of particles to each other instead to the with partial bevel of 45° in the direction of enamel
surface rods so that metal margin can be burnished against
◆◆ Increase in brittleness. the tooth.
vi. If additional retention is required under cuts are
B. Underheating
placed in facial and lingual walls by small inverted
Underheating results in incomplete removal of surface cone bur (No. 33½ bur). Figures 21.5 and 21.6 show
contaminants. This makes the gold less cohesive, thus one restoration of 2nd premolar and 1st molar with
piece of gold may not cohere to another. direct filling gold.
Viva Voce
Degassing is a better term instead of annealing because in Class II Tooth Preparation
annealing, along with removal of surface contaminants, internal
stress relief or recrystallization also occurs but in degassing Class II preparation for incipient caries is ideal for gold
procedure only surface contaminants are removed. foil. Outline of preparation is made using No. 330 bur. It is
similar to amalgam except that:
principles of tooth preparations i. It is more conservative and angular. All angles except
axiopulpal line angle are very sharp.
Fundamental prerequisites for optimal gold restoration: ii. Dove tail is not necessarily required as in amalgam.
◆◆ Rubber dam for tooth isolation iii. Isthmus has reverse S-shaped outline facially and
◆◆ Set of good hand and rotary cutting instruments lingually due to very narrow occlusal preparation in
◆◆ Good tooth preparation that satisfies the requirements transition to regular contact area.
laid down by GV Black iv. Cavity width should not be more than 1/5th the
◆◆ Tooth preparation according to type of gold used. Since
intercuspal distance.
gold is available in different forms for use, viz. foil in
v. Gingival margins should be cervical to the contact
pellet, sheet or laminated form, mat, powdered gold.
areas. It should not be placed subgingivally.
Each requires a specific technique if optimum results
vi. Proximal portion of preparation shows one sided
are to be achieved.
inverted truncated cone shape. Truncation of wall is
◆◆ Instruments for proper compaction and finishing of the
toward the functional cusp side, i.e. in maxillary teeth,
restoration.
truncation is at the expense of palatal proximal wall
and in mandibular teeth, truncation is at the expense
Class I Tooth Preparation
of buccal proximal wall.
Outline form is kept as conservative as possible. It involves vii. Reverse bevel is placed on gingival floor toward axial
removal of all carious fissures and extending them to the wall.
point of immunity. Preparation is done with No. 330 bur viii. Buccal and lingual walls should be extended to contact
(pear-shaped bur). It is similar to amalgam with following area but breaking of contact is not required as in case
modifications: of amalgam restoration.
i. Presence of definite and sharp line and point angles ix. Cavosurface margins are beveled at 45° to the enamel
instead of rounded (Fig. 21.4). walls.
ii. Extension in facial and lingual grooves in molars
forming spear like shape that is pointed termination
rather than rounded.
Class III Tooth Preparation
iii. Facial and lingual margins are on inclined planes of For class III preparation, Ferrier design, Loma Linda
cusps making width of cavity not more than 1/5th the design, Ingraham design, Lund and Baum design and
intercuspal distance. Woodbury design are prepared.
A B
C D
Figs. 21.5A to D: Direct gold filling restoration of maxillary 2nd premolar: (A) Preoperative photograph;
(B) Tooth preparation; (C) Gold foil restoration; (D) Postoperative photograph.
(Courtesy: Anil Chandra)
A B
Figs. 21.6A and B: Direct filling gold restoration of class I cavity of mandibular first molar.
(Courtesy: Anil Chandra)
1. Ferrier Design making restoration almost invisible. Lingual margins are

located far enough into lingual surface to include marginal
This design is indicated if after removal of carious tooth ridge. In Loma Linda preparation, line and point angles
structure, bulky labial, lingual and incisal walls remain. It are more rounded and incisal internal retention mode
is also indicated if labial extension of the lesion facilitates appears to be bulkier than Ferrier design.
minimum extensions of the cavity labially.
Steps: Ingraham Design
i. Preparation is made triangular in shape using No.
This preparation is indicated when:
331/2 inverted cone bur. Incisal margin is kept
◆◆ There is incipient proximal lesion
cervical to contact area so as to provide access for
◆◆ Aesthetics is important
instrumentation. It meets the facial and lingual
◆◆ Patient has low caries susceptibility
margins in a smooth curve.
◆◆ Oral hygiene is good.
ii. Planing of labial and lingual wall and incisal outline
Shape of preparation is parallelogram which is confined
is done using Wedelstaedt chisel. Planning of incisal
to the contact area. In this, lesion is approached from the
wall is done using angle former.
lingual side with an inverted cone bur.
iii. Labial, lingual, axial and gingival walls are planed to
establish resistance form by using hoe. Hoe is also
used to accentuate linguo-gingival line angle and Class V Tooth Preparation
linguo-gingivo-axial point angle. Outline form of the class V preparation for direct gold is
iv. Planning of axial wall is done using Hoe. trapezoidal in shape. Outline form is obtained by using a
v. Angle former is used to accentuate point angles and small inverted cone bur (Figs. 21.7A and B). Preparation
axiogingival line angle. is finished with a 6.-2.-9 hoe (Fig. 21.7C). Wedelstaedt
vi. Bibeveled Hatchet is used to establish incisal retentive chisel is used to refine occlusal wall and margins (Fig.
angle in chopping motion. 21.7D). Chisel is used to bevel the gingival cavosurface
margins (Fig. 21.7E).
2. Loma Linda Design Gingival outline is shorter than occlusal margin because
This design is used in cases where: tooth is narrower gingivally. Occlusal margin is straight
◆◆ Lingual marginal ridge is involved and parallel to occlusal surface of tooth. Mesial and distal
◆◆ Facial surface has to be preserved margins should be straight and meet occlusal and gingival
◆◆ Aesthetics is most important. margin at acute and obtuse angle respectively. Angles
In this method, access is made through lingual should be sharp and well defined. Retention is provided
approach. In this, gingival margins are similar to Ferrier by convergence of the occlusal and gingival walls, acute
design. Labial margins may be located in contact area axiogingival line angle (Fig. 21.7F).
A B C
D E F
Figs. 21.7A to F: Steps of class v tooth preparation. (A) Obtain outline form using a small inverted cone bur; (B) keep the bur prependicular to
long axis of the tooth; (C) Finish the preparation using hoe; (D) Using Wedelstaedt chisel refine occlusal wall and margins; (E) Using Chisel, bevel
the gingival cavosurface margins; (F) Final class v tooth preparation.
Variations in Class V Preparation (Figs. 21.8A to D)
When caries in upper incisors are near the gingival line,
curvature of gum tissue would make a straight gingival
wall unpleasant. In these cases, curve the gingival and
incisal wall to follow the gingival contour.
Incisal outline is modified to follow the contour of
soft tissue mesiodistally when caries extends occlusally.
Sometimes fine chalky lines run up mesially and distally
angles of labial surfaces of the tooth into the embrasures
much farther than in the normal preparation. In these
cases, curvature of occlusal or incisal wall is made to
include these lines without cutting too much of tooth
structure in middle third area.
Fig. 21.9: Instruments used for compaction of direct filling gold.
In automatic mallet, programmed force is applied

which is controlled by a spring present inside the mallet.
When desired force is attained, the spring is released.
A B
In pneumatic condenser compaction strokes are
controlled by a rheostat attached to an electric motor.
Condensation pressure is controlled by a button present
on back of the handpiece. Condenser has a working tip
and it fits into the malleting handpiece.
Electromallet compaction of gold is most efficient way
C D
of condensing gold. Here vibrating condenser head is used
Figs. 21.8A to D: Variations in class V preparation.
to compact the gold.
Compaction of Direct Filling Gold Factors Affecting Compaction of Gold

When direct gold is placed in the prepared cavity, it is i. Amount of Force
compacted to adapt the gold into all cavity walls and Condensers are available in different sizes and shapes like
angles resulting in dense void free restoration. round, parallelogram and rectangular. Round is used to
start the compaction and form ties. Parallelogram is used
Objectives of Compaction to build the bulk of the restoration. Rectangular is used
Two main principles of compactions which control the for compaction at cavosurface and surface hardening.
quality of final gold restorations are welding and wedging. All have pyramidal serrations so as to prevent slipping of
i. Welding is the process of forming atomic bonds gold while compaction. Pressure applied for compaction
between pellets so as to make a cohesive mass. of gold is inversely proportional to size of the condenser
ii. Wedging is the process of pressurized adaptation tip. Smaller the nib, more square inch force is delivered
of gold to the preparation walls and minimizing the (F = 1/r2).
voids
ii. Direction of force
Compacting Instruments (Fig. 21.9) Compacting force should be such that it takes advantage of
Compaction of gold can be done either by hand pressure, hand property of gold to flow under pressure, in the direction of
mallet, pneumatic mallet, automatic mallet, or electromallet. force. Force of condensation should be 45° to preparation
In hand condensation, gold is packed into prepared walls so as to have maximum adaptation of gold to
tooth in right direction with the help of condenser. End preparation walls. Bisect the line angle and trisect the point
of the condenser shank is blunt to receive blows from the angle to have maximum adaptation, minimum irritation
mallet and it is about 15 cm in length. to pulp and dentin. To an already compacted gold, force
In hand mallet method, gold is condensed by tapping should be applied at 90° to prevent displacement of gold
mallet. pieces (Figs. 21.10A to C).
3. Compaction of restoration
4. Finishing of the restoration
•• Burnishing
•• Contouring
•• Polishing
•• Final burnishing
A B
1. Building of Restoration
Gold is placed in the preparation in the form of three-step
build up. These are:
i. Tie formation: In this, two opposite starting points
are filled with gold so as to form a tie which acts as a
foundation for gold restoration (Fig. 21.11A).
C D
ii. Wall banking: In this, each wall is built from its floor
Figs. 21.10A to D: Factors affecting condensation: (A) Force of or axial wall to cavosurface margin (Fig. 21.11B). It
compaction should be 45° to preparation walls so as to have maximum
should be done simultaneously on surrounding walls
adaptation of gold; (B) Bisect the line angle and trisect the point angle
to have maximum adaptation of gold; (C) To an already compacted of the preparation.
gold, force should be applied at 90° to prevent displacement of gold iii. Formation of shoulder: This is made by joining two
pieces; (D) Start at a point angle on one side and proceed to another opposite walls with the help of direct filling gold (Fig.
side, each succeeding step of the condenser should overlap the half of 21.11C).
the previous step, this is called stepping of gold.
iii. Pattern of using Force

It is important to step the condenser in a controlled pattern.
After compacting first increment of gold at corner of the
preparation, next increment is placed and compacted. A B C
Always start at a point angle on one side and proceed
Figs. 21.11A to C: Building of restoration; (A) Tie formation; (B) Wall
to another side. Each succeeding step of the condenser banking; (C) Formation of shoulder.
should overlap the half of the previous step. This is called
as “stepping” (Fig. 21.10E). Stepping helps in maximum
adaptation of gold to the preparation walls and reduction 2. Paving of Restoration
in number of voids. In spite of careful compaction, some
Every part of the cavosurface margin should be covered
void spaces may occur in compacted gold and along the
with excess gold so as to overfill the preparation.
preparation walls. This is called bridging. Bridging should
be minimum for a successful restoration.
Each type of gold requires different technique for 3. Compaction of Gold
manipulation. For example, in contrast to compaction of Compaction is done using high condensation energy so as
gold foil, condensers with a slightly larger face and finer to strain harden the surface of gold and achieve a void free
serrations are required for mat gold to get better results. For restoration.
powdered or granular pellets, heavy pressure is required for
malleting and they need to be opened up in the preparation 4. Finishing of Restoration
before compaction begins, to minimize voids in the mass.
i. Burnishing: First step in finishing of gold restoration
iv. Energy of Compaction is burnishing. Especially designed Spratley burnisher
is moved with pressure over restoration to close
Less energy is required inside the cavity preparation.
the voids (Fig. 21.12A). This also enhances surface
gradually, increase in the energy of condensation is
hardness of the restoration.
required as build up proceeds to the surface. Maximum
ii. Contouring: Extra material from restoration is
energy is needed at surface of the restoration.
removed with sharp knives, gold foil carver, files, and
Steps of direct filling gold abrasive stones (Fig. 21.12B).
iii. Polishing: Fine garnet and cuttle disks are moved
restoration
from gold towards tooth surface for final finishing.
1. Building of restoration Finishing can be done using tin oxide powder on
2. Paving of restoration rubber cup or soft bristle brushes.
VIVA QUESTIONS
1. What are indications and contraindications of direct
filling gold?
2. What are advantages and disadvantages of direct
filling gold?
3. What are different forms of gold?
A B
4. What are different methods of Degassing/Annealing
Figs. 21.12A and B: Finishing of restoration.
in direct filling gold?
5. What should be the angle of handle of condenser to
iv. Final burnishing: Final burnishing is done to make preparation wall?
the surface of the restoration shiny and smooth free of 6. Define ductility and malleability.
voids. 7. What is Karat and fineness?
8. What are different steps of direct filling gold
Future of Gold in Dentistry restorations?
9. How do you classify direct filling gold?
Historical development work on gold has provided a
10. What is Corrugated gold foil?
wide range of gold-based dental alloys. If requirements
like function, aesthetics, biocompatibility, longevity, and 11. What is Platinized gold foil?
ease of manufacture are considered, high gold alloy is 12. What is Mat foil?
the choice of material for dental restorations. However, 13. What is Gold-dent?
evolution is required on the alternative materials because 14. What are hazards during degassing?
of technique sensitivity, high cost and less aesthetics. 15. What is Ferrier design for class III preparation?
16. What are objectives of compaction in direct filling
gold?
Conclusion
17. What are factors affecting compaction of gold?
Direct-filling gold is very useful for restoration of 18. What are different steps of direct filling gold
teeth. It has number of advantages like nobility, good restoration?
compressive strength, wear resistance similar to tooth, etc, 19. Discuss the finishing of gold restoration.
if manipulated properly, a direct filling gold restoration 20. Discuss the class V preparation in direct filling gold.
can serve for lifelong. One should take utmost care during 21. Discuss the class I preparation in direct filling gold.
cavity preparation, handling of the gold and compaction
so as to have optimal restoration. bibliography
1. Baum L. Gold foil (filling gold) in dental practice. DCNA. 1965.
EXAMINER’S CHOICE QUESTIONs p. 109.
1. What are the properties and indications of direct 2. Baum L. Gold foil (filling golds) in dental practice. Dent Clin
filling gold (DFG)? North Am. 1965;29:199-212.
2. Write various stages and steps of tooth preparation 3. Baum L. Gold foil. Oper Dent. 1984;9:42-9.
4. Birkett GH. Is there a future for gold foil? Oper Dent. 1995;20:41.
according to modern concept. Describe in brief class
5. Dwinelle WH. Crystalline gold, its varieties, properties, and use.
V tooth preparation for gold foil. Am J Dent Sci. 1855;5:249-297.
3. Discuss the various types of direct gold material 6. Ferrier WI. The use of gold foil in general practice. J Am Dent
available for restoring teeth in detail. Assoc. 1941;28:691.
4. Write short notes on: 7. Harken BJ. Gold foil. A potential practice builder in the 80s.
a. Compaction of direct gold. Oper Dent. 1985;10:28-9.
8. Hodson JT. Structure and properties of gold foil and mat gold. J
b. Storage of direct gold.
Dent Res. 1963;42:575.
c. Matgold. 9. Lund MR, Baum L. Powered gold as a restorative material.
d. Gold foil. J Prosthet Dent. 1963;13:1151-9.
e. Degassing/Annealing of gold. 10. Stibbs GD. Direct golds in dental restorative therapy. Oper Dent.
f. Steps of direct filling gold restoration. 1980;5:107-14.
Chapter
22
Cast Metal Restorations
Chapter Outline
Introduction Disadvantages
Components of Cast Gold Alloys Basic Design of Cast Metal Inlay
Classification of Cast Gold Alloys Cavity Preparation for Class Ii Cast Metal Inlays
Properties of Cast Gold Alloys Modifications in Class Ii
Definitions Cast Metal Onlay
Indications for Class Ii Gold Inlays Technique of Making Cast Metal Restoration
Contraindications Casting Defects
Advantages Pin-retained Cast Restorations
INTRODUCTION and restorative longevity. After 1970s, aesthetic restorative

materials came into light because of increase in awareness
Various defects of teeth can be restored using different of tooth colored restorations in comparison to cast gold
restorative materials like amalgam, composite resins, restorations.
direct filling gold and cast metal restorative materials.
Each material has its own indications, contraindications,
advantages and disadvantages. When sufficient tooth Components of cast gold alloys
structure is not present for the support of restoration, Element Function
then cast metal restorations are indicated. Cast metal
Gold • Primary constituent
restorations were introduced in dentistry about 100 years • Provides yellow color, density, nobility and
ago and soon they became a subject of great interest to both castability
dentists and patients. Most of the cast metal restorations Copper • Second most important constituent
are made from alloys formed by combination of gold • Increases hardness and strength
with other metals such as silver, copper, zinc, platinum, • Reduces corrosion resistance of alloy
and palladium. Casting procedures have been used for • Imparts reddish color
replacement of teeth by means of fixed and removable • Reduces density of alloy
partial denture prosthesis, and full mouth restorations. Silver • Lightens the color
There are two techniques of fabrication of cast metal • Increases deformability
restorations: • Decreases nobility
1. Direct technique. Platinum and • Increases hardness and strength
2. Indirect technique. palladium • Increases tarnish and corrosion resistance
• Whitens the alloy
In direct technique, the wax pattern is directly prepared
• Increases melting range
on the tooth preparation in mouth, invested and casted.
In indirect technique, the wax pattern is fabricated on Zinc Scavenger for oxygen, i.e. deoxidizer
the model prepared from the impression taken. Indium, They reduce the grain size of gold alloy
Cast gold restorations became most popular from the ruthenium,
rhodium
year 1930s to 1970s because of their acceptable functions
Cast Metal Restorations 249
Classification Of Cast Gold Alloys 2. Melting Range
In 1927, the Bureau of Standard divided gold casting alloys It varies from 920°C to 960°C. Low melting range facilitates
into type I to IV, according to their use. use of simple heating and casting procedures.
1. Type I (Soft) 3. Nobel and Inert

◆◆ Soft, weak, ductile and easily burnishable Cast gold alloys resist oxidation. They tend to slow
◆◆ Gold content ranges between 75% and 83%
tarnish and corrosion if there is high percentage of silver
◆◆ Used in low stress bearing areas
content.
◆◆ Simple inlays in class I, III or V cavities
◆◆ Not capable of being heat treated.
4. Biocompatibility
2. Type II (Medium) Gold alloys are relatively biocompatible. They do not
◆◆ Harder and stronger than type I release harmful products when come in contact with oral
◆◆ Gold content ranges from 70% to 75% environment.
◆◆ Ductility same as type I though yield strength is high
◆◆ Used in moderate stress areas 5. Strength
◆◆ Used for three quarter crowns, pontics and full crowns
They have high strength and can withstand high forces
◆◆ Not capable of being heat treated
without fracture.
Type I and II are often referred as inlay golds.
3. Type III (hard) 6. Modulus of Rigidity

◆◆ Used in high stress areas It measures rigidity of alloy. Gold alloys are not rigid, they
◆◆ Gold content ranges from 65% to 70% are flexible in nature.
◆◆ Less burnishable than type I and II
◆◆ Can be age hardened 7. Hardness
◆◆ High stress inlays, full crowns, pontics, and short span They have high degree of hardness varying from 80 VHN
FPDs.
to 150 VHN. This indicates their resistance to wear during
4. Type IV (Extra Hard) function.
◆◆ Used in very high stress areas

◆◆ Gold content is 60% 8. Elongation and Yield Strength
◆◆ Least ductile These are measures of deformability (burnishability) of
◆◆ Responsive to age hardening the material and forces needed to achieve deformability.
◆◆ High stress inlays, bars and clasps and long span FPDs. Type I gold alloys can be easily burnished. Alloys with low
elongation are very brittle.
Classification of Cast Gold Alloys
According to Marzouk
9. Density
i. Class 1—Gold and platinum-based alloys
ii. Class 2—Low gold alloys with gold content <50% High density of gold alloys allow them to flow easily into
iii. Class 3—Non-gold platinum based alloys mold space before it cools.
iv. Class 4—Nickle-chromium-based alloys
v. Class 5—Castable, moldable ceramics. 10. Coefficient of Thermal Expansion
JAPANESE GOLD Gold alloys have low coefficient of thermal expansion.
It is copper-based nonprecious casting alloy. It is also known This allows low shrinkage when they cool from solidus
as Technique Alloy/Orden Golden Casting Alloy. temperature to room temperature.
Composition:
Copper: 53%
Zinc: 45% 11. Polishability
Aluminium: 1.3%
Iron: 0.2% Hardness of gold alloys allow them to have excellent
polishability with abrasives. They also maintain their
Properties of cast gold alloys polish, thus plaque resistance quality.
1. Color
color of cast gold alloys varies from yellow to white 12. Solderability
depending on whitening elements present in alloy. Gold alloys can be easily soldered using gold solders.
DEFINITIONS 2. High caries index

1. Inlay Cast metal restoration is not indicated in patients with
poor oral hygiene and high caries index.
It is an indirect intracoronal restoration fabricated extra
coronally and then cemented on prepared tooth.
3. Young Permanent Teeth
2 Class II inlay Cast metal restoration is not indicated in young permanent
teeth because of chances of iatrogenic pulp exposure due
This is an indirect restoration that caps one or more cusps to high pulp horns.
of a posterior tooth, but not all the cusps.
4. Dissimilar Metals
3. Onlay
In patients having restorations with different metals since
It is an indirect restoration which is partly intracoronal dissimilar metals cause galvanic currents when they come
and partly extracoronal that covers all cusps of a posterior in contact with each other.
tooth.
5. Occlusal Disharmony
INDICATIONS for class ii gold inlays
Cast metal restorations are not used in patients with severe
1. Correction of Occlusion occlusal interferences or other defects.
To maintain and restore proper interproximal contact,
contour and for occlusal plane correction, cast restorations 6. Cost Factor
are ideal. For patient of low economic status, inlay and onlay are not
given because of higher cost.
2. Extensive Tooth Involvement
Cast gold restorations are indicated in teeth with extensive Advantages
proximal caries in posterior teeth involving buccal and
lingual line angles. 1. Optimal Contacts and Contours
Since inlays are fabricated by indirect technique, there is
3. Attrition better reproduction of contacts and contours.
In teeth with attrition and heavy occlusal forces, cast metal
restorations are ideal because of their good strength and 2. Good Wear Resistance
wear rate similar to that of enamel.
Cast metal restorations wear at same rate as that of enamel,
so they do not cause wear of opposing tooth.
4. Already Present Cast Metal Restoration
When teeth already with cast gold restoration are present, 3. Biocompatible
cast metal restorations are indicated to prevent galvanic
Cast metal restoration are biocompatible with good tissue
current.
response.
5. Low Incidence of Caries
4. Strength
Patients to receive a cast restoration should have low caries
Due to good strength, cast gold alloys are strong enough to
index and plaque accumulation.
reinforce the weak tooth surfaces. They have good resistance
to tensile forces, thus used for inlays, onlays and crowns.
6. Proximal Margins Extending Subgingivally
When proximal margins of preparation extend subgingi- 5. Noble
vally, cast metal inlay is preferred because a well-polished Cast gold restorations are noble so not affected by tarnish
gold alloy is compatible with periodontium. and corrosion and exhibit excellent durability in mouth.
CONTRAINDICATIONS
6. Extraoral Finishing and Polishing
1. Aesthetics
Since cast gold restorations are finished and polished
Where aesthetics is prime consideration, cast metal extraorally, so finishing and polishing procedure does not
restorations are not indicated because of metallic color. damage the pulp.
7. Less Internal Stresses
Casting restorations have fewer voids, no layering effect, less
internal stresses and stress patterns.
Disadvantages
1. Microleakage
Being a cemented restoration, many interphases are
formed at tooth-cement-casting junction. So, these cast
metal restorations are more prone to microleakage. Fig. 22.1: Inlay should have single insertion path opposite to
the occlusal load and parallel to the long axis of tooth.
2. Technique Sensitive
Fabrication of cast gold restoration requires precise this angle forms the line of draw which is perpendicular to
attention for all steps. Any error during fabrication can pulpal floor (Fig. 22.2).
result in faulty restoration. Ideally, the opposing walls should be kept parallel for
having good retention. But if tapering is given, it should be
3. Unaesthetic given in the range of 2–5° per wall. Taper of wall is increased
with increase in length of wall, but it should not exceed the
Due to their color, cast gold restorations are unaesthetic
limit. Taper of one wall of preparation should not be more
for anterior teeth.
than the other because it can result in more than one path
of insertion (Figs. 22.3A and B). For shallow preparations,
4. More Number of Appointments
axis of taper is parallel to long axis of the tooth and for class
Minimum two appointments are required for fabrication
of cast gold restoration.
5. Expensive
Laboratory charges and cost of gold alloys make cast gold
restorations expensive when compared to amalgam and
direct composite resin.
6. Repair
Once cemented, repair is difficult with cast gold
restorations.
BASIC design OF CAST METAL INLAY

Cast metal restorations involve making of a wax pattern
which should be removed from cast or die without any
distortion. Hence, some fundamental basic designs are
incorporated during preparation of class II inlay.
Fig. 22.2: Inlay taper.
1. Path of Draw
Preparation should have single insertion path opposite
to the occlusal load and parallel to the long axis of tooth
(Fig. 22.1). This helps in retention of the restoration and
minimizes any rocking during function.
2. Inlay Taper
To have unhindered removal and placement of wax pattern
and seating of final casting, intracoronal and extracoronal
tooth preparation should have slight diverging walls from
gingival to occlusal surface. This is called concept of A B
taper. Extension of opposing walls which diverge toward Figs. 22.3A and B: More taper of one wall of preparation than other
the occlusal surface form a convergent angle. bisection of can result in more than one path of insertion.
V preparations, axis of taper is perpendicular to long axis 2. Short Bevel

of the tooth. It involves the beveling of full thickness of enamel wall but
not dentin. It is most commonly used for cast gold inlay
3. Circumferential Tie cavities.
Circumferential tie refers to the design of cavosurface 3. Long Bevel
margin of an inlay cavity preparation. This junction This bevel involves full thickness of enamel and half or
between tooth, cement, and inlay is the weakest part of less than half thickness of dentin. It is also used for inlay
the cast metal restoration. For success of the restoration, cavities. It preserves the internal “boxed up” resistance
margins of restoration should be designed so as to achieve and retention features of the preparations.
its maximum adaptation to tooth structure. Cavosurface
4. Full Bevel
margins of an inlay preparation can be of two types:
This bevel involves full enamel and dentinal wall. Full bevel
I. Bevels
is usually avoided because it deprives the preparation of its
II. Flares.
internal resistance.
I. Bevels 5. Counter Bevel
Bevel is defined as plane of cavity wall or floor directed It is used when cusps require capping to protect them. It is
away from cavity preparation. An accurate wax pattern and given opposite to an axial wall of preparation on facial or
casting may not have precise adaptation to the margins of lingual surface of the tooth.
tooth preparation, if bevel is not given. Objective of bevel 6. Hollow Ground (Concave) Bevel
is to form a metal wedge of 30–35°, thus enhancing the Hollow ground is concave in shape and not a bevel in
chance to achieve closure at the interface of cast gold and true sense. It is used for base metal alloys and castable
tooth by burnishing. By beveling, a strong enamel margin ceramics. since, these materials have poor castability,
with an angle of 140–150° can be produced. hollow ground design provides bulk for these materials.
Types of bevel (Fig. 22.4)

Functions of Bevels
According to their shape and type of tissue involved, bevels
◆◆ By beveling, weak enamel is removed.
are of following six types:
◆◆ Beveling produces obtuse-angled tooth margins.
1. Ultrashort or Partial Bevel Resultant cavosurface angle of 135–140° forms the
It involves bevel of less than two-thirds of the total enamel strongest and the bulkiest configuration.
thickness. It is mainly used to trim the enamel rods from ◆◆ Acute-angled metal margins (35–45°) allow the metal
preparation margins. margins to be burnished against tooth surface.
◆◆ Beveling increases retention, resistance, aesthetics, and
color matching for composite resin restoration.
◆◆ It improves junctional relationship between the
restorative material and tooth.
◆◆ Bevels are the flexible extensions, i.e. they allow
inclusion of faults, wear facets, etc. without
overextending the preparation margins.
◆◆ Gingival bevel makes the restoration more amenable to
finishing and cleansing at gingival margins.
◆◆ Counter bevel increases the resistance form to
remaining tooth structure.
◆◆ Because of beveling, the gingival margin has a lap
sliding fit which provides better fit at this region.
II. Flares (Fig. 22.5)

Flares are concave or flat peripheral portions of the facial
or lingual proximal walls. They are of two types:
1. Primary Flare
It is basic part of circumferential tie. Primary flare is like
Fig. 22.4: Types of bevel. a long bevel directed 45° to the inner dentinal wall. It is
◆◆ Permits easy burnishing and finishing of the restoration.
◆◆ Produces more obtuse-angled and stronger cavosurface
margin.
4. Modifications of Proximal Box Preparation

Following modifications can be made in proximal box:
i. Box Preparation
It was introduced by Dr GV Black. In this, proximal cavity is
prepared like a box (Fig. 22.6A). It provides resistance and
retention form and causes minimal display of metal. But
this preparation causes, more removal of tooth structure,
narrow bevels which leave a sharp edge, and while taking
impression, distortion or damage of wax pattern can occur.
Fig. 22.5: Primary and secondary flares.
ii. Slice Preparation
indicated when normal contacts are present and when In this modification, proximal surface is flat without
there is minimal extension of caries in buccolingual definite side walls. Slice preparation involves conservative
direction. disking of proximal surface to establish buccal and lingual
Advantages: extend of finish lines, providing a lap joint (Fig. 22.6B).
◆◆ Perform same functions as bevels. It is indicated in teeth which are used as abutments
◆◆ They bring facial and lingual margins of the cavity to and with proximal undercuts that can be eliminated by
self-cleansable areas. this preparation, facilitating indirect wax pattern and
impression taking.
2. Secondary Flare Advantages: Less tooth structure is sacrificed, well
protected enamel margins and increase resistance and
It is a flat plane superimposed peripherally to the primary retention by exposing large amount tooth structure.
flare. It may have different angulations, involvement, and Disadvantages: It causes more display of metal, difficult to
extent depending upon requirement. Secondary flare is take direct wax pattern because it is difficult to distinguish
not given in the areas where aesthetics are more important. the margins and metal margins can distort due to less
Indications of secondary flare: thickness.
◆◆ When broad contact area is present.
◆◆ To include the faults present on facial and lingual walls iii. Auxiliary Slice Preparation
beyond primary flare. It wraps partially around proximal line angles, thus
◆◆ When caries is widely extended in buccolingual provides additional resistance and retention form (Fig.
direction. 22.6C).
◆◆ To include the undercuts present at cervical aspect of
facial and lingual walls. iv. Modified Flare
Advantages: It is combination of box and slice preparation (Fig. 22.6D).
◆◆ Secondary flare ensures cavosurface margins to extend In this, minimum disking of proximal wall is done for
into embrasures (self-cleansing area). better finishing and polishing.
A B C D
Figs. 22.6A to D: (A) Box preparation; (B) Slice preparation; (C) Auxillary slice preparation; (D) Modified flare preparation.
5. Additional Resistance and Retention Features retention 8–10 times and thus placed at the periphery of
preparation close to marginal ridge. It should be at least
In addition to primary retention forms, following auxiliary 2 mm in dimension. Internal box is contraindicated in
means of retention can be used to provide additional class IV and V preparations.
retention to the cast restorations.
4. External box (Fig. 22.7D)
1. Grooves (Fig. 22.7A)
It is a box-like preparation opening to the axial surface of the
Grooves provide additional retention and resistance to tooth. It may have three, four or five walls with a floor. The
lateral displacement of mesial, distal, facial or lingual peripheral portion of these walls can be flared or beveled.
part of the restoration. Internal grooves are given when
preparation is shallow and small. They are contraindi 5. Pins
cated when preparation is deep with the danger of pulp
involvement. External grooves are indicated in extra Various pins can be used to increase the retention of cast
coronal preparations which lack retention because of restorations. These can be cemented, threaded, parallel,
short preparation with severe taper or excessive width. cast, and wrought.
2. Reverse bevel (Fig. 22.7B) 6. Slot (Fig. 22.7E)

It is indicated for class I, II, and III restorations. It is used Slot is an internal cavity prepared within the floor of
when sufficient dimensions of gingival floor are present so preparation. It is indicated in tooth preparation with shallow
as to accommodate it. It is placed at gingival floor forming depth, and when dovetail cannot be prepared because of
an inclined plane directed gingivally and axially. restricted occlusal anatomy. They have depth of 2–3 mm
and are prepared using round and tapered fissure bur.
3. Internal box (Fig. 22.7C)
7. Skirt (Fig. 22.7F)
It is prepared in dentin which forms vertical walls with
definite line and point angles. Internal box is indicated It is a specific extension which involves a part of axial wall
when sufficient dentin bulk is present. It increases the of the tooth preparation. It is indicated when restoration
A B
C
D E F
Figs. 22.7A to F: Resistance and retention features for cast restorations. (A) Grooves and coves; (B) Reverse bevel;
(C) Internal box; (D) External box; (E) Slots; (F) Skirt.
has short/missing facial or lingual wall and when defect
is more extensive. Skirt is also indicated in cases where
contact and contour of the tooth is to be changed.
8. Collar
It is the surface extension which involves facial or lingual
surfaces of one or more cusps. It helps in increasing
retention and resistance in case of grossly decayed teeth, in
short teeth and in the teeth where pins are contraindicated,
collar is prepared 1.5–2 mm deep.
9. Cusp Capping
Cusp capping increases the resistance and retention form,
provided sufficient height of cusp is present.
Fig. 22.8: Burs for tooth preparation for cast metal restoration.
10. Reciprocal Retention
In case of cemented preparations, if restoration is not For complete description of cavity preparation, disto
locked from the opposite end of locked side, movements occlusal cavity of maxillary premolar is explained below.
of the free end create stresses in the locked end. To reduce
this, reciprocal retention is provided by placing retention Initial Tooth Preparation
mode at every end of the preparation in the form of 1. Occlusal Outline Form
grooves, dovetail or internal box.
Penetrate the tooth with No. 271 bur held parallel to
Steps of Inlay Preparation long axis of the tooth to initial depth of 1.5 mm. Entry
• Tooth preparation
point should be closest to the involved marginal ridge
• Impression taking (Fig. 22.9A). Keeping the bur parallel, extend the tooth
• Die making preparation while maintaining the initial pulpal depth of 1.5
• Wax pattern mm. while preparing the occlusal outline, circumvent the
• Investing of the pattern and creating the mold cusps by curving facial and lingual walls of the preparation,
• Gold casting. maintain uniform taper, and flat pulpal floor (Fig. 22.9B).
give dovetail on mesial side of occlusal preparation to
resist distal displacement of final restoration (Fig. 22.9C).
cavity PREPARATION FOR CLASS II Cast Conserve the mesial marginal ridge and if any faulty
Metal INLAYS shallow fissure is present, manage it by enameloplasty or
including it in cavosurface bevel. maintain the isthmus
Instruments Used for Cavity Preparation for width of one-third of intercuspal distance.
Cast Metal Restorations (Fig. 22.8)
1. No. 271. Tungsten carbide tapering fissure bur with 2. Proximal Box Preparation
0.8 mm width. While maintaining the same pulpal depth and holding the
2. 169L tapered fissure bur with 0.5 mm width. bur parallel to long axis of tooth, extend the preparation
3. No. 8862 slender fine grit flam-shaped diamond for toward contact area of the tooth. Isolate the distal enamel
preparing cavosurface bevels. by proximal ditch cut. Width of this cut should be 0.8 mm
4. Chisel, hatchet, and Wedelstaedt for removal of with 0.5 mm in dentin and 0.3 mm in enamel. Extend this
undermining enamel and producing primary and ditch facially and lingually to the sound tooth structure
secondary bevels. and proceed gingivally (Fig. 22.9D).
5. Spoon excavator for removal of remaining soft caries. Gingival extension should remove any caries present
6. Gingival margin trimmer for creating gingival bevels. on the gingival floor and it should provide at least 0.5 mm
7. Torpedo-shaped stone or bullet-shaped stone along clearance from the adjacent tooth. To break contact from
with round bur for creating hollow ground bevel. adjacent tooth, make two cuts with no. 271 bur; one on facial
8. Tapered fissure bur followed by hatchet or binangle limit and other at lingual limit of the proximal box (Fig.
chisel for reverse secondary flare. 22.9E). Extend these cuts gingivally till the bur is through
9. 12 fluted or 40 fluted carbide bur for smoothening of the proximal surface. Contour of axial wall should follow
tie. the faciolingual contour of the tooth. Keep a small slice of
A B C D
E F G H
I J K L
Figs. 22.9A to L: Tooth preparation for class II gold inlays: (A) Penetrate the tooth with No. 271 bur held parallel to long axis of the tooth to initial
depth of 1.5 mm; (B) Extend the tooth preparation while maintaining the initial pulpal depth of 1.5 mm, uniform taper and flat pulpal floor; (C)
Give dovetail to resist displacement of final restoration; (D) Make proximal ditch cut, 0.8 mm wide with 0.5 mm in dentin and 0.3 mm in enamel.
Extend this ditch facially and lingually and proceed gingivally; (E) To break contact from adjacent tooth, make two cuts with No. 271 bur; one on
facial limit and other at lingual limit of the proximal box; (F) Remove the remaining thin slice of unsupported enamel using spoon excavator; (G)
Remove remaining caries, and using spoon excavator or slow speed round bur; (H) Use pulp protective agents whenever indicated; (I) Place re-
tention grooves in axiofacial and axiolingual line angles using number 169 L carbide; (J) Prepare gingival bevel of 30–45° to remove unsupported
enamel and provide a stronger obtuse angle of tooth structure for lap sliding fit and sealing of margins of the restoration; (K) Give occlusal bevel
of 30–40° using flame-shaped bur; (L) When cusps are steep, little or no bevel is placed.
enamel at the contact area to prevent accidental damage caries and/or old restorative material. Remove remaining
to the adjacent tooth. Remaining thin slice of unsupported caries using spoon excavator or slow speed round bur
enamel wall can be removed using spoon excavator (Fig. 22.9G). In this, two step pulpal floor is made, i.e. only
(Fig. 22.9F). using enamel hatchet or binangle chisel, plain portion of tooth which is affected by caries is removed,
the ragged enamel margins of proximal surface. leaving the remaining preparation floor untouched. Use
pulp protective agents whenever indicated (Fig. 22.9H).
3. Removal of Remaining Carious Dentin and Pulp
Protection 4. Placement of Grooves
Clean the prepared tooth with air/water spray or with Place retention grooves in axiofacial and axiolingual
cotton pellet and inspect it for removal of remaining line angles using number 169 L carbide bur (Fig. 22.9I).
while preparing the grooves, hold the bur parallel to line Table 22.1: Difference in cavity preparation of silver amalgam and
of draw. cast gold inlay.
Silver amalgam Class II gold inlay
5. Gingival Bevel • Outline form is narrow • Outline form is wide
Prepare gingival bevel of 30–45° with the help of gingival • Intercuspal width is • Intercuspal width is one-third
margin trimmers. Gingival bevel should include one-half one-fourth of intercuspal of intercuspal distance
distance
width of the gingival wall. Gingival bevel removes weak or
• Prepared with burs 245 and • Prepared with burs 271 and
unsupported enamel, provides a stronger obtuse angle of
330 169 L
tooth structure which aids in finishing of the casting and
• Preparation walls converge • Preparation walls are parallel
lap sliding fit and sealing of margins of the restoration occlusally or have 2–5° divergence
(Fig. 22.9J). Gingival bevels more than 45° results in • Buccal and lingual proximal • Buccal and lingual walls are
overextension of the gingival and proximal margins which walls converge occlusally parallel
causes difficulty in impression making, fabricating the wax • Reverse curve may be present • Reverse curve is not provided
pattern, and finishing of the restoration. in proximal outline
• Butt joint at cavosurface • Cavosurface bevel is given
6. Occlusal Bevels margin
Give occlusal bevel of 30–40° using flame-shaped bur • Beveling is done only at • Beveling is occlusal and
(Fig. 22.9K). It removes any irregularities in the preparation gingival seat to remove gingival cavosurface margin
unsupported enamel is done for better retention
or unsupported enamel rods at the cavosurface margin,
• Rounded internal line angles • Well-defined internal line
creates 30–40° of marginal metal which is more amenable
angles
to burnish. When cusps are steep, little or no bevel is
• Beveled axiopulpal line angle • Rounded axiopulpal line angle
placed (Fig. 22.9L), but when shallow cusps are present, a
• No reverse bevel is given • Reverse bevel is given
more distinct bevel is placed. sometimes for providing
When it is required to cover a cusp with cast metal, retention to inlay
prepare a hollow ground bevel using a twelve fluted, • Secondary retention is • Secondary retention is
round-ended bur. This allows bulk of the restoration at provided by grooves, slots, provided by grooves, slots,
cavosurface margin. Finally finishing of walls and margins pins, etc. boxes, skirts, collars, etc.
is done by removing all unsupported enamel.
3. In Maxillary Molars with Unaffected and
7. Final Cleaning, Drying, and Inspection of the Cavity Strong Oblique Ridge
Final stage of inlay preparation is to clean the preparation In maxillary molars, if oblique ridge is sound and
thoroughly with water and air spray. Then dry it with moist unaffected by caries, then it should be preserved to
air. maintain the strength of the tooth. If tooth preparation is
Table 22.1 summarizes the differences in tooth to be done on both mesial and distal sides, two separate
preparation for amalgam and class II inlay restoration. preparations are made instead of one MOD (Fig. 22.10).
Mesio-occlusal preparation is same as described above.
But following points should be kept in mind while
MODIFICATIONS IN CLASS II
preparing distal side, especially when the palatal develop
1. In Mandibular First Premolar mental groove is carious or prone to caries:
Because of different anatomy of mandibular first premolar,

following things are kept in mind during cavity preparation:
◆◆ Small lingual cusp may require cusp capping whenever
indicated.
◆◆ If transverse ridge is strong, smooth, and without a
faulty central groove, then it should be conserved while
cavity preparation.
2. Aesthetic Reasons
In teeth which are aesthetically important, for example,
maxillary premolars and first molars, involving mesial
surface, less mesiofacial flare is given and secondary flare
is omitted for minimal or no metal display. Fig. 22.10: Conservation of oblique ridge in maxillary molars.
◆◆ Wall of preparation should be almost parallel or have the cusp tip, cusp capping is desirable and it is mandatory
maximum of 2° occlusal divergence. if two-thirds or more of this distance is involved.
◆◆ Involve distopalatal cusp in the casting, if indicated.
◆◆ Palatal groove extension should not be very close to Steps
the distal proximal side, because this will result in Cusp reduction should be started after making a groove
weakening of the distopalatal cusp. (Fig. 22.12A). Groove helps in accurate and uniform
◆◆ Prepare mesoaxial and distoaxial grooves in the palatal cutting. While reducing the adjacent cusp, lingual or
groove extension and palatal and facial retention buccal developmental groove should be involved in
grooves in the mesial or distal box. Cusp capping preparation. Prepare a reverse bevel or counter-bevel on
prevents fracture of the underlying tooth structure the facial or lingual side of the reduced facial or lingual
since occlusal margins of the preparation are placed cusp, respectively (Figs. 22.12B and C). This bevel is not
away from strong occlusal forces. given in the areas where aesthetics is a prime concern like
facial margins on maxillary premolars and the first molar.
4. Class II Preparation with Gingival Extensions Figures 22.13 and 22.14 show restoration of teeth with
inlay.
to Include the Root Surface Lesion
Gingival extension should be achieved by lengthening the CAST METAL ONLAY
gingival bevel in cases of root surface lesions (Fig. 22.11).
Onlay is an indirect restoration which is partly intracoronal
5. Capping of Cusp and partly extracoronal which covers all the cusps of
posterior teeth.
When removal of caries results in loss of the occlusal
surface more than half the distance from primary groove to Indications for onlays
◆◆ Cast gold onlays are indicated in teeth with extensive
proximal caries in posterior teeth involving buccal and
lingual line angles.
◆◆ When teeth already with cast gold restoration are
present, cast metal onlays are indicated to prevent
galvanic current.
◆◆ Onlays are indicated to maintain and restore proper
interproximal contact, contour, and occlusal plane
correction.
◆◆ Postendodontic restorations are preferably done by
onlays to strengthen the remaining tooth structure and
to distribute occlusal forces.
◆◆ Abutment teeth of removable partial denture are
Fig. 22.11: In case of root surface lesions, gingival extension should indicated for onlays because they provide superior
be achieved by lengthening the gingival bevel. physical properties to withstand the forces imparted
A B C
Figs. 22.12A to C: (A) Cusp reduction starts after making grooves so as to have uniform and accurate cutting; (B) Bevel on facial or lingual cusp;
(C) Counter bevel on facial or lingual side of cusp.
Fig. 22.13: Restoration of maxillary second premolar with inlay.

(Courtesy: Rakesh Singla).
Fig. 22.14: Restoration of first mandibular molar with inlay.

(Courtesy: Rakesh Singla).
by the partial denture. Moreover, contours of rest Steps of Tooth Preparation for Onlay
seats, guiding planes, are better controlled in indirect
technique. 1. Occlusal Outline Form (Fig. 22.15A)
◆◆ In teeth with attrition and heavy occlusal forces, cast Start the preparation at central fossa with no. 271 bur held
metal restorations are ideal because of their good parallel to long axis of tooth. Keeping the bur parallel,
strength and wear rate similar to that of enamel. extend the preparation while maintaining the initial pulpal
depth of 2 mm. widen the occlusal outline, circumvent
the cusps and involve all defective pits and fissures. Give
Contraindications for onlays uniform taper of 3° to 5° for each cavity wall.
◆◆ In young patients due to presence of high pulp horns.
◆◆ Teeth with short clinical height because they do not 2. Proximal Box Preparation
provide sufficient retention. Using the same bur (No. 271), extend the preparation on
◆◆ In patients with high caries risk. mesial and distal side to expose proximal dentinoenamel
A B C D E
Figs. 22.15A to E: Steps of tooth preparation for onlay. (A) Prepare uniform cavity with 2 mm depth with taper of 3°–5° for each cavity wall;
(B and C) Give depth cut grooves of 1.5 mm and perform uniform cutting; (D) Give counter bevel on facial or lingual cusp; (E) Tooth preparation
for onlay.
junction. Isolate the proximal enamel by proximal ditch protrusive movements should be evaluated before and
cut. Proximal boxes for onlay are prepared in same way as after tooth preparation. After the tooth preparation, the
that for inlay. impression of the prepared and adjacent teeth is taken
3. Cusp Reduction (Fig. 22.15B) using an elastomeric impression material.
Before taking impression, gingival retraction cord
Cusp reduction is done using no. 271 carbide bur after should be applied first for better recording of gingival
making depth cuts of 1.5 mm (for nonfunctional cusp) and 2
margins of the preparation. Most commonly used material
mm (functional cusp) depth on the cuspal crest. depth cuts
for taking impression is addition polyvinyl siloxane
serve as guide for uniform and complete cuspal reduction.
While reducing the adjacent cusp, involve lingual or buccal impression because it has adequate strength, excellent in
developmental groove in cutting. reproduction of details, dimensionally stable, and easy to
handle.
4. Retention and Resistance Form
For increasing retention and resistance, grooves are made 2. Record of Interocclusal Relationship
in the facioaxial and linguoaxial line angles in the dentin.
Give a counter bevel holding the flame shaped bur at For single tooth inlay procedure, simple hinge type articu-
30° to the external enamel surface on the facial or lingual lators are sufficient. But for restoring multiple teeth with
side of the reduced facial or lingual cusp respectively (Fig. cast metal restorations, the semi-adjustable articula-
22.15C). Bevel should be wide enough so that cavosurface tors are used. Final adjustments in centric occlusion and
margins extend at least 1 mm beyond the occlusal contacts various mandibular movements are made in the mouth
with opposing teeth. Exceptions for giving bevel are facial before cementation to assure complete functionally
cusp of maxillary premolars and first molar because harmonious restoration.
aesthetics is a prime concern in these areas.
Prepare gingival bevels and flares of the proximal
enamel wall in same way as in inlay preparation. 3. Temporary (Interim) Restoration
5. Final Preparation (Fig. 22.15D) Interim restoration is given to the prepared tooth for the
time period between tooth preparation and cementing
Clean the preparation with air/water spray or with cotton
pellet and inspect it. In large preparations with soft caries, the restoration so as to protect and stabilize it and to
remove carious dentin using spoon excavator or slow speed provide comfort to the patient. an interim restoration
round bur. In this, two-step pulpal floor is made, i.e. only should be nonirritating, aesthetically satisfactory, protect
portion of tooth which is affected by caries is removed, and maintain the health of periodontium, and should
leaving the remaining preparation floor untouched. Apply a have adequate strength and retention to withstand the
protective base on the floor of the preparation (Fig. 22.15E). masticatory.
The interim restorations are made up of acrylic resin
TECHNIQUE of MAKING CAST METAL which can be prepared by direct and indirect technique.
RESTORATION
1. Impression Taking for Cast Metal Restoration Direct Technique
For achieving better results, the occlusal contacts in ◆◆ Take preoperative impression of the patient, prepare
maximum intercuspal position and in all lateral and the tooth.
◆◆ Pour self-cure acrylic resin in the preoperative alginate along with all inaccessible unprepared area of the tooth.
impression in the prepared tooth area and seat the Though various die materials are available with different
impression onto the prepared tooth and remove it properties, the ideal die material should:
after resin is cured. Do final finishing and polishing of ◆◆ Be compatible with impression materials
temporary restoration. ◆◆ Have a smooth nonabradable surface
◆◆ Produce accurate details of impression
Advantage
◆◆ Have adequate strength
Takes less time.
◆◆ Be easy and quick to fabricate
Disadvantage ◆◆ Have contrasting color to that of inlay wax.
Pulp and periodontal tissue may get trauma from heat
produced by direct polymerization of the acrylic and its Materials Used For Making Die
monomer. 1. Type IV and V dental stones
2. Electroformed dies
Indirect Technique
3. Epoxy resins
◆◆ Take preoperative alginate impression (called 4. Divestment.
impression no. 1). Preserve this impression in humid 1. Type IV and V dental stones: Most commonly used
conditions by covering with wet cotton. die material is type IV dental stone (high strength)
◆◆ Take an impression of the prepared tooth with alginate
and type V dental stone (high strength and high
(called impression no. 2).
expansion). Setting expansion of type IV dental stone
◆◆ Pour the impression no. 2 with fast setting plaster. Apply
is 0.1%. Higher setting expansion (0.3%) of type V
cold mold seal-separating media over the prepared
stone compensates for larger solidification shrinkage
tooth and about 5 mm around it.
of base metal alloys.
◆◆ Mix acrylic resin and pour it over impression no. 1 only
in the prepared tooth area and seat the cast prepared Advantages Disadvantages
by impression no. 2 in the impression no. 1 so as to give
• Compatible with all • Poor resistance to abrasion.
shape to the resin for making temporary restoration. impression materials To improve abrasion
◆◆ Remove excessive resin from the embrasure areas. • Dimensional stability resistance, they are coated
◆◆ Wait for resin to cure completely and remove the cast • Reproduction of details with cyanoacrylates but
after it is cured. • Inexpensive these reduce the accuracy or
◆◆ Take out resin crown from impression no. 1 and do the dimensional stability
final finishing and polishing.
2. Electroformed dies: These are used to overcome poor
Advantages abrasion resistance of gypsum. Electrodeposition
◆◆ Better marginal accuracy. of copper or silver on the impression gives a high
◆◆ Since polymerization takes place outside the mouth, strength, adequate hardness, and good abrasion
pulp and periodontal tissues are not traumatized by resistance to the cast.
heat of polymerization and monomer. Electroforming (Electroplating/Electrodeposition)
◆◆ Resin cannot be locked on preparation surface of tooth is a process in which thin coating of metal (copper
in small undercuts and in the cervical areas. or silver) is deposited on the impression, and then a
◆◆ Less chairside time. gypsum cast is poured into the impression. This cast
will have hard metallic surface.
4. Working Cast
Working cast is an accurate replica of the prepared
and adjacent unprepared teeth over which cast metal • Excellent accuracy • Expensive
restoration can be fabricated. • Good abrasion resistance • Time consuming for die
• High strength fabrication
For making working cast, commonly Type IV or V dental
• Special equipment required
stones are used since they have superior properties. For • Silver cyanide is poisonous
making a working cast with removable dies, twice pouring and requires proper care
of cast is required from an elastic impression. First cast is
used to prepare the removable die and second cast is used 3. Epoxy resins: Traditionally, they were supplied in
for establishing the intra-arch relationship (called “master paste and liquid system which were mixed before
cast”). These casts are known as split casts. insertion into the impression. On mixing, they formed
a viscous paste and poured into impression. Abrasive
5. Working Die resistance, strength, and reproduction of details are
much better than that of gypsum products. Now,
Die is the positive replica of a prepared tooth. Dies should they are made available in automixing systems which
replicate the tooth preparation in the most minute details directly inject the resin into the impression.
Advantages Disadvantages ◆◆ Examine the occlusal surface for high points and
remove them. Do the occlusal carving.
• Accuracy more • Exhibit polymerization shrinkage
than gypsum • Not compatible with hydrocolloids and ◆◆ Pass a floss through the contact area while holding the
• Good abrasion polysulfide impression materials pattern in place.
resistance • Long setting time ◆◆ Smoothen the proximal surface of the pattern with fine
soft silk.
4. Divestment: Divestment is a combination of die
◆◆ Evaluate and correct all the margins of the pattern.
material and investing material. Divestment is mixed
Burnish and remove any excess wax over the axial
with a colloidal silica liquid, then a die is prepared
margins with a warm Hollenback waxing instrument.
from the mix and a wax pattern is made on it. After
◆◆ Finally, examine the pattern. There should be a slight
this, the wax pattern with die is invested in divestment.
excess of wax over the gingival margin. Add positive
Divestment is gypsum-based material and thus
contact by applying soft wax.
suitable for cast gold restorations.
◆◆ Once the satisfactory wax pattern is formed, attach sprue
Advantages Disadvantages former at 45° to the thickest portion of the wax pattern.
◆◆ Remove wax pattern from the preparation and examine
• Excellent accuracy for cast • Poor abrasion resistance
gold alloys • Not suitable for high fusing it for marginal integrity.
• Ease of use alloys
Direct wax pattern without use of matrix band: Here,
• Compatible with most of
impression materials technique is same except that matrix band is not used
during fabrication of wax pattern. In this, after the carving of
occlusal portion is done, use dental floss to remove extra wax
6. Wax Pattern Fabrication
from the proximal portion and to produce proper contact
There are two methods for wax pattern fabrication: and contour.
1. Direct Wax Pattern Method Advantages

◆◆ Less chances of discrepancies
In this, wax pattern is prepared in the oral cavity. Direct ◆◆ Less laboratory work.
wax pattern produces better fitting than indirect method.
This method is possible only in inlays and onlays and not Disadvantages
in crowns and bridges, etc. ◆◆ Requires more chair side time
◆◆ Requires more skill
Direct wax pattern using matrix band ◆◆ Finishing and polishing should be done on prepared
◆◆ Isolate the tooth using cotton rolls. tooth.
◆◆ Apply separating media like vaseline uniformly on
prepared tooth surface and adjacent soft tissues. Apply 2. Indirect Wax Pattern Method
matrix band and retainer. Coat the internal surface of
band using separating media like vaseline. In this wax, pattern is fabricated on a die of the prepared
◆◆ For making direct wax pattern, type I inlay wax is tooth.
used.
Indications
◆◆ Soften the inlay wax by heating and move it over alcohol
◆◆ Large preparations like onlays, full coverage crowns,
flame. Wax is rotated to heat till it becomes shiny and
and MOD restoration
soft, and can be compressed between the fingers.
◆◆ Insufficient access and visibility in patient’s mouth
◆◆ Compress the softened inlay wax into the prepared tooth
◆◆ When minute details like skirts and collars are present.
for few minutes with finger pressure. This technique is
called “compression technique”. Steps for fabricating
◆◆ Since cooling of wax to the mouth temperature results ◆◆ Use type II inlay wax for indirect wax pattern
in shrinkage, it can be compensated by holding the wax ◆◆ Lubricate the die using separating media like petroleum
in the preparation under finger pressure until it reaches jelly.
mouth temperature. ◆◆ Adapt the inlay wax to the die by flowing or by the
◆◆ Remove excess of wax using warm carving instrument. compression technique.
With a hot egg burnisher, contour the occlusal portion ◆◆ Do the carving using a warm instrument.
of the wax pattern. ◆◆ Attach a sprue former to the wax pattern to the thickest
◆◆ Now remove the matrix band and retainer carefully portion as in direct method.
without disturbing the wax pattern.
◆◆ Ask the patient to bite in centric occlusion for a few Advantages
seconds after placing a thin layer of cotton soaked in ◆◆ Less chair side time
warm water. ◆◆ Finishing and polishing can be done on die.
Disadvantages Sprue former should be attached to the thickest portions
◆◆ More laboratory work of wax pattern, i.e. proximal surface or marginal ridge area
◆◆ Errors in cast can result in inadequate casting. because of following reasons:
i. This helps in minimizing the turbulence of molten
7. Spruing the Wax Pattern alloy
1. purpose of Sprue Former ii. It reduces the residual stresses in wax during
attachment of sprue former
◆◆ Sprue former provides a channel so that molten metal iii. It ensures that molten metal has filled the thinner
flows into mold space after the wax pattern has been section of the mold.
eliminated.
◆◆ Provides a reservoir of molten metal to compensate for 5. Sprue Length (Fig. 22.17)
metal shrinkage during solidification.
◆◆ Forms a channel for elimination of wax. Length of sprue former should be long enough so that the
end of wax pattern is one-eighth to one-fourth of an inch
2. Types of Sprue Former (3–6.5 mm) away from the open end of casting ring. This
permits the investment to withstand the impact of molten
A sprue former can be made up of wax, resin or metal.
alloy and it also allows gases to escape.
Sprue formers made of wax or resin have low thermal
conductivity so do not distort the wax pattern and can If length is made too short: wax pattern removed from
be easily burnt during wax burn out so need not to be end of the casting ring that gases cannot be adequately
removed but they lack rigidity. metal sprue formers have vented to permit the inflow of molten metal, resulting in
good rigidity, high thermal conductivity so distort the wax porosity.
pattern and have to be removed after wax elimination. If length is made too long: it causes internal porosity
During removal, they can loosen some investment called shrinkage porosity. The metal will solidify in the
resulting in voids or casting defects. sprue before it solidifies in inlay, thus preventing more
metal from entering in the mold.
3. Sprue Diameter
Sprue diameter depends upon the size of wax pattern. It 6. Angulation of the Sprue Former
should be either equal or greater than the thickest part
Sprue should always be attached at an angle of 45° to the
of wax pattern. Diameter of sprue former ranges from 8
gauge to 18 gauge (3 mm–1 mm). bulkiest portion of the wax pattern. If sprue is attached at
90° angulation to floor of wax pattern, it can result in:
i. Concavity on the mold wall opposite to point of
4. Attachment of Sprue Former (Fig. 22.16)
sprue attachment causing convexity in the casting
Sprue former should not be attached to thin or delicate preventing its proper seating.
parts of wax pattern as molten alloy may fracture the ii. Hot spot at first site of impact of molten metal resulting
investment in that area and may cause failure of casting. in suck-back porosity in the casting.
Fig. 22.16: Attachment of sprue. Fig. 22.17: Length of sprue and investment of wax pattern.
7. Reservoir Principles of Investing

Reservoir is added around sprue former and close to wax in order to confine the investment material around the wax
pattern, i.e. 1–2 mm away from wax pattern. Reservoir pattern, casting ring is used. Most commonly, stainless
helps in providing constant supply of molten metal to fill steel rings are used.
the mold space. The alloy in reservoir solidifies in the last To allow mold expansion, uniform setting and hygro
after mold space is completely filled. It helps in reducing scopic expansion of investment, a liner is placed inside
the localized shrinkage porosity. the ring. Commonly, ring liners are made up of asbestos,
nonasbestos (cellulose or ceramic), and combination of
above.
8. Removal of Wax Pattern Casting ring liner is kept 3 mm short at each end of
Wax pattern is carefully removed from the prepared tooth the ring. Minimum liner thickness is 1 mm. Liner can be
or die in direction opposite to its path of insertion. It has to used either dry or wet. But wet liner is preferred because
be invested immediately to prevent its distortion. it affords greater setting expansion along with hygroscopic
expansion of the investment.
Two main methods of investing the wax pattern are:
9. Washing of Wax Pattern 1. Hand investing
Before investment, the wax pattern should be washed 2. Vacuum investing.
and covered with detergent. Soap and 3% hydrogen Hand investing
peroxide is applied with a brush to remove cavity ◆◆ Investment powder is incorporated to the liquid in the
debris and blood which could result in rough casting. mixing bowl in the proper powder-liquid ratio. Here,
It is then rinsed with water. After washing, a layer of the mixing for the investment material is done by hand
detergent is applied to reduce surface tension which followed by mechanically mixing under vacuum (as in
aid in flow of the investment material over the wax case of phosphate-bonded investments).
pattern eliminating small bubbles that may remain. ◆◆ Mixing is done in accordance with the manufacturer’s
These agents are also called wetting agents. Soap is not instructions.
a good wetting agent as it reacts with calcium sulfate of ◆◆ Pattern is painted with a layer of investment and the
the binder forming a precipitate. Synthetic detergents remainder is vibrated slowly into the ring.
are common like lissapol, teepol, cetavlon cetrimide, ◆◆ Ring is tilted once the investment reaches the level of
etc. Pattern must be left to dry for 10 minutes before pattern, minimizing entrapment of air.
investing takes place. ◆◆ After that, the investment is allowed to set.
◆◆ If hygroscopic expansion technique is used, the ring is
placed in 37°C water bath for 1 hour.
10. Investing the Wax Pattern (Fig. 22.17)
Disadvantages
Once the wax pattern is cleaned, it is surrounded by an ◆◆ Increased porosity in investment
investment that hardens and forms the mold in which ◆◆ Less reproduction of detail than vacuum investing
casting is made. ◆◆ Less tensile strength
Investment materials basically consist of: ◆◆ Less smooth cast than that obtained by vacuum investing.
1. Refractory material: Silica is main refractory material Vacuum investing: For prevention of air entrapment
in form of quartz and cristobalite. during investing, vacuum investing is done.
2. Binder: it binds the refractory materials together. Vacuum investing is further of two types:
Types of investment materials based on nature of 1. Mechanical vacuum investing: In this type,
binder are: mixing of investment and its filling into ring is done
i. Gypsum-bonded investment: used for casting mechanically under vacuum.
gold, can withstand temperature of 700°C. 2. Manual vacuum investing: Here, investment is
ii. Phosphate-bonded investment: used for spatulated by hand under vacuum and then ring is
metal ceramic and cobalt-chromium alloys, can filled. Manual investing is more appropriate as greater
withstand higher temperature (850–1,100°C). control during addition of investment.
iii. Ethyl silica-bonded investment: used for base
metal alloy partial dentures, can withstand
11. Burnout of Wax Pattern/Wax Elimination
higher temperature (1,100°C). and Heating
3. Additives: Sodium chloride, boric acid, graphite, Once the investment has set for about 1 hour, it is ready
and copper powder are added to improve physical for burn out. If delayed, it is kept in 100% humidor. It is
properties of the investment. recommended to begin the burnout procedure while
the mold is still wet because water trapped in pores
of investment reduces the absorption of wax, as water
vaporizes, it flushes wax from the mold.
For proper elimination, the mold is placed in the
furnace with sprue hole placed downward. This allows
wax elimination as liquid, more circulation of oxygen into
the cavity to react with wax and form gases rather than fine
carbon.
Heating should be gradual as 400°C in 20 minutes
and maintained for 30 minutes. For next 30 minutes,
temperature is increased to 700°C and maintained for 30
minutes (1 hour and 20 minutes). The casting procedure
should be completed without permitting the mold to cool.
Temperature Requirements for Various Investments

For gypsum-bonded investment: Fig. 22.18: Centrifugal casting machine.
◆◆ In hygroscopic low heat technique: Temperature
required—468°C for 60–90 minutes. Casting done
immediately after investment. ◆◆ When the gold alloy is fully melt, release the lock of the
◆◆ In high heat thermal expansion technique: Slow casting arm so as to force the molten gold into the mold
heating to 650°C in 60 minutes, held for 15–20 minutes. by centrifugal force.
Gypsum investments disintegrate at 700°C to release ◆◆ Remove the ring from the casting machine and keep it
sulfur gas which causes black and brittle castings. in the water keeping sprue end upward and above the
water level, and dry, till the ring is cooled.
For phosphate-bonded investments: ◆◆ Recover the casting and clean it with a bristle toothbrush
Heated to 315°C for 30 minutes and usually burn out takes and water to remove investment from the casting.
place between 750°C and 900°C.
Advantages
◆◆ Simplicity of design and operation
12. Casting Machines
◆◆ Opportunity to cast both small and large castings on
Different types of casting machines are used for casting of same machine.
dental alloys.
Air Pressure Casting Machine
Basically, two types of casting machines are used:
1. Centrifugal casting machine In this, compressed air or gases such as carbon dioxide or
2. Air pressure casting machine. nitrogen is used to force the molten alloy into the mold.
This type of machine is preferred for small castings.
Centrifugal Casting Machine (Fig. 22.18)
Other Casting Machines
It is very popular and cheap in cost, giving good results
for small castings. Here, the centrifugal force is used to ◆◆ Electrical resistance heated casting machine
accelerate the flow of molten metal into the mold space. ◆◆ Induction casting machine
Sequence of steps to be followed in gold alloy casting is as ◆◆ Direct current arc melting machine
follows: ◆◆ Titanium casting.
◆◆ Heat the ring in which wax pattern has been invested to
1,200°F and keep it at this temperature for 15 minutes 13. Melting the Alloy
in the furnace.
Various devices are used for melting of alloys. These can
◆◆ Move the arm of the casting machine by 2–3 turns in
clockwise direction and lock it so that the arm does not either be by torch or by electrical means.
rotate back.
Torch melting
◆◆ Heat the gold alloy in the crucible of the casting machine
until it becomes bright orange in color and has a shiny It uses—
appearance. ◆◆ Gas/air: The gas used is mainly propane and has the
◆◆ Place the casting ring in the cradle of the casting lowest temperature of all sources. Used for small inlays
machine. The end of the ring with the sprue should be and type I and II alloys.
toward the crucible. Move up the crucible as close as ◆◆ Natural gas/oxygen: It has high temperature and can
possible to the casting ring. be used for PFM alloys.
◆◆ Acetylene/oxygen: It has the highest temperature and is Advantages

used for base metal alloys. ◆◆ When water comes in contact with hot investment, a
violent reaction ensues. The investment becomes soft,
Zones of flame (Fig. 22.19): There are four zones in a flame:
granular, and facilitates easy removal of casting from
i. Mixing zone:
casting ring.
a. Dark in color
b. Air and gas are mixed here before combustion ◆◆ Keeps the gold alloy in annealed state for easy
c. No heat is present burnishing and polishing.
ii. Combustion zone:
a. Surrounds the inner zone Pickling
b. Green in color Surface of casting usually appears dark due to presence
c. Here, the gas and air is partially burned. This zone of oxides and other contaminants. This type of film can
is definitely oxidizing in nature. be removed by method known as “Pickling”. Pickling is a
d. Should always be kept away from the molten alloy process in which discolored casting is heated with an acid
during fusion. in test tube or beaker.
iii. Reducing zone:
a. Dimly blue and located just beyond the tip of the Solution preferred for pickling are:
green combustion zone is the reducing zone. ◆◆ 50% HCl solution (best suited for gypsum-bonded
b. Hottest part of the flame and it should be kept investment).
constantly on the alloy during melting. ◆◆ 50% sulfuric acid.
iv. Oxidizing zone:
Precautions to be taken during pickling:
a. Zone in which final combustion between gas and
◆◆ best method for pickling is to place casting in a test
surrounding air occurs
tube and pour acid over it. Acid solution should not be
b. Not used for fusion of alloys
boiled rather it should be heated.
c. This portion of the flame should not be used to melt
◆◆ Use fresh pickling solution every time, because copper
the alloy.
from previous casting can contaminate the new casting.
◆◆ Electric melting units: These machines use resistance
◆◆ Casting should not be heated and then dropped into the
or induction heating system for alloy melting.
pickling solution as margins of casting may be distorted
during heating.
◆◆ Casting should not be held with steel instruments as
this may contaminate pickling solution and casting.
Instead of steel tweezer, rubber-coated or Teflon
tweezer should be used.
15. Finishing and polishing

Examine the fitting of restoration for any nodules or
defects. If present, these can be removed using carbide
bur. Try in the casting with sprue button. It should fit the
prepared tooth passively. If found satisfactory, remove
the sprue close to inlay/onlay using carborundum disc.
Burnish the inlay margins of die with ball burnisher. Refine
Fig. 22.19: Zones of flame.
occlusal anatomy using dull round bur at slow speed.
Check occlusion and remove any prematurities. Polish the
casting using rubber abrasive points. Finally, using Tripoli
14. Cleaning of Casting
or rough with felt wheel polish the casting for final luster.
After completion of casting, casting ring is removed from
casting machine and quenched. 16. Trying in the Casting
Quenching ◆◆ Before “trying in” procedure, remove temporary
restoration and cement completely and carefully. Place
Quenching involves rapid cooling at room temperature a four-layered gauze piece as a throat screen during
water bath or ice water bath. It does not allow sufficient time trying in and removal of small indirect restoration till
for atomic movements to form an ordered structure. This the cementation of casting.
disordered structure is retained at room temperature, making ◆◆ Place casting on tooth using light pressure. If it does
it soft and ductile. This helps in final adjustments easier. not seat properly, do not force it in the preparation.
◆◆ Use a base material on deep areas of the preparation.
◆◆ Apply a resin dentin-desensitizer.
◆◆ Avoid overfilling the casting with cement.
◆◆ Seat the casting gently.
◆◆ Protect the cement from moisture contamination.
◆◆ Clean up excess cement only after it has fully set;
this prevents the cement from being pulled out from
underneath margins.
Viva Voce
What should be done if casting is short of proximal contact
with adjacent tooth?
Fig. 22.20: Check occlusion by occluding the teeth. Improper occlusal To treat this problem, a solder of 650 or higher is added to
contact makes the tooth unstable and tend to deflect it. the casting. The difference between solidus temperature
of inlay and liquidus temperature of solder should be
Overcontoured proximal surfaces may also prevent 100°F.
seating of casting. Steps of soldering:
◆◆ Check occlusion by asking patient to bite on bite paper. Treat the proximal surface of casting with abrasive wheel
High points in restoration result in perforation of to remove traces of any polishing agents, as they may act
articulating paper. Improper occluding contacts make as antiflux.
the tooth unstable and tend to deflect it (Fig. 22.20). Cut a strip of solder, it should extend 1 mm beyond contact
area.
◆◆ Evaluate the embrasures and judge the points where prox-
Apply borax type flux on the contact area of the casting
imal recontouring is required. Contacts can be present too and on both the surfaces of the piece of solder.
occlusally, broad faciolingually or occlusocervically. Place the solder at proper place on the contact area
◆◆ Pass dental floss through contact to find out the requiring build-up and direct the pinpoint flame of bunsen
tightness of the contact and its locations. burner to the solder with the help of blow pipe, so that the
◆◆ Adjust contact area so that casting seats passively. Fine solder melts and flows.
carborundum particles, impregnated rubber disks or Apply melt solder on to the casting.
wheels can be used for adjusting the proximal contact Trim and polish the contact.
and contours.
CASTING DEFECTS
17. Cementation of the Casting Various steps in making of casting should be followed
◆◆ Clean the casting thoroughly before cementation. systematically, otherwise chances of casting defects are
◆◆ Isolate the prepared tooth, clean it, and apply a thin increased.
layer of varnish in the preparation. Casting defects are of many types and may be classified as:
◆◆ Apply warm air to the gingival sulcus of the prepared
tooth to dry it. A. Distortion (Fig. 22.21)
◆◆ Apply a thin layer of luting cement on the surfaces of the
Distortion of casting usually occurs due to distortion of
casting which will be in contact with the tooth surface
inlay wax pattern during formation and removal of wax
and on the tooth preparation surface.
pattern from mouth or die.
◆◆ Seat the casting with the help of hand pressure using a
suitable instrument. Causes of distortion of casting Remedies
◆◆ Ask the patient to bite on a small cotton pellet which is Distortion of wax pattern Proper manipulation and
placed on the occlusal surface of the casting. handling of wax pattern
◆◆ Clean the area with dry cotton for removing the Time lag between fabrication Invest the pattern immediately
remnants of set cement. and investment after fabrication
◆◆ Recheck the occlusion for harmony of centric Overheating or sudden cooling Do not over heat or cool it
occlusion. of wax suddenly
◆◆ Finally, check the gingival sulcus for any remnants of
cement to avoid irritation to the supporting tissues. B. Surface Roughness and Irregularities
Surface roughness is defined as relatively finely spaced
To Prevent Postcementation Pain imperfections whose height, width, and direction establish
◆◆ Do not desiccate the tooth. the predominant surface pattern. Surface irregularities
◆◆ Use the proper powder-to-liquid ratio of luting cement. are isolated imperfections like nodules, they are not
◆◆ Do not remove the smear layer. characteristics of entire surface area.
Causes of water films Remedies

If pattern is moved, jarred or Avoid movement or vibration of
vibrated after investing pattern after investm ent
High water/powder ratio Use optimal water/powder ratio
If painting procedure does not Application of wetting agent
result in close contact between should produce intimate contact
investment and pattern between wax and investment
Fig. 22.21: Wax distortion.
Causes
1. Air Bubbles
Air bubbles on wax pattern cause nodules on casting (Fig.
22.22). Air bubbles can occur inside or outside the casting.
If nodules occur outside, they are removable but take time.
If nodules occur on internal surface, their removal is very
difficult, and restoration has to be recasted.
Fig. 22.23: Water film on wax pattern.
Reasons for presence
of air bubbles Remedies of air bubbles
Inadequate vacuum Follow vacuum investing technique 3. Prolonged Heating
during investing
When high heat casting technique is used, prolonged heating
inadequate vibration Use mechanical mixer with vibration before of mold at casting temperature may cause disintegration of
during mixing and after mixing should be done
gypsum-bonded investment causing roughness of walls
lack of surfactant/ • Wetting agent prevents collection of air of mold. Moreover, sulfur compounds are products of
wetting agent bubbles on surface of pattern
• Air dry the wetting agent because any decomposition which may contaminate the alloy affecting
extra liquid dilutes the investment surface texture. To prevent this, mold should be heated to
causing surface irregularities casting temperature, never higher than that.
4. Underheating
If heating time is too short or if insufficient air is available
in the furnace, it results in incomplete elimination of wax
residues. These factors are particularly important with low
temperature investment techniques.
5. Rapid Heating Rate
Fig. 22.22: Air bubbles on wax pattern causing formation of nodule.
2. Water Films
If investment gets separated from wax pattern, a water
film may form irregularly over the pattern surface as wax
is repellent to the water. It appears as ridges and veins on
the surface of casting (Fig. 22.23).
6. Premature Heating C. Porosities
If setting is not complete at the time ring is placed in the Porosity is considered as a major defect in the casting
oven, the mold may be weak and unable to withstand which can occur on the internal as well as on the external
steam pressure during burnout, and consequently, surface of casting. External porosity causes surface
investment may fracture. Thus, burnout should be initiated roughness, internal porosity which weakens the casting.
only after recommended setting time. Porosities can be classified as:
a. Solidification shrinkage porosity:
7. Pattern Position (Fig. 22.24) •• Localized shrinkage porosity
•• Suck-back porosity
Fins occur when cracks are produced in the investment
•• Microporosity
which radiate out from surface of the pattern. Molten alloy
flows into the cracks forming fins on the casting. •• Subsurface porosity
If many patterns are invested, they should not be placed b. Gaseous defects:
too close and in same plane in the mold. Expansion of •• Pinhole porosity
wax is much higher than that of investment, causing •• Gas inclusion porosity
breakdown of investment if spacing between patterns is c. Back-pressure porosity.
less than 3 mm. It leads to formation of fins.
Solidification Shrinkage Defects
1. Localized Shrinkage Porosity: This porosity occurs
due to shrinkage of molten alloy during solidification.
It mainly occurs where solidification occurs the last,
usually near sprue-casting junction.
Causes
•• If direction of sprue former is at 90°, then it will cause
“hot spot” in the casting, i.e. alloy will remain in
molten state at that spot whilst solidifies everywhere
else.
•• Diameter of sprue is too narrow.
Fig. 22.24: Pattern position in an investment. •• Length of sprue former is long, i.e. molten alloy
prematurely solidifies in the sprue before reaching
8. Temperature of Alloy to mold.
•• Absence of reservoir.
if alloy is heated at too high temperature, surface of Prevention
investment is likely to be attacked resulting in roughness. •• Direction of sprue former should be at 45°.
•• Avoid using excessively long and narrow sprue
9. Casting Pressure former.
Too high pressure during casting can produce surface •• Use reservoir in sprue of thickness more than thickest
roughness. Casting should provide the enough force portion of the pattern and as close as possible to the
to cause liquid alloy to flow on to heated mold. Gauge pattern (1mm) (Fig. 22.25).
pressure of 0.10–0.14 MPa in air pressure casting machine 2. Suck-back porosity/hot spot porosity: It occurs in
is sufficient or three to four turns of centrifugal casting fitting surface of crown near area of sprue, usually
machine is sufficient for small castings. occurs when sprue is attached at right angle to the
pattern. A hot spot may retain a localized pool of molten
10. Inclusion of Foreign Bodies metal after other areas of casting have been solidified. It
causes local region to freeze last resulting in suck-back
Inclusion of foreign bodies like pieces of investment, porosity (Fig. 22.26).
carbon from (flux, crucible or investment), carelessness Prevention
during removal of sprue former may result in surface •• By reducing the temperature difference between the
roughness, voids, and incomplete areas. mold and molten alloy.
•• The sprue should be attached at 45° to the pattern for
11. Impact of Molten Alloy optimal flow of molten metal (Fig. 22.27).
Direction of sprue former should be such that molten alloy 3. Microporosity: It is usually seen in fine grain molten
does not hit a weak portion of the mold surface. If it hits metal alloy castings. This occurs when solidification is
directly, it causes depression in mold which appears as too rapid for microvoids to segregate to the liquid pool.
raised area in the casting, preventing its seating. It occurs in form of small and irregular voids.
Causes
•• Too low casting temperature
•• Rapid solidification of molten alloy.
Prevention
•• Increase the casting temperature.
•• Increase the melting temperature of alloy.
Gaseous Defects
Two types of defects are seen:
1. Pinhole porosity: Gases are dissolved by some metals
(for example, copper and silver dissolve oxygen) when
they are in molten state, during solidification, these
gases during solidification are expelled resulting in
pinhole porosity.
2. Gas inclusion porosity: Gas inclusion porosity is
having spherical voids larger in size than pinhole
porosity.
Causes: These are usually caused by entrapment of gas in
Fig. 22.25: Localized shrinkage porosity can be prevented
alloy. Various causes are:
by placing sprue at 45° and use of reservoir. ◆◆ Not using the reducing zone of flame.
◆◆ Poor adjustment of torch flame.
Prevention
◆◆ Use reducing zone of the flame.
◆◆ Position of torch flame should be correctly adjusted.
Entrapped Air/Residual Air/Back-pressure Porosity

It usually occurs on the inner surface of the casting due to
entrapment of gases. As the liquid enters the mold through
the sprue, the air trapped in the mold is compressed at
the extremities which can exert back pressure preventing
A B
the liquid alloy to occupy this region. It produces large
concave depressions.
Figs. 22.26A and B: (A) If sprue is placed at 90°, alloy remains in molten
state at that spot after other areas of casting have been solidified, this Causes
area solidifies in the last resulting in suck-back; (B) Sprue attached at 1. Use of dense investment material: Increased density of
45° to pattern allows optimal flow of molten metal, preventing suck investment prevent the vent out of trapped air. Density
back porosity.
of investment increases with low water/powder ratio.
Investment materials in increasing order of density
are:
Gypsum-bonded > Silica-bonded > Phosphate-bonded
Thus, silica-bonded and phosphate-bonded materials
frequently produce incomplete castings.
2. Low casting temperature
3. Low casting pressure
4. Improper wax burnout.
Prevention
◆◆ Use of porous investment material
◆◆ Adequate casting temperature
◆◆ Adequate casting pressure
◆◆ Proper wax burnout.
D. Discoloration
Casting usually appears dark after removing from the
investment due to presence of oxides. This can be removed
Fig. 22.27: Prevention of suck-back porosity. by a process known as “pickling”.
Causes amalgam restorations. Cast pin channels are prepared
with the help of tapering fissure bur having a diameter of
◆◆ Prolonged heating: Heating the investment above 1 mm with the depth of about 3 mm.
700°C usually causes breakdown of investment as
well as formation of sulfur compounds, which causes
blackening of cast. Indications for Pin-retained Cast Restorations
◆◆ Sulfur content of torch flame also affects the casting. ◆◆ When occlusogingival height is very short.
◆◆ Underheating of the investment also leaves the wax ◆◆ In case of excessively tapered tooth preparation.
residues in the casting, affects the color of the casting. ◆◆ Cuspal fractures where large occlusal inlays and onlays
◆◆ Contamination with copper during the process of are to be prepared.
pickling causes discoloration. ◆◆ When the proximal box is very long. Pin channel is
prepared at the other end of occlusal lock.
Prevention ◆◆ In full crown preparation, when one wall is very short
◆◆ Avoid prolonged heating of the investment and another wall is very long. In these cases, pin
◆◆ Change the source of flame channel is prepared towards the shorter wall.
◆◆ Proper heating should be done ◆◆ For shallow and wide preparations, when it is not
◆◆ Tips of tongs must be covered with rubber to avoid possible to place surface extensions for retention.
contamination with copper during pickling. ◆◆ In very thin and fragile teeth where extensive tooth
preparation can be detrimental.
E. Incomplete Casting (Fig. 22.28) ◆◆ In absence of gingival floor, resistance and retention
can be achieved by the use of pins.
It results due to inadequate amount of molten metal
entering the mold. It can occur due to following reasons: conclusion
i. Incomplete melting of alloy
ii. Too low casting force Cast gold restorations have been used in dentistry for
iii. Blocking of sprue due to loose investment particle more than 100 years. They offer durability, optimal
iv. Incomplete dewaxing contacts and contours, and long-term functionality if used
v. Blocking due to solidification in sprue where indicated. Fabrication of cast metal restoration
vi. Insufficient alloy. is technique sensitive as it involves precise clinical and
laboratory steps. Even with best cavity preparation for
cast restoration, any carelessness in laboratory step may
result in casting defect. An unsuccessful casting can result
in treatment failure which can be avoided by careful
observation of the procedures governed by fundamental
principles and rules. When casting failure occurs, one
should troubleshoot each casting to diagnose the cause of
the problem so that it can be avoided while remaking.
EXAMINER’S CHOICE QUESTIONs

1. What are the indications and contraindications of cast
metal restorations?
2. What are different casting defects? What are their
causes and how can we prevent them?
3. Write short note on compensation of casting shrinkage.
4. What are indications and contraindications for gold
inlay? Discuss the difference in class II tooth preparation
for gold inlay and silver amalgam preparation.
5. What are methods of preparing inlay wax pattern?
Compare and contrast each method in detail.
Fig. 22.28: Incomplete casting.
6. Describe in brief indications, contraindications, and
advantages or disadvantages of gold inlay.
PIN-RETAINED CAST RESTORATIONS 7. Write short notes on:
a. Difference in tooth preparation for class II
Pins are generally used for providing additional retention. amalgam and cast gold restoration.
Cast pin channels are wider and have slightly divergent b. Bevels.
walls in comparison to pin holes prepared for pin-retained c. Primary and secondary flares.
d. Casting defects. 29. Define working casts.

e. Additional retention and resistance form features 30. Name few die materials.
for cast restoration. 31. Write how many methods are there for wax pattern
f. Porosity in casting. fabrication in cast restorations?
g. Sprue. 32. What are the principles of optimal sprue design?
h. Casting defects. 33. Sprue is made up of which material?
i. Die material. 34. What are the functions of sprue former?
j. Cavosurface bevel. 35. What is the diameter of sprue?
36. What should be the length of sprue?
VIVA questions 37. What should be the direction of sprue?
1. What are the indications and contraindications of cast 38. What are the principles of investing?
metal restorations? 39. Name commonly used ring liners.
2. What are different techniques of fabrication of cast 40. What are the types of casting crucibles?
metal restorations? 41. What are the two main methods of investing wax
3. Define inlay. pattern?
4. What is the difference between inlay and onlay? 42. Define casting procedure.
5. Name the cast restoration which covers the full 43. Who introduced the casting procedure technique and
portion of the tooth. casting machine in dentistry?
6. Name few properties of dental casting alloys. 44. What are different devices used for melting of alloys?
7. What are different types of alloys used for cast 45. Name types of casting machines.
restorations? 46. What is quenching?
8. What are disadvantages of base metal alloys? 47. What is pickling?
9. Name recently used alloy for cast metal restoration. 48. What are the solutions preferred in pickling?
10. Name three basic principles of cast metal restorations. 49. How to prevent post-cementation pain?
11. How much degree of taper is present in the walls of 50. Enumerate cast defects.
inlay cavity? 51. What are the causes of incomplete casting?
12. Define circumferential tie. 52. What is back pressure porosity?
13. Define bevels. 53. What are the indications for pin-retained cast
14. What are the objectives of bevel? restoration?
15. What are the different types of bevel?
16. What are the functions of bevel? Bibliography
17. Define flares. 1. Allan FC, Asgar K. Reaction of cobalt-chromium casting alloy
18. What are the different types of flares. with investment. J Dent Res. 1966;45(5):1516-28.
19. Enumerate different steps of class II inlay preparation. 2. Anusavice KJ. Phillips’ Science of dental materials, 11th edition.
US: Elsevier; 2003.
20. Which numbers burs are used for inlay preparation?
3. Fisher DW, Caputo AA, Shillingburg HT Jr, et al. Photoelastic
21. What should be the intercuspal distance of inlay analysis of inlay and onlay preparations. J Prosthet Dent.
cavity? 1975;33:47-53.
22. Name the secondary retentive feature given in the 4. Hasegawa J. Dental casting materials. Trans Acad Dent Mater.
inlay cavity. 1989;2:190-201.
23. What should be the angle of gingival bevel in the inlay 5. Powers JM, Sakaguchi RL, Craig RG. Craig’s restorative dental
materials, 12th edition. US: Elsevier; 2006.
cavity?
6. Rosenstiel E. To bevel or not to bevel? Br Dent J. 1975;138:389-92.
24. Which bevel we prepare to cover a cusp with cast 7. Santos JF, Ballester RY. Delayed hygroscopic expansion of
metal? phosphate bonded investments. Dent Mater. 1987;3:165-7.
25. What are the differences between cast metal and 8. Smyd ES. Factors which influence casting accuracy: a universal
amalgam restoration? casting technique. J Am Dent Assoc. 1948;36:160-72.
26. What are the indications of cusp capping? 9. Tucker RV. Variation in inlay cavity design. J Am Dent Assoc.
1972;84:616-20.
27. Enumerate additional retention and resistance form
10. Vorhees FH. History and progress of the cast gold inlays. J Am
for cast restorations? Dent Assoc. 1930017:2111-3.
28. Enumerate different designs of margins of cast 11. Wataha JC. Biocompatibility of dental casting alloys: a review. J
restorations. Prosthet Dent. 2000;83:223-34.
Chapter
23
Adhesion in Operative Dentistry
Chapter Outline
Introduction Dentin Adhesive Systems

Indications for Use of Adhesives Evolution of Dentin-bonding Agents
Advantages of Adhesives Hybridization
History Smear Layer
Definitions Classification of Modern Adhesives
Enamel Bonding Glass Ionomer-based Adhesive System
Dentin Bonding Failure of Dentin Bonding
Introduction ◆◆ For pit and fissure sealants

◆◆ To bond composite restorations
traditional “drill and fill” approach is fading now because ◆◆ To bond amalgam restorations
of numerous advancements taking place in restorative ◆◆ To lute crowns
dentistry. For a restorative material, adhesion is the primary ◆◆ To bond orthodontic brackets.
requirement so that restorative materials can be bonded to
enamel or dentin and without the need of extensive tooth
preparation. Initial advancement in adhesive dentistry Advantages of adhesives
was made by a pedodontist, Buonocore, in 1955, who ◆◆ Adhesion of composite resin restorations to enamel
developed acid etching of the enamel. He showed that and dentin
when enamel is treated with a dilute acid for 30 seconds, ◆◆ Minimizes removal of sound tooth structure
it results in a microscopically roughened, porous surface ◆◆ Management of dentin hypersensitivity
into which the resin forms retentive tags. When resins are ◆◆ Adhesion reduces microleakage at tooth restoration
used, they form an intermediate layer with the exposed interface
tooth surface which can be then bonded to the retentive ◆◆ As a part of resin cements for bonding cast restorations
inner surface of the restoration by means of a resin. ◆◆ Adhesion expands the range of aesthetic possibilities
Past decade has seen increased use of bonding agents ◆◆ Bonding of porcelain restorations, e.g. porcelain inlays,
in concurrence with traditional dental materials. The onlays, and veneers
availability of adhesive techniques permits the placement ◆◆ Reinforces weakened tooth structure
of aesthetic restorations like composite resins, aesthetic ◆◆ For repair of porcelain or composite
inlays and veneers, etc. ◆◆ Bonding amalgam restorations to tooth
◆◆ Repair of amalgam restorations
Indications for Use of Adhesives ◆◆ To bond orthodontic appliances.
◆◆ To treat carious and fractured tooth structure
◆◆ To restore erosion or abrasion defects in cervical areas History
◆◆ To correct aesthetic contours, positions, dimensions, or
shades of teeth ◆◆ 1955—Buonocore applied acid to tooth to make it
◆◆ To treat dentinal hypersensitivity more receptive to adhesion.
◆◆ For the repair of fractured porcelain, amalgam, and ◆◆ 1956—First commercially available bonding agent
resin restorations (NPG-GMA).
◆◆ 1962—Bowen introduced Bis-GMA. A

◆◆ 1980s—Total etch concept gained acceptance
◆◆ 1982—Hybrid layer concept by Nakabayashi
◆◆ 1970—1st generation of bonding agent was developed B
◆◆ Late 1970s—2nd generation of bonding agent was
developed
◆◆ Early 1980s—3rd generation of bonding agent was
developed C
◆◆ 1990s—Multistep and one step adhesive systems was
introduced
Figs. 23.2A to C: Types of adhesion.
◆◆ Early 1990s—4th generation of bonding agent was
developed.
◆◆ 1991—Bertolotti and Kanca introduced concept of example, penetration of resin and formation of resin tags
wet bonding. with the tooth structure.
◆◆ 1992—Product containing 4-META was developed
to bond to dentin as well as amalgam, metal, and
ii. Adsorption
porcelain.
◆◆ 1995—5th generation of bonding agent was developed. Chemical bonding to organic or inorganic components of
◆◆ Late 1990s—6th generation of bonding agent tooth structure.
developed.
◆◆ Early 2000s—7th generation of bonding agent iii. Diffusion
developed.
◆◆ 2010—8th generation bonding agent developed. Precipitation of substance on the tooth surface to which
◆◆ 2011—Universal adhesives developed. resin monomer can bond mechanically or chemically.
iv. Combination
Definitions
A substance can bond by combination of any of the above
Adhesion or Bonding means.
Adhesion is defined as the forces or energies between
atoms or molecules at an interface that hold two phases Factors Affecting Adhesion
together.
i. Wetting
Adhesive Wetting is an expression of the attractive forces between
A material that can join substances together, resist separation molecules of adhesive and adherent. It depends on two
and transmit loads across the bond is an adhesive. The factors:
material to which it is applied is adherend (Fig. 23.1). ◆◆ Cleanliness of the adherend: Cleaner the surface,
greater is the adhesion.
Mechanism of Adhesion ◆◆ Surface energy of the adherend: More surface energy
Adhesion can take place by any of the following means results in better adhesion.
(Figs. 23.2A to C):
ii. Contact Angle
i. Micromechanical
Here bonding occurs because of penetration of one Contact angle refers to the angle formed between the
material into another at the microscopic level. For surface of a liquid drop and its adherent surface (Fig.
23.3). Smaller the contact angle is, better is the adhesion.
iii. Surface Energy

Harder the surface is, higher will be the surface energy
means adhesive properties of the material will be
higher.
iv. Surface Contamination

Cleaner the surface is, better is the adhesion. Presence of
Fig. 23.1: Adhesive/adherent. saliva, blood, moisture, oil, etc. reduces adhesion.
Adhesion in Operative Dentistry 275
Fig. 23.3: Schematic representation of wetting.
v. Water
Lesser the water content, better is the adhesion. Water can
react with both materials by remaining high polar group
and hydrogen bond which can hamper the adhesion. Fig. 23.5: Etchant.
Enamel bonding
Viva Voce
Enamel consists of 95% mineralized inorganic and 4%
organic substance (Figs. 23.4A and B). Buonocore, in 37% phosphoric acid is used for 15–30 seconds.
1955, was the first to reveal the adhesion of acrylic resin If concentration is greater than 50%, then monocalcium
to acid etched enamel. He used 85% phosphoric acid phosphate monohydrate gets precipitated.
If concentration is lower than 30%, dicalcium phosphate
for etching, later Silverstone revealed that the optimum
monohydrate is precipitated which interferes with
concentration of phosphoric acid should range between adhesion.
30% and 40% to get a satisfactory adhesion to the enamel. Deciduous teeth require longer time for etching than
Standard treatment protocol for etching is use of 37% permanent teeth because of the presence of aprismatic
phosphoric acid for 60 seconds. But now studies have enamel in deciduous teeth.
shown that enamel should not be etched for more than
15 to 20 seconds. etchant in gel form allows better control
and precision in dispensing as compared to liquid form Abbreviations commonly used for resin chemicals
(Fig. 23.5). Acid is usually applied by means of brush and Bis-GMA Bisphenol A-glycidyl methacrylate
syringe. HEMA 2-hydroxyethyl methacrylate
TGDMA/TEGDMA Triethylene glycol dimethacrylate
Viva Voce 4-META 4-methacryloxyethyl trimellitate
anhydride
If enamel is etched for more than required time, it results in
UDMA Urethane dimethacrylate
deeper etch. Since a bonding agent has a high viscosity, surface
tension effect of agent does not allow its full penetration into PMDM Pyromellitic acid
etched enamel. This results in ‘dead space’ beyond the bonded diethylmethacrylate
area. When enamel bends, or weak resin based bond breaks NPG-GMA N-phenylglycine-glycidyl
off, the dead space gets exposed to oral fluids. These oral fluids methacrylate
have lower surface tension and thus penetrate into the dead GPDM Glycerophosphoric acid
space. This may result in secondary caries or discoloration of the dimethacrylate
margins.
EDTA Ethylenediamine tetraacetic acid
PENTA Dipentaerythritol pentaacrylate
monophosphate
MDP 10-methacryloyloxydecyl
dihydrogen phosphate
MDPD 10-methacryloyl oxydodecyl
pyridinium bromide
A B Conditioning
It is the process of cleaning the surface and activating the
Figs. 23.4A and B: Composition of enamel. calcium ions, so as to make them more reactive.
Etching
It is the process of increasing the surface reactivity by
demineralizing the superficial calcium layer and thus
creating the enamel tags. These tags are responsible for
micromechanical bonding between tooth and restorative
resin.
Steps for Enamel Bonding

◆◆ Perform oral prophylaxis procedure using
nonfluoridated and oil less prophylaxis pastes.

◆◆ Clean and wash the teeth. Isolate to prevent any
contamination from saliva or gingival crevicular fluid.

◆◆ Apply acid etchant in the form of liquid or gel for 10–15
Fig. 23.6: Etched and unetched enamel rods..
seconds.

◆◆ Wash the etchant continuously for 10–15 seconds.

◆◆ Note the appearance of a properly etched surface. It
should give a frosty white appearance on drying.

A B C
◆◆ If any sort of contamination occurs, repeat the
procedure. Figs. 23.7A to C: Pattern of enamel etching: (A) Demineralization of
prism core leaving peripheries intact, giving honeycomb appearance;
 (B) Removal of interprismatic enamel leaving core intact giving cob-
◆◆ Now apply bonding agent and low viscosity monomers blestone appearance; (C) Mix of type I and II.
over the etched enamel surface. Generally, enamel
bonding agents contain Bis-GMA or UDMA with When seen microscopically, three types of enamel
TEGDMA added to lower the viscosity of the bonding etching patterns are seen (Figs. 23.7A to C):
agent. The bonding agents due to their low viscosity, Type I: Preferential demineralization of enamel prism
rapidly wet and penetrate the clean, dried, conditioned core leaving the prism peripheries intact giving
enamel into the microspaces forming resin tags. The honeycomb appearance.
resin tags which form between enamel prisms are Type II: It is reverse of Type I. Here prefer preferential
known as macrotags. removal of interprismatic enamel leaving
 the prism cores intact, giving it cobblestone
◆◆ Finer network of numerous small tags is formed across appearance.
the end of each rod where individual hydroxyapatite Type III: In this, the pattern is less distinct, including areas
crystals were dissolved and are known as microtags. that resemble type I and II patterns and areas
These microtags are more important due to their which bear no resemblance to enamel prism.
larger number and greater surface area of contact. The Type IV: This pattern has pitted appearance where pits
formation of resin micro- and macrotags within the occur in patches over enamel surface. It displays
enamel surface constitute the fundamental mechanism a random distribution of depression with
of enamel-resin adhesion (Fig. 23.6). no preferential destruction of either cores or
Clinically, an optimally etched enamel surface has peripheries.
frosty white appearance. Type V: In this enamel shows flat smooth surface
after etching lacking microirregularities for
Mechanism of Etching penetration and retention of resins.
Basically, acid etching creates a 5–50 micron deep

Effects of Etching
microporous layer into which adhesive resin flows. This
results in a long-lasting enamel bond achieved via micro- ◆◆ Cleanses debris from enamel
mechanical interlocking between the resin and enamel. ◆◆ Produces a complex three-dimensional microtopo
Bond strength of etched enamel to composite resin usually graphy at the enamel surface
varies between 15 MPa and 25 MPa. ◆◆ Increases the enamel surface area available for bonding
◆◆ Produces micropores into which there is mechanical
interlocking of the resin
◆◆ Exposes more reactive surface layer, thus increasing its
wettability.
Factors Affecting Effects of Etching on Enamel A B

◆◆ Form of acid used, i.e. either gel or liquid form
◆◆ Concentration of acid used and time of etching
◆◆ Type of acid used Figs. 23.8A and B: Composition of dentin.
◆◆ Chemical nature of enamel
◆◆ Whether enamel is fluoridated or demineralized
◆◆ Type of dentition, i.e. primary or permanent.
Summary of Acid Etching and Enamel Bonding

◆◆ Acid used: 37% phosphoric acid
◆◆ Etching time: 15–20 seconds
◆◆ Form of acid: Liquid or gel (gel form preferred) applied
by syringe or brush
◆◆ Effects of etching: Three-dimensional microtopography
at the enamel surface resulting in frosty white
appearance of etched enamel. Fig. 23.9: Intratubular permeability of dentin is responsible for forma-
◆◆ Bonding agent used: Bis- GMA or UDMA tion of resin tags whereas intertubular permeability is responsible for
◆◆ Bond strength: 15 to 25 MPa hybrid layer formation.
◆◆ Bonding mechanism: Etching produces micropores
into which there is mechanical interlocking of the resin. for dentin hypersensitivity and formation of resin tags
(Fig. 23.9).
Dentin bonding ii. Intertubular permeability: This permeability is
diffusion of monomer into demineralized inter
Bonding to dentin has been proven more difficult and less tubular dentin, i.e. dentin between the tubules. For
reliable and predictable than enamel. This is because of hybrid layer formation, intertubular dentin must
difference in morphologic, histologic and compositional
be demineralized to expose the collagen fibrils and
differences between the two.
create diffusion pathways for monomer infiltration.
Problems Encountered during Moist versus Dry Dentin (Fig. 23.10)

Dentin bonding
By etching dentin, the smear layer and minerals from it are
1. Dentin has more amount of organic matter and water removed, exposing the collagen fibers. Areas from where
in comparison to enamel (Figs. 23.8A and B). minerals are removed are filled with water. This water acts
2. Hydroxyapatite crystals have a regular pattern in as a plasticizer for collagen, keeping it in an expanded soft
enamel whereas in dentin, hydroxyapatite crystals are state. Thus, spaces for resin infiltration are also preserved.
randomly arranged in an organic matrix. But these collagen fibers collapse when dry and if the
3. Fluid present in dentinal tubules constantly flows
organic matrix is denatured. This obstructs the resin from
outward from pulp which reduces the adhesion of the
reaching the dentin surface and forming a hybrid layer.
composite resin.
Water keeps collagen fibrils from collapsing, thus helping
4. Presence of smear layer makes wetting of the dentin
in better penetration and bonding between resin and
by the adhesive more difficult.
dentin. Therefore, presence of moist dentin is needed to
achieve successful dentin bonding.
Permeability of Dentin
variation in permeability of dentin affects the bonding If the Dentin Surface is Made Too Dry
mechanism in bonding. There are two types of perme ◆◆ Collapse of the collagen fibers and demineralized
abilities in dentin: dentin occurs.
i. Intratubular permeability: It accounts the ◆◆ This results in low bond strength because of ineffective
movement of fluid within the tubules. It is responsible penetration of the adhesive into the dentin.
Methods of Conditioning of Dentin

1. Chemical modification
Example:
•• 17% EDTA
•• 1% nitric acid
•• 2.5% maleic acid
•• 10% citric acid
•• Ferric oxalate
•• Polyacrylic acid
2. Thermal modification
Lasers—example: Pulsed Nd:YAG laser
3. Mechanical modification
Microabrasion.
2. Primer
Primer is a hydrophilic, low viscosity resin which is usually
Fig. 23.10: Dry and wet dentin.
bifunctional monomer in a volatile solvent like acetone or
alcohol. Monomers commonly used in primers are HEMA,
If the Dentin Surface is Too Wet NPG-GMA, PMDM, BPDM, etc.
◆◆ One cannot check for the “frosted” etch appearance of Objectives

the enamel.
◆◆ There is reduction in bond strength because presence Primer is used to:
of water droplets dilutes resin primer and outcompetes i. Increase spreadability of monomer
it for sites in the collagen network which prevents ii. Increase surface wettability
hybridization. iii. Increases surface free energy
iv. Improve monomer penetration
Dentin adhesive systems v. Due to bifunctional molecules, it wets and envelops
the exposed collagen fibrils.
Dentin adhesive systems consist of following main
components: 3. Dentin-bonding Agents
1. Conditioner
2. Primer Dentin-bonding agents form bond via dentinal tubules
3. Bonding agent to etched dentin. It forms chemical bond to inorganic
and organic or both the components. It is bifunctional
1. Conditioner structure, i.e. it has both hydrophilic and hydrophobic
ends.
Dentin conditioner is an acidic agent that dissolves the Structure of bonding is represented as:
inorganic structures in dentin resulting in collagen mesh
that allows infiltration of an adhesive resin.
Objectives
It is done to create a surface capable of micromechanical Here,
bonding to dentin-bonding agent. M is double bond of methacrylate which copolymerizes
with composite resin,
Effects of Conditioner on Dentin R is spacer to make molecule large, and
X is functional group for bonding to organic or inorganic
1. Physical changes: conditioning causes:
component of dentin.
i. Removes smear layer and smear plugs
ii. Demineralizes intertubular and peritubular
dentin Ideal Requirement of Dentin-bonding Agent
iii. Increases surface roughness An ideal dentin-bonding agent should be:
2. Chemical changes: These occur: i. Provide optimal bond strength similar to bond
i. Decalcification of inorganic portion strength of composite to resin
ii. Exposes collagen fibril arrangements. ii. Be biocompatibile
iii. Have long-term stability ◆◆ Instability of NPG-GMA in solution.
iv. Attain high bond strength early Hydrolysis of glycerophosphoric acid dimethacrylate in
v. Be easy to apply and not be technique sensitive oral environment.
Classification of Modern Adhesives 2. Second Generation Dentin-bonding Systems

Based on Generations These were introduced in 1970s. In these, bonding agents
were attempted to bond chemically to either organic or
1. First generation bonding agent inorganic components of dentin. Phosphate groups, amino
2. Second generation bonding agent acid groups or carboxylic acid groups present in bonding
3. Third generation bonding agent agents affect the bond to calcium or collagen of dentin but
4. Fourth generation bonding agent not much success was achieved. Examples: Scotchbond
5. Fifth generation bonding agent (3M), Prisma universal bond (Dentsply).
6. Sixth generation bonding agent
7. Seventh generation bonding agent Disadvantages
8. Eighth generation bonding agent
◆◆ Low bond strength (1–5 MPa)
9. Ninth generation bonding agent.
◆◆ Unstable interface between dentin and resin because of
hydrolysis of phosphate calcium bond.
Based on Smear Layer Treatment
◆◆ Smear layer modifying agents
3. Third Generation Dentin-bonding Systems
◆◆ Smear layer removing agents
◆◆ Smear layer dissolving agents. Third generation dentin-bonding systems were introduced
in 1979, which were designed not to remove the entire
Based on Number of Steps smear layer but to modify it to allow penetration of acidic
monomer. These were applied for:
◆◆ Three steps
◆◆ Two steps Total etching of dentin was avoided in these bonding
◆◆ Single step. agents to avoid pulp inflammation. Mild acids employed
in 3rd generation were 10% citric acid, 10% phosphoric
acid, 2% nitric acid, 3% ferric chloride, etc.
Evolution of Dentin-Bonding Examples: Scotch Bond II (3M), GLUMA (KULZER).
Agents
Advantages
1. First Generation Dentin-bonding Systems
◆◆ Higher bond strengths (8–15 MPa)
Development of NPG-GMA (N-phenylglycine-glycidyl ◆◆ Reduced microleakage
methacrylate) a surface active co monomer was the basis ◆◆ Form a strong bond to both sclerotic and moist dentin
of commercially available DBA. In this, NPG-GMA was ◆◆ Reduced need for a retentive tooth preparation
supposed to chelate with calcium of dentin to form water ◆◆ Can be used for porcelain and composite repairs.
resistant chemical bond to dentin. First step to achieve
bonding to dentin was done by application of a coupling Disadvantages
agent such as glycerol-phosphoric acid dimethacrylate Since bonding agents have hydrophobic nature, mild acid
as a primer and N-2-hydroxy-3-methacryloxypropyl and etching did not much improve dentin bond strength:
N-phenylglycine (NPG-GMA) and silane coupling agents. ◆◆ Decrease in bond strength with time
The first dentin-bonding agent to appear on the market ◆◆ More chair side time
was Cervident (SS White Co, King of Prussia, PA). ◆◆ Technique sensitive.
These products ignored the smear layer. Mechanism of
adhesion was deep penetration of the resin tags into the 4. Fourth Generation Dentin-bonding Agents
exposed dentinal tubules after etching and the chelating
component which could bond to the calcium component These were developed in early to mid-1990s. These
of dentin. Since they could chelate with calcium ions of the bonding agents applied concept of total etching of enamel
tooth structure, they formed stronger bonds with enamel and dentin simultaneously using 37% phosphoric acid.
than dentin. Smear layer is considered as obstacle which should be
removed so that resin can be bonded to underlying dentin
Disadvantages surface.
Fourth generation DBA consists of (Fig. 23.11):
◆◆ Low bond strength (2–3 MPa) i. An acid etchant to remove smear layer which is
◆◆ Loss in bond strength over time washed off.
2. Scotchbond Multipurpose (3M)

3. Optibond FL (Kerr)
4. Clearfil Liner Bond-2 (Kuraray).
Advantages
◆◆ Ability to form a strong bond with both enamel and
dentin
◆◆ High bond strength to dentin (17–30 MPa)
◆◆ Ability to bond strongly to moist dentin
◆◆ It can also be used for bonding to substrates such as
porcelain and alloys (including amalgam).
Disadvantages
Fig. 23.11: Fourth and fifth generation dentin-bonding agents.
ii. Solution of primers which contains monomers like ◆◆ More number of steps
HEMA (2-hydroxyethyl methacrylate) and 4-META ◆◆ Technique sensitive.
(4-methacryloxyethyl trimellitate anhydride) dissolved
in acetone or ethanol. 5. Fifth Generation Dentin-bonding Agents
iii. Bonding agent which combines with monomers to
form resin reinforced hybrid layer and resin tags to Fifth-generation DBAs were made available in the
seat the dentinal tubules. mid-1990s. They are also known as “one-bottle” or
“one-component” bonding agents. In these agents the
4th generation bonding system is characterized by: primer and adhesive resin are combined in one bottle.
i. Complete removal of smear layer Basic differences between fourth and fifth generation is the
ii. Total etch technique number of basic components of bottles. Fourth generation
iii. Hybrid layer formation bonding system is available in two bottles, one primer and
iv. Wet bonding.
other adhesive, fifth generation dentin-bonding agents are
Mechanism of Bonding available in one bottle only (Fig. 23.11).
Concept of hybridization comes with fourth generation Advantages

bonding agents. It was given by Nakabayashi in 1982.
This is the zone where resin of dentin-bonding agent ◆◆ High bond strength, almost equal to that of fourth
micromechanically interlocks with intertubular dentin generation adhesives, i.e. 20–25 MPa
and surrounding collagen fibers. It is also known as ◆◆ Easy to use and predictable
resin-dentin inter-penetration/inter-diffusion zone (Fig. ◆◆ Little technique sensitivity
23.12). ◆◆ Reduced number of steps
◆◆ Bonding agent is applied directly to the prepared tooth
Examples of the fourth generation DBAs: surface
1. All Bond-2 (Bisco) ◆◆ Reduced postoperative sensitivity.
Fig. 23.12: Mechanism of bonding in fourth generation bonding agents.

Types of Sixth Generation Bonding Agents (Fig. 23.14)
Sixth generation bonding agents are of two types:
I. Self-etching Primer and Adhesive/Two Step/
Non-rinsing Conditioner
• Available in two bottles; primer and adhesive
• Primer is applied prior to the adhesive
• Water is the solvent in these systems.
II. Self-etching Adhesive/All-in-One System
• Available in two bottles; primer and adhesive
A drop from each bottle is taken, mixed and applied to
the tooth surface; for example, Prompt L-Pop and Xero III.
Mechanism of Bonding
In these agents as soon as the decalcification process starts,
infiltration of the empty spaces by the dentin-bonding
Fig. 23.13: Fifth generation dentin-bonding agent (single bond) agent is initiated (Fig. 23.15).
(Courtesy: 3M ESPE).
Advantages
Disadvantages
◆◆ Comparable adhesion and bond strengths to enamel
◆◆ Lesser bond strength than fourth generation bonding and dentin.
agents. ◆◆ It etches the dentin less aggressively than total etch
Examples of fifth generation DBA: products.
•• Prime and Bond (Dentsply)
•• Optibond Solo (Kerr)
•• Single Bond (3M) (Fig. 23.13).
6. Sixth Generation Dentin-bonding Agents/

Self-etch Primers
These were made available in 2000. In fifth-generation,
primer and adhesive are available in single bottle, and
etchant in separate bottle. In sixth generation etching
step is eliminated, because in sixth generation etchant,
primer and bonding are available in single solution. Most
self-etching primers are moderately acidic with a pH that
ranges between 1.8 and 2.5. Because of the presence of an
acidic primer, sixth generation bonding agents do not have
a long shelf-life and thus have to be refreshed frequently. Fig. 23.14: Sixth generation dentin-bonding agent.
Fig. 23.15: Mechanism of bonding in sixth generation dentin-bonding agent.

◆◆ Demineralized dentin is infiltrated by resin during the Advantages

etching process.
◆◆ Simple to use
◆◆ Since they do not remove the smear layer, the tubules
◆◆ Less technique sensitive
remain sealed, resulting in less sensitivity.
◆◆ Less postoperative sensitivity.
◆◆ Less technique sensitive as the fewer number of steps
are involved for the self-etch system.
Disadvantage
Disadvantages Complex nature of mixed solutions, thus more prone to
phase separation.
◆◆ pH is inadequate to etch enamel, hence bond to enamel
is weaker as compared to dentin.
◆◆ Sufficient bond strength to dentin but poor strength to 8. Eighth Generation Bonding Agent
enamel Eighth generation bonding agent was developed as time
◆◆ Since they consist of an acidic solution, they cannot be saving product for direct and indirect restorations. These
stored and have to be refreshed. bonding agents combine etching, priming, and bonding in
◆◆ May require refrigeration. one bottle.
◆◆ High hydrophilicity due to acidic primers. In 2010, 8th generation bonding agent was developed
by VOCO America, Futurabond DC (self-etching, dual-
7. Seventh Generation Dentin-bonding Agents/ cured dental adhesive) (Fig. 23.18A).
All- in-One System Futurabond DC contains polyfunctional adhesive
monomers, i.e. phosphoric acid modified methacrylate
they are truly all-in-one self-etch adhesives that require esters. These acidic esters, when combined with water,
no mixing, thus avoiding any mistakes in mixing (Fig. produce a pH value of 1.4. This lower pH favors the complete
23.16). Seventh generation DBAs have shown very little removal of smear layer and dissolution of hydroxyapatite
or no postoperative sensitivity. However, due to complex creating a deeper retentive pattern on tooth surface.
mixed solution, they are prone to phase separation and Moreover, it contains nanofillers with average particle size
formation of droplets within their adhesive layers. Example of 12nm which increase the penetration of resin monomers
of a seventh generation bonding agent is Xeno IV, G-Bond, and thickness of hybrid layer, thus increasing the mechanical
and I-Bond (Fig. 23.17).
Fig. 23.16: Seventh generation dentin-bonding agent.
B
Fig. 23.17: Xeno-IV. Figs. 23.18A and B: Eighth generation dentin-bonding agent:
(Courtesy: Dentsply) (A) Futurabond dc (Voco india); (B) G-premio bond (gc india).
properties of bonding systems and better marginal integrity. 2. Middle layer: Consists of interfibrillar spaces in which
It can achieve the bond strength of 30 MPa. This bonding hydroxyapatite crystals have been replaced by resin
agent contains fluorides, so has anticariogenic effect. monomer because of the hybridization process.
GC G-Premio BOND is a universal, 8th generation 3. Bottom layer: Consists of almost unaffected dentin
bonding agent which is compatible with total-etch, self- with a partly demineralized zone of dentin.
etch and selective etch techniques providing excellent
versatility (Fig. 23.18B). It has high bond strength and is Properties of Hybrid Layer
used for direct restorations, repair indirect restorations
without the use of primer and in combination with a silane ◆◆ It is primarily organic in nature.
when repairing glass or hybrid ceramic. It consists of ◆◆ Hybrid layer is resistant to acids and proteolysis.
combination of three functional monomers (4-MET, MDP ◆◆ Its modulus of elasticity is lower than dentin, i.e. more
and MDTP). elastic than dentin. Thus, it acts as elastic buffering
layer which can absorb resin composite polymerization
shrinkage stress.
Hybridization
◆◆ It is more tough and less hard than dentin.
Hybridization (Given by Nobuo Nakabayashi in
Viva Voce
1982)
hybridization is defined as “process of diffusion and Hybridoid layer is that area of demineralized dentin into which
resin fails to penetrate.
impregnation of resin into the substrate of a partially
demineralized dentin followed by its polymerization
creating a “resin reinforced hybrid layers” or a resin dentin Viva Voce
interdiffusion zone”.
HEMA
It is basically a micromechanical bonding mechanism
2-hydroxyethyl methacrylate
leading to formation of resin reinforced zone. When Has both hydrophilic and hydrophobic ends
dentin is treated with a conditioner, it exposes the collagen Helps in increasing the wettability of hydrophobic agents
fibril network with interfibrillar microporosities. When Its low molecular weight infiltrates into the dentinal
primer is applied, these spaces are filled with low viscosity tubules
monomer. This layer formed by demineralization of dentin, Other monomers of same type are BPDM (biphenyl
infiltration of monomer and subsequent polymerization is dimethacrylate), PMDMC (pyromellitic acid dimethacrylate
called hybrid layer/resin reinforced layer. This hybrid and NTG-GMA (N-polyglycine glycidyl methacrylate)
layer is responsible for micromechanical bonding between It retains water within adhesive formulations to decrease
bonding
tooth and resin.
It can polymerize only by linear polymerization so shows
weak polymerization in high concentrations.
Zones of the Hybrid Layer META (By Takeyama in 1978 as META/MMA-TBB)
Hybrid layer consists of three different zones (Fig. 23.19): 4-methacryloxyethyl trimellitate anhydride
1. Top layer: Consists of loosely arranged collagen fibrils Contains both hydrophilic and hydrophilic ends
and interfibrillar spaces filled with resin. Bonds to tooth due to excellent infiltration and chelation
with Ca2+ ions as coupling agents
Available as powder (containing PMMA) and liquid
(containing MMA, META, TBB)
Used as amalgam bonding agent and as a component in
resin luting cement.
SMEAR LAYER
when a tooth surface is altered using hand or rotary
instruments, cutting debris are gathered on enamel and
dentin surface, forming a smear layer (Fig. 23.20). this
term was suggested by Skinner in 1961 and coined by
Boyde in 1963.
Definition
smear layer is defined as mineralized debris produced
by reduction or instrumentation of enamel, dentin or
Fig. 23.19: Zones of hybrid layer. cementum.
Inorganic components in smear layer are made

up of tooth structure and some nonspecific inorganic
contaminants.
Organic components may consist of heated coagulated
proteins (gelatin formed by the deterioration of collagen
heated by cutting temperature), necrotic or viable pulp
tissue and odontoblastic processes, saliva, blood cells, and
microorganisms.
To Remove or Keep the Smear Layer?

Fig. 23.20: Smear layer.
There are many controversies regarding removal or
keeping the smear layer.
Formation
When tooth structure is cut, instead of being uniformly Retain the smear layer because Remove the smear layer because
sheared, mineralized matrix shatters. Considerable It lowers the dentin Exposed collagen provides
quantities of cutting debris made-up of very small particles permeability reactive groups
of mineralized collagen matrix are produced. Provides barrier to bacterial Exposed collagen enhance
penetration micromechanical bonding to
Structure resin by providing a framework
Lowers the effect of pulpal Permeability of dentin increases
When viewed under a scanning electron microscope, the pressure on bond strength up to 9 times
smear layer has an amorphous, irregular and granular Prevents decrease in bond Elimination of bacteria present
appearance. It has two layers: strength with some bonding in smear layer
1. One superficial and loosely attached to the underlying systems when deeper dentin is
dentin. prepared
2. Smear plugs which occludes orifices of dentinal
tubules.
Classification of Modern
Depth Adhesives
Morphology, composition and thickness depend on tooth Basically, three adhesion strategies have been employed
preparation. to modern dentin-bonding agents on the basis of their
Depth of smear layer depends on the following factors: interaction with the smear layer. These are:
◆◆ Dry or wet cutting of the dentin ◆◆ Smear layer modifying agents
◆◆ Type of instrument used ◆◆ Smear layer removing agents
◆◆ Smear layer dissolving agents.
◆◆ Chemical composition of irrigating solution when
doing root canal treatment.
Smear Layer Modifying Agents
Smear layer has an average thickness of 1–5 µm but
in dentinal tubules, it may go up to 40 µm. Smear layer is In this strategy, bonding agents modify the smear layer and
thickest when tooth is cut by means of coarse diamond incorporate it in the bonding process. According to these,
point without coolant. the smear layer acts as a natural protective barrier to the
Smear layer from enamel gets easily washed away but pulp, protecting it against bacterial penetration and also
remains adherent to dentin. Dentin is composed of two limiting the outflow of dentinal fluid which can hamper
different layers. Superficial dentin is dentin near the the bonding process.
enamel. Deep dentin is near the pulp. Smear layers on
deep dentin contain more organic material than superficial Steps
dentin because of greater number of proteoglycans lining
the tubules and by the greater number of odontoblastic In these, enamel is selectively etched with 37%
processes near the pulp. phosphoric acid (taking care not to etch dentin). After
washing and drying the tooth, primer and adhesive are
applied separately or in combination. This results in
Components of the Smear Layer micromechanical interaction of dentin and bonding
smear layer consists of both organic and inorganic system without exposure of collagen fibrils. For example,
components. Prime and Bond.
Smear Layer Removing Dentin Adhesives Steps
These bonding agents completely remove the smear Here instead of etching with phosphoric acid, both enamel
layer employing the total etch concept. They work on the and dentin are conditioned using polyacrylic acid and
concept of hybridization and formation of resin tags. washed. Polyacrylic acid conditions the tooth surface by
removing the smear layer and exposing the smear plugs.
Steps After this, adhesive is applied and light cured. For example,
In these, enamel and dentin are etched simultaneously Fuji bond LC.
using an acid (preferably 37% phosphoric acid). After
washing and drying the tooth surface, primer and bonding Advantages
agent are applied either separately or in combination. For ◆◆ Easy and simple application
example: ◆◆ Anticariogenicity because of fluoride release
◆◆ Scotchbond multipurpose
◆◆ Dual bonding mechanism:
◆◆ Gluma.
•• Micromechanical
•• Chemical
Smear Layer Dissolving Adhesives ◆◆ Adhesive filled with viscous particles, thus act as a
These agents partly demineralize the smear layer and the shock absorber.
superficial dentin surface without removing the remnants
of smear layer or the smear plugs. They make the use of Disadvantages
acidic primers also termed as self-etch primers or self-etch
◆◆ Adequate bonding requires smear layer removal
adhesives which provide simultaneous conditioning and ◆◆ Coarse particles present in the formulation may result
priming of both enamel and dentin. After this, adhesive is in white lines around restoration
applied without washing the tooth surface. ◆◆ Long-term clinical research not present.
Basis for the use of these systems is to condition the
dentin and to simultaneously penetrate to the depth
Failure of Dentin bonding
of demineralized dentin with monomers which can be
polymerized. For example: Reasons for Failure of Dentin bonding
◆◆ Self-etch primer: Adper prompt
Dentin can show poor bonding because of the following
◆◆ Self-etch adhesive: Prompt-L-Pop.
reasons (Fig. 23.21):
◆◆ Variable structure of dentin.
Glass ionomer-based adhesive ◆◆ Contamination of dentin with sulcular fluid or saliva.
system ◆◆ Structural changes of dentin close to the pulp makes it
difficult to bond.
Glass ionomer-based adhesive is resin diluted version of ◆◆ Thickening of bonding agent because of evaporation
resin modified glass ionomers where bonding occurs by of solvent. This reduces the penetration of the bonding
interdiffusion of resin which forms the hybrid layer and agent.
then the chemical bonding takes place between tooth and ◆◆ Contamination of tooth surface by lubricants used in
the glass ionomer. handpieces.
Fig. 23.21: Failure of composite adhesive and tooth joint can occur between: (i) Mineralized and demineralized dentin;
(ii) Dentin and bonding agent; (iii) Within bonding agent; (iv) Composite resin and bonding agent.
◆◆ Any contact of tooth surface with blood can result in discuss the reasons for failure of dentin-bonding
decrease in bond strength. agent.
Critical Steps for Success of Dentin bonding a. Enamel bonding.
b. Moist versus dry dentin-bonding.
◆◆ Adequate isolation: It should be done using rubber c. Smear layer.
dam. Any contamination due to saliva, blood or d. Self-etch primers.
crevicular fluid can interfere with micromechanical e. Hybridization.
bonding. f. Acid etching technique.
◆◆ Pulp protection: Use calcium hydroxide as liner and g. Bonding system.
resin modified glass ionomer as base in deep cavities.
◆◆ Acid etching: Do not overetch dentin, first apply
etchant to enamel then dentin, then wash off the Viva Questions
etchant thoroughly.
◆◆ Moist dentin: Dentin has to be kept moist for 1. What are the factors affecting adhesion?
penetration of monomer into exposed collagen fibers. 2. What are different types of enamel etching pattern?
Overdrying of dentin can result in collapse of collagen 3. Why deciduous teeth require more etching time?
fibers which may prevent penetration of monomers 4. Why fluorosed teeth require more etching time?
and thus interfere with bonding. 5. Why we encounter problems during dentin bonding
◆◆ Application of bonding agent: It should be applied in as compare to enamel bonding?
2–3 coats. Do not air thin it too aggressively because if it 6. Why bonding in moist dentin better than dry dentin?
is all blown away there is nothing to bond. 7. Which generation bonding agents were based on total
◆◆ Placing composite resin: Place composite restoration etch technique?
in increments. 8. What is hybrid layer?
9. Define smear layer.
10. What are the reasons for failure of dentin bonding?
Conclusion 11. Explain tooth conditioner, tooth primer and bonding
Concept of adhesive dentistry came in 1955 with the work resin.
of Bunocore, since then it has undergone great progress 12. What are 7th and 8th generation bonding systems?
in the last decades. In favor of minimal-invasive dentistry, 13. Are all flowable composites similar?
adhesive dentistry promotes a more conservative tooth 14. What is the best matrix band to use for posterior
preparation which relies on the effectiveness of current composites?
enamel-dentin adhesives. With changing technologies, 15. What is the best technique for filling the box of class II
dental adhesives have evolved from no-etch to total- composite?
etch (4th and 5th generation) to self-etch (6th, 7th, and 16. What is the difference between layering and
8th generation) systems. The manufacturers are putting incremental fill?
emphasis on development of new dentin adhesives aiming 17. What are different challenges in dentin bonding?
to simplify the process and improve the clinical results. In 18. What is adhesion?
future with continued growth of new systems, it will be 19. What is wetting?
the clinician’s choice to use bonding system as per patient 20. What happens if enamel is etched for more than
requirement. required time?
21. What is concentration of etchant used?
22. What are microtags and macrotags?
examINER’S CHOICE Questions
23. What are problems encountered during dentin
1. What is the scope of adhesive dentistry? Discuss in bonding?
detail about the mechanism and factors affecting 24. Why do we need moist dentin for dentin bonding?
adhesion. 25. What is primer?
2. Explain in detail dentin-bonding agents. 26. Who gave the acid etch technique?
3. Write in brief about the enamel etching and bonding 27. What are the various concentrations of phosphoric
agents. acid that have been used to etch enamel?
4. Discuss in detail about the smear layer. 28. What is etching time recommended for enamel and
5. What are dentin-bonding agents and discuss its dentin?
different generations of dentin-bonding agents? Also 29. What is the role of water in self-etch adhesive?
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design and filling techniques. Int Dent J. 1988;38:97-104. agents. Eur J Oral Sci. 1997;105:434-9.
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4. Bowen RL, Nemoto K, Rapson JE. Adhesive bonding of various Comparative Evaluation of Tensile Bond Strength of 6th, 7th,
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materials during hardening. J Am Dent Assoc. 1983;106: 2015;7:41-3.
475-7. 12. Leinfelder KF. Generation by generation: Not all bonding
5. Bowen RL, Tung MS, Blosser RL, et al. Dentin and enamel systems are created equally. Oral Health J. 2004;4:1-5.
bonding agents. Int Dent J. 1987;37:158-61. 13. Reinhardt JW, Stephens NH, Fortin D, et al. Effect of Gluma
6. Burke FJ, McCaughey AD. The four generations of dentin desensitization on dentin bond strength. Am J Dent. 1995;8:
bonding. Am J Dent. 1995;8:88-92. 170-2.
Chapter
24
Composite Restorations
Chapter Outline
Introduction Steps of Clinical Procedure for Composite Restoration

Definition Tooth Preparations for Anterior Composite Restorations
History Tooth Preparation for Posterior Composite Restoration
Composition of Dental Composites Stamp Technique of Restoration
Classification of Composites Failures of Composite Restorations
Types of Composites Repair of Composite Restorations
Recent Advances in Composites Indirect Resin Composite
Properties of Composite Classification of Indirect Composites
Degree of Conversion in Composites Tooth Preparation for Composite Inlays and Onlays
INTRODUCTION of resin-based composites. Earlier composites were

recommended only as a restorative material for anterior
Aesthetic dentistry has shown much advancement in restorations, but now they have become one of the most
materials and technology since the last century. Materials commonly used direct restorative materials for both
which have been used for aesthetic restorations are silicate anterior and posterior teeth. Principal reasons for shifting
cement, glass ionomer, acrylic resins, composites, and from dental amalgam to composites are reduced need
fused porcelain. for preparation and strengthening effect on remaining
Modern history of tooth-colored restorative materials
tooth. Nowadays, composite resins are considered as an
started with silicate cement which was introduced
economical and aesthetic alternative to other direct and
by Fletcher in the year 1878 in England, and further
indirect restorative materials.
encouraged by Steenback and Ashor in 1903. However,
use of silicate cements declined with time because of their
poor strength, irritation to pulpal tissue, brittleness, and Definition
need of conventional design of tooth preparation.
1. In materials and science world, composite refers to
Self-curing acrylic resins were developed in 1930 in
a solid formed from two or more distinct phases that
Germany, but they became popular in dentistry in late
1940s. they too showed poor physical properties like have been combined to produce properties superior
high polymerization shrinkage and coefficient of thermal to or intermediate to those of individual components
expansion (CTE), lack of wear resistance, poor marginal (Sturdevant).
seal, irritation to pulp, and dimensional instability. In 2. A highly cross-linked polymeric material reinforced by
an attempt to improve their properties, R Bowen, in a dispersion of amorphous silica, glass, crystalline or
1962, developed a polymeric dental restorative material organic resin filler particles, and/or short fibers bonded
reinforced with silica particles used as fillers. These to the matrix by a coupling agent (skinners).
materials were called “composites”. 3. A three-dimensional combination of atleast two
Over the past three decades, there has been a chemically different materials with a distinct interface
substantial progress in the development and application separating the components (DCNA).
Composite Restorations 289
the backbone of composite resin system. Most preferred
History monomer is:
1901 Synthesis and polymerization of methyl ◆◆ Bis-GMA (Bisphenol A-glycidyl methacrylate)
methacrylate ◆◆ urethane dimethacrylate (UDMA)
1930 Use of PMMA as denture base resin ◆◆ combination of Bis-GMA and UDMA.
1944 First acrylic filling material •• Since resin matrix is very viscous, to improve hand
1951 Addition of inorganic fillers to direct filling ling and to control viscosity, low viscosity monomers
materials like triethylene glycol dimethacrylate (TEGDMA),
1955 Acid-etch technique introduced by Buonocore and methyl methacrylate (MMA) are added.
1956 Bowen investigated Bisphenol A-glycidyl metha
Viva Voce
crylate (Bis-GMA) and silanized inorganic filler
1962 Introduction of silane coupling agents Methacrylates are used because of their refractive index of 1.3
1964 Marketing of Bis-GMA composites which is close to tooth. This allows metamerism (chameleon
1968 Development of polymeric coatings on fillers effect) giving the effect of similar color.
1973 UV-cured dimethacrylate composite resins
1976 Introduction of microfilled composites
1977 Visible light-cured dimethacrylate composite resins 2. Fillers
1996 Development of flowable composites Dispersed phase of composite resins is made up of an
1997 Development of packable composites inorganic filler material. Commonly used fillers are
1998 Development of fiber reinforced, ion-releasing silica, quartz, barium glass, etc. Nowadays, calcium
composites, and ormocers metaphosphate is also used because it is softer than
1999 Single crystal modified composites glass, so cause less wear of opposing tooth. Filler content
2002 Nanofilled composites. ranges from 30% to 70% by volume and 50% to 85% by
weight. Within the limits, greater is the percentage of
COMPOSITION OF DENTAL COMPOSITES filler particles, better are the physical properties of
composites, and these can be achieved by appropriate
Composition of Dental Composites (Fig. 24.1)
particle size and distribution of the filler particles
1. Resin matrix (Flowchart 24.1). Composites are classified according to
2. Filler or dispersed phase filler size. In general, composites with large filler particle
3. Organosilane or coupling agent size show rough surface texture, decreased curing depth,
4. Activator-initiator system and scattering of light, so appear opaque and tend to
5. Inhibitors stain. Composites with small filler particle size show
6. Coloring agents smooth surface texture, increased curing depth, and less
7. Ultraviolet absorbers. scattering of light, so appear less opaque and show high
aesthetics.
Flowchart 24.1: Properties of composites according

to filler particle size.
Fig. 24.1: Particle size distribution in dental composite.
1. Resin Matrix
Resin matrix consists of polymeric mono-, di-, or trifunc
tional monomers like Bis-GMA or UDMA. It represents
Advantages of adding fillers to resin matrix: Table 24.1: Differences between chemically-cured and light-cured
◆◆ Reduce the coefficient of thermal expansion composites.
◆◆ Reduce polymerization shrinkage Chemically cured Light cured
◆◆ Increase abrasion resistance • Polymerization is central, i.e. • Polymerization is towards the
◆◆ Decrease water sorption towards the center source of light
◆◆ Increase tensile and compressive strengths • Less color stability • More than chemically cured
◆◆ Increase fracture toughness
• Curing is done in single step, • Curing is done in multiple
◆◆ Increase flexure modulus
i.e. at one time steps due to incremental
◆◆ Provide radiopacity build up
◆◆ Improve handling properties
• Less working time • Adequate working time for
◆◆ Increase translucency. insertion and contouring
• Less aesthetics • Good aesthetics
3. Coupling Agents (Fig. 24.2)
• Economical • Expensive
Coupling agents bind filler particles to the organic resin. • More polymerization • Less polymerization
these are composed of bifunctional molecules. The silane shrinkage shrinkage
group chemically bonds to the inorganic materials and • Less abrasion resistant • More abrasion resistant
ethoxy and methoxy group of coupling agents bind to • Rapid setting occurs • Sets after activation of light
the resin molecules of matrix. Commonly used coupling
agents are vinyltriethoxysilane and gamma-methacryloxy
propyltrimethoxysilane. Since coupling agents work best Table 24.2: Initiator-activator system used in various types of
with silica particles, so most of the composites contain composites.
silica-based fillers. Sl. Types of
No. composite Initiator Activator
1. Chemically- Benzoyl peroxide N,N-dimethyl-p-
cured composite toluidine
2. Light-cured
composite
i. Ultraviolet 0.1% Benzoin Tertiary amine
light-activated methyl ether
composite
ii. Visible 0.06% Dimethylaminoethyl
light-cured camphorquinone methacrylate
composite
Fig. 24.2: Coupling agents.

Table 24.3: Differences between visible light and ultraviolet light
curing.
Functions of Coupling Agent
i. Bonding of filler and resin matrix. Features Visible light curing UV light curing
ii. Transfer forces from flexible resin matrix to stiffer Wavelength Wavelength required for Wavelength required for
filler particles. activation is 400–500 activation is 360–400
iii. Prevent penetration of water along filler resin inter nm nm
face, thus provide hydrolytic stability. Depth of Greater depth of curing Limited penetration
iv. Decrease crack propagation. curing is possible (up to 3 mm) (up to 1–2 mm)
Intensity Intensity remains Intensity decreases with
4. Activator-initiator Agents constant usage
Harmful Less side effect to Harmful to operator and
Polymerization of composite resin takes place by release of effects operator and patient’s patient’s eyes, can cause
free radicals which can be done either by chemical reaction eye corneal burns
or light activation. Tables 24.1 to 24.3 show differences
Color Better color stability Lesser than visible light
between chemically- and light-cured composites, different stability
initiator-activator systems used for various systems, and
Warm-up No warm-up time Units need warm-up
differences between visible light and ultraviolet light
time required time of 5 minutes
curing.
5. Inhibitors IV. Classification according to Bayne and Heyman:
These agents inhibit the free radical generation by Category Particle size
spontaneous polymerization of the monomers. Commonly 1. – Megafill 1–2 mm
used inhibitor is butylated hydroxytoluene (0.01%). 2. – Macrofill 10–100 µm
Functions:
3. – Midifill 1–10 µm
i. extend storage life
ii. Increase working time. 4. – Minifill 0.1–1 µm
Mechanism of action 5. – Microfill 0.01–0.1 µm
6. – Nanofill 0.005–0.01 µm
V. Classification according to matrix compositions:
1. Bis-GMA
2. UDMA.
VI. Classification according to polymerization method:
1. Self-curing
6. Coloring Agents 2. Light curing:
a. Ultraviolet light curing
Coloring agents are used in very small percentage to b. Visible light curing.
produce different shades of composites. Mostly metal 3. Dual curing
oxides such as titanium dioxide and aluminium oxides 4. Staged curing.
are added to improve opacity of composite resins. darker VII. Generations of composite restorations (Marzouk):
shades and greater opacities have decreased depth of 1. First-generation composites
curing so for optimal curing, they should be cured for 2. Second-generation composites
more time and applied in thin layers. 3. Third-generation composites
4. Fourth-generation composites
7. Ultraviolet Absorbers 5. Fifth-generation composites
They are added to prevent discoloration, in other words 6. Sixth-generation composites.
they act like a “sunscreen” to composites. Commonly used
UV absorber is benzophenone. Generations of Composite Restoration
(Marzouk)
CLASSIFICATION OF COMPOSITES A. First-generation composites
I. According to Skinner: •• Consist of macroceramic reinforcing phase
1. Macrofilled/Traditional or conventional compos- •• Have good mechanical properties
ites—8–12 µm •• Highest surface roughness
2. Small particle-filled composites—1–5 µm B. Second-generation composites
3. Microfilled composites—0.04–0.4 µm •• Consist of colloidal and microceramic silica
4. Hybrid composites—0.6–1 µm •• Low strength
II. Philips and Lutz classification according to filler •• Unfavorable coefficient of thermal expansion
particle size: •• Wear resistance better than first generation
1. Traditional composite resins—1.5 μm •• Best surface texture
2. Hybrid composite resins—0.05–0.1 μm C. Third-generation composites
3. Homogenous microfilled composites—0.05–0.1 μm •• Hybrid composite [combination of macro and micro
4. Heterogenous microfilled composites—0.05–0.1 (colloidal) ceramics]
μm, 1–25 μm •• Good surface smoothness and reasonable strength
III. According to the mean particles size of the major D. Fourth-generation composites
fillers: •• Hybrid composite [heat-cured, irregularly shaped,
1. Traditional composite resins highly reinforced composite macroparticles with
2. Hybrid composite resins micro (colloidal) ceramics]
3. Homogeneous microfilled composites—if the •• Comparatively better surface characteristics and
composite simply consists of fillers and uncured mechanical properties
matrix material, it is classified as homogeneous. E. Fifth-generation composites
4. Heterogeneous microfilled composites—if it •• Hybrid composite [heat-cured, spherical, highly
includes procured composites and other unusual reinforced composite macroparticles with micro
filler, it is called as heterogeneous. (colloidal) ceramics]
•• Improved workability Disadvantages

•• Surface texture and wear is similar to second-
◆◆ Rough surface finish due to plucking of fillers from the
generation composites
matrix
•• Physical and mechanical properties similar to
◆◆ Poor polishability
fourth-generation composites
◆◆ More wear
F. Sixth-generation composites
◆◆ More prone to staining.
•• Hybrid composite [agglomerates of sintered micro
Due to their many disadvantages, these composites are
(colloidal) ceramics and microceramics]
not commonly used nowadays.
•• Highest percentage of reinforcing particles
•• Best mechanical properties
•• Wear and surface texture similar to fourth generation
2. Small particle-filled composites
•• Least polymerization shrinkage. Small particle composites have better surface smoothness
than traditional composites. Average particle size of small
TYPES of composites (Fig. 24.3) particle composite resins ranges from 1 µm to 5 µm. The
small particle size results in smooth polished surface
1. Macrofilled/Traditional or conventional which is resistant to plaque, debris, and stains. Filler
composites content is 80% by weight and 65% by volume. Fillers used
are heavy metal glasses like lithium, barium, zirconium,
These were developed during early 1970s. Average particle and quartz. These composites are used in stress-bearing
size of macrofilled composite resin ranges from 8 µm to areas like class I and II, large class III and IV preparations.
12 µm. It exhibits a rough surface texture because of the
relatively large size and extreme hardness of the filler Advantages
particles. Due to roughness, discoloration and wearing
of occlusal contact areas and plaque accumulation take ◆◆ Superior polishing and texturing properties
place faster than any other type of composites. ◆◆ Good abrasion and wear resistance
◆◆ Lower coefficient of thermal expansion
Advantage ◆◆ Decreased polymerization shrinkage
◆◆ Less water absorption
Physical and mechanical performance is better than ◆◆ Increased modulus of elasticity and compressive strength
unfilled acrylic resins. ◆◆ Good aesthetics.
Fig. 24.3: Evolution of composites.

Disadvantage Disadvantages
Long-term durability of these composite resins is question ◆◆ Not appropriate for heavy stress-bearing areas
able due to presence of heavy metal glass fillers because ◆◆ Not highly polishable as microfilled because of presence
these fillers are softer and prone to hydrolysis. of larger filler particles in between smaller ones
◆◆ Loss of gloss occurs when exposed to toothbrushing
3. Microfilled composites with abrasive toothpaste.
Microfilled composites were introduced in early 1980s. Two new generations of hybrid composite resins are:
Average particle size ranges from 0.04 µm to 0.4 µm. Filler 1. Nanofill and nanohybrids
content is 30–40% by weight. Small particle size results 2. Microhybrids.
in smooth polished surface which is resistant to plaque, 1. Nanofill and nanohybrid composites: Nanofill and
debris, and stains. But because of less filler content, nanohybrid composites have average particle size less
physical properties are inferior. Microfilled composites than that of microfilled composites.
have low modulus of elasticity and high polishability, Use of these extremely small fillers and their proper
excellent translucency however, they exhibit low fracture arrangement within the matrix results in physical
toughness and increased marginal breakdown. They are properties equivalent to the original hybrid composite
indicated for the restoration of anterior teeth and cervical resins.
abfraction lesions. Advantages:
•• Highly polishable
Advantages •• Tooth-like translucency with excellent aesthetics
•• Optimal mechanical properties
◆◆ Highly polishable
•• Good handling characteristics
◆◆ Good aesthetics.
•• Good color stability
•• Stain resistance
Disadvantages •• High wear resistance
◆◆ Poor mechanical properties due to more matrix content •• Can be used for both anterior and posterior resto
◆◆ Poor color stability rations and for splinting teeth with fiber ribbons.
◆◆ Low wear resistance 2. Microhybrid composites: Microhybrid composites
◆◆ Less modulus of elasticity and tensile strength have evolved from traditional hybrid composites.
◆◆ More water absorption Filler content in microhybrids are 56–66% by
◆◆ High coefficient of thermal expansion. volume with average particle size of 0.4–0.8 µm.
Incorporation of smaller particles enhance their
polishability and handling than their hybrid
4. Hybrid composites
counterparts. Because of presence of large filler
Hybrid composites are named so because they are made content, microhybrid composites have improved
up of polymer groups (organic phase) reinforced by an physical properties and wear resistance than
inorganic phase. Hybrid composites are composed of microfilled composites.
glasses of different compositions and sizes, with particle Advantages:
size diameter of less than 2 µm and containing 0.04 µm •• Better polishability and surface finishing
sized fumed silica. Filler content in these composites is •• Easy handling
75–80% by weight. This mixture of fillers is responsible for •• Improved physical properties
their physical properties similar to those of conventional •• Good wear resistance.
composites with the advantage of smooth surface
texture. RECENT ADVANCES IN COMPOSITES
Advantages 1. Flowable composite resin
2. Condensable (packable) composites
◆◆ Excellent polishing and texturing properties 3. Compomers
◆◆ Good abrasion and wear resistance 4. Ormocers
◆◆ Similar coefficient of thermal expansion 5. Antibacterial/ion-releasing composites
◆◆ Ability to imitate the tooth structure 6. Smart composites
◆◆ Decreased polymerization shrinkage 7. Expanded matrix resins composites
◆◆ Less water absorption 8. Nano composites
◆◆ Improved radiopacity due to heavy metal glass/fillers. 9. Self-healing composites.
1. Flowable Composite Resin 2. Condensable (Packable) Composites

Flowable composites were introduced in dentistry in late Condensable/packable composites have improved
1996. Matrix present in flowable composite is TEGDMA, mechanical properties and handling characteristics. Main
i.e. triethylene glycol dimethacrylate. It has low viscosity basis of packable composites is Polymer rigid inorganic
thus contributes to flow of the composite. Filler content matrix material (PRIMM). Here, components are resin
is 60% by weight with particle size ranging from 0.02 µm and ceramic inorganic fillers which are incorporated
to 0.05 µm. Low filler loading is responsible for decreased in silanated network of ceramic fibers. These fibers are
viscosity of composites, which allows them composite to be composed of alumina and silicon dioxide which are fused
injected into small preparations, this makes them a good
to each other at specific sites to form a continuous network
choice for pit and fissure restorations. But incorporation of
of small compartments.
lower filler content results in poor mechanical properties
Filler content in packable composites ranges from 48%
of these composites than hybrid composites.
to 65% by volume with average particle size ranging from
Flowable composite is called Dental Caulk, because it can flow 0.7 µm to 20 µm.
into small crevices along the restoration margins.
Properties of Packable Composites
Indications
i. Packable composites have improved mechanical
i. Preventive resin restorations properties because of presence of ceramic fibers.
ii. Small pit and fissure sealants
ii. Improved handling properties because of presence of
iii. Small, class V lesions
higher percentage of irregular or porous filler, fibrous
iv. Repair of small porcelain fractures
filler, and resin matrix.
v. Repair of crown margins
iii. Consistency of condensable composites is like freshly
vi. Repair of composite resin margins
vii. Liner and base in class I and II cavities triturated amalgam, so it can be pushed into posterior
viii. In pediatric patient, it is indicated for narrow and tooth preparation and has greater control over
deep pits and fissures. proximal contour of class II preparations.
iv. Deeper depth of cure is due to light conducting
Contraindications properties of ceramic fibers. Each increment of
composite can be condensed like amalgam and cured
High stress bearing areas like class I and II cavities because to a depth of over 4 mm.
of low strength and more wear. v. Low polymerization shrinkage of 0.6–0.9% due to
presence of ceramic fibers and incorporation of resin
Advantages matrix in this network.
◆◆ Low viscosity
◆◆ Improve marginal adaptation of posterior composites Indications
by acting as an elastic, stress absorbing layer over which
◆◆ Indicated in stress-bearing areas
composite is placed
◆◆ In class II restorations as they allow easier establishment
◆◆ High wettability of the tooth surface
of physiological contact points.
◆◆ High depth of cure
◆◆ Penetration into every irregularity of preparation
◆◆ Ability to form layers of minimum thickness, thus Advantages
eliminate air entrapment ◆◆ Increased wear resistance because of presence of cera
◆◆ High flexibility, so less likely to be displaced in stress mic fibers
concentration areas ◆◆ Condensability similar to silver amalgam restoration
◆◆ Radiopaque ◆◆ Greater ease in achieving good contact point
◆◆ Availability in different colors ◆◆ Deeper depth of cure
◆◆ Require minimally invasive tooth preparations ◆◆ High flexural modulus
◆◆ Decreased polymerization shrinkage because of
Disadvantages presence of ceramic fibers
◆◆ More susceptible to wear in stress-bearing areas ◆◆ Reduced stickiness
◆◆ Weaker mechanical properties ◆◆ Physical and mechanical performance is similar to that
◆◆ More polymerization shrinkage of silver amalgam
◆◆ Sticks to the instrument, so difficult in handling it. ◆◆ Increased radiopacity due to presence of alumina.
Disadvantages ◆◆ Physical properties: Physical properties such as
strength, fracture toughness are very much similar to
◆◆ Difficulty in adaptation of one composite layer with
composites.
another
◆◆ Bond strength: It is similar to composite.
◆◆ Difficult handling
◆◆ Adaptation at cervical margin is similar to composite
◆◆ Poor aesthetics in anterior teeth.
resins.
◆◆ Fluoride release: It is greater than composite resins but
3. Compomers (Polyacid Modified + Composite less than glass ionomer systems.
Resins) ◆◆ Color matching and optical properties are superior to
glass ionomer cements.
Compomers provide combined advantages of composites
(term “Comp” in their name) and glass ionomer (“Omers”
in their name). They are available in single paste, light
Advantages
enable material in syringe or compules. ◆◆ Optimal aesthetics
The first compomer was introduced in 1993 under the ◆◆ Easy to manipulate
name “Dyract”. Initially, the compomers were introduced ◆◆ Easy to polishing
as a type of glass ionomers which offered fluoride release ◆◆ Require no mixing
along with improved physical properties. But in terms of ◆◆ Bond strength is higher than glass ionomers.
clinical use and performance, it was considered as a type
of composite resin. Later on, “Compoglass” followed by Disadvantages
Hytac was introduced.
◆◆ Require use of bonding agent
◆◆ Technique sensitive
Composition of Compomers ◆◆ Limited fluoride release
1. Resin matrix: Dimethacrylate monomers with two ◆◆ Microleakage more than resin-modified glass ionomers
carboxylic groups present in their structure. For ◆◆ Expansion of matrix due to water sorption
example, urethane dimethacrylate (UDMA) and ◆◆ Physical properties decrease with time.
butane tetracarboxylic acid (TCB)
2. Filler: Strontium fluorosilicate glass, a reactive silicate Indications
glass containing filler Compomers are indicated in:
3. Photoinitiators 1. Pit and fissure sealant
4. Stabilizers. 2. Class III and Class V cavities
There is no water in the composition and ion leachable 3. cervical abrasion/erosion
glass is partially silanized to ensure bonding to matrix. 4. Repair of defective margins in restorations
5. Core build up material
Setting Reaction 6. Restoration of primary teeth.
These materials set by free radical polymerization reaction.
There are two stages in the polymerization reaction: Difference between compomers and giomers:
In compomers, variable amount of polyalkenoic acid is
1. Stage 1: Typical light-activated composite resin
incorporated into the resin matrix and acid does not react
polymerization reaction occurs which helps in with glass until the water uptake occurs into restoration.
forming resin networks enclosing the filler particles. In giomers, fluoroaluminosilicate glass particles are reacted
This reaction causes hardening of products. with polyalkenoic acid in water prior to their incorporation
2. Stage 2: It occurs after the initial setting of material. into the resin matrix.
The restoration absorbs water and carboxyl groups
present in the polyacid and metal ions in the glass
ionomers show slow acid-base reaction. This results in
4. Organically Modified Ceramic (ORMOCER)
formation of hydrogel. It is like glass ionomer cement ORMOCER is an organically modified nonmetallic inor-
within the set resin structure. Slow release of fluoride ganic composite material.
also occurs here.
Composition
Properties ◆◆ Organic molecules of methacrylate groups forming a
◆◆ Adhesion: Adhesion to tooth structure is by micro cross-linked matrix.
mechanical means and requires acid etching and use ◆◆ Inorganic condensing molecules to make three-
of primer/adhesive. dimensional network are formed by inorganic
polycondensation. This makes the backbone of ii. Methacryloyloxydodecyl Pyridinium Bromide (MDPB)
ORMOCER molecules (Fig. 24.4).
Use of methacryloyloxydecyl pyridinium bromide (MDPB)
◆◆ Fillers.
was recommended by Imazato in 1994. It has the following
features:
◆◆ Its antibacterial property remains constant and
permanent.
◆◆ It has shown to be effective against streptococci.
◆◆ It does not have adverse effect on the physical properties
of Bis-GMA-based composites.
◆◆ On polymerization, it forms chemical bond to the
resin matrix; therefore, no release of any antibacterial
component takes place.
iii. Silver
Silver ions cause structural damage to the bacteria. In
these composites, the antibacterial property is due to
direct contact with bacteria and not because of release of
silver ions. Addition of silver into composite without silica
gel does not affect its physical properties like depth of cure,
compressive strength, tensile strength, color stability, and
Fig. 24.4: Components of ORMOCER. polymerization. Silver ions can be added to composites by
any of the following methods:
Properties
◆◆ Incorporation into inorganic oxide like silicone
◆◆ More biocompatible than conventional composites dioxides.
◆◆ Higher bond strength ◆◆ Incorporation into silica gel and then films are coated
◆◆ Polymerization shrinkage is least among resin-based over the surface of composites.
filling material ◆◆ Hydrothermally supported into the space between the
◆◆ Highly aesthetic, comparable to natural tooth crystal lattice network of filler particles.
◆◆ High compressive (410 MPa) and transverse strength
(143 MPa). 6. Smart Composites
Indications Smart composites work based on the recently introduced
◆◆ Restoration for all type of preparations alkaline glass fillers which inhibit the bacterial growth
◆◆ For aesthetic veneers and thereby reduce incidence of secondary caries. It was
◆◆ As orthodontic bonding adhesive. introduced in 1998 under the name Ariston pHc (Vivadent).
In these, micron size sensor particles are embedded into
composites during manufacturing process. These sensors
5. Antibacterial Composites/Ion-releasing interact with resin matrix and generate quantifiable ions
Composites like fluoride, hydroxyl, and calcium ions if the pH falls in
Since composites show more tendency for plaque and the vicinity of the restoration. Fall in pH occurs because of
bacteria accumulation in comparison to enamel, attempts plaque deposition in that area.
have been made to develop caries-resistant antibacterial Paste of smart composites contains barium, aluminium
composites. For this, following have been tried to fluoride, and silicate glass fillers with silicon dioxide,
incorporate in the composites: ytterbium trifluoride, and calcium silicate glass in dimetha
crylate monomers. Filler content in these composites is
i. Chlorhexidine 80% by weight.
Though chlorhexidine has shown antibacterial properties,
but its addition to composites has been unsuccessful
7. Expanding Matrix Resins Composites
because of the following reasons: Composites show polymerization shrinkage on curing
◆◆ Weakening of the physical properties of composites which can result in marginal leakage, postoperative sensi
◆◆ Release chemicals which show toxic effects tivity, and secondary caries. Therefore, slight expansion
◆◆ Temporary antibacterial activity of the composites during polymerization is desired to
◆◆ Shift in microorganisms and plaque to adjacent areas reduce these effects. For this, Spiro orthocarbonates
of the tooth. (SOCs) are added in composites because they expand
A B C
Figs. 24.5A to C: Polymerization shrinkage. (A) Formation of a gap between resin-based composite and the preparation wall;
(B and C) Shrinkage occurs uniformly toward the center in light-cured composites.
on polymerization. Epoxy resins contract 3.4% and SOCs and the preparation wall (Fig. 24.5A). It accounts for
expand 3.6%. Both are mixed to achieve desired expansion. 1.67–5.68% of the total volume. In light-cured composites,
about 70% polymerization occurs within first 10 minutes,
8. Nanocomposites and polymerization reaction continues for period of 24
hours. Shrinkage in light-cured composites occurs in
Nanocomposites are composites in which at least one of
the direction of light. For chemical-cured composites,
the phases shows dimensions in the nanometer range
shrinkage occurs slowly and uniformly toward the center
(1 nm = 10–9 m). Colloidal silica particles of a diameter of
of restoration (Figs. 24.5B and C).
approximately 40 nm have been used in microfilled and
hybrid composites for more than 10 years. Nanoparticle-
filled composites show excellent aesthetics, are easy to Polymerization Shrinkage can Result in
polish, and possess an enhanced wear resistance. ◆◆ Postoperative sensitivity
◆◆ Recurrent caries
9. Self-healing Composites ◆◆ Failure of interfacial bonding
◆◆ Fracture of restoration and tooth (Fig. 24.6).
This is an epoxy system which contains resin-filled
microcapsules. If a crack occurs in the epoxy composite
Polymerization Shrinkage can be Reduced by
material, some of the microcapsules are destroyed near
the crack and release the resin. The resin subsequently fills I. Decreasing monomer level.
the crack and reacts with a Grubbs catalyst dispersed in II. Improving composite placement technique: Placing
the epoxy composite, resulting in a polymerization of the successive layers of wedge-shaped composite (1–1.5
resin and repair of the crack. mm) that decreases polymerization shrinkage.
PROPERTIES OF COMPOSITE
1. Coefficient of Thermal Expansion
Coefficient of thermal expansion of composites is
approximately three times higher than normal tooth
structure. This results in more contraction and expansion
than enamel and dentin when there are temperature
changes thus resulting in loosening of the restoration. it
can be reduced by adding more filler content. Microfill
composites show more coefficient of thermal expansion
because of presence of more polymer content.
2. Polymerization Shrinkage
Composite materials shrink while curing which can result Fig. 24.6: Schematic representation of fracture of tooth due to po-
in formation of a gap between resin-based composite lymerization shrinkage.
III. Polymerization rate: C-factor can be reduced by: 5. Wear Resistance (Fig. 24.7)
i. “Soft-start” polymerization: In soft-start
Composites are prone to wear under masticatory forces,
technique, curing begins with low intensity and
toothbrushing, and abrasive food. Site of restorations in
finishes with high intensity. Photopolymerization
dental arch and occlusal contact relationship, size, shape,
stress buildup is inspired by chemical initiation
and content of filler particles affect the wear resistance of
by providing an initial low rate of polymerization
the composites. Greater are the occlusal forces, more is
thus extending the available time for stress
the wear. Lesser is the polymerization, more is the wear
relaxation before reaching gel point. of composites. Condensable composites are more wear
resistant than flowable or microfilled composites.
ii. Ramping curing: The intensity is gradually

increased up during exposure which causes stress
relaxation. Longer the time period available for
relaxation, lower are the residual stresses.
Fig. 24.7: Wear resistance.
Wear in Composites
Two principal modes of wear are:
3. Aesthetics of Composites i. Two-body wear: When there is direct contact of
restoration with opposing tooth or adjacent proximal
Composites have shown good aesthetics because of their surface of tooth, it leads to high stress development.
property of translucency. Composites are available in ii. Three-body wear: It is caused due to contact with the
different opacities and shades, so they can be used in food bolus as it is forced across the occlusal surface.
different places according to aesthetic requirements. But This type of wear depends upon degree of monomer
due to oxidation, moisture, and exposure to ultraviolet conversion, filler loading, type of filler particles, and
light, etc. some chemical changes can occur in the resin stability of silane coupling agent.
matrix which results in discoloration of composite with
time. But improvements in composites like increase in filler 6. Surface Texture
content, decrease in tertiary amines, and improvement Size and composition of filler particles determine the
in light curing techniques have shown more stability in smoothness of surface of a restoration. Microfill compos-
composite shade. ites offer the smoothest restorative surface. This property
is more significant if the restoration is in close approxi
4. Water Absorption mation to gingival tissues.
Composites have tendency to absorb water which can lead
7. Radiopacity
to the swelling of resin matrix, filler debonding, and thus
restoration failure. Composites with higher filler content Resins are inherently radiolucent. Presence of radiopaque
exhibit lower water absorption and therefore better fillers like barium glass, strontium, and zirconium makes
properties than with lower filler content. the composite restoration radiopaque.
Aluminum is used as standard reference for radiopacity. Com-

Factors Affecting Water Absorption
posites have radiopacity equivalent to 2 mm of aluminium,
of Composites dentin has radiopacity equal to 2.5 mm thickness of alumin-
ium, enamel equivalent to 4 mm of aluminium, and amalgam
◆◆ More the filler content, lesser will be water sorption. has radiopacity more than 10 mm thickness of aluminium
◆◆ More the degree of polymerization, lesser is water sorp-
tion.
◆◆ Type and amount of monomer and diluent affect water
8. Modulus of Elasticity
sorption. For example, UDMA-based composites show Modulus of elasticity of a material determines its rigidity
less sorption and solubility. or stiffness. Microfill composites have greater flexibility
than hybrid composites since they have lower modulus of Mixing for Self-cure Composites
elasticity.
Self-cure composites come in two syringes. One
syringe contains the peroxide initiator or catalyst while
9. Solubility other syringe contains the amine accelerator. They are
Composite materials do not show any clinically significant dispensed in equal amounts and then thoroughly mixed
solubility in oral fluids. Water solubility of composites for 20–30 seconds. For mixing, plastic or wooden spatulas
ranges between 0.5 mg/cm2 and 1.1 mg/cm2. are preferred. Use of metal spatula is avoided because
inorganic filler particles are abrasive, they can abrade
10. Creep small amount of metal, and thus discolor the composite.
The working time for self-cure composite resins is 60–90
Creep is progressive permanent deformation of material seconds. Once the mixture starts hardening, it should not
under occlusal loading. More is the content of resin matrix, be disturbed for 4–5 minutes (setting time).
more is the creep. For example, microfilled composites
show more creep because they contain more resin matrix. 14. Cavity Configuration or C-factor
Cavity configuration or C-factor was introduced by
11. Microleakage and Nanoleakage
Professor Carol Davidson and his colleagues in 1980s.
Microleakage C-factor is the ratio of bonded surface of restoration
to unbonded surfaces (Fig. 24.8). Higher the value of
It is passage of fluid and bacteria in microgaps (10–6 m) “C”-factor, greater is the polymerization shrinkage.
between restoration and tooth. Microleakage can occur Class I and V have the highest C-factor and thus are at
due to polymerization shrinkage of composites, poor more risk to the effects of polymerization shrinkage.
adhesion, and thermal stresses. Microleakage results in
secondary caries, pulpal involvement, and tooth discolora
tion. Degree of conversion in composites
Complete polymerization of the composite is determined
Nanoleakage by degree of conversion of monomers into polymers.
Degree of conversion measures the percentage of carbon-
It is passage of fluid in nanosized (10–9 m) gaps. These nano
carbon double bonds that have been converted into single
sized porosities occur within hybrid layer. It can occur
bond to form a polymeric resin.
because of inadequate polymerization of primer before
application of bonding agent and incomplete resin infiltra-
tion. Nanoleakage can result in sensitivity during occlusal Factors Affecting Degree of Conversion
and thermal stresses. 1. Curing time: Curing time depends on different factors
like shade of the composite, intensity of the light used,
12. Biocompatibility temperature, depth of the preparation, thickness of the
resin, curing through tooth structure, and composite
Chemical insult from composites is possible if components filling.
leach out from composite and reach pulp. If composites 2. Shade of composite: Darker shades of composite
are optimally polymerized, they exhibit minimum polymerize slower as compared to lighter shades.
solubility, so unreacted particles are leached in very small
quantities. This makes them biocompatible; however, in
very rare conditions, some patients and dental personnel
can develop an allergic response to composites.
13. Working and Setting Times

Light Cure Composites
In these composites, application of light source to the
composite material starts the polymerization. Usually,
70% of polymerization takes place during first 10 minutes,
though the polymerization reaction continues for a period
of 24 hours. Not all available unsaturated carbon double
bonds reacts; 25% remains unreacted in bulk of the Fig. 24.8: C-factor for different tooth preparations for
restoration. composite restorations.
3. Distance and angle between light source and resin: 8. Luting cement: For cementation of indirect resto
Recommended distance between light source and rations like inlays, onlays, and crowns.
resin is 1 mm. Intensity of light decreases as the 9. Miscellaneous:
distance is increased (Fig. 24.9). curing light should • For periodontal splinting of weakened teeth or
be kept perpendicular to resin. If angle of light diverges mobile teeth
from 90°, intensity decreases. • For repair of fractured ceramic crowns
4. Temperature: Cold composite takes more time to • For bonding orthodontic appliances.
polymerize than composite used at room temperature.
5. Resin thickness: Resin thickness should be 0.5–1.0 Contraindications
mm for optimum polymerization.
6. Intensity of curing light: For optimal results, 1. Difficult moisture control: When isolation of
wavelength of light should range between 400 nm and operating field is difficult or accessibility problem is
500 nm. Intensity of curing light decreases as lamp present.
ages. 2. Heavy occlusal stresses: Patients with very high
7. Type of filler: Microfine composites are more difficult occlusal forces or bruxism are not good choice for
to cure than heavily loaded composites. composite restorations.
3. Lack of technical skill: When clinician does not
possess the necessary technical skill for restoration.
4. High caries susceptibility and poor oral hygiene:
Patients with high caries susceptibility and poor
oral hygiene pose great risk of secondary caries and
marginal discoloration.
5. Subgingival or root caries: When preparation
extends subgingivally or root surface, composites do
not provide a favorable marginal seal.
Advantages of Direct Composite Restorations

1. conservation of tooth structure: Since composite
Fig. 24.9: Curing distance and angle between light source and resin.
restoration requires minimal tooth preparation,
maximum conservation of tooth structure is possible.
Indications 2. Aesthetically acceptable
3. Composite resin can be used in combination with
1. class I and class Ii tooth preparations: For resto
other materials, such as glass ionomer, to provide the
ration of mild-to-moderate class I and class II tooth
benefits of both materials.
preparations, as pit and fissure sealants and as
4. low thermal conductivity: Composites have low
preventive restorations of all teeth.
thermal conductivity, thus no insulation base is
2. class III, IV, and V preparations: For restoration of
required to protect underlying pulp.
class III, IV, and V preparations of all teeth, especially
5. Mechanical bonding to tooth structure: Restorations
when aesthetics is important.
are bonded with enamel and dentin, hence show good
3. class VI preparations: Restoration of class VI
retention. Composite restorations can bond directly
preparations of teeth where high occlusal stresses are
to the tooth, making the tooth stronger than it would
not present.
be with an amalgam filling.
4. Aesthetic improvement procedures: Composites
6. Immediate finishing and polishing: Restoration with
are used in aesthetic procedures like laminates, composite resins can be finished immediately after
partial veneers, full veneers, treatment of tooth curing.
discolorations, and diastema closures. 7. It can be repaired rather than replaced if minor defect
5. Erosion or abrasion defects: For restoration of is present in old restoration.
erosion or abrasion defects in cervical areas of teeth 8. low microleakage: Composite restoration show low
where aesthetics are the main concern. microleakage than unfilled resins.
6. hypoplastic or other defects: For restoration of 9. Controlled working time: Controlled working time of
hypoplastic or other defects on the facial or lingual composites makes their manipulation easier.
areas of teeth. 10. Restoration can be completed in one dental visit.
7. Core build: As core buildup restorative material for 11. No galvanism (because composite resins do not
grossly damaged teeth and endodontically treated contain any metals), so these can be used if amalgam
teeth. or cast inlay restorations are already present in mouth.
Disadvantages of Direct Composite Restorations that with the high filler content. For restorations of anterior
teeth, aesthetics is the main concern, so, composites with
1. polymerization shrinkage: Because of polymeri submicronic fillers or nanoparticles are preferred in these
zation shrinkage, gap formation on margins may cases.
occur resulting in secondary caries, staining, and
postoperative sensitivity.
2. time-consuming: Composites restorations require
4. Shade Selection
good isolation and number of steps for their place Shade selection depends on factors like complexity of
ment, making them time-consuming. restoration and polychromatic characteristics of the tooth
3. Expensive: Composite is more expensive than to be restored. In cases where the dentin is to be replaced,
amalgam. composites having dentin shade and opacity are preferred.
4. technique sensitive: It is more technique sensitive In cases where enamel is to be replaced, composites with
than amalgam because composite placement requires enamel shades and translucency are preferred (Fig.
optimal isolation and multiple steps. 24.10).
5 Low wear resistance: Composites have low wear
resistance than amalgam.
6. High linear coefficient of thermal expansion: High
LCTE may result in marginal percolation around
composite restorations.
Steps of Clinical Procedure For

Composite Restoration
1. Local anesthesia
2. Oral prophylaxis
3. Composite selection
4. Shade selection Fig. 24.10: Shade selection palette.
5. Isolation
6. Tooth preparation Guidelines for Initial Shade Selection
7. Pulp protection
8. Matrix application ◆◆ Teeth and shade guide should be wet to simulate oral
9. Etching and bonding environment.
10. Composite placement ◆◆ Shade matching should be carried in natural daylight.
11. Polymerization of composite resins Otherwise, if dental operating light is to be used, it has
12. Final contouring, finishing, and polishing of composite to be kept away from patient’s face. This decreases the
restoration. intensity of the light and allows effects of shadows to be
seen.
1. Local Anesthesia ◆◆ Dentin shade is selected from cervical third of tooth,
local anesthesia is given because it reduces apprehension, and enamel shade is selected from its incisal third.
saves time, and reduces the salivation. Shade selection should be done in less than 30
seconds, because after 30 seconds, it becomes difficult
2. Oral Prophylaxis for eye to distinguish almost similar colors.
◆◆ To confirm final shade, a small increment of selected
Operating site is cleaned using slurry of pumice in order
composite is placed adjacent to the area to be restored
to remove plaque, calculus, and superficial stains prior
and then light cured for matching.
to the procedure. This procedure improves bonding to
composite resins. one should avoid using prophylactic
pastes containing glycerin or fluorides, etc. as these pastes 5. Isolation
may interfere with acid etching.
Contamination of etched enamel or dentin by saliva results
in a decreased bond strength and contamination of the
3. Composite Selection composite material during insertion results in degradation
Composite selection is dependent on site of tooth of its physical properties. Isolation is best done by using
preparation. For restoration requiring high mechanical rubber dam, though it can be done using cotton rolls,
performance, class I, II, and class VI, choice of composite is saliva ejector, and retraction cord.
6. Tooth Preparation Features

◆◆ Prepared enamel margins should be 90° or greater
General concepts for tooth preparation for composite ◆◆ Butt joint cavosurface margin is made on root surfaces
restorations: ◆◆ Prepared tooth surface is roughened to increase the
bonding.
1. conservation of Tooth Structure
2. Beveled Conventional Tooth Preparation
Tooth preparation is limited to extent of the defect. For This design is almost similar to conventional design but
composite restorations, extension for prevention rule and enamel margins are beveled (Figs. 24.11A to F).
proximal contact clearance is not necessary unless it is
required to facilitate proximal matrix placement. Indications
◆◆ When restoration is being used to replace an existing
2. variable Depth of Pulpal Floor and Axial Wall restoration exhibiting a conventional design.
◆◆ To restore a large preparation and especially indicated
Pulpal and axial walls need not to be flat. for classes III, IV, V, and VI restorations.
◆◆ In combination preparations, that is one part of the
3. rough Tooth Preparation Walls preparation is on crown and another part is on root, the
root surface is prepared as conventional preparation
To facilitate bonding, tooth surface is made rough by using
and enamel surface portion is prepared as beveled
diamond abrasives.
conventional preparation where enamel margin is
beveled.
4. enamel Bevel
3. Modified (Conservative Tooth Preparation)
Enamel bevel is given in some cases to increase the surface
It has scooped-out appearance without definite line
area for etching and bonding.
angles. It is indicated for initial or small carious lesions
(Figs. 24.12A to F).
5. butt Joint on Root Surface
Features
Cavosurface present on root surfaces has to be butt joint. ◆◆ Preparation has scooped-out appearance.
◆◆ It does not have specified wall configuration or pulpal
Designs of Tooth Preparation for Composites and axial wall depth.
◆◆ Extent and depth of the preparation depends upon the
Following three types of designs or their combination
extent and the depth of carious lesion.
are most commonly prepared for composites:
1. Conventional 7. Pulp Protection
Conventional design is similar to the tooth preparation
In case of shallow cavities, application of bonding agent is
for amalgam restoration, except that there is less outline
sufficient for pulp protection. In case of deep preparations,
extension and preparation walls are made rough.
pulp protection is done using a light-cured calcium
Indications for Conventional Tooth Preparation hydroxide base followed by resin modified GIC. Zinc
◆◆ Preparations located on root surface oxide-eugenol should not be used as a sub-base because
◆◆ Moderate-to-large class I or class II restorations. it inhibits the polymerization of resins.
A B C D E F
Figs. 24.11A to F: Beveled conventional tooth preparation.

A B C D E F
Figs. 24.12A to F: Modified conservative tooth preparation.
8. Matrix Application For details of matrices for composite restorations, refer to

Chapter 15.
Matrix helps in confining the excess restorative material
and in development of appropriate axial tooth contours.
Matrix is applied before acid etching and bonding. After 9. Etching and bonding
applying matrix, it should be stabilized by a wedge. Matrix First of all, proximal surface of adjacent unprepared
should extend 1 mm beyond the incisal and gingival tooth should be protected from involuntary etching
cavosurface margins. by covering it with a polyester strip. Then, apply a gel
etchant with a syringe or brush to the prepared surfaces,
Matrices Used for Composite Resin
approximately 0.5 mm beyond the cavosurface margins
◆◆ Tofflemire matrix retainer and band onto the unprepared tooth surface. Etching is done using
◆◆ Clear polyester matrices 37% phosphoric acid for 15–20 seconds. Properly etched
◆◆ Compound supported metal matrix surface has frosted appearance.
◆◆ Contact forming instruments After etching, a primer and an adhesive are applied
◆◆ Sectional matrices and contact rings like Palodent- according to the instructions provided. Use disposable
BiTine Ring System, Composi-Tight matrix, precon brushes or applicator tips for applying the adhesive agents.
toured sectional matrix bands, etc. If the system does not contain both primer and adhesive,
For class III restoration, a properly contoured wedge then bonding adhesive is applied after the primer and
supported, clear polyester strip matrix is used. For small- polymerized with curing light.
sized class IV preparations, a flexible polyester matrix
strip should be placed and wedged. The strip should
be folded at the position of lingual line angle to prevent 10. Composite Placement
undercontoured restoration in this area. Incisally, it should Instruments Used for Composite Placement
not protrude more than 1–2 mm beyond incisal edge.
For large class IV preparation, an impression compound i. Hand instruments: Hand instruments used for
supported metal matrix should be used. placing composites are usually made up of coating
Clear polyether matrices are used with Tofflemire of Teflon, so as to avoid sticking of composite to the
retainers and light reflecting wedges. These matrices instrument (Fig. 24.13A). These instruments are
transmit light through band, so as to ensure adequate simple and easy-to-use but the problem of air trapping
polymerization in class II cavities. But problems with these during insertion of composite can occur.
matrices are that they lack rigidity and cannot be properly ii. Composite gun: Composite gun is made up of plastic.
contoured. It is commonly used with composite-filled ampules.
Sectional matrices and contact rings are based on For use, a composite ampule is fitted in the gun and
precontoured sectional dead soft metal matrices which the pressure is applied so that composite comes out
are available in different shapes, thicknesses, and sizes from the ampule (Fig. 24.13B).
depending on the manufacturer, for perfectly contoured iii. Syringe: Composite syringe usually carries the low
restorations. These matrices and rings offer ease of viscosity composite which can easily flow through
use, good visibility, good gingival adaptation of the needle (Fig. 24.13C). This technique has advantage
restoration, and formation of optimal contact, contour, of providing an easy way for placement of composite
and embrasures. with decreased chances of air trapping.
A B C
Figs. 24.13A to C: Composite placement by: (A) Hand instruments; (B) Composite gun; (C) Syringe.
(Courtesy: Coltene India)
Composite Placement Techniques gap at gingival wall which is formed due to polymerization
shrinkage, hence postoperative sensitivity and secondary
Irrespective of location of restoration, composites should caries.
be placed and polymerized in increments. This ensures
complete polymerization of the whole composite mass Oblique Technique (Fig. 24.14C)
and aids in the anatomical buildup of the restoration. In this technique, wedge-shaped composite increments
Each increment should not be more than 2 mm in are placed to prevent deformation of preparation walls.
thickness, because it is difficult to cure and results in more Here, each increment is cured twice first through cavity
polymerization shrinkage stress. walls then from occlusal surface to direct the vectors of
polymerization toward adhesive surface. This technique
I. Incremental Layering Technique
reduces C-factor.
This technique utilizes composite layers of less than 2
mm thickness for polymerization. Incremental layering Three-site Technique (Fig. 24.14D)
of dentin and enamel composite creates layers with This technique uses clear matrix and reflective wedges, i.e.
high diffusion which allows optimal light transmission curing light is directed through the matrix and wedges to
within the restoration, thus increasing aesthetics but this direct the vectors toward gingival margin thereby reducing
technique has shown to increase C-factor thereby increase gap formation. Here, wedge-shaped increments are placed
in polymerization shrinkage. Following methods are which further reduce the C-factor.
employed for incremental placement of composites:
Split Increment Horizontal Technique (Figs. 24.15A to D)
Horizontal Layering Technique (Fig. 24.14A) In conventional horizontal layering, each increment
Here, the increments are placed horizontally in less than is surrounded by four cavity walls, producing highest
2.0 mm thickness. This technique increases the C-factor C-factor and thus polymerization shrinkage. It is modified
and thus polymerization shrinkage. as split increment horizontal layering in which each
Vertical Layering Technique (Fig. 24.14B) horizontal increment is split in four triangle portions each
Here, small increments are placed in vertical pattern placed against one cavity, wall, and part of floor and then
starting from one wall, i.e. buccal or lingual and carried to one diagonal cut is filled with composite and then cured.
another wall. Curing is initiated from behind the wall, i.e. This technique is followed till complete restoration is
if buccal increment is placed on the lingual wall, it is cured done. This sequence prevents resin from contacting two
from outside of the lingual wall. This technique reduces the opposite cavity walls thus reduces C-factor.
A B C D
Figs. 24.14A to D: Incremental layering technique. (A) Horizontal layering technique; (B) Vertical layering technique;
(C) Oblique layering technique; (D) Three-site technique.
A B
A
B
C D
Figs. 24.15A to D: Split increment horizontal technique: (A) First un-

cured horizontal increment of dentin shade; (B) Complete filling of one
diagonal cut; (C) One-half of three diagonal cut filled with composite
and cured; (D) Other half of cut is filled and cured.
Successive Cusp Build-up Technique (Figs. 24.16A to F)

Here, individual cusps are restored, each, by applying C
small sloping increments to each corner of the cavity, D
though it is time-consuming but reduces finishing time by
reconstructing the natural morphology.
Separate Dentin and Enamel Buildup
In this technique, sloping increments are applied to cavity
walls and cured till DEJ. In last, the final enamel layer is F
E
placed and cured.
Figs. 24.16A to F: Successive cusp build-up technique.
Centripetal Build-up Technique (Figs. 24.17A to F)
In this technique, a thin metal matrix band and wooden
wedges eliminate the need for transparent matrix bands.
A B C
D E F
Figs. 24.17A to F: Centripetal build-up technique: (A) Preoperative photograph; (b) Tooth preparation; (c) Selective etching of enamel;
(d) Application of bonding agent; (e) Centripetal composite build up from periphery towards the center; (F) Restoration of tooth.
(Courtesy: Jojo Kottoor).
Here, a very thin proximal layer is built up and cured ii. Plasma Arc Curing (PAC) Unit (Fig. 24.18B)
internally. This also reduces cervical gap formation, if gap
develops, the next consecutive layer which is packed toward In this, high frequency electrical field is generated using
gingival floor can fill gap. Once peripheral composite wall high voltage. This field ionizes the xenon gas into a mixture
is created, the cavity is managed as a simple class I cavity. of ions, electrons, and molecules, thereby releasing energy
in the form of plasma. Light guide helps in filtering the
II. Dual Shade Layering Technique
light to spectrum of visible light (450–500 nm) for peak
In this technique, opaque dentin shade is applied and
absorption of camphorquinone. PAC produces high
cured first. after this, enamel layers are applied on palatal,
proximal, and labial surfaces over the dentin shade. intensity light more than 1,800 mW/cm2 and curing cycle
in PAC is 6–9 seconds.
III. Polychromatic Layering Technique
It was proposed by Lorenzo Vanini. In this technique, Advantages Disadvantages
different shades of composite are used to replicate the • Short curing time due to • Expensive
layers seen in natural teeth. These layers are described high energy output • Device is of large size and heavy
as palatal enamel layer, dentin layer, opalescent, • Better polymerization • Heat production need to be
characterizations, etc. of composites when controlled
compared to QTH units • Filter and ventilating fans required
11. Polymerization Using Curing Lamps • Rapid polymerization can result in
polymerization shrinkage
(Figs. 24.18A to C)
Curing lamp is a handheld device which contains the iii. Light-emitting Diode Unit (Fig. 24.18C)
light source and has a rigid light guide made up of fused
optical fibers. Most commonly used light source is quartz Light-emitting diode (LED) unit emits powerful blue light.
bulb with a tungsten filament in a halogen environment. This light falls in narrow wavelength range of 440–480
Following four types of curing lamps are used: nm. This corresponds to range of camphorquinone
photoinitiator found in most of composite resins.
i. Tungsten-quartz Halogen Curing Unit (Fig. 24.18A)
Tungsten-quartz halogen (QHL) curing unit is
• Low power • Only suitable for camphorquinone-
conventional unit which consists of quartz bulb with
consumption based composites (because it has
tungsten filament. It uses visible light in the wavelength
• It does not require filter limited wavelength spectrum)
in the range of 410–500 nm. Halogen bulb has limited • Long life, i.e. 10,000 • Expensive
effective lifetime of around 100 hours. At the start of curing hours (approximately)
cycle, this light emits a low power density (400–900 mW/ • Minimal changes in light
cm2). It means there is lesser polymerization at the start output over time
of cycle and maximum polymerization at the end of cycle.
Advantages Disadvantages iv. Argon Laser Curing Unit

• Easy to install • Limited bulb life, i.e. 100 hours Argon laser light has wavelength of 490 nm which is
• Inexpensive • Intensity of bulb decreases with time monochromatic in nature. It produces intensity of 200–300
• Time-consuming
mW.
A B C
Figs. 24.18A to C: (A) Tungsten-quartz halogen curing unit; (B) Plasma arc curing (PAC); (C) Light-emitting diode.
Advantages Disadvantages in metal and plastic backing. In class III lesion to avoid
damage to contact area, strip should be used in S-shaped
• Polymerization is uniform, • May affect adjacent
not affected by distance restorations pattern. If it is placed on same side, it may cause opening
• Greater depth of curing can • Chances of damage to pulp of contact areas.
be achieved can occur due to rise in
• Small and portable temperature TOOTH PREPARATIONS for ANTERIOR
COMPOSITE RESTORATIONS
12. Final Contouring and Finishing
(Figs. 24.19A to F) 1. Class III Tooth Preparation
Final finishing and contouring can be done immediately Class III caries occurs on proximal surfaces of anterior teeth
after placement of restoration. For composite restorations, without involving the incisal edge. While approaching a
the amount of contouring required after final curing can class III lesion, direction for entry of bur is preferred from
be minimized by careful placement technique. Decreased lingual side because of the following reasons:
need of contouring of the cured composite ensures that i. Preservation of facial enamel for aesthetics
margins and surface of composite restoration remain ii. Color matching is not critical
sealed and free of microcracks that can be formed while iii. Unsupported facial enamel can be preserved for
contouring. 12, 16, or 30 fluted carbide burs are used for bonding with composite resin
gross finishing. Then, fine finishing diamond burs are used iv. Future discoloration of composite is less visible.
for final finishing. scalpel blade and carving instruments
Facial approach is indicated when:
are used to refine gingival margins and interproximal
◆◆ There is involvement of facial enamel
area. Since burs and disks can cause soft tissue damage in
◆◆ Malaligned teeth which make lingual approach difficult
gingival area, No. 12 scalpel blade can be used to remove
are present
gingival excess. Flexible disks with soft flexible backing
◆◆ Faulty old restoration placed facially requiring replace
are used to have smooth finished restoration. Rubber
ment.
finishing and polishing points impregnated with abrasive
points are also used for finishing. These points provide
access to grooves and irregularities of tooth surface thus
I. Conventional Class III Tooth Preparation
replicating the natural anatomy of tooth. Contact areas Indication: Conventional preparation is indicated for
are finished by using finishing strips which are available lesion present on the root surface.
A B C
D E F
Figs. 24.19A to F: Final contouring and finishing of a composite restoration.

Steps: Preparation is initiated using round carbide or Retention in conventional tooth preparation is attained
diamond bur of a size compatible to extent of lesion. by:
The point of entry is located within the incisogingival ◆◆ Roughening of the preparation surface
dimension of the lesion. Bur is directed perpendicular to ◆◆ Parallelism or convergence of opposing external walls
the enamel surface, and preparation is made, using light ◆◆ Giving retention grooves in axiogingival and axioincisal
pressure and intermittent cutting. Remove any remaining line angles
caries on the axial wall using spoon excavator or round bur. ◆◆ Grooves should be located at least 1 mm from tooth
If possible, outline form should not include (1) the surface and at least 0.5 mm deep into dentin.
entire proximal contact area, (2) extend onto the facial
surface, and (3) be extended subgingivally. Extensions II. Beveled Conventional Class III Tooth
should be minimal, including only the tooth structure that Preparation
is compromised by caries. The design of cavity should be
like a box-shaped pattern with definite external walls and Indications
90° cavosurface angle (Figs. 24.20A and B). ◆◆ For replacing an existing defective restoration on crown
portion of an anterior tooth.
◆◆ For large class III lesion (Figs. 24.21A to E).
Steps:
1. Approach carious area lingually with a no. 1/2, 1,
or 2 round bur and move the bur in incisogingival
direction.
2. Initial depth of axial wall should be 0.75 mm deep
gingivally and 1.25 mm deep incisally. This results in
the axial wall depth of 0.2 mm into the dentin.
3. Axial wall should follow contour of the tooth, i.e. shape
of axial wall should be convex outwardly.
4. Keep external walls of tooth preparation perpendicular
to the enamel surface with all enamel margins beveled.
A B
Prepare bevels using flat end tapering fissure diamond
Figs. 24.20A and B: Steps of conventional class III preparation: bur at cavosurface margins. bevel should be 0.2–0.5
(A) Caries on root surface; (B) Stepped floor in case of deep caries. mm wide at an angle of 45° to external tooth surface.
A B C
D E
Figs. 24.21A to E: Steps of beveled conventional class III tooth preparation: (A) Preoperative photograph; (b) Beveled tooth preparation;
(c) Band and wedge applied; (d) Composite build up; (e) Photograph showing restoration of the tooth.
(Courtesy: Jojo Kottoor).
5. Bevels are not given in areas of heavy occlusal stresses wall depth should be kept 0.5 mm into dentin. Bevels are
or cemental cavosurface margins. prepared at 45° to tooth surface with a width of 0.25–2 mm,
6. If required, prepare retentive grooves and coves along depending on amount of retention required. All internal
gingivoaxial line angle and incisoaxial line angles with angles should be rounded to avoid any stress concentration
the help of no. 1/4 or 1/2 round burs. depth of these points. Various modes of gaining retention are placing
grooves should be 0.2 mm into the dentin. grooves, coves, undercuts, flares, bevels, and pins.
III. Modified (Conservative) Class III Tooth III. Modified (Conservative) Tooth Preparation
Preparation Modified class IV preparation is done in small class
It is the most conservative type of tooth preparation used IV lesions or for treatment of small traumatic defects.
for composites. Preparation for modified class IV preparation should be
Indications: done conservatively without removing the normal tooth
◆◆ Small-to-moderate class III lesion. structure (Figs. 24.24 and 24.25).
◆◆ In this tooth preparation, basically infected carious area
is removed as conservatively as possible by “scooping” 3. Class V Tooth Preparation
out. This results in “scooped-out” or “concave” Class V cavities are found in gingival one-third of the
appearance of the preparation. facial and lingual tooth surfaces. Composites are material
Steps: of choice for restoration of class V lesions which are
1. Make initial entry through palatal surface with a small aesthetically prominent. Among composites, microfill
round bur. composites are material of choice because they provide
2. Design and extent of preparation is determined by better and smoother surface and have sufficient flexibility
extent of carious lesion. to resist stresses caused by cervical flexure, when tooth
3. Modified preparation does not have definite axial wall flexes under heavy occlusal forces.
depth and walls diverge externally from axial depth in a
scoop shape. I. Conventional Class V Tooth Preparation
4. Finally check the preparation after cleaning and provide
(Figs. 24.26 to 24.28)
pulp protection.
Indication: If caries is present on root surface.
2. Class IV Tooth Preparation Steps:
Class IV caries are smooth surface caries present on 1. In conventional class V tooth preparation, shape of the
proximal surfaces of anterior teeth involving the incisal preparation is “box” type. Use tapered fissure bur to
angle of the tooth. Traumatic injuries can also result in make entry at 45° angle to tooth surface initially. After
class IV defects which can be restored using composite this, keep long axis of bur perpendicular to the external
restorations. surface in order to get a cavosurface angle of 90°.
2. During initial tooth preparation, keep the axial depth
I. Conventional Class IV Tooth Preparation of 0.75 mm into the dentin. Move the bur mesially,
incisally, and gingivally for placing the preparation
Conventional type of class IV design is primarily indicated margins onto the sound tooth surface while main
in those areas that have margins on root surface and where taining a cavosurface margin of 90°.
restoration is to be placed in high stress-bearing area. 3. Axial wall should follow the contour of facial surface
Features of conventional class iv preparation for com- incisogingivally and mesiodistally.
posites: 4. If additional retention is required, place retention
◆◆ Box-like preparation with facial and lingual walls para grooves along the whole length of incisoaxial and
llel to long axis of tooth, and gingival floor perpendicular gingivoaxial line angles using a no. 1/4 or 1/2 round
to the long axis of the tooth. bur 0.25 mm deep into the dentin. At this stage, all the
◆◆ In deep caries, pulp protection is provided by calcium external walls appear outwardly divergent.
hydroxide liner and glass ionomer base.
◆◆ Retention is obtained by means of dovetail and grooves II. Beveled Conventional Tooth Preparation
placed gingivally and incisally in the axial wall using no.
Indications:
1/4 round bur.
1. For replacing defective existing restoration
II. Beveled Tooth Preparation (Figs. 24.22 and 2. For restoring a large, carious lesion.
Steps:
24.23) 1. Initial axial wall depth should be limited to only 0.25
Beveled preparation is indicated for treatment of a large mm into the dentin, when retention grooves are not
lesion or replacing old defective restoration. Initial axial placed and 0.5 mm when retention groove is placed.
A B C
D E
G H
Figs. 24.22A to H: Restoration of maxillary central incisor with class IV lesion: (A) Preoperative photograph; (B) Tooth preparation; (C) Application
of bonding agent after etching and rinsing; (D) Light curing; (E) Composite build-up; (F) Finishing and polishing of restoration; (G) Final restora-
tion; (H) Photograph of before and after restoration of tooth.
(Courtesy: Deepak Mehta)
2. When class V lesion extends onto the root surface, 2. Small enamel defects like decalcified and hypoplastic
gingival preparation has conventional design. areas present in cervical third of the teeth.
Bevel is given on the enamel margins 0.25–0.5 mm Technique: Tooth preparation should have “scooped-out”
wide at 45° to external surface. when class V lesion appearance with divergent walls and axial wall either in
extends onto the root surface, gingival preparation enamel or dentin.
has conventional class V design with initial axial
depth of 0.75 mm. Beveling is done only on enamel
TOOTH PREPARATION FOR POSTERIOR
cavosurface margins.
COMPOSITE RESTORATION
III. Modified (Conservative) Tooth Preparation Posterior composite restorations were introduced in the
Indications: late 1960s. due to improvements in physical properties of
1. Restoration of small and moderate carious lesions and composites and bonding systems, composites have been
defects. widely used as restorative material for posterior teeth. The
A B C
D E F
G H I
Figs. 24.23A to I: Steps of beveled tooth preparation: (A) Preoperative photograph showing defective composite restoration on maxillary central
incisors; (B) Beveled tooth preparation; (C) Application of etchant; (D) Bonding agent application; (E) Composite build-up; (F) Composite build-up
continues; (G) Final restoration; (H) Before restoration; (I) After restoration.
(Courtesy: Jojo Kottoor)
American Dental Association (ADA) indicates composites 7. Composites have adequate radiopacity to be seen in
for use as pit and fissure sealants, preventive resin resto the radiographs.
rations, and class I and II restorations for initial and mode 8. Since it does not contain metal, so no risk of galvanism.
rate-sized lesions, using modified conservative tooth
preparations. It also says that “when used correctly in the Disadvantages
primary and permanent teeth, the longevity of composite 1. Polymerization shrinkage can result in postoperative
restorations can be comparable to that of amalgam”. sensitivity and secondary caries.
Modifications in composites have led the increase in 2. More technique sensitive than amalgam.
demand for restoration of class I and II lesions. Listed below 3. Less resistance to wear especially the microfilled
are advantages, disadvantages, indications, and contra composites.
indications of direct posterior composite restorations. 4. Takes more time for placement.
5. Expensive in comparison to amalgam restoration.
Advantages
1. Good aesthetics.
Indications for Direct Posterior Composite
2. Conservation of tooth structure because of adhesive Restorations
tooth preparation. 1. Incipient lesions.
3. Low thermal conductivity of composites provides 2. Small-to-moderate sized lesions in posterior teeth.
insulation to thermal changes. 3. In premolars and first molars where aesthetics is the
4. Because of their micromechanical bonding, tooth main concern.
preparation is easier, simple, and less complex. 4. When moisture control of operating site is possible.
5. Economically cheap when compared to indirect 5. When tooth being restored does not experience
restorations and crown forms. occlusal stresses.
6. Because of adhesion to tooth, there is increased reten 6. In patient with low caries risk.
tion and strengthening of remaining tooth structure. 7. As a core foundation for full crown restoration.
A B C
D E F
G H I
J K L
Figs. 24.24A to L: Modified (conservative) preparation: (A) Preoperative photograph; (B) Wax up; (C) Making Index; (D) Putty index; (E) Isolation
using rubber dam; (F) Bevelled preparation; (G) Selective etch; (H) Bonding; (I) Putty and shell making; (J) Palatal shell making; (K) Build up using
layering technique; (L) Postoperative photograph (Courtesy: Priya Titus).
A B
Figs. 24.25A and B: Modified (conservative) preparation.
A B
Figs. 24.26A and B: Restoration of class V lesion maxillary lateral incisor and canine using composite resins.
B A
Figs. 24.27A and B: Restoration of class V lesion on maxillary anterior
teeth using direct composite restoration.
Contraindications for Direct Posterior

Composite Restorations
1. When it is difficult to achieve moisture control.
2. When large lesion is present extending onto the root
surface.
3. When restoration is subjected to high occlusal stresses.
4. When heavy contacts are present on the restoration.
5. In patients with high caries risk and poor oral hygiene.
6. In patients with parafunctional habits like clenching
and bruxism. B
Figs. 24.28A and B: Restoration of class V lesion on maxillary central
I. Pit and Fissure Sealants incisors using direct composite restoration.
Pits and fissures typically occur on occlusal surfaces of either preventive or therapeutic uses, depending on the
posterior teeth. They result from an incomplete coal patient’s caries risk, tooth morphology, or presence of
escence of enamel. These areas are susceptible sites of incipient enamel caries.
food impaction and thus easily prone to caries. They can i. Pits and fissures of permanent posterior teeth
be sealed with low-viscosity fluid resin sealants which immediately after eruption.
provide a safe and effective method of preventing caries. ii. In case of high caries risk patients.
iii. Incipient caries not extending to dentinoenamel
indications junction.
sealants should be used primarily for the prevention of Most currently used sealant materials are light-
caries rather than for the treatment of existing carious activated urethane dimethacrylate or Bis-GMA (bisphenol
lesions. Sealants are indicated, irrespective of age, for A-glycidyl methacrylate) resins.
Clinical Technique (Figs. 24.29A and B) II. Preventive Resin and Conservative
i. Isolate the tooth by using rubber dam (or another Composite Restorations (Figs. 24.30A
effective isolation method such as cotton rolls along and B)
with saliva ejector). If proper isolation cannot be When minimal carious pits and fissures on an otherwise
maintained, the bond of the sealant to the tooth healthy tooth are to be restored, an ultraconservative prep-
surface can be compromised, resulting in either loss aration design is recommended. In this, minimal removal
of the sealant or caries under the sealant. of tooth structure is done followed by use of composite or
ii. Slightly prepare the suspicious grooves with a thin sealant to seal radiating noncarious fissures which are at
flame-shaped diamond, fissurotomy bur, or 169L high risk for subsequent caries activity. This concept of
tapered fissure bur to lightly roughen the enamel, ultraconservative restoration is known as “conservative
remove the fluoride-rich enamel that is more resistant composite restoration” (given by Simonsen in 1978).
to acid-etching, and open the grooves and fissures for Earlier, it was referred as “preventive resin restorations”.
better resin penetration.
iii. Clean the area with a slurry of pumice on a bristle brush
and then rinse the tooth thoroughly. Bristles reach into
faulty areas better than a rubber prophy cup.
iv. Then after drying the tooth surface, apply 37% phos
phoric acid etchant for 15–30 seconds. Wash the
tooth thoroughly for 20 seconds and dry it. Properly
acid-etched enamel surface has a slight frosted
appearance.
A
v. Apply the sealant with an applicator or small hand
instrument. Using a probe, sealant is gently teased
into place; to avoid entrapping air, it should be
overfilled slightly, but it should not extend on to
unetched surfaces. If excess of sealant is applied, it can
be removed with a microbrush before polymerization.
Polymerize the sealant using curing light for 20 seconds.
vi. After light activation, remove the rubber dam.
(Fig. 24.29A and B).
vii. Check the occlusion by using articulating paper. a B
round carbide finishing bur or white stone is used to Figs. 24.30A and B: Preventive resin and conservative composite
remove any excess sealant. restorations.
Prepare the tooth ultraconservatively using pear-

shaped diamond point till caries are removed. Acid etch
the preparation and adjacent pits and fissures for 15–30
seconds, rinse thoroughly, and dry. Apply adhesive and
polymerize it using curing light. Restore the conservatively
prepared area using hybrid composite and cure it. Seal the
adjacent etched pits and fissures using a pit and fissure
sealant.
A III. Class I Tooth Preparation

1. Small-to-Moderate Class I Direct Composite
Restorations (Figs. 24.31 to 24.33)
Small-to-moderate class I direct composite restorations
use minimal tooth preparations and do not require
typical resistance and retention form features. In these
cases, preparation has scooped-out appearance extended
B only to extent of caries. Preparation is done using small
Figs. 24.29A and B: Photograph showing pit and fissure applied on round or elongated pear diamond bur without uniform
mandibular first molar. and flat pulpal or axial walls. The initial pulpal depth is
B
Figs. 24.33A and B: Moderate class I direct composite restorations.
Fig. 24.31: Small-to-moderate class I direct composite restorations.
Fig. 24.34: Schematic representation of class I tooth preparation for

composites.
strong tooth and restoration marginal configurations

so as to have resistance form in less conservative tooth
preparations. Since, composite is bonded to the tooth
structure, other less involved areas can be sealed as part of
the conservative preparation techniques. To prepare tooth
for large class I defect, pulpal floor is prepared to an initial
B
depth of 0.2 mm into dentin. The instrument is moved
Figs. 24.32A and B: Moderate class I direct composite restorations. mesially, distally, facially, and lingually as dictated by the
caries, keeping the pulpal floor moderately flat.
approximately 0.2 mm inside the DEJ but may not be
After extending the outline form to sound tooth
uniform (Fig. 24.34).
structure, if any caries or old restorative material remains
Figures 24.35A to K showing restoration of class I caries
on the pulpal floor, it should be removed with the
using composite restoration.
appropriately-sized round bur or hand instrument. The
occlusal margin is left as prepared. No attempt is made
2. Moderate-to-large Class I Direct Composite
to place additional beveling on the occlusal margin
Restorations (Figs. 24.36 and 24.37) because it may result in thin composite in areas of heavy
Tooth preparation for moderate-to-large class I preparation occlusal contact. Because of the occlusal surface enamel
have flat floor perpendicular to occlusal forces, along with rod direction, the ends of the enamel rods already are
A B C D E F
G H I J K
Figs. 24.35A to K: Steps of class I cavity preparation and restoration using composite: (A) Preoperative photograph; (B) Isolation of teeth;
(C) Tooth preparation; (D) Application of etchant; (E) Application of bonding agent; (F to J) Composite build-up; (K) Final restoration.
(Courtesy: Priya Titus)
A B C
Figs. 24.36A to C: Moderate class I direct composite restorations.
exposed by the preparation, which further reduces the ◆◆ Use No. 330 or 245 pear-shaped bur kept parallel to long
need for occlusal bevels. axis of the tooth to start preparation in a pit opposite to
Other fundamentals of tooth preparation are similar to the affected proximal side.
that of amalgam except for following differences: ◆◆ Keep the outline as conservative as possible. Maintain
◆◆ Faciolingual dimensions of preparation are kept as the depth of pulpal floor 1.5 mm from central groove
small as possible (one-fifth of intercuspal distance). area. Make the occlusal walls converging and occlusal
◆◆ No need to prepare dovetail or other retention features. cavosurface obtuse.
◆◆ For proximal box preparation, extend the occlusal
IV. Class Ii Tooth Preparation preparation using straight fissure bur into marginal
◆◆ Prepare occlusal part similar to class I (Fig. 24.38A) but ridge. Keep bur perpendicular to the pulpal floor.
the proximal box preparation depends upon extent of ◆◆ Thin out the marginal ridge and deepen the preparation
caries, contour of proximal surface, and masticatory toward the gingival direction as to give proximal ditch
stresses. cut. This will form the width of 1.0–1.5 mm (Fig. 24.38B).
A B
C
Figs. 24.37A to C: Large class I direct composite restorations.
(Courtesy: Roma Turetskyi)
◆◆ For small carious lesion, proximal walls can be left in ◆◆ Final conventional tooth preparation for composite
the contact but for large carious lesion, contact area is is more conservative than for traditional amalgam
broken. restoration (Fig. 24.38C).
◆◆ Keep gingival floor flat with butt joint cavosurface angle.
Whether or not to give gingival beveling, depends on Modifications
location and the width of gingival seat. If gingival seat 1. Saucer Shaped or Scooped-out Preparation
is supragingival and above cementoenamel junction,
When minimal caries is present, saucer-shaped class II
beveling can be done but if gingival seat is close to preparation is done. Here, preparation is deepened only
cementoenamel junction, beveling is avoided so as to to the extent where caries is present. The scooped-out
preserve the enamel present in this area. preparation does not have uniform depth (Fig. 24.39).
A B C
Figs. 24.38A to C: (A) Occlusal preparation; (B) Proximal ditch out; (C) Conventional tooth preparation in case of
amalgam (purple) and composite (red) restoration.
Fig. 24.39: Saucer shaped or scooped-out preparation.
2. Box-like Preparation Fig. 24.41: Slot preparation.
When caries are present only on proximal surface, box

◆◆ Gingival floors should clear the contact apically and
only preparation is indicated. In this, proximal box is
they should be butt joined.
prepared without the need of secondary retention features
(Fig. 24.40). Figures 24.42 and 24.43 showing class II composite
restorations.
Table 24.4 summarizes the differences in tooth
preparation for amalgam and composite restoration.
Stamp technique of restoration

(Figs. 24.44 and 24.45)
“Stamp technique” is practiced for direct composite resin
restorations to achieve the precise occlusal anatomy. It
consists of fabricating an occlusal matrix to duplicate
the occlusal anatomy of posterior teeth before tooth
preparation takes place. Stamp is like an index, which is the
mini impression made by placing flowable composite resin
Fig. 24.40: Box-like preparation in case of proximal caries not on intact occlusal surface after application of separation
involving the occlusal surface. agent on unprepared tooth. Tip of microbrush is used as
handle and immersed into the composite. This is cured
3. Slot Preparation and removed from tooth surface. This stamp replicates the
original anatomy of the tooth structure by virtue of copying
When proximal caries can be approached from facial or the original unprepared tooth structure. The advantages
lingual side, slot preparation is indicated (Fig. 24.41). In of using stamp are the reproduction of original occlusal
this, bur is kept perpendicular to long axis of the tooth and anatomy and occlusion, minimal requirement of finishing
entry to lesion is made through facial or lingual surface. and polishing, and minimal voids at the occlusal anatomy.
Here, preparation has cavosurface angle of 90°.
Features of Class Ii Composite Tooth Preparation: FAILURES of composite restorations
◆◆ Tooth preparation for class II has decreased pulpal Composite restorations may show failure because of:
depth of axial wall which allows greater conservation of ◆◆ Incomplete removal of carious lesion.
tooth structures. ◆◆ Incomplete etching or incomplete removal of residual
◆◆ Occlusal and proximal walls converge occlusally and acid from tooth surface.
provide additional retention form. ◆◆ Excess or deficient application of bonding agent.
◆◆ Proximal box preparation has cavosurface angle at right ◆◆ Lack of moisture control.
angles to the enamel surface facially and lingually. ◆◆ Contamination of composite with finger/saliva.
◆◆ Bevels on occlusal surface are optional due to direction ◆◆ Following bulk placement technique during
of enamel rods whereas on proximal surface, beveling polymerization of composite.
must be done prudently. ◆◆ Improper polymerization method.
A B C
D E
Figs. 24.42A to E: Class II composite preparation not involving the occlusal surface.
Table 24.4: Differences in tooth preparation for amalgam and composite restoration.
Features Amalgam Composite
Outline form • Includes all pits and fissures and adjacent suspicious areas • Includes faults but need not to be
• For class II tooth preparation, proximal contact has to be extended to adjacent pits and fissures
broken
• For class II tooth preparations, proximal contact need not to
be broken in all the cases
Pulpal depth • Should be maintained uniform • Need not be uniform
• Depth—1.5 mm (minimum) • Depth—1–2 mm (usually)
Axial depth • Should be uniform • Not necessarily uniform
• Depth—0.2–0.5 mm inside DEJ • Depth—to extent of the defect
Cavosurface margin 90° at margin Equal to and greater than 90° at margin
Nature of prepared walls Smooth Rough
Primary retention form Occlusal convergence Etching, priming, and bonding
Bevels Not indicated in large preparations Bevels indicated
Resistance form • Box-shaped preparation • Not indicated
• Flat pulpal and gingival floor • For small-to-moderate preparations
Secondary retention Grooves, coves, slots, pins, locks, and bonding Indicated only for extensive preparations
Pulp protection and base • By use of varnish, liner Varnish not indicated
• Base: GIC, calcium hydroxide liner
◆◆ Incomplete finishing and polishing of composites. ◆◆ Secondary caries (Fig. 24.47A)

◆◆ Inadequate occlusion of restored tooth. ◆◆ Postoperative sensitivity
Following failures are commonly seen in composite ◆◆ Gross fracture of restoration
restorations (Fig. 24.46): ◆◆ Loss of contact after a period of time
◆◆ Discoloration, especially at the margins (Fig. 24.47B) ◆◆ Accumulation of plaque around the restorations.
◆◆ Fracture of margins (Fig. 24.47C)
A B
C D
E F
G
Figs. 24.43A to G: Management of class II tooth preparations using direct resin restorations.
A B C
D E
Figs. 24.44A to E: Stamp technique.
A B C
D E F
G H I
Figs. 24.45A to J: Stamp technique of restoration: (A) Preoperative photograph; (B) Liquidam; (C) Application of vaseline; (D) Application of
liquidam; (E) Applicator tip attached to liquidam and cured; (F) Stamp prepared; (G) Tooth preparation; (H) Placement of composite on prepared
tooth; (I) Placement of Teflon tape and stamp; (J) After removal of stamp and polymerization.
Fig. 24.46: Schematic representation of different failures of composite restorations.

A B C D
Figs. 24.47A to D: (A) Secondary caries; (B) Discoloration of margins; (C) Fracture of margins;
(D) Secondary caries and fracture of restoration.
Marginal Defects in Composite Restorations preparation. After this, place a matrix and wedge and etch
the enamel margins. Apply primer and bonding agent and
Marginal defects in composites can occur in the following finally place composite. Cure it and do the final finishing
forms: and polishing.
◆◆ Surface fracture of excess material
◆◆ Voids in restoration because of air entrapment during
placement
Guidelines to Minimize Chances of Composite
◆◆ Composite wear resulting in progressive exposure of Failure
axially-directed wall ◆◆ Tooth preparation should be kept as small as possible
◆◆ Gap formation. since composite in bulk leads to failure.
◆◆ Avoid sharp internal line angles in tooth preparation.
Glazing/Rebonding (Fig. 24.47D) ◆◆ Deeper preparations should be given base of calcium
hydroxide or glass ionomer cement.
Surface smoothness and shine of a composite restoration
◆◆ Strict isolation regimen is to be followed.
can be increased by “glazing”. Glazing/rebonding is the
◆◆ Avoid inadequate curing, because it leads to hydrolytic
process of placing a thin layer of unfilled resin over the
breakdown of composites.
finished composite resin.
◆◆ Use small increments, holding each increment with
Purposes of Glazing/Rebonding Teflon-coated instruments.
◆◆ Fill proximal box separately and create proper contact
◆◆ Improves aesthetics. areas.
◆◆ Seals microcracks produced during finishing and ◆◆ Composite, especially at beveled areas, should be
polishing of restoration. finished and polished properly.
◆◆ Creates a smooth glossy surface, resistant to plaque
retention.
◆◆ Improves marginal seal.
INDIRECT resin composite
◆◆ Reduces surface wear of composite. Dental resin composites were introduced initially as
anterior restorative materials. Later, with developments
Steps of newer techniques, material modifications and nano
◆◆ Etch the surface of composite restoration using low technology, direct composite restorations became mate
concentration of hydrofluoric acid. rial of choice for posterior teeth as well. Newest direct
◆◆ Wash and dry the surface. composite resins have excellent optical and mechanical
◆◆ Apply bonding agent and cure it. properties, and their use in larger posterior restorations
is still a question due to problems associated with them,
which led to development of indirect resin composite
REPAIR OF COMPOSITE RESTORATIONS
restorations.
When the area to a defective restoration is accessible, for Indirect composites are also referred as prosthetic
repair, the old restoration is roughened with a diamond composites or laboratory composites. Following
stone and the enamel margins are etched. After this, shortcomings of direct resin composites lead to need of
primer and adhesive are applied and finally composite indirect resin composite restorations:
is placed, finished, and polished. In case, when the 1. Incomplete polymerization: Degree of conversion
defective restoration is in area which is difficult to access, in direct composites is 55–65% which can lead to
the defective restoration should be exposed by tooth polymerization shrinkage.
2. Polymerization shrinkage: It can cause gap formation shrinkage and wear seen with direct composite
between tooth and restoration interface resulting in restorations. But these also had poor physical properties
microleakage, discoloration, and secondary caries, because of low filler and high matrix load. They include
etc. SR-Isosit system, Coltene and Kulzer system.
3. Depth of cure: It is difficult to cure if depth of cure is
greater than 4 mm.
4. Inability to achieve optimal contacts and contours. • Improved aesthetics • Low modulus of elasticity
• Improved anatomy and • Low resistance to wear
5. Excessive wear in stress-bearing areas. interproximal contact abrasion
• Chair side repair • Low flexural strength
Classification of Indirect Composites • Ease of fabrication • Fracture of restoration and
debonding because of poor
1. Classification Based on Method of Fabrication bonding between restoration
and the cement
i. Direct-indirect/Semi-indirect Method
In this, after making preparation, a suitable separating ii. Second generation
media and matrix system is applied on the tooth for easy They were introduced in mid 1990s to overcome the
removal of the inlay after the initial intraoral curing. disadvantage of first-generation indirect restorations. Here,
The composite material is condensed into the cavity. improvements were done in structure and composition,
The restoration is then exposed to extraoral light or heat polymerization technique, and fiber reinforcement.
tempering in an oven (for example, DI-500 Oven from a. Structure and composition: The second-generation
Coltene Whaledent at 110°C for 7 minutes). composites have “microhybrid” filler which is twice
that of the organic matrix. this increase in filler load
ii. Indirect improved both mechanical properties and wear
In this, after the separating medium is applied to the resistance, and reduced poly merization shrinkage.
die, composite material is packed in increments into the Examples are Artglass®, BelleGlass HP®, and Solidex®.
cavity and light cured for 40 seconds for each surface. b. Polymerization techniques: Even extraoral curing
Restoration is then removed and heat cured in an oven at did not result in optimum polymerization; therefore
100°C for 15 minutes. Examples of indirect materials are following special conditions like heat, vacuum,
SR-Isosit®, Clearfil CR Inlay®, Conquest®, Dentacolor®, pressure, and oxygen-free environment are employed
and Visio-Gem®. for polymerization of 2nd-generation indirect
composites:
• Heat polymerization: in this, temperature
2. Classification Based on Method of Curing of 120–140°C is used for polymerization. This
i. Conventional Cured temperature is above the composite’s glass
transition temperature (Tg) which increases the
In this technique, curing is done on a die of prepared tooth polymer chain mobility, and thus additional cross-
by the use of one method only, for example, light curing. linking. Postcure heating of composite decreases
amount of unreacted monomer after initial light
ii. Secondary Cured curing by bonding of residual monomer to polymer
In this technique, curing is done in two cycles. Initial network resulting in more polymerization and
curing is done at room temperature using light followed by evaporation of unreacted monomers during
additional curing using heat and light. heating process. Example of this type is Charisma®.
• Nitrogen atmosphere: Oxygen present in air
iii. Superficial Cured tends to inhibit polymerization. Nitrogen atmos
phere removes internal oxygen before composite
In this technique, curing is done in one step only. Curing begins to polymerize. This causes improved
is done under very high temperature and pressure in one polymerization, aesthetics, wear resistance, and
stage rather than light cure. abrasion. Examples of composites cured by this
method are BelleGlass HP® and Sculpture Plus®.
3. Classification Based on Evolution • Soft start or slow curing: In this, composite is
cured at slower rate for better polymerization and
i. First generation
to reduce residual stresses. BelleGlass HP® and
First generation of indirect restorations was composite Cristobal® are cured by this method.
based, introduced in early 1980. These materials were • Electron beam irradiation: In this method,
developed in an attempt to overcome polymerization polymers like polyethylene, polycarbonate,
or polysulfone are subjected to electron beam

irradiation. This result in chain breakage and chain
linkage reactions causing dense packing and thus
improving the mechanical properties.
• Fiber reinforcement: Smith introduced fiber-
reinforced composites in 1960s. Fibers stop the
crack propagation and improve the properties of
composites. The fibers can run in one direction
(unidirectional) or parallel to each other/or in mesh-
type architecture (Fig. 24.48). Fiber reinforcement
improves flexural strength, modulus of elasticity and
fracture toughness, and decreases polymerization
shrinkage of resin composites. Fig. 24.48: Orientation of fibers in fiber-reinforced composites.
Second-generation indirect resin composites

S. No. Name Composition Polymerization Clinical significance
1. ® • Filler 70% (barium silicate of Photocured in special unit using Used for fabrication of inlays,
Artglass (1995 by
Kulzer) 0.7 µ size) xenon stroboscopic light emitting onlays, veneers, and crowns
• Matrix 30% (organic resin) high intensity for 20 milliseconds
followed by darkness for 80
milliseconds. This nonexposure
time allows cured composite to
relax and make availability of
carbon groups for reaction
2. Targis (1996 by Filler 77% (barium glass Targis is coated with glycerin gel Targis is used to fabricate inlays,
Ivoclar Vivadent) particles of 1 µ size), spheroid to prevent formation of oxygen onlays, veneers, and anterior
silica (–0.25 µ), and colloidal inhibited surface layer and placed crowns
silica (–0.015 to –0.05 µ) in curing unit with cycle as:
Light emission for first 10 minutes,
with increase of temperature to
95% for 25 minutes, and then
cooling for 5 minutes
3. BelleGlass HP® • Base and surface composites Base composite is placed and Small filler size offers good
(1996 by Belle de St. −− Base composite has filler cured with conventional light polishability and smoothness
Claire) 78% (barium glass fillers of cure. Surface composite is heat
0.6 µ size) cured in oven at 140°C at 80 psi
−− Surface composite has for 20 minutes under nitrogen gas
75% filler (borosilicate) pressure
• Resin matrix of dentin has
bis-GMA
• Resin matrix of enamel is a
combination of hydrocarbon
saturated methacrylate
diurethane of TEGDMA and
dimethacrylate
4. Sculpture Plus® by • Filler silanated barium Sculpture curing light is automatic Restoration is fluorescent, color
Pentron borosilicate glass, zirconia light curing under pressure in stable with high flexural strength
silicate, nanoparticulated nitrogen atmosphere. Two curing
silica cycles are buildup cycle and final
• Matrix-difunctional cycle when restoration is done
methacrylates of GMA,
Bis-GMA, UDMA, and HDDMA
5. Solidex® • Filler 53% (silicon dioxide and Additional polymerization is done —
(Introduced by aluminium oxide and ceramic in soliditite system with 4 halogen
Shofu) microfilaments) lamps for fast curing in 1–5 minutes
• Matrix 25% (multifunctional
resin)
• 22% conventional resin
Contd…
Contd…
S. No. Name Composition Polymerization Clinical significance

6. Paradigm MZ 100 • Filler 85% ultrafine zirconia Made from Z100 resin under Substitute for CEREC restorations.
by 3 M ESPE silica ceramic particles optimum process conditions so as Ultrafine zirconia silica filler offers
• Matrix consists of Bis-GMA to have optimum polymerization. optimum properties
and TEGDMA and tertiary Paradigm MZ100 blocks are made
initiator system in cylindrical sizes equal to CEREC
sizes
7. Vita Zeta® LC by • Filler 45% Feldspar frits and Additional light curing done at Used for veneers and crowns
Vita Zahnfabrik silicon dioxide 40°C at wavelength of 350–500 nm
• Matrix—Bis-GMA, TEGDMA,
and UDMA
8. Gradia® (GC • Filler—silica powder, Secondary light cure with alpha II —
Corporation) silicate glass powder, for 5 minutes
prepolymerized filler (75%)
• Matrix—UDMA
9. Estenia C and B • Filler—alumina ultrafine filler, Secondary light cure with alpha II —
(Kuraray) glass filler 92% for 5 minutes
• Matrix—UDMA Secondary heat cure—KL 100 at
110°C for 15 minutes
Differences between direct and indirect resin composites

Direct resin Indirect resin
Properties composite composite
Polymerization More Less
shrinkage
Microleakage More Less
around margins A B
Residual stresses More Less Figs. 24.49A and B: Tooth preparation for composite
after curing inlays and onlays.
Wear resistance Less More
Color stability Less More
form should result in smooth curves surrounding the
cusps.
Reproduction Difficult Can be achieved
◆◆ To facilitate passive seating of the inlay, facial and
of contacts and
contours lingual walls should have 6–8° of divergence.
◆◆ Areas to be restored using inlay or onlay need 1.5 mm of
Tensile strength 70–80 N/mm2 90–120 N/mm2
clearance in all excursions to prevent fracture.
Modulus of elasticity 4,000–5,500 N/mm2 7,000–10,000 N/mm2 ◆◆ Extend the proximal box to allow a minimum of 0.5–1
Vickers hardness 360–410 N/mm2 500–600 N/mm2 mm of proximal clearance for proper finish of these
number margins and impression making.
◆◆ Use butt joint for all cavosurface margins. Bevels are
Tooth Preparation for Composite contraindicated because bulk is needed to prevent
Inlays and Onlays fracture.
◆◆ Any undercut, if present, should be removed or blocked
Give local anesthesia and isolate the tooth using rubber by glass ionomer lining. Margin of restoration should be
dam for visibility and moisture control. Before applying kept supragingival, which will make isolation during the
the rubber dam, mark and assess the occlusal contact cementation easier and improve access for finishing.
relationship with articulating paper (Figs. 24.49A and B). ◆◆ For pulp protection, place a resin-modified glass
ionomer cement base if indicated.
i. Outline Form ◆◆ Check the final tooth preparation after the removal
of rubber dam. There should be 1.5 mm clearance to
◆◆ Outline form is usually guarded by the existing resto
prevent fracture in all excursions.
rations and caries. It is grossly similar to that for
cast metal inlays and onlays except that there are no
ii. Impression Making
bevels or secondary flares. For the creation of round
internal angles, use tapered fissure bur with round tip. An accurate elastomeric impression is taken to form a replica
Hold the bur parallel to long axis of the tooth. Outline of the tooth, onto which composite restoration is made.
iii. Die Fabrication and Composite Buildup Intraoral finishing and polishing Intraoral finishing and polishing
is easier is time-consuming
Die is fabricated. Before placing composite, apply
Easier adjustment and seating Fragile and brittle, so prone to
separating media and building composite on it. Composite fracture while seating
is initially light cured for one minute on each surface. Not abrasive to opposing Abrasive to opposing enamel
Successive layers are added and polymerized till full enamel
contour is built. Final curing of restoration is achieved by Intraoral repair is possible Intraoral repair is not possible
placing the restoration into curing oven at 100°C for 15
minutes. Then, allow it to cool and do final trimming and
finishing on die.
iv. Try in and Cementation

1. Once the inlay is fabricated, try it on the tooth under a
dental dam isolation to avoid any gingival and salivary
contamination.
2. Do pumice prophylaxis to remove any surface deposits.
3. Etch the prepared tooth surface using phosphoric acid
for 15 seconds and wash and dry it. Apply two thin
coats of bonding agents and light cure it. The chemical
treatment of the tooth surface allows an adhesion of
the composite by microlocking in the enamel and the
hybrid layer in the dentin by tangling between the
adhesive system.
4. Etch the internal surface of inlay/onlay with Fig. 24.50: Indirect resin composite inlay restoration.
sandblasting with 50 µm aluminium oxide using an
intraoral sandblasting device. Conclusion
5. Apply silane coupling agent on etched surface of
restoration. Patient’s demands for aesthetics, evolution in composite
6. Apply dual cure adhesive resin onto the fitting surface resin as a material, manipulation, nanotechnology,
of restoration and in the preparation. position the curing techniques, etc. have made the composite resin
restoration onto the prepared tooth. material as a material of choice for anterior as well as
7. Remove excess of cement before polymerization posterior teeth. Due to availability of wide range of
using dental probe and light cure the resin cement for colors, shades, translucencies, viscosities, and tones, the
90 seconds. present composite materials have enabled to provide
the restoration that mimics the natural tooth structure in
form, function, and aesthetics. Further research is always
v. Final finishing being carried onto reduce or eliminate the drawbacks of
1. finish the occlusal margins with 12 fluted pear- composite resin materials.
shaped bur.
2. finish the interproximal margins with 12 fluted flame- EXAMINER’S CHOICE QUESTIONs
shaped bur and No. 12 scalpel blade.
3. Smoothen the restoration and polish it using 1. Effect of ‘C’ factor on finishing and polishing compo
composite finishing kit. sites.
Table 24.5 summarizes various differences between 2. What are the various types of abrasive use?
ceramic and composite inlays. 3. Diamond polishing paste consist of:
Figures 24.50 to 24.52 showing indirect resin composite 4. Indication of using burs, discs and strips for finishing
inlay restorations. and polishing.
5. Factors affecting polymerizing shrinkage.
Table 24.5: Differences between composite and ceramic inlays. 6. Difference between incremental and bulk fill tech-
Composite inlays Ceramic inlays nique.
Good aesthetics Excellent aesthetics 7. Depth cure for bulk fill and incremental technique.
May stain with time Does not stain
8. Recent concept of giving bevel in composite.
Relatively less expensive than Expensive
9. Disadvantages of indirect over direct composite.
ceramic 10. What are advantages of polymer over monomer?
Simple laboratory steps Complex laboratory steps 11. Can we use bulk filling in indirect composite?
A B
C D
Figs. 24.51A to D: Management of carious 1st molar with indirect composite inlay.
(Courtesy: Mohan Bhuvaneswaran)
20. In fluorosed teeth what is the effect of time on acid

etching.
21. Difference between total etch and self-etch.
22. Why we do not give bevel in large Class I or Class II
composite restorations?
Viva questions
1. Define the word composite.
2. What are the most commonly used fillers in
composites?
A B 3. What are the advantages of fillers in composites?
Figs. 24.52A and B: (A) Preoperative and postoperative photograph 4. What is the function of coupling agent in composites?
of composite inlay restoration; (B) X-ray after inlay restoration. 5. Which is the most common photoinitiator in
composite?
6. Which is the inhibitor used in composite?
12. Curing phenomenon of bulk filling composite.
7. Which is UV absorber in composite?
13. What is priming? How do we do priming?
8. What are the differences between chemically cured
14. How is priming different from condensing? and light cured composites?
15. What is the thickness of bonding agent? 9. What are recent advances in composites?
16. At night time, how do we do shade selection? 10. What are indications and contraindications of
17. Why do we give bevel in composite? flowable composite resin?
18. Concentration of etchant in self-etch. 11. What are different theories of composite wear?
19. Difference in etching time for permanent and primary 12. What are the most common disadvantages of compo
teeth. site resin?
13. What are antibacterial composites? 2. Bausch JR, de Lange K, Davidson CL, et al. Clinical significance
14. How can we minimize polymerization shrinkage in of polymerization shrinkage of composite resins. J Prosthet
composite? Dent. 1982;48(1):59-67.
3. Bayne SC, Heymann HO, Swift EJ. Update on dental composite
15. What is configuration or C-factor?
restorations. J Am Dent Assoc. 1994;125(6):687-701.
16. What is value of C-factor for different cavity prepara 4. Bryant RW. Direct posterior composite resin restorations: a
tions (Class I to Class V)? review. 2. Clinical technique. Aust Dent J. 1992;37(3):161-71.
17. What are indications or contraindications of compo 5. Bryant RW. Posterior composite resin restorations—a review of
site resin? clinical problems. Aust Prosthodont J. 1987;1:41-50.
18. What are guidelines for initial shade selection in 6. Burke FJ, Watts DC, Wilson NH, et al. Current status and rationale
composites? for composite inlays and onlays. Br Dent J. 1991;170(7):269-73.
7. Leinfelder KF. Indirect posterior composite resins. Compend
19. What are different designs of tooth preparation for
Contin Educ Dent. 2005;26(7):495-503.
composite? 8. Mazer RB, Leinfelder KF. Clinical evaluation of a posterior
20. What are the reasons for failure of composite composite resin containing a new type of filler particle. J Esthet
restorations? Dent. 1988;1(1):66-70.
21. What are the advantages of bevel in composite? 9. McCune RJ, Cvar JF, Ryge G. Clinical comparison of anterior
and posterior restorative materials (Abstract No. 482). Int Assoc
Dent Res. 1969;2(3):161.
BIBLIOGRAPHY 10. Nandini S. Indirect resin composites. J Conserv Dent. 2010;13(4):
1. Baratieri LN, Monteiro Júnior S, Correa M, et al. Posterior resin 184-94.
composite restorations: a new technique. Quintessence Int. 11. Peutzfeldt A. Indirect resin and ceramic systems. Oper Dent.
1996;27(11):733-8. 2001;200(3):1153-76.
Chapter
25
Smile Designing in Operative Dentistry
Chapter Outline
Introduction Soft Tissue Component of Smile Design

Elements of Dental Aesthetics Aesthetics and Operative Dentistry
Facial Composition Veneers
Dental Composition Repair of Veneers
Hard Tissue Components of Smile Design
INTRODUCTION periodontal therapy, cosmetic dentistry, and plastic

surgery. Thus, aesthetic approach to patient care produces
Aesthetic means pertaining to sense of being beautiful. the best dental and facial beauty. Facial analysis should be
Importance of beautiful smile has been known since ages. done at conversational distance.
Smile reflects an individual’s capacity to express a range of
feelings with structure and function of teeth and lips and Face is examined from two views, i.e.
patient’s confidence in social life. Modern dentistry is not 1. Frontal view
limited to just repair of teeth. Dental practice in the field 2. Profile view
of aesthetic dentistry has been growing since last many
years. Goal of aesthetic makeover is to develop a peaceful 1. Frontal View
and stable masticatory system, where the teeth, tissues, In this, following lines are examined (Fig. 25.1):
muscles, skeletal structures, and joints all function in
harmony. To attain a successful, healthy, and functional
result requires an understanding of the interrelationship
among all the supporting oral structures, including the
muscles, bones, joints, gingival tissues, and occlusion.
Elements of dental AESTHETICS

To achieve a harmonizing aesthetic smile, a perfect
combination of facial composition and dental composition
is desired. The facial composition includes the hard and
soft tissues of the face. The dental composition includes
teeth and their relationship to gingival tissues.
Facial Composition
Facial beauty is based on standard aesthetic principles
that involve proper alignment, symmetry, and propor-
tion of face. Analyzing, evaluating, and treatment plan-
ning for facial aesthetics often involves a multidiscipli-
nary approach like orthodontics, orthognathic surgery, Fig. 25.1: Facial analysis—frontal view.
i. Interpupillary Line 2. Profile View

It is the line passing through center of pupil of eye. The i. Evaluation of Rickett’s Plane
interpupillary line should be perpendicular to the midline An imaginary line drawn from tip of nose to the tip of chin
of the face and parallel to the occlusal plane and if any (Fig. 25.3).
discrepancy exists, it is corrected before starting any dental Normal upper lip is 4 mm from E-plane. Lower lip is 2
alteration. mm from E-plane.
If the patient’s profile appears very convex, the lips are
ii. Commissural Line on or anterior to the “E” plane, one should be careful to not
It is the line passing through corner of the mouth when make the anterior teeth too large or too white, as the teeth
upper and lower lips meet. Maxillary incisal edges run in this profile already dominate the smile
parallel to the interpupillary and commissural lines. For concave profiles, where the lips are well behind
the “E” plane, it is recommended to increase the anterior
iii. Facial Midline tooth size both in length and facial prominence.
It passes through the glabella, tip of the nose, center of ii. Nasolabial Angle
philtrum, center of cuspids, and center of chin.
Face can be classified as horizontal and vertical as Nasolabial angle is the angle that forms between
following: perpendicular line from top of the philtrum and line from
bottom of the columella (Figs. 25.4A and B).
1. Vertical Normal values of nasolabial angle for men ranges from
90° to 95° and for women, it ranges between 100° and 105°.
The facial height is divided into three equal parts from the
forehead to the eyebrow line, from the eyebrow line to the
base of the nose and from the base of the nose to the base
of the chin (Fig. 25.2A). The lower part of the face from
the base of the nose to the chin is further divided into two
parts, the upper lip forms one-third of it and the lower lip
and the chin two-thirds of it.
2. Horizontal
The width of the face should be equal to the width of five
“eyes”. The distance between the eyebrow and chin should
be equal to the width of the face (Fig. 25.2B).
The basic shape of the face when viewed from the
frontal aspect can be one of the following:
a. Square
b. Tapering Fig. 25.3: Rickett’s line is an imaginary line drawn from tip of nose to the
c. Square tapering tip of chin. Generally, upper lip is 4 mm and lower lip is 2 mm from E-plane.
d. Ovoid
A B
Figs. 25.4A and B: Nasolabial angle is angle formed between

perpendicular line from top of the philtrum and line from bottom of
A B the collumella. For men, it ranges from 90-95° and for women, it ranges
Figs. 25.2A and B: Vertical and horizontal face profile. from 100–105°.
Smile Designing in Operative Dentistry 331
The lateral profile of an individual can be any one of the
following:
a. Straight
b. Convex
c. Concave
These factors play a role in determining the tooth
size, shape, and the lateral profile; in short, the tooth
morphology is dependent on the facial morphology.
Dental Composition
Vital elements of smile designing (Fig. 25.5)
Hard tissue components Soft tissue components
1. Dental midline 1. Gingival health
2. Incisal lengths 2. Gingival levels and harmony
3. Tooth dimensions 3. Cervical embrasure
4. Zenith points 4. Smile line Fig. 25.6: Deviation of mandibular midline in
5. Axial inclinations comparison to facial midline.
6. Interdental contact area (ICA)
and point (ICP) i. Maxillary and mandibular midline coincides with the
7. Incisal embrasure facial midline.
8. Symmetry and balance ii. Maxillary midline is deviated towards right and left as
compared to facial midline.
HARD TISSUE COMPONENTS OF SMILE DESIGN iii. Mandibular midline is deviated towards right and left
as compared to facial midline (Fig. 25.6).
1. Dental Midline Minor discrepancies between facial and dental midlines
The midline refers to the vertical contact interface between are acceptable and sometimes not even noticeable. The
two maxillary centrals. It should be perpendicular to the maximum allowed discrepancy can be 2 mm and in some
incisal plane and parallel to the midline of the face (Fig. cases even more than 2 mm discrepancy is aesthetically
25.5). The philtrum of the lip is one of the most accurate of acceptable if dental midline is perpendicular to the inter-
these anatomical guide posts. The center of the philtrum pupillary line. Maxillary and mandibular midlines do not
is the center of the cupid’s bow and it should match the coincide in 75% of cases. Discrepancy between maxillary
papilla between the centrals. If these two structures match and mandibular midline does not affect aesthetics because
and the midline is incorrect, then the problem is usually mandibular teeth are not usually visible while smiling.
incisal inclination. If the papilla and philtrum do not
match, then the problem is a true midline deviation. 2. Incisal Lengths/Incisal Edge Positions
When dental midline is compared with facial midline, Maxillary incisal edge position is considered as the most
following possibilities can occur: important determinant in smile designing, once estab-
lished, it serves as a reference point to decide the proper
tooth proportion and gingival levels (Figs. 25.7A to C).
Following parameters are used to establish the maxillary
incisal edge position:
i. Degree of Tooth Display

When the mouth is relaxed and slightly open, 3.5 mm of the
incisal third of the maxillary central incisor should be visible
in a young individual (Figs. 25.8A to C). As age increases,
tooth display decreases due to decrease in the muscle tonus.
ii. Phonetics (Figs. 25.9A to D)

To determine the lip, tongue, incisal support, and tooth
position, following phonetic exercises are evaluated:
a. M sound: It tells physiologic rest position and the
Fig. 25.5: Evaluation of dental midline. amount of display of teeth after pronunciation of M
A B C
A B C
Figs. 25.8A to C: Amount of display of maxillary incisors in relaxed and slightly open mouth.
A C
B D
Figs. 25.9A to D: Phonetics: (A) “Mmm” sound shows incisal display at rest position; (B) “E” sound shows incisal edge midway upper and lower lip;
(C) “S” sound shows slight space between maxillary and mandibular teeth; (D) “F” and “V” sounds show maxillary incisor edge position in relation
to lower lip.
sound. Minimum tooth display in this position is 2–4 between wet and dry border of lower lip. These sounds
mm. help to determine the labiolingual position and length
b. E sound: Widest smile or extended pronunciation of E of the maxillary teeth.
or saying cheese the space between upper and lower
lips should be almost completely filled by maxillary iii. Patient Input
incisors.
c. S sound: Mandibular central incisors should be Intraoral cosmetic preview and provisional restorations
positioned 1 mm behind and 1 mm below maxillary help to confirm proper placement of the final incisal edge
incisal edge. position. The patient input means that his/her expectations
d. F and V sounds: Incisal edges of maxillary anterior for smile must be met in the best possible way, unless they
teeth are positioned directly over the demarcation do not interfere with the parameters as discussed above.
Correct incisal edge position is crucial because it is Central incisor is wider than the lateral by 2–3 mm and
related to the pitch of the anterior teeth, labial contours, canine by 1–1.5 mm. Canine is wider than the lateral by
lip support, anterior guidance, lingual contours, and tooth 1–1.5 mm and canine and central incisors are longer than
display. The pitch of each anterior tooth is determined lateral by 1–1.5 mm.
by the combination of correct lip support and the lingual Size of body is visible according to the light reflected
labial position of the incisal edge. This location influences from it. It controls the width and length which is perceived
anterior guidance and the labial and lingual contours. by a viewer. When a tooth is highlighted upon direct
In short, all these factors play a dominant role in both light, the area of depression is shadowed. Tooth size
aesthetics and function. and appearance can be changed by creating different
prominences on facial surface. These illusions are useful
3. Tooth Dimensions for creating apparent size of tooth different from actual
size. These concepts are important in correction of
Correct dental proportion is related to facial morphology diastema, smile designing cases.
and is important for creating an aesthetically pleasing
smile. Central incisors are key to smile, and must be the ii. Shape
dominant teeth in the smile. They are evaluated by size
and shape for correct proportions. It is determined by age, sex, and personality of the
individual. A young and feminine smile shows teeth with
i. Size rounded incisal angles, open incisal, and facial embrasure
(Fig. 25.11A), while a masculine smile shows closed
It is determined by dividing cervicoincisal length of tooth incisal embrasures with prominent incisal angles (Fig.
to mesiodistal width, i.e. 25.11B). If in females slightly broader teeth are present,
Size of tooth = Width/height ratio they require conservative minor modification to produce
To have optimal dimension, width/height ratio of better aesthetics. This is called “cosmetic contouring”. To
central incisor should range from 0.75 to 0.8 (Figs. 25.10A create younger and more feminine smile, incisal angles are
to C). rounded and incisal embrasures are opened.
◆◆ Ideal ratio 0.75 to 0.8 The shape and location of the centrals influences or
◆◆ <0.75—narrower tooth determines the appearance and placement of the laterals
◆◆ >0.8—wider tooth and canines. Most commonly followed guidelines for
A B C
Figs. 25.10A to C: Width/height ratio of central incisor should range from 0.75 to 0.8: (A) Ideal ratio 0.75 to 0.8;
(B) <0.75—Narrower tooth; (C) >0.8—Wider tooth.
A B
Figs. 25.11A and B: Incisal embrasures in feminine and masculine smile: (A) Feminine smile shows teeth with rounded incisal edges, open
incisal and facial embrasures; (B) Musculine smile shows closed incisal embrasures and prominent incisal angles.
Fig. 25.12: Rule of Golden proportion.
establishing correct proportions in an aesthetically pleasing Fig. 25.14: Dimensions of individual tooth.
smile are given by Lombardi as a rule of golden proportion. canine is visible from the frontal view when the patient
rule of golden proportion: It states that when viewed smiles. Canines support the frontal muscles, and the
from the facial aspect, the width of each anterior tooth is size and characteristic of buccal corridor is determined
60% of the width of the adjacent tooth (Fig. 25.12). For by the size, shape, and position of the canine.
example, for maxillary central incisor, the apparent width d. Maxillary premolars: They play a very important
is 1.6, for lateral incisor, it is 1, and for canine, it is 0.6. But role for the arch design. They should fill the buccal
many studies have shown that golden proportion is not corridor.
always present in natural dentition, yet an aesthetically
pleasing smile can be there. So rather than having a specific iii. Buccal Corridor
ratio, a dentition should have repeating proportion.
Recurring esthetic dental (Red) proportion: It states Refers to dark space (negative space) visible during smile
that the width proportion between two adjacent teeth formation between the corners of the mouth and the
as viewed from frontal aspect should remain constant buccal surfaces of the maxillary teeth (Figs. 25.15A and
progressing successively distally. In other words, each B). Its appearance is influenced by:
tooth becomes smaller by a fixed percentage as we move a. Width of smile and the maxillary arch
posteriorly (Fig. 25.13). b. Prominence of the canines especially at distal facial
Following factors help in guiding the dimensions of line angle
individual tooth (Fig. 25.14): c. Facial surface of maxillary premolars
a. Maxillary central incisor : Approximate length of the d. Tone of the facial muscles.
central should be 10–11 mm and the width is calculated
accordingly so that the ratio falls between 75% and 80%.
b. Maxillary lateral incisor: They provide individu-
ality, are not symmetrical, and influence gender
characterization.
c. Maxillary canine: They play a critical role in smile
designing because they are the junction between the
anterior and posterior teeth so only mesial half of
B
Figs. 25.15A and B: Buccal corridor is dark space visible between
corners of mouth and buccal surfaces of maxillary teeth. C means
Fig. 25.13: Recurring esthetic dental (Red) proportion. distal surface of the upper canine; Ch refers to corner of the mouth.
Ideal arch is broad and conforms to a U shape with central incisors appearing to be almost vertical, lateral
minimal buccal corridor. A narrow arch is V-shaped with incisors, and canines tipping more toward midline. After
unpleasing buccal corridor which can be reduced by canines, the posterior teeth display an inclination that is
restoring the premolars. parallel to canines.
4. Zenith Points 6. Interdental Contact Area and Point

Cementoenamel junction and osseous crest determine
the curvature of gingival margin of tooth, called gingival i. Interproximal Contact Area (ICA)
shape. Mandibular incisors and maxillary laterals have It is defined as the broad zone in which two adjacent
oval and maxillary centrals and canines have elliptical teeth touch. It follows the 50:40:30 rule in reference to the
gingival shape. Gingival zenith represents the most apical maxillary central incisor (Fig. 25.18). By increasing the
point at which each tooth emerges from the free gingival ICA, one can create illusion of longer teeth by making them
margin. For an aesthetically pleasing smile, it should wider and also extend apically to eliminate black triangles.
be positioned distal to center of each tooth in maxillary
anterior segment. Distal position gradually increases from ii. Interproximal Contact Point (ICP)
central incisor to canine. The lateral is an exception as its
zenith point may be centrally located (Fig. 25.16). It is the most incisal aspect of the ICA. As we move posterior
Zenith points are the most apical position of the to midline, ICP moves apically (Fig. 25.19).
cervical tooth margin where the gingiva is most scalloped.
It is located slightly distal to the vertical line drawn down 7. Incisal Embrasures (Fig. 25.20)
the center of the tooth. Establishing the proper location of
zenith points is an important step during management of The triangular space incisal to the contact is defined as
diastema and correction of tooth angulation. embrasure. Embrasure area gets larger as the teeth progress
posteriorly. The contact points in their apical progression
5. Tooth Inclinations (Fig. 25.17) should mimic the smile line. Failure to provide adequate
A line extending from free gingival margin to center of the embrasure form will make the teeth appear too uniform
incisal edge implies axis inclination of each tooth. Maxillary and will give a box-like appearance to dentition.
anterior teeth display mesio-axial inclination, with the
Fig. 25.18: Interproximal contact area is the broad zone in which two
adjacent teeth touch, it shows 50:40:30 rule in reference to the maxil-
lary central incisor.
Fig. 25.16: Zenith point.
Fig. 25.19: Interproximal contact point is

Fig. 25.17: Tooth inclinations. most incisal aspect of contact area.
Fig. 25.20: Incisal embrasures.
8. Symmetry and Balance

Symmetry is the harmonious arrangement of several
Fig. 25.22: Gingival level and harmony: Differences between the
elements to one another. Symmetrical length and width is heights of the apical gingival margins of anterior teeth.
critical for the centrals. It becomes less concerned as we move
further away from the midline. Static symmetry refers to the
height of the centrals should be bilaterally symmetrical and
mirror image of maxillary central incisors whereas dynamic
should match the canines. For lateral incisors, it should be
symmetry stands for two similar but distinguishable. Right
cervical to that of centrals and canines (Fig. 25.22).
and left sides of smile are said to be balanced when balance
is observed as the eyes move distally from the midline.
3. Cervical Embrasure
Soft tissue Component of Smile Design Embrasure located cervical to interproximal contact area
is called as cervical embrasure. Darkness of oral cavity
1. Gingival Health (Fig. 25.21) which is visible in the interproximal triangle between the
The gingiva acts as the frame for the teeth, thus, final gingiva and the contact area is called black triangle (Fig.
aesthetic outcome of case is influenced by the gingival 25.23). It is unaesthetic and negatively affects the smile
health. Healthy gingiva should be pale pink in color, of an individual. It is important to avoid black triangles by
stippled, firm in consistency which is paramount for considering most apical part of restoration 5 mm or less
long-term success and aesthetic value of treatment (Fig. from alveolar crest so as to encourage the formation of
25.21). It should have pointed papillary contour and fill healthy pointed interdental papilla.
the interdental spaces to the point, because black triangles
make the smile unattractive. 4. Smile line
smile line is an imaginary line running along the incisal
2. Gingival Level and Harmony edges of the maxillary anterior teeth and coinciding with
Setting up precised gingival levels for each individual tooth
is the key in creating a balanced smile. The cervical gingival
Fig. 25.23: Embrasure present cervical to contact area is cervical

Fig. 25.21: Healthy gingiva appears pale pink, firm with pointed embrasure. Black triangle is space visible in interproximal triangle
papillary contour and fills the interdental spaces to the point. between gingiva and contact area.
the curvature of lower lip (Fig. 25.24A). it is also known as b. Medium Smile Line
gull wing course while smiling.
25–75% of interproximal gingiva and marginal gingiva are
Reverse/Inverse Smile Line visible. It is the most perfect and attractive smile (Fig. 25.25B).
It is when maxillary central incisors appear shorter than c. High Smile Line
canines along the incisal plane (Fig. 25.24B). It is usually
seen in attrition, erosion, and altered patterns of eruption 75% interproximal gingiva and all marginal gingiva are
or poor quality dental treatment. visible. When greater than 3 mm of gingiva above the cervical
line of the tooth is visible, it is a gummy smile (Fig. 25.25C).
a. Low Smile Line
Less than 25% of interproximal gingiva is visible while AESTHETICS AND OPERATIVE DENTISTRY
marginal gingiva is invisible. Only 20% of maxillary and There are number of problems which can alter the
mandibular teeth seen (Fig. 25.25A). aesthetics of anterior teeth like:
A B
Figs. 25.24A and B: (A) Smile line runs along the incisal edges of maxillary anterior teeth and coincides
with curvature of lower lip, also known as gull wing course while smiling; (B) Reverse line is when maxil-
lary central incisors appear shorter than canines along the incisal plane.
A B
C
Figs. 25.25A to C: (A) Low smile line; (B) Medium smile line; (C) High smile line.
◆◆ Caries 1. Aesthetic Contouring

◆◆ Tooth discoloration because of trauma, hypoplasia,
and other factors It helps in improving minor changes in contour of tooth
◆◆ Tooth malformations by recontouring enamel. It is done to smoothen the
◆◆ Diastema between teeth roughened enamel margins, fractured tooth surfaces, and
◆◆ Malalignment of teeth to soften interproximal angles.
◆◆ Fracture of tooth Indications Contraindications
◆◆ Cervical lesions like erosion, abrasion, and abfraction • Alteration of tooth shape • Large pulp horns
◆◆ Attrition of teeth • Minor orthodontic problem • Thin enamel
◆◆ Ectopic eruptions. • Trauma from occlusion • Susceptibility to caries
Following treatment options are available which can • Removal of stains and discoloration • Hypersensitive teeth
be employed to improve the aesthetics of affected tooth/ • Reshaping of maxillary incisors to • Extensive occlusal
give youthful look disharmony
teeth.
Treatment options for Achieving Aesthetics Technique

i. Illusion effect: Plan the treatment to give illusion effect
1. Aesthetic contouring
so as to have desired shape with minimal reduction of
2. Tooth whitening
tooth structure. illusion is provided to teeth by means of
3. Aesthetics with composites
changing the surface, color, shape, light, and contour of
4. Aesthetics with ceramics
teeth so as to make them perceive as they are meant to.
For example, among two teeth with same crown length
An Ideal Aesthetic Treatment Plan and width, the one with darker color will be perceived
i.Be minimally invasive to be shorter than the one with lighter color. Similarly,
ii.Preserve maximum natural tooth structure of the two teeth which are of the same crown length,
iii.Enhance the aesthetics the narrower one will appear longer. Teeth with convex
iv. Realign teeth to maintain form, function, and aesthetics surfaces appear smaller when compared to flat surface
v. Fulfill patient’s input by treatment options and mock teeth (Figs. 25.26A to C). Some little illusions can
up change the look of the teeth significantly. This process
vi. Never compromise on patient’s oral health and must work effectively from position in which the teeth
stability of teeth. are viewed the most. In providing the illusion effect,
A B C
A B C
Figs. 25.26A to C: Illusion effect.

there is a significant role of developmental grooves. For 2. Tooth Whitening
example, if grooves are placed apart, teeth appear wider
and vice versa. Similarly, if there is dark pigmentation Teeth with mild to moderate superficial discolorations can
at the periphery and light in the central part, teeth can be treated by tooth whitening (Fig. 25.28). For details on
appear narrower by illusion effect. Horizontal lines on bleaching of teeth, please refer to Chapter 28.
teeth make them appear wider and vertical lines make
them appear longer. 3. Aesthetics with Composites
ii. Angle of correction: angle of view is important while (Figs. 25.29A and B)
shaping the teeth, especially the mandibular incisors.
Conservative treatment approach with composites giving
If mandibular incisors extend above the incisal plane,
quick, aesthetic, and economical results have made them
they became quite obvious. This is because of angle
the material of choice for aesthetic procedures. Composite
of view, mandibular anterior teeth which are in
resins are indicated for treatment of minor defects present
linguoversion appear more prominent than the teeth
on incisal edges or labial surfaces of teeth like caries,
which are inclined labially. Therefore, in these teeth,
fracture, correction of diastema, peg-shaped laterals, etc.
incisal edge should be beveled lingually.
for detailed use of composites in management of carious
iii. Reshaping: reshaping is done carefully to avoid
lesions refer to Chapter 24.
color change due to removal of enamel. Because,
over reduction of tooth structure can show the inner
4. Aesthetics with Ceramics
dentin color, reduction should be carefully carried out
with diamond burs at high speed with coolant. Final Advances in ceramic materials and veneering techniques
shaping of mesial, distal, incisal, and embrasures allow the clinicians to restore function and aesthetics using
should be done with thin diamond points followed by conservative methods along with promoting long-term
white or green finishing stones (Fig. 25.27). oral health. All-ceramic crowns and veneers are indicated
Fig. 25.27: Reshaping of maxillary anterior teeth.
Fig. 25.28: Preoperative and postoperative view of vital tooth bleaching.

A B
Figs. 25.29A and B: Management of fractured central and lateral incisor using direct composite resin.
to correct unacceptable tooth contour, diastemas, Types of Veneers based on the

malpositioned teeth, mask tooth discoloration or to Method of Fabrication
correct minor tooth alignment issues. Ceramic veneers,
when well-planned and indicated, provide excellent result A. Direct veneers
due to the material properties, biocompatibility, and i. Partial veneers
possibility of being handled in low thicknesses, without ii. Direct full veneers
harming the resistance or the aesthetics of the material. a. Full veneer with window preparation
b. Full veneer with incisal overlapping
Veneers B. Indirect veneers
Veneer can be described as a layer of tooth colored mate-
rial which is applied on the tooth surface for aestheti- A. Direct Veneer Technique
cally restoring localized or generalized defects or intrinsic
i. Direct Partial Veneers
discolorations.
Laminates maintain the color and usually require no Are placed on localized discolorations or defects which are
tooth preparation. surrounded by sound enamel (Figs. 25.30A and B). these
Veneers change the color and require preparation. are indicated when there is localized discoloration and
Constructing a veneer and bonding it to the tooth structure entire facial surface is not involved (Fig. 25.31).
is called laminating.
Technique
Indications Contraindications ◆◆ Perform oral prophylaxis and select the shade.
• Damaged, defective and • Deep dentinal discolorations ◆◆ Isolate the teeth with cotton roll or rubber dam.
malformed facial surface • Large gaps between the teeth ◆◆ Outline the extent of the defect and with the help of a
• Discolored facial surface • Malpositioned teeth coarse elliptical diamond bur reduce 0.5–0.7 mm of
• Lengthening of short/worn • Wear pattern
out teeth • Less available enamel for
tooth structure.
• For youthful appearance bonding ◆◆ Fill the defect with microfilled composite after etching
• To close spaces and application of bonding agent.
A B
Figs. 25.30A and B: Partial direct veneer of maxillary incisors.
(Courtesy: Roma Turetskiy)
• Single appointment • More chair side time
• Useful for young patients • Technique sensitive
• Useful for localized defects
• Economical
ii. Direct Full Veneers

Are indicated in following cases:
◆◆ Diastema closure (Figs. 25.32 and 25.33)
◆◆ Tetracycline stained teeth
◆◆ Improper contours and shape of teeth
◆◆ Grossly stained and pitted teeth
Fig. 25.31: Direct composite veneering. ◆◆ Gross enamel hypoplasia of anterior teeth.
A B C
D E F
G H I
J K
Figs. 25.32A to K: (A) Preoperative photographs; (B) Isolation and tooth preparation; (C) Putty index; (D) Application of etchant; (E) Application
of bonding agent; (F) Palatal shell fabrication; (G) Palatal shell fabrication; (H) Composite build up; (I) Composite build up continues; (J) Build up
using layering technique; (K) Postoperative photograph.
A B
Figs. 25.33A and B: Management of diastema by indirect processed veneers.
Procedure ◆◆ Indirect veneers produce better contour, contacts, and

◆◆ Perform oral prophylaxis and select the shade. shade.
◆◆ Reduce 0.5–0.75 mm of enamel mid-facially and 0.2–0.5 ◆◆ More durable than direct veneers.
mm along the gingival margin. Give chamfer finish Indirect veneers are commonly made-up of the following:
line for definite cavity margins. At the proximal side, I. Processed composite
preparation should be facial to the contact point. II. Etched porcelain
◆◆ Do acid etching, washing and drying followed by III. Castable ceramic.
application of bonding agent.
◆◆ Place composite in increments. When adding compos- I. Processed Composite Veneers
ites, care should be taken to create proper physiological
contour, contact point, and smooth surfaces. Composite veneers can be processed in a laboratory
Preparation for full veneers is of two types: to have improved physical and mechanical properties
1. Window preparation: It is indicated in the following compared to traditional chairside composites. These
cases: can be produced using intense light, heat, vacuum, pres-
•• To preserve functional, lingual and incisal surfaces sure, or a combination of these. Moreover, indirectly
of anterior teeth fabricated composite veneers offer superior shading
•• To prepare maxillary canines in patients with and characterizing potentials as well as better control of
canine guided occlusion facial contours.
•• In patients with high occlusal stresses. Advantages Disadvantages
Advantages • Superior physical and mechanical • Limited bonding, so
•• Saves the functional, lingual and incisal surfaces of properties surface conditioning
anterior teeth. • Easy to finish and polish or sandblasting is
•• It does not extend subgingivally or involves incisal • Can be easily repaired required
• Processed veneers are made in the • Multiple large
edge.
cases which show attrition of anterior existing restorations
•• Decreases the chances of wear of opposing teeth. teeth due to occlusal stresses compromise bonding
2. Incisal lapping preparation: It is indicated in the
following cases: Procedure
•• When crown length is to be increased (Figs. 25.34A 1st appointment:
to E). ◆◆ Window preparation is indicated due to limited bond
•• When incisal defect is severe and restoration is strength, incisal lapping is given only if indicated.
necessary. ◆◆ After intra-enamel preparation, take elastomeric
Advantages impression and fabricate the veneer.
•• Improved aesthetics along the incisal edge. 2nd appointment:
◆◆ Check the fit of the veneer.
B. Indirect Veneer Technique ◆◆ Since processed composites have less potential to form
chemical bond with bonding medium, thus additional
It is done in two appointments. micromechanical features are added by surface
Advantages conditioning or sandblasting.
◆◆ Less technique sensitive than direct veneers. ◆◆ Etch the tooth, wash, dry, and apply bonding agent.
◆◆ Multiple teeth can be done in less time. ◆◆ Apply adhesive cement on veneer, place the veneer on
◆◆ Chair time required for indirect veneers is less. the tooth and remove excess cement.
A B
C D
E F G
H
Figs. 25.34A to H: (A) Preoperative photograph showing worn off incisal edges of maxillary teeth; (B) Occlusal view; (C) Isolation of teeth and
composite build up procedure; (D) Composite build up using putty index; (E) Application of etchant; (F) Composite build-up; (G) Build-up
continues; (H) Postoperative photograph.
(Courtesy: Deepak Mehta)
◆◆ Light cure it for 40–60 seconds from both facial and Steps
lingual side.
◆◆ After cleaning and shade selection, isolate the teeth.
II. Etched Porcelain Veneers ◆◆ Prepare the tooth, take impression and send it to
laboratory for veneer formation.
In these porcelain veneers, internal surface is acid-etched
◆◆ Check the fit of veneer.
which forms stronger bond with etched surfaces of tooth
◆◆ Condition the internal surfaces of veneers with 7%
(Figs. 25.35A and B).
hydrofluoric acid, wash and apply silane coupling agent
Advantages Disadvantages to increase the wettability.
◆◆ Etch the prepared tooth with phosphoric acid, wash,
• Better bond strength • Technique sensitive
• Durable • Difficult repair dry, and apply bonding agent by rubbing it for 20
• Good aesthetics • Require tooth preparation seconds and cure it. Apply unfilled resin to the prepared
• Resistance to abrasion • Extremely fragile tooth surface and the inside of laminate veneer, do not
• Expensive cure it.
A B
Figs. 25.35A and B: Management of malformed and discolored teeth by ceramic veneers.
(Courtesy: Mohan Bhuvaneswaran)
◆◆ Apply adhesive cement on the veneer surface and seat not finished with rotary instruments as rotary instruments
it passively on the tooth. Remove the extra cement from cause loss of surface color.
margins using hand instruments and then cure it.
Repair of veneers
Cementation of ceramic veneers
Preparation of tooth Preparation of veneer
Failures of aesthetic veneers occur because of breakage,
discoloration, or wear. One should consider conservative
Clean Clean
repairs of veneers if the remaining tooth and restoration
Isolate Etch with hydrofluoric acid are sound. The material most commonly used for making
Etch with phosphoric acid Apply silanating agent repairs is light cured composite.
Apply bonding agent Apply bonding agent
i. Direct Composite Veneers
III. Castable Ceramic Veneers
For direct composite veneers, repairs should be done
These are fabricated for light-to-moderate discolorations with the same material that was used originally. After
because of its translucent nature. These are fabricated by cleaning the area, select the shade, roughen the damaged
lost wax technique. Preparation of tooth and cementation surface of the veneer with a coarse, rounded end diamond
is the same as etched porcelain veneers. These veneers are instrument to form a chamfered cavosurface margin.
Differences between direct resin, indirect processed resin, and ceramic veneers
Considerations Direct resin Indirect Processed resin Porcelain indirect

Indications 1. Need to cover dark shades 1. Routine veneers for patients which 1. Veneers for superficial stains
2. Patients with financial problems are not deeply stained 2. Treatment of multiple teeth
3. Single tooth treatment 2. Patients with parafunctional habits
3. Treatment of multiple teeth
Contraindications Dentist does not have skills to Difficult to cover dark stains and 1. Difficult to cover dark stains and
develop tooth anatomy striations without placement of striations without placement
underlying opaquer before impression of underlying opaquer before
for veneers impression for veneers
2. Patients with parafunctional habits
Aesthetics Good to excellent if clinician can Good to excellent with high level Excellent with high level laboratory
produce it with artistic skills laboratory and correct patient support and correct patient selection
selection
Longevity Atleast 5–7 years with aesthetic At least 5–10 years with aesthetic 10 years with aesthetic acceptability
acceptability, if placed correctly acceptability if laboratory fabricates it if laboratory fabricates it properly and
properly and cemented correctly cemented correctly
Considerations Direct resin Indirect Processed resin Porcelain indirect

Strength Moderate Moderate High
Cost to patient Affordable Moderately expensive Expensive
Placement Placement moderately difficult Placement not difficult because Difficult because:
unless dentist has aesthetic sense for veneer material is same as cementing 1. Veneer is fragile and can break
color and contour medium 2. Selection of cement color
3. Loss of glaze through finishing
Commonly seen 1. Incisal edge fracture 1. Incisal edge fracture 1. Very little repair needed in 2 years
failures 2. Discoloration of gingival and 2. Discoloration of gingival and of observation
proximal margins, if not placed proximal margins 2. Discoloration of gingival and
correctly proximal margins if not placed
correctly
Repair difficulty Simple Simple Difficult
Apply etchant, rinse and dry the area. Apply bonding agent use of advanced materials and techniques by a skilled
to existing composite and enamel and cure it. Then place dentist”.
composite material, cure, finish, and polish it. Contemporary concept of aesthetics is revolutionizing
in the way a clinician diagnosis, treats, and communicates
ii. Indirect Processed Composite Veneers with patients. Techniques for achieving aesthetics have
improved and expanded the use of photography to analyze
Indirect processed composite veneers are repaired in a
existing aesthetic problems and communicate possible
similar manner as direct composite veneers.
treatment alternatives. Patient satisfaction is achieved
when the clinician meets the patient’s expectations.
iii. Ceramic Veneers Satisfaction is attained only through a balance in diagnosis,
Use 20% buffered concentration of hydrofluoric acid to effective communication, and evidence-based planning
etch the fractured porcelain. For protection of oral tissues, and proper treatment options which can be done for the
do not use full strength hydrofluoric acid or do it after delivery of excellence in cosmetic dental treatment.
applying rubber dam. After this, apply a silane-coupling
agent and then resin-bonding agent. Following this, place EXAMINER’S CHOICE QUESTIONs
composite material, cure, and finish it.
1. What are characteristic features of a good smile?
Enumerate various options available for smile
iv. Faulty Veneers in Metal Restorations designing.
Clean the teeth with slurry of pumice and select the shade 2. Write in detail about elements of dental aesthetics.
of composite. Old resin material is removed with No. 1558 3. Discuss in detail about veneers. What are indications,
carbide metal cutting bur. Extend outline of preparation contraindications, advantages, and disadvantages of
gingivally by removing some of the gold and give chamfer window and incisal lapping designs?
finish line. Give retention grooves of 0.25 mm depth along 4. Write short notes on:
the line angles by using No. 331⁄2 carbide bur in the metal. a. Rule of Golden proportions.
Etch the preparation with acid etchant for 30 seconds, b. Indirect veneer materials and technique.
rinse and dry it. The acid is used only to clean the surface, c. Repair of veneers.
not to etch the metal. Place an opaque resin over prepared
metal surface and cure it. Adhesive resins containing Viva QUESTIONs
4-META can bond to metal, so, should be used for
additional retention and masking effect. Apply composite 1. What are hard tissue and soft tissue components of
material at cervical area and cure it. Then place composite smile design?
increments on middle and incisal thirds, cure and finish 2. What is rule of golden proportion?
the final restoration. 3. What is red proportion?
4. What is buccal corridor?
5. What is Zenith point?
CONCLUSION
6. What is reverse inverse smile line?
“A well designed smile is a product of consolidated efforts 7. What are indications and contraindications of
accomplished by accurate diagnosis, treatment planning, aesthetic contouring?
8. What are indications and contraindications of 2. Gurel G. The science and art of porcelain laminate veneers–
veneers? London: Quintessence; 2003.
9. What are advantages of direct veneers? 3. Morley J, Eubank J. Macroesthetic elements of smile design. J
10. What is window preparation for full veneers? Am Dent Assoc. 2001;132(1):39-45.
4. Valo TS. Anterior esthetics and the visual arts: beauty, elements
11. How do you repair the veneers?
of composition, and their clinical application to dentistry. Curr
Opin Cosmet Dent. 1995:24-32.
bibliography 5. Ward DH. Proportional smile design using the recurring
1. Bhuvaneswaran M. Principles of smile design. J Conserv Dent. esthetic dental (RED) proportion. Dent Clin North Am.
2010;13(4): 225-32. 2001;45(1):143-54.
Chapter
26
Glass Ionomer Cements
Chapter Outline
Introduction Disadvantages of Glass Ionomer Cement

Classification of Glass Ionomer Cements Indications of Glass Ionomer Cements
History Contraindications of Glass Ionomer Cements
Composition Clinical Steps for Placement
Recent Advances in Gic Other Clinical Applications of Glass Ionomers
Setting Reaction of Glass Ionomer Cement Atraumatic Restorative Treatment
Properties of Glass Ionomer Cements Sandwich Technique
Advantages of Glass Ionomer Cements Tunnel Preparation
introduction ◆◆ Type VII: Fluoride releasing cements

◆◆ Type VIII: For Atraumatic Restorative Technique (ART)
Glass Ionomer Cement (GIC) was introduced to
◆◆ Type IX: Pediatric glass ionomer cements.
dentistry in 1972 by Wilson and Kent. First commercial
glass ionomer was made by De Trey Company and Facts
distributed by the Amalgamated Dental Co. in England
and by Caulk in the United States, known as ASPA Extensive use of glass ionomer cement to replace dentin has
given it different names:
(Aluminosilicate Polyacrylate). It consisted of an ion
Dentin substitute
leachable aluminosilicate glass and an aqueous solution
Man-made dentin
of a copolymer of acrylic acid. Artificial dentin.
Glass ionomer cement is also described as hybrid
of dental silicate cements and zinc polycarboxylates
where phosphoric acid of silicate cements is replaced by
History
polyacrylic acid of zinc polycarboxylates. Year Name of scientists Description
1972 Wilson and Kent Development of GIC
CLASSIFICATION OF GLASS IONOMER
in London
CEMENTS 1977 - Introduced in USA as ASPA
Traditional Classification According to Skinners (Aluminosilicate
◆◆ Type I: Luting cements polyacrylate)
◆◆ Type II: Restorative cements 1977 Wilson Development of Luting
◆◆ Type III: Liner or Base. cement
1980 Simmons Miracle mix
Classification of GICs According to their Use 1984 Hunt Knight Tunnel preparation
◆◆ Type I: For luting cements 1985 McLean Sandwich technique
◆◆ Type II: For restorations 1985 McLean and Cermet
◆◆ Type III: Liners and bases Gasser
◆◆ Type IV: Fissure sealants 1994 McLean Atraumatic Restorative
◆◆ Type V: Orthodontic cements Technique (ART)
◆◆ Type VI: Core build up
COMPOSITION I. Silver Alloy Admix Glass Ionomer Cement

1. Conventional GIC Sced and Wilson in 1980 incorporated spherical silver
amalgam alloys into glass powder in ratio of 1:7. This
Glass ionomer is an acid-soluble calcium fluoroalumino physically blended mix is mixed with glass ionomer liquid,
silicate glass, i.e. an ion leachable glass. e.g. Miracle Mix (Fig. 26.1).
This cement has improved strength but poor resistance
Composition of glass ionomer powder to abrasion and poor aesthetics.
1. Silica 29 Forms mass of the cement
2. Alumina 16
3. Aluminium 5 i. Acts as flux and
fluoride decreases fusion
4. Calcium 34 temperature
fluoride ii. Improves translucency
iii. Improves strength and
5. Sodium 5 wearing characteristics
aluminium
fluoride
6. Aluminium 9.9 i. Improves translucency
phosphate ii. Adds body to mix
cement
7. Lanthanum, Traces Radiopacifiers
Barium, and
Strontium
Composition of liquid Fig. 26.1: Miracle Mix.
1. Polyacrylic 45 Main component— (Coutesy: GC India).
acid contributing for formation of
cement matrix II. Cermet Cement
2. Water 50 Reaction medium-essential It was introduced by McLean and Gasser in 1987. Cermet
part of cement structure is manufactured by sintering compressed pellets made
helps in ionic exchange
from fine silver powder and glass ionomer powder at
reaction
temperature of 800°C. The sintered metal and glass fit is
3. Modifiers 5 i. Improves reactivity
then ground into fine form which results in ceramicometal
like: Itaconic between liquid and glass
acid ii. Prevents gelation of particles of fused metal and ground glass. Most accepted
liquid which is formed metal for sintering with glass ionomer is silver or gold.
due to hydrogen bond of Titanium dioxide (5%) is added to improve the color and
two polyacrylic chains make it more aesthetic.
Maleic acid i. Stronger than polyacrylic Powder: Sintered silver and glass powder—5% Titanium
acid
ii. More carboxylic acid
oxide
groups causing rapid Liquid: Glass ionomer cement liquid.
cross linking
Cermet has improved compressive and tensile strength,
Tartaric acid i. Hardener which controls greater abrasion resistance, and radiopacity when
pH of set cement
ii. Increases working time
compared to conventional GICs. Example: Ketac Silver.
iii. Facilitates extraction of
ions from glass 3. Resin-modified Glass Ionomer Cement
(Fig. 26.2)
These raw materials are fused at a temperature of 1,100–
1,500°C to form uniform glass. This glass is then ground to Composition of resin modified glass ionomer cement is:
powder having particle size of 15–50 µm. Powder: Fluoroaluminosilicate glass particles along with
photoinitiator or chemical initiator.
2. Metal Reinforced Glass Ionomer Cements Liquid:
In order to improve physical properties of GICs, metal i. Polyacrylic acid modified with methacrylate groups
powder is added to glass powder to form metal modified and HEMA monomers (15–25%)
GICs. It can be done in the following ways: ii. Water.
Glass Ionomer Cements 349
Liquid: Water or water with tartaric acid.
When powder is mixed with water, acid powder
dissolves to reconstitute the liquid acid and this process is
followed by the acid–base reaction.
Recent advances in GIC

1. Giomer
In this, fluoroaluminosilicate glass reacts with polyalkenoic
acid to form a stable phase of GIC. This prereacted glass is
then mixed with the resin depending on the amount of glass
which has reacted. it is considered as true hybridization
of glass ionomer and composite because it exhibits both
fluoride release and recharges the glass ionomer cement.
Other advantages of giomers are good aesthetics, ease
Fig. 26.2: Resin-modified glass ionomer cement. of handling and improved physical properties of the set
material.
4. Highly Viscous Conventional Glass Ionomer
2. Condensable/Self-hardening GIC
Cement/High Viscosity Autocure Glass Ionomers
These are chemically activated resin-modified glass
Highly viscous glass ionomers were developed to
ionomer cements (RMGICs) with no light activation at
substitute amalgam for posterior restorations. In these
all. Advantages over conventional GICs are that these
cements, polyacrylic acid is made into finer grain size so
are packable, condensable, easy placement, nonsticky,
that higher powder-liquid ratios can be used, as compared
improved wear resistance, and low solubility in oral fluids.
to conventional GIC, these have better physical properties
and improved strength, for example, Ketac Molar and Fuji
IX (Fig. 26.3). 3. Zirconomer
In this, zirconia fillers are incorporated in glass component
to reinforce the structural integrity of the cement and
improve the mechanical properties of GIC.
4. Low Viscosity/Flowable GICs

These are mainly used for lining, pit, and fissure sealing, as
endodontic sealers, for sealing of hypersensitive cervical
areas.
5. Bioactive Glass
It was developed by Larry Hench in 1973. It takes into
account that on acid dissolution of glass, a rich layer of
Ca and PO4 ions is formed around the glass. Such a glass
can form intimate bioactive bonds with bone cells and
gets fully integrated with the bone. Bioactive glass bonds
Fig. 26.3: Highly viscous conventional glass ionomer cement. to both hard and soft tissues. It has antibacterial effect,
combination of bioactive nanosilica with dental cement
5. Water Mixed GICs/Water Hardening Glass improves its biocompatibility. It is used as retrograde filling
Ionomer Cements material, for perforation repair, augmentation of alveolar
ridges in edentulous ridges and implant cementation.
Polyacid in solution form has shown an increase in
viscosity of the liquid which makes the manipulation of
cement difficult. To solve this problem, “water mixed” or 6. Calcium Aluminate GIC/Ceramir
“water hardened” GIC was developed. Another advancement in glass ionomer cement is calcium
Powder: Freeze-dried polyacid powder mixed with glass aluminate–glass ionomer luting cement which has hybrid
powder. composition. It sets by combination of a glass ionomer
reaction and an acid–base reaction occurring in hydraulic

cements. Due to presence of glass ionomer component,
cement has improved flow, adhesion to tooth structure,
and has initial good strength, whereas presence of calcium
aluminate in the cement helps in increased strength and
retention over time, biocompatibility, and lack of solubility.
7. Fiber-reinforced GIC
In this, alumina fibers are incorporated into the glass
powder of resin-modified GIC which help in improving
the flexural strength of GIC. This technology is called as
Polymeric Rigid Inorganic Matrix Material (PRIMM).
This increases the depth of cure, reduces the polymerization
shrinkage, improves wear resistance, and increases the
flexural strength of the set cement.
8. Casein Phosphopeptide‑amorphous Calcium

Phosphate Incorporated Glass Ionomer Cements
Fig. 26.4: Setting reaction of glass ionomer cement.
Casein phosphopeptide‑amorphous calcium phosphate
(CPP‑ACP) nanocomplexes have shown to promote Three Stages of GIC Setting Reaction
remineralization of enamel. Zalizniak et al. found that the
incorporation of CPP–ACP into GIC increases the calcium 1. Ion-leaching phase: When powder and liquid are
and phosphate ion release, so it can be used in cases to mixed, polyacid attacks the glass particles (called
inhibit demineralization, seen in caries. leaching) to release Ca2+ and Al3+. These ions react with
fluoride ions to form CaF2– and AlF3–. Soon because of
continued increase in acidity, CaF2– dissociates and
9. Proline-containing GIC reacts with acrylic copolymer to form a stable matrix.
It is an amino acid-containing GIC, which has better Initially, calcium complexes predominate but later
surface hardness properties, and is more biocompatible. aluminium complexes are more prominent.
2. Gelation phase: At critical pH and ionic concentration,
10. Chlorhexidine Impregnated Glass Ionomer precipitation of insoluble polyacrylates takes place.
This initial set occurs because of calcium polyacrylate
Cement
but hardening of cement is due to the slow formation
It is developed to increase the anticariogenic action of GIC. of aluminium polyacrylate. This reaction occurs in
But this modification is still under experimental stage. 5–10 minutes after mixing and maturation takes place
over next 24 hours when aluminium polyacrylates
11. Nanotechnology in GICs form a rigid cross-linking structure. Water plays a
critical role in setting of GIC. It serves as the reaction
Nanotechnology involves the use of materials like TiO2,
medium initially and then slowly hydrates the cross-
nanoapatite, nano-fluorapatites that have size in the range
linked agents thereby yielding stable gel structure.
of 1–100 nm. This incorporation forms a high density of
3. Hardening and slow maturation: This phase occurs
particles within the GIC matrix, improving mechanical
when the mix reaches its final set. In this stage,
properties of the cement like increase in compressive,
continued attack of hydrogen ions causes delayed
tensile, and flexural strengths.
release of Al ions from silicate glass in the form of AlF3–
ions which are deposited in the already preformed
SETTING REACTION of GLASS IONOMER matrix to form a water-insoluble Ca-Al-Carboxylate
CEMENT gel. Aluminium ions are responsible for providing
strength to the cement.
Setting Reaction of Autocure Glass Ionomer
Cement Structure of Fully Set Cement
In autocure glass ionomer cement, the setting reaction It consists of glass particles surrounded by silica gel in
is an acid–base reaction between acidic polyelectrolyte a matrix of polyanions, cross-linked by ionic bridges
and aluminosilicate glass. It occurs in three different but (Fig. 26.5). Within the matrix are small particles of silica
overlapping stages (Fig. 26.4). gel-containing fluoride crystallites. Finally, a slow hydration
Fig. 26.6: Setting reaction of resin-modified glass ionomers.

Fig. 26.5: Structure of fully set cement.
of both the silica gel and the polycarboxylates occurs PROPERTIES OF GLASS IONOMER CEMENTS
which results in further improvement of cement’s physical
properties. This reaction may continue for several months. 1. Adhesion
Two clinically important results of setting reaction are: Glass ionomer cement is adhesive to tooth structure because
1. Physical properties of glass ionomer cements take bond strength to enamel is stronger than dentin due to
long time to fully develop because of cement’s long- inorganic content and greater homogeneity. For improved
setting reaction. adhesion, prepared tooth surface should be conditioned
2. Cement is sensitive to desiccation and moisture using 10–25% polyacrylic acid for 10–15 seconds.
contamination.
• If freshly mixed, cement is exposed to air without Mechanism of Adhesion (Fig. 26.7)
any protective covering, the surface will crack as a
◆◆ According to Wilson, Prosser, and Powis: When freshly
result of desiccation.
mixed cement is placed on the tooth, the polyalkenoic
• If freshly mixed cement gets exposed to moisture, it
acid attacks dentin and enamel and displaces
results in dissolution of matrix forming cations and
calcium and phosphate ions from hydroxyapatite.
anions.
An intermediate layer of calcium and aluminium
phosphates and polyacrylates by chemical bonding is
Setting Reaction of Resin-modified Glass formed.
Ionomers ◆◆ According to Wilson: Initial adhesion is by hydrogen
Two types of setting reactions occur in resin-modified bonding from free carboxylic groups. Later on these
glass ionomers: bonds are replaced by ionic bonds. Polymeric polar
1. Acid–base neutralization reaction chains of acids bridge the interface between cement
2. Free radical methacrylate cure. and the tooth.
Because of these two reactions, the following can be
accounted: 2. Fluoride Release
1. Formation of two different matrices—an ionomer salt
Glass ionomer cement contains 10–23% of fluoride which
hydrogel and poly-HEMA matrix. This whole system
lies free in the matrix. This fluoride is released mainly by
can inhibit acid–base reaction.
sodium and to lesser extent by calcium but not by fluoride
2. There are multiple cross-linking chain formations
content of glass. Fluoride release shows its peak in first 24
which occurs by acid–base reaction, light cure
hours after that mixing, after the rate of release decreases
reaction, and resin autocure mechanism.
and remains sustained for a period of 18 months (Fig. 26.8)
When powder and liquid are mixed and activated
(Wilson et al., 1985). The influence of fluoride action is
with light, a photoinitiated setting reaction starts. The
seen at least 3 mm around GIC restoration.
methacrylate group of polymer grafts into polyacrylic
acid chain and methacrylate groups of HEMA. This cross-
linking of HEMA and of methacrylate group of polymer Fluoride Recharge
causes hardening of the cement (Fig. 26.6). But acid–base Glass ionomer cement acts as a rechargeable fluoride
reaction continues for some days. releasing system. Glass ionomers have synergistic effects
when used with extrinsic fluorides.
Structure of set RMGI Application of topical fluorides, fluoridated dentifrices,
Set cement has either multiple cross-linked matrix or and mouth rinses help in recharging of glass ionomer with
matrix containing two separate phases of polysalt matrix fluorides. This capacity of GIC to recharge with fluoride is
and poly HEMA matrix. called reservoir effect. These recharged glass ionomers
Fig. 26.7: Mechanism of adhesion.
release fluoride from reservoir when it is depleted (Fig.

26.9). usually, thickly mixed cement releases more
fluorides than thinly mixed. Conventional GIC releases
more fluoride than resin-modified GIC.
3. Water Sensitivity
Conventional glass ionomer cement is sensitive to
moisture contamination during initial stage of setting
reaction and desiccation when cement begins to harden.
◆◆ If moisture contamination occurs in first 24 hours
of setting, calcium and aluminium ions leach out of
set cement, thus they are prevented from forming
polycarboxylates. This results in formation of chalky
Fig. 26.8: Fluoride release from glass ionomer cement.
Fig. 26.9: Fluoride recharge cycle.

and eroded rough surface of restoration with low are radiopaque in nature because of presence of silver and
surface hardness. heavy metal salts.
◆◆ If desiccation occurs during initial setting of cement,
it retards the setting reaction since water plays an
8. Solubility
important role in setting reaction.
◆◆ If desiccation occurs in later stages, it prevents Conventional GIC has low solubility as compared to RMGI
increase in strength of cement because hydration of which is even more resistant to solubility. Use of topical
silica-based hydrogel and polycarboxylates cannot fluorides and APF gel, etc. can erode the cement surface.
occur. It can also result in crazing, decreased aesthetics, In patients with xerostomia, GIC can undergo rapid
and early deterioration of the cement. disintegration so it should be used in such patients.
Therefore, to prevent moisture contamination and
desiccation of freshly-placed cement, surface of restoration
should be covered with low viscosity bonding resin,
9. Abrasion Resistance
varnish, cocoa butter or vaseline. Glass ionomers have low abrasion resistance than
composite resins, but cermet cement and RMGI show
4. Biocompatibility better resistance than conventional GIC.
Glass ionomer cements are biocompatible because:

◆◆ Polyacrylic acid present in the liquid is a weak acid. 10. Strength
◆◆ Dissociated hydrogen ions present in GIC are further Glass ionomer cements have high compressive strength
bound to the polymer chains electrostatically. and modulus of elasticity but low fracture toughness,
◆◆ Long polymer chains tangle with one another. This flexure strength, and wear resistance. This makes GICs a
prevents their penetration into dentin tubules. hard but brittle material. Therefore, it should not be used
in high stress-bearing areas. Cermet cement has more
5. Aesthetics strength but its fracture resistance remains low. Resin
modified glass ionomer has more flexural and tensile
Glass ionomer cement is available in different shades strength and lower modulus of elasticity as compared to
and as translucent material but its aesthetics is inferior conventional glass ionomer cement. These properties
to composite restoration. In conventional glass ionomer make RMGI more resistant to fracture but wear resistance
cements, translucency gets better over first 24 hours. But, has still not improved much.
in resin-modified glass ionomers, color matching, and
translucency can be achieved immediately after light
curing. These cements have shown good color stability. Advantages of GLASS IONOMER
Though glass ionomer cements are reasonably tooth- CEMENTS
colored and available in different shades (formed by
addition of pigments like metal oxides, ferric oxide), they 1. Adhesion
are still considered inferior to composites. Inherent adhesion to tooth structure because of chemical
Glass ionomers can be made more translucent by: bonding to enamel and dentin through ion exchange.
◆◆ Reducing fluoride content
◆◆ Using more translucent glasses
◆◆ Using tartaric acid, polymaleic acid, etc. for improving 2. Biocompatible
the properties of cement. GIC is biocompatible because large-sized polyacrylic
◆◆ Adding resin in RMGIs. acid molecules prevent the acid from producing pulpal
response.
6. Margin Adaptation and Leakage
Coefficient of thermal expansion of glass ionomer cement
3. Anticariogenic
is almost similar to that of the tooth. This is responsible for GIC is anticariogenic because of fluoride release. This
good marginal adaptation of glass ionomer restoration. fluoride can also be recharged from topical fluoride
applications.
7. Radiopacity
Conventional glass ionomer cements are radiolucent,
4. Conservative Tooth Preparation
but are made radiopaque by presence of lanthanum, Because of its adhesive nature, GIC requires minimal tooth
barium, and strontium. Metal-modified glass ionomers preparation.
5. Aesthetic 3. As Luting Agents

Good color matching and translucency makes it aesthetic. Glass ionomer is used for permanent cementation of
crowns, bridges, veneers, and orthodontic bands, because
6. Less Technique Sensitive it is adhesive, anticariogenic, has fine film thickness, and
low solubility.
Glass ionomers are less technique sensitive than composite
resins.
4. For restorations of Class I Lesions
7. Low Solubility Glass ionomer cement is indicated for buccal and palatal
pits of molars and lingual pits of anterior teeth.
Glass ionomers show less solubility than other cements.
Disadvantages of Glass Ionomer 5. For Restorations of Class III and Class V Lesions
Cements Lesions which are not under occlusal load can be
successfully restored with a glass ionomer alone.
1. Brittle and Low Fracture Resistance
Glass ionomers are brittle and have low fracture resistance 6. Restoration of Root Caries
when compared to composite restorations. They have low
Glass ionomer cement is the material of choice for
modulus of elasticity.
restoration of root caries because of its adhesion to dentin,
anticariogenicity, nearly aesthetic, and ease of use.
2. Low Wear Resistance
Glass ionomers show low wear resistance when compared 7. High Caries Risk Patients
to composite restorations.
High viscosity glass ionomers are used in caries
management of patients with high risk for caries because
3. Water Sensitivity During Setting Phase
of their adhesion, abrasion resistance, and anticariogenic
Glass ionomer is sensitive to moisture contamination properties.
and desiccation soon after placement, which can affect
physical properties and aesthetics. Therefore, it requires
moisture control during manipulation and placement.
8. Emergency Temporary Restorations
Fractured cusps or restorations can be temporarily
4. Opaque in Nature stabilized using glass ionomer because of property of
adhesion which gives retention even if mechanical support
Opacity of glass ionomer cement makes it less aesthetic is absent. GIC is used in covering the exposed dentin to
than composites.
provide patient comfort with minimal chair time.
5. Radiolucent
9. For Intermediate Restorations
Conventional glass ionomer is not inherently radiopaque.
Because of their adhesive nature and satisfactory
aesthetics, GICs are also used as interim restorations.
Indications OF GLASS IONOMER
CEMENT
10. For Core Build Up
1. As Pit and Fissure Sealants Glass ionomers cements can be used for building cores.
Use of glass ionomer cements as fissure sealants is Since GICs are inadequately strong to support major core
recommended especially in children with high caries risk buildups, so it is recommended that a tooth should have
because of anticariogenicity and adhesive properties. at least two structurally intact walls, if a GIC core is to be
considered.
2. As Liners and Bases
Glass ionomer is adhesive in nature and releases fluoride
11. In Endodontics
which not only prevents decay but also minimizes Glass ionomer cement can be used as core build up
incidence of secondary caries. It can be used beneath both material, root canal sealer, perforation repair material, and
composite resin and amalgam. as retrograde filling material.
Contraindications OF GLASS IONOMER this helps in preserving the facial enamel. Prepare butt-
CEMENTS joint cavosurface margins since glass ionomer is a
brittle material, it cannot be placed over the bevels.
1. In stress-bearing areas like class I, class II, and class ◆◆ Retention and resistance form: Since retention in glass
IV preparations because glass ionomers lack fracture ionomer is chemical in nature, so placing undercuts
toughness. and dovetail is not mandatory.
2. In cuspal replacement cases due to lack of strength ◆◆ Small grooves incisally or cervically may provide
and fracture resistance. additional retention form when required.
3. In patients with xerostomia because restorations can ◆◆ Convenience form: Lingual wall is sometimes broken
become opaque, brittle, and disintegrate over a short for access in maxillary teeth. Teeth may be mechanically
period of time. separated for convenience form.
4. In mouth breathers because restoration may become ◆◆ Pulpal protection: If less than 0.5 mm of remaining
opaque, brittle, and may fracture over time. dentin is present, calcium hydroxide liner is placed for
5. In areas requiring aesthetics like veneering of pulp protection.
anterior teeth.
Class v Tooth Preparation
CLINICAL STEPS FOR PLACEMENT
Indications:
Steps for Placement of GIC ◆◆ Patients with high caries incidence
1. Isolation ◆◆ When aesthetics is not of primary concern
2. Tooth preparation: ◆◆ In root surface lesions.
i. Cavity preparation steps:
ii. Surface conditioning ◆◆ Outline form: External outline form is limited to the
3. Manipulation of cement extension of the lesion.
4. Finishing and polishing ◆◆ Retention and resistance form: Retention is primarily
5. Surface protection. achieved by chemical bonding, so nothing special is
required for added retention. Prepare rounded grooves
1. Isolation into occlusal and cervical dentin wall, if required in
wider tooth preparations.
Saliva control is important for successful glass ionomer ◆◆ Pulp protection: Same as for class III.
restorations. If moisture contaminates the cement during
manipulation and setting, the gel will weaken and wash Class I Tooth Preparation
out prematurely. Commonly used methods for isolation are Indications:
rubber dam, retraction cords, cotton rolls, and saliva ejectors. ◆◆ Deep pits and fissures
◆◆ Recently erupted teeth in patients with high caries index.
2. Tooth Preparation Steps:
Tooth preparation for glass ionomer cement is done in two ◆◆ Outline form: Use a small round bur to enter in the
ways: fissure and remove carious dentin. After this, use fine
tapered fissure bur to widen the fissures. This fissure
i. Cavity Preparation widening helps in better flow and increased retention
Glass ionomer can be used for class III, class V, and small of glass ionomer cement (Figs. 26.10A and B).
class I and II tooth preparations.
Class iii Tooth Preparation

Glass ionomer is the material of choice to restore the class
III lesion when caries extends onto the root surface.
Indications:
◆◆ In patients with high caries index
◆◆ When caries extend onto the root surface
◆◆ In areas with low occlusal stress
◆◆ When labial enamel is intact.
Steps:
◆◆ Outline form: Using a small inverted cone bur, make
an access through lingual marginal ridge. Extend the
bur toward incisal or gingival area depending on caries. A B
This helps in maintaining aesthetics and exposing less Figs. 26.10A and B: (A) Class I tooth preparation; (B) Placement of
material to dehydration. Do not try to break the contact, glass ionomer cement.
◆◆ Retention form: Since glass ionomer cement bonds 3. Manipulation of the Cement
chemically to tooth structure, so no special retention
aid is required. Hand Mixing
◆◆ Convenience form: Widen the fissures properly for Powder liquid system (Fig. 26.12): Glass ionomer cement
better flow of the glass ionomer. is supplied as powder and liquid, paste-paste system, and
as pre-proportioned capsules. Manipulation of cement
ii. Surface Conditioning (Fig. 26.11) can be done as hand and mechanical. Mixing should be
done at room temperature for 40–60 seconds on a cool
For better adhesion of GIC to tooth structure, many
and dry glass slab or paper pad with the help of a flat and
conditioning agents have been used. These are 50% citric
firm agate spatula. If metal spatula is used for mixing, glass
acid, 10% EDTA, 20% polyacrylic acid, 3% hydrogen
particles of powder may abrade the metal and may cause
peroxide, and 25% tannic acid. Polyacrylic acid is the most
the mix to become gray in color.
commonly used conditioner.
For mixing, divide the powder into two equal portions.
Conditioner: Mix first portion of powder with liquid for 10–15 seconds,
◆◆ Removes smear layer then add 2nd half of powder and mix for another 15–20
◆◆ Promotes ion exchange seconds in folding motion by gently but rapidly folding
◆◆ Chemically cleans the dentin powder into the liquid. The objective is to wet the particles,
◆◆ Increases surface energy. and not dissolving them. Mixing should be completed
In resin-modified glass ionomers, an additional step within 40–60 seconds. Working time for glass ionomer
of priming the tooth surface is done in which primer is cement is 60–90 seconds.
applied in a thin coat and light cured for 20–40 seconds. ◆◆ For restoration, bring the mix together. One should
be able to pick up the mix without sticking to the
instrument.
◆◆ For luting consistency, “1 inch” string should be formed
when flat surface of spatula is pulled from the mixed
cement.
Paste-paste system: In paste-paste, equal proportion of
two pastes are delivered on paper pad. These are mixed to
form a uniform mixed cement.
Mechanical Mixing
In this, preproportioned capsules containing premeasured
powder and liquid are mixed using amalgamator. Mixed
cement is delivered into the cavity by nozzle attached to
syringe.
Loss of gloss/slump test: Final mixed cement should
have glossy appearance. Loss of gloss shows end of work-
ing time. it is 60–90 seconds for conventional cement and
Fig. 26.11: Surface conditioning. 3–3.5 minutes for resin-modified glass ionomers.
Fig. 26.12: Hand mixing method of GIC.

After mixing, glass ionomer cement is carried with the evaluated in Tanzania in 1980, and since then it has become
help of cement carrier for placement into the prepared very popular. It allows restorative treatments in places with
tooth. For optimal restoration and to reduce the number no electricity and without the aid of sophisticated dental
of voids, use of matrix is always advisable. After placing equipment. ART restores tooth decay without using the
the cement, the gross excess is removed immediately drill or injecting a local anesthetic. It involves the removal
and final contouring is done. In case of chemically cure of carious lesions by hand instruments such as spoon
glass ionomer, matrix is held till the initial hardening excavators, sometimes, together with a caries softening
of cement starts but in case of light cure glass ionomers, gel. After the caries is removed, the tooth is restored with
photoactivation can be done for accelerated setting. high viscosity glass ionomer cement.
4. Finishing and Polishing Indications of ART Technique

As we know, surface of glass ionomers is sensitive to both 1. Areas without electricity and sophisticated dental aids
moisture contamination and dessication. During initial 2. Children from poor families
phase of cement setting, it is always preferred to delay 3. In homes for mentally and physically disabled, and the
finishing and polishing of glass ionomer cements. It is elderly patients
delayed for at least 24 hours after the cement placement 4. Small to moderate pit and fissure caries.
because by then, the surface of restoration attains ionic
equilibrium in the environment. But in case of resin- Steps for ART Technique
modified glass ionomer cements, finishing is started after
their placement. ◆◆ Tooth is isolated using cotton rolls
After placing the restoration, gross finishing is done ◆◆ Access is made by breaking off undermined enamel
following the matrix removal. Before starting the finishing ◆◆ After removal of soft demineralized dentin by exca
procedure, the surface of restoration is coated with vation, tooth is restored using a modified GIC. This
protective agent. A sharp knife is used to remove the modified GIC is basically reinforced GIC so as to give
extra cement. For this, rotary or hand cutting instruments increased strength under functional loads and is radio
can also be used, though it is believed that hand cutting paque in nature.
instruments can tear or pull the restoration margins leading ◆◆ Restored tooth is contoured and occlusion is checked.
◆◆ Since no rotary instruments can be used, all adjustments
to marginal breakdown. Final finishing of restoration is
should be completed while the restorative material is in
done with the help of superfine diamond points, soflex
a workable state.
disk, and abrasive strips in moist condition. After final
◆◆ Restoration is covered using petroleum jelly.
finishing and polishing is done, surface of restoration is
protected using petroleum jelly, varnish or bonding agent.
Advantages
5. Surface Protection ◆◆ Mechanics needed for ART does not require compli
cated mechanical instrument.
Since glass ionomers show sensitivity to both moisture ◆◆ Employs use of already present hand instruments.
contamination and surface desiccation, the newly placed ◆◆ Minimal discomfort to patient.
restoration should always be protected immediately after ◆◆ Low-cost of the treatment.
matrix removal so as to prevent water exchange. It can be ◆◆ Safe and cost effective treatment.
done with the help of resin-bonding agent, cocoa butter, ◆◆ Minimal intervention dentistry.
petroleum jelly or varnish. Among these, resin-bonding ◆◆ Advantages of glass ionomer cements in form of
agents provide the best surface protection as they fill the adhesion, biocompatibility, and anticariogenicity.
microporosities of the surface and stay for longer time in
comparison to other agents. Disadvantages
OTHER CLINICAL APPLICATIONS OF GLASS ◆◆ Poor access and visibility, especially in posterior region
◆◆ Hand fatigue during instrumentation.
IONOMERS
Other clinical applications of glass ionomers are discussed Sandwich Technique
below:
Term “sandwich technique” refers to a laminated
restoration techique using glass ionomer to replace dentin
atraumatic Restorative Treatment and composite resin to replace enamel. This technique was
Atraumatic restorative treatment (ART) was introduced in developed by McLean et al. in 1985. Composite resin bonds
South Africa by Jo Frencken in 1996. This technique was first micromechanically to the set glass ionomer and chemically
to the HEMA in resin-modified glass ionomers. Because of ◆◆ It is only necessary to etch a GIC with acid if the
sandwich technique, one gets the advantages of both the restoration has been in place for some time and
materials, viz. glass ionomer’s anticariogenicity, chemical has fully matured. If the GIC is freshly placed and is
adhesion, fluoride release, reduced microleakage and immature, bonding can be achieved simply by washing
remineralization, and composite resin’s enamel bonding, the GIC surface because water causes washout of GIC
surface finish, durability, and aesthetic superiority. matrix from around the filler particles which gives
microscopically rough surface to which the composite
Synonyms of Sandwich Technique will adhere.
Replacement dentin technique ◆◆ Now coat the surface of prepared tooth either with an
Bilayered technique unfilled resin or a dentin bonding agent for optimal
Laminate restoration technique. adhesion and cure it for 20 seconds.
◆◆ Place composite and cure in usual manner.
To achieve optimal results from sandwich technique,
Indications of Sandwich Technique the following should be done:
◆◆ Large Class III, IV, V, and class I and II lesions ◆◆ Use high strength glass ionomer available.
◆◆ When any part of gingival margin of class II has been ◆◆ Before placing glass ionomer, condition the tooth
extended past CEJ. preparation for better adhesion.
◆◆ Before placing composite over glass ionomer, let the
glass ionomer set fully.
Types of Sandwich Technique ◆◆ Before placing composite, remove glass ionomer from
Closed sandwich technique: In this, underlying gic does margins to expose the enamel as composite-enamel
not come in contact with the oral cavity (Fig. 26.13A). bond is the strongest.
◆◆ Glass ionomer cement should be radiopaque in nature.
Open sandwich technique: it is usually for class II
◆◆ Contact area should be built with composite resins, not
restorations, underlying GIC forms the part of axial wall
glass ionomers.
and is exposed to oral cavity (Fig. 26.13B).
Advantages
Steps of Sandwich Technique
◆◆ Open Sandwich technique is used for deep class II
◆◆ Isolate the tooth and carry out tooth preparation. forms where the cervical margin lacks enamel, shows
◆◆ Keep the cavosurface margins involving dentin as improved resistance to microleakage and caries in
butt joint. Bevel the enamel margins to increase the comparison to resin bonding at a dentin margins.
composite resin bonding. ◆◆ Better strength, aesthetics, and finish of composite
◆◆ Provide pulp protection using calcium hydroxide base, resins.
if indicated. ◆◆ Fluoride release from GIC.
◆◆ Condition the prepared tooth using polyacrylic acid for ◆◆ Reduced bulk of composite resins pose less polymeri
optimal adhesion of GIC. zation shrinkage.
◆◆ Place freshly mixed fast setting GIC in the prepared ◆◆ Minimizes the number of increments of composite
tooth. resin to be placed, so saves time.
A B
Figs. 26.13A and B: (A) In closed sandwich technique, underlying GIC does not come in contact with the oral cavity; (B) In open sandwich
technique, underlying GIC is exposed to oral cavity.
◆◆ Use of GIC eliminates acid etching of dentin and thus Advantages
reduces postoperative sensitivity caused by incomplete
sealing of etched dentin. ◆◆ Conservative tooth preparation
◆◆ Preservation of marginal ridge
◆◆ Good pulpal response because of biocompatibility of
◆◆ Less damage to adjacent tooth structure
GIC.
◆◆ If carious structure is more extensive than originally
thought, tunnel preparation can be easily converted to
Disadvantages traditional class II design
◆◆ Technique sensitive ◆◆ Results in more aesthetic restoration
◆◆ Time consuming. ◆◆ Less microleakage
◆◆ Less chances of proximal overhang
Tunnel Preparation ◆◆ Since caries usually starts below contact point, contact
area is preserved
A tunnel preparation is made for removal of proximal ◆◆ Cost effective.
caries by making an access through occlusal surface while
leaving the marginal ridge intact. This technique was
Disadvantages
first used in primary molars by Jinks in 1963. Hunt and
Knight later on used this technique for restoration of small ◆◆ Difficult to fill and finish
proximal carious lesions. ◆◆ Difficult to practice
◆◆ Needs precise control during preparation
Indications ◆◆ More chances of developing secondary caries
◆◆ Reduces strength of marginal ridge
◆◆ Indicated when life expectancy of tooth is not more
◆◆ More chances of injury to pulp or periodontium
than 5 years like in deciduous teeth or mobile teeth in
geriatric patients. ◆◆ Limited access and visibility
◆◆ Incipient proximal lesions of posterior teeth. ◆◆ Anatomical landmarks are not clear
◆◆ Low caries index of patient. ◆◆ Poor marginal adaptability of restoration
◆◆ Risk of incomplete removal of caries.
Contraindications
Steps
◆◆ When proximal decay undermines the marginal ridge.
◆◆ Difficult access. ◆◆ Before initiating the treatment, determine location and
◆◆ Excessive occlusal loading on marginal ridges. extent of the caries (Fig. 26.14A).
A B C
D E F
Figs. 26.14A to F: Steps of tunnel preparation. (A) Determine location and extent of the caries; (B) Start tooth preparation by using round bur 2
mm inside the marginal ridge; (C) Angle of bur should be 45° to the carious lesion; (D) Place a matrix band on proximal surface; (E) Pack the glass
ionomer cement; (F) Final restoration after tunnel preparation.
◆◆ Isolate and dry the tooth to be restored with tunnel Viva Questions
preparation.
1. Who introduced GIC in the dentistry and when?
◆◆ Place a wedge cervical to carious proximal portion.
2. Tell different names of GIC.
◆◆ Penetrate the occlusal surface of tooth with a round bur.
3. Classify GIC.
Entry of bur should be 2 mm inside the marginal ridge
4. Name man-made dentin.
(Fig. 26.14B). Angle of bur should be 45° to the carious
5. What is the composition of GIC?
lesion (Fig. 26.14C). 6. Who introduce metal-reinforced GIC?
◆◆ After enamel has been penetrated, spoon excavator is
7. What will happen if freshly mixed cement gels exposed
used to remove the caries. Use periodontal probe to
to moisture?
measure the depth of the lesion. Widen the preparation
8. What is the setting time of GIC?
using tapered fissure bur.
9. What is the film thickness of GIC?
◆◆ Now remove the caries by cutting into proximal lesion
10. What are the indications and contraindications of
and remove the wedge to see the extent of preparation.
GIC?
◆◆ Once the complete caries removal is confirmed, place
a matrix band and wedge on the proximal surface so as 11. Enumerate the properties of GIC.
to avoid overhanging restoration and injury to gingiva 12. How much percent GIC contains fluoride?
(Fig. 26.14D). 13. Which variety of GIC cement is radio-opaque?
◆◆ Use restorative material and condense it from occlusal 14. What are the uses of GIC?
surface, avoiding any void (Fig. 26.14E). 15. Why GIC is used as luting agent also?
◆◆ Remove wedge and matrix and do final finishing and 16. What is sandwich technique?
polishing of the restoration (Fig. 26.14F). 17. What are clinical steps for placement of GIC?
◆◆ After completion of the preparation, take a radiograph 18. What is tunnel preparation?
to confirm the complete removal of the carious lesion 19. After how many hours we should finish and polish
and soft dentin. GIC restoration?
CONCLUSION BIBLIOGRAPHY
Glass ionomer cements (GICs) have proven to be useful in 1. Al Otaibi G. Recent advancements in glass ionomer materials
with introduction of nanotechnology: A review. Int J oral care
restorative dentistry. Many advantages of GIC include res. 2019;7(1):21-3.
its ability to bind chemically with tooth structures, 2. Frencken JE, Songpaisan Y, Phantumvanit P, et al. An atraumatic
anticariogenicity due to fluoride ion release and recharge, restorative treatment (ART) technique: evolution after one year.
low coefficient of thermal expansion, and acceptable Int Dent J. 1994;44:460.
aesthetics. But major concern of conventional glass 3. Hunt PR. A modified class II cavity preparation for glass ionomer
restorative materials. Quintessence. 1984;10:1011.
ionomers is their brittleness and low wear resistance.
4. Mitra SB, et al. Setting reaction of Vitrebond light cure glass
Many modifications are being done in glass ionomers to ionomer liner/base. Trans Acad Dent Mater. 1992;5:1-22.
have improved physical properties so that it can be used as 5. Mount GJ. Restoration with glass ionomer cements.
a material of choice in future. Requirement for clinical success. Oper Dent. 1985;6:59.
6. Mount GJ. Some physical and biological properties of glass
ionomer cement. Int Dent J. 1995;45:135.
EXAMINER’S CHOICE Questions 7. Najeeb S, Khurshid Z, Zafar MS, et al. Modifications in
1. Classify GICs. What are their advantages and glass ionomer cements: nano-sized fillers and bioactive
disadvantages? nanoceramics. Int J Mol Sci. 2016;17:1134.
8. Restorative Department, Riyadh Elm University, Riyadh,
2. What is composition of glass ionomer cement? Write
Kingdom of Saudi Arabia. 2019 International Journal of Oral
in detail setting reaction of GIC. Care and Research | Published by Wolters Kluwer – Medknow
3. Classify various cements used in dentistry. Describe 9. Ruse ND. What Is a “Compomer”? J Can Dent Assoc. 1999;65(9):
in detail about the composition, setting reaction, 500-4.
advantages, disadvantages, properties, and uses of 10. Sajjad A, Bakar WZW, Mohamad D, et al. Various recent
glass ionomer cement. reinforcement phase incorporations and modifications in glass
4. Write short notes on: ionomer powder compositions: A comprehensive review. J Int
Oral Health. 2018;10(4):161-7.
a. Fluoride release property of GIC.
11. Silvey RG, Myers GE. Clinical study of dental cements: VII.
b. ART technique. A study of bridge retainers luted with three different dental
c. Sandwich technique. cements. J Dent Res. 1978;57:703-7.
d. Adhesion of GIC. 12. Srikumar GPV, Naiza E, Mookambika R, et al. Newer advances
e. Tunnel restoration. in glass ionomer cement: A review; 2016.
Chapter
27
Dentin Hypersensitivity
Chapter Outline
Introduction Diagnosis
Definition Treatment
Historic Review Ideal Properties of a Desensitizing Agent
Theories of Dentin Hypersensitivity Classification of Desensitizing Agents
Incidence and Distribution Recent Trends to Treat Dentin Hypersensitivity
Etiology and Predisposing Factors
Differential Diagnosis
INTRODUCTION ◆◆ Lukomsky (1941) advocated sodium fluoride as a

desensitizing obtundent.
Dentinal hypersensitivity is a common clinical condition ◆◆ Brannstrom (1962) described hydrodynamic theory of
frequently associated with exposed dentinal surfaces. It dentinal pain.
can affect patients of any age group and most commonly ◆◆ Kleinberg (1986) summarized different approaches
affect the canines and premolars of both the arches. The that are used to treat hypersensitivity.
most common symptom reported by patient is a sharp
transient pain produced by one of several different stimuli: Theories of dentin hypersensitivity
thermal, chemical, tactile, evaporative, and osmotic.
But it should be differentiated from tooth sensitivity Several theories have been proposed over more than a
which may elicit from other clinical conditions such as century to explain the mechanism involved in dentin
dental caries, microleakage, cracked tooth or fractured hypersensitivity like direct stimulation theory, odonto
restorations. The clinical management of hypersensitivity blastic transduction theory, and hydrodynamic theory
has been a challenge for clinicians. (Fig. 27.1).
DEFINITION 1. Direct Stimulation Theory/Neural Theory

Dentin hypersensitivity is defined as “sharp, short pain Neural theory attributes to activation of nerve endings
arising from exposed dentin in response to stimuli lying within the dentinal tubules. It says that stimuli
typically thermal, evaporative, chemical, tactile or osmotic initially excites the nerve ending with in the dentinal
and which cannot be ascribed to any other form of dental tubule which is conducted along the parent primary
defect or pathology”. afferent nerve fibers present in the pulp to dental nerve
—Holland et al. 1997 branches and then to brain.
But this theory failed because:
◆◆ Nerves in dentinal tubules are not commonly seen and
HISTORIC REVIEW
even if they are present, they do not extend beyond
◆◆ Leeuwenhoek (1678) described “tooth canals in dentin”. inner dentin.
◆◆ JD White (1855) proposed that dentinal pain was caused ◆◆ Topical application of local anesthetics does not abolish
by movement of fluid in dentinal tubules. the sensitivity.
such as cold stimuli stimulate fluid to flow away from

the pulp creating more rapid neural responses than
heat stimuli, which cause somewhat sluggish fluid flow
toward the pulp. This is aligned with the observation
that dentin hypersensitivity patients more frequently
complain of pain in response to cold stimuli than to heat.
Pain produced when sugar or salt solutions are placed
in contact with exposed dentin can also be explained by
dentinal fluid movement. Dentinal fluid is of relatively
low osmolarity, which has tendency to flow toward
solution of higher osmolarity, i.e. salt or sugar solution
(Fig. 27.2).
Fig. 27.1: Mechanism of dentin hypersensitivity: (1) Direct stimulation

theory says stimuli initially excite the nerve ending within the dentinal
tubule which is then conducted along primary nerve fiber; (2) Odonto-
blastic transduction theory says that stimuli initially excite odontoblas-
tic process and then due to synapse-like relation between odonto-
blastic processes and sensory nerve endings impulse is transmitted to
brain; (3) Hydrodynamic theory says stimuli causes outward or inward
movement of fluid of dentinal tubules, which in turn activates mecha-
noreceptors present on A delta fibers.
◆◆ Newly erupted teeth are sensitive even when plexus of

nerves are not yet established.
2. Odontoblastic Transduction Theory Fig. 27.2: Schematic representation of hydrodynamic theory.
This theory assumed that odontoblast process is the

primary structure excited by stimulus and then due to INCIDENCE AND DISTRIBUTION
synapse-like relation between odontoblastic processes
and sensory nerve endings impulse is transmitted to brain. ◆◆ Most commonly seen in 20–40 years of age.
But, this theory also failed because: ◆◆ Females are affected more than males.
◆◆ No evidence of neurotransmitter found in odonto ◆◆ Reduced incidence of dentin hypersensitivity in older
blastic processes. individuals may occur because of sclerosis of dentin,
◆◆ Membrane potential of odontoblastic process is too low deposition of secondary dentin, and fibrosis of the pulp.
to permit transduction. These all interfere with the hydrodynamic transmission
◆◆ Failed to explain dentin sensitivity even after destruction of stimuli through exposed dentin.
of odontoblastic layer.
Intraoral Distribution
3. Hydrodynamic Theory
◆◆ Hypersensitivity is most commonly seen on buccal
The currently most accepted mechanism of dentin cervical zones of permanent teeth. Although any tooth
hypersensitivity is the hydrodynamic theory which was may get affected, but canines and premolars in either
proposed by Brännström in 1964. According to this jaw are the most frequently involved.
theory, when the exposed dentin surface is subjected ◆◆ Regarding the side of mouth, in right-handed
to thermal, chemical, tactile or evaporative stimuli, toothbrushers, the dentin hypersensitivity is greater
the fluid flow within the dentin tubules moves either on the left-sided teeth compared with the equivalent
in outward or inward direction. This fluid movement contralateral teeth.
activates the mechanoreceptors present on A delta
fibers. Accordingly, the number and the diameter of
the dentin tubules are considered important factors in
ETIOLOGY AND PREDISPOSING FACTORS
initiating pain from dentin hypersensitivity. Hence, the Dentin is covered by enamel in the crown region and by
higher the number and greater the diameter of the open cementum in the radicular region. Dentin may become
dentin tubules, the more intense will be the pain from exposed by two processes; either by loss of enamel or by
dentin hypersensitivity. It has been noted that triggers loss of cementum (Flowchart 27.1).
Dentin Hypersensitivity 363
Flowchart 27.1: Etiology and predisposing factors of dentin hyper- Table 27.1 is showing the distinguishable features of
sensitivity. different types of dental pain which may lead to a correct
diagnosis of dentin hypersensitivity.
Table 27.1: Differential diagnosis of dentin hypersenstivity.
Differential
diagnosis Confounding features
Cracked tooth Sharp intermittent pain elicited on biting
syndrome as the occlusal force increases and relief of
pain occurs on withdrawal of pressure. Test
is done by using bite test, a tooth slooth, or
tapping of a single cusp.
Chipped teeth • Enamel fracture shows superficial, rough
edges which may cause tongue or lip
irritation, but there is no sensitivity or pain.
• Enamel and dentin fracture may show
rough edge on the tooth and it is usually
accompanied by tooth sensitivity or pain.
Pulpitis • Reversible pulpitis induces sharp pain
produced by cold, or sweet. The pain
disappears after stimulus is removed.
• Irreversible pulpitis shows severe, sharp,
throbbing, intermittent or continuous pain
that may keep the patient awake at night.
Pain is induced by hot, chewing, lying flat,
DIFFERENTIAL DIAGNOSIS and persists after removal of stimulus.
Dentin hypersensitivity is perhaps a symptom complex Periapical Deep continuous dull pain increased on
rather than a true disease and results from stimulus periodontitis biting.
transmission across exposed dentin. A number of dental Pericoronitis Deep continuous dull pain increased on
conditions are associated with dentin exposure and, biting.
therefore, may produce the same symptoms. Bleaching It occurs due to penetration of bleaching
sensitivity agent into pulp chamber, taking the form of
Such conditions include: reversible pulpitis.
◆◆ Chipped teeth
Iatrogenic During cavity preparation: Pain may occur
◆◆ Fractured restoration sensitivity due to:
◆◆ Restorative treatments • Heat generation during cutting of tooth
◆◆ Dental caries structure.
◆◆ Cracked tooth syndrome • Excessive pressure during cutting.
• Vibration due to bur eccentricity.
◆◆ Other enamel invaginations. • Dentin desiccation which may cause water
imbalance in dentin contributing toward
DIAGNOSIS sensitivity of vital dentin.
• Postoperative pain: It can be because of
A careful history together with a thorough clinical and following reasons:
radiographic examination is necessary before arriving at − For composite restoration,
a definitive diagnosis of dentin hypersensitivity. Identify postrestorative hypersensitivity may
etiological and predisposing factors, and make differential occur due to leakage, improper bonding
diagnosis to exclude all other dental conditions. Check procedure, or fractured restoration.
− For amalgam restoration, reason can
for evidence of tooth wear like attrition, abrasion,
be lack of pulp protection, leakage,
erosion, gingival recession, etc. Check about the past fractured restorations, premature
dental treatments like vital tooth bleaching, periodontal contacts or galvanic stimuli.
procedures, and medical conditions that result in tooth
wear like bulimia and gastroesophageal reflux disease
(GERD). TREATMENT
A simple clinical method of diagnosing dentin hyper Hypersensitivity can resolve without the treatment
sensitivity includes a jet of air or using probe or explorer or may require several weeks of desensitizing agents
on exposed dentin in mesiodistal direction. before improvement is seen. In some cases, pain
hypersensitivity is self-limiting because of decrease in ideal properties of a desensItizing

dentin permeability due to following reasons: agent
i. Formation of reparative dentin.
ii. Dentin sclerosis causing obliteration of tubules by According to Grossman et al. 1931, an ideal desensitizing
formation of mineral deposits. agent should:
iii. Calculus formation on the surface of dentin. • Be readily acting with long-term effects
Management of dentin hypersensitivity should be initially • Be painless and easy to apply
focused on its prevention, i.e. to eliminate the predisposing • Be nonirritating to the pulp
factors. Prevention of dentin hypersensitivity includes: • Be well-tolerated by patients
i. Ensure proper oral hygiene practice like correct tooth • Not stain the tooth.
brushing technique, use of nonabrasive dentifrice, etc.
ii. Avoid excessive brushing with excessive pressure.
iii. Avoid brushing immediately after taking acidic drinks. Classification of desensitizing
iv. Avoid overinstrumentation of root surfaces during agents
scaling and root planing.
1. Mode of administration
v. Avoid taking food causing erosive loss of tooth
− At home desensitizing agents
structure.
− In-office treatment
vi. Manage patient with gastroesophageal reflux disease 2. On the basis of mechanism of action
(GERD) by medical help, fabrication of occlusal splint A. Nerve desensitization
so as to cover affected areas, and prevent their contact - Potassium nitrate
with acids. B. Protein precipitation
Since dentin hypersensitivity is caused by fluid - Glutaraldehyde
movement in dentinal tubules which stimulate the - Silver nitrate
peripheral nerve endings, the principal treatment options - Zinc chloride
for dentin hypersensitivity are shown in Figure 27.3: - Strontium chloride hexahydrate
1. Occlude the dentinal tubules: It is done by C. Plugging dentinal tubules
- Strontium acetate
a. Formation of smear layer and plugging the tubule
- Sodium floride
openings
- Stannous fluoride
b. Increasing formation of intratubular dentin - Potassium oxalate
c. Inducing formation of tertiary dentin - Calcium phosphate
2. Decreasing intradental nerve excitability. - Calcium carbonate
- Bioactive glasses (SiO–PO–CaO–NaO)
D. Dentin adhesive sealers
- Fluoride varnishes
- Oxalic acid and resin
- Glass ionomer cements
- Composites
- Dentin bonding agents
E. Periodontal soft tissue grafting
F. Anti-inflammatory corticosteroids
G. Crown placement and restorative materials
H. Lasers
- Neodymium:yttrium aluminium garnet (Nd-YAG) laser
- GaAlAs (Galium-aluminium-arsenide laser)
- Erbium-YAG laser
I. Homeopathic medication
- Propolis
Home Care with Dentifrices

Dentifrices
Dentifrices containing 10% strontium chloride or 5%
potassium nitrate or sodium monofluorophosphates are
effective in treating dentin hypersensitivity. Potassium
Fig. 27.3: Treatment options for management of dentin nitrate acts by penetrating A delta fibers reducing their
hypersensitivity. excitability.
Dentin Hypersensitivity 365
In-office Treatment Procedure anti-inflammatory, antioxidant, antimicrobial, and
anesthetic properties. Flavonoids present in propolis are
1. Varnishes, Fluoride Varnish main active agents capable of stimulating reparative dentin
Open tubules can be covered with a thin film of varnish, formation and thus reduce dentin permeability efficiently.
providing a temporary relief; varnish such as copalite can
be used. For sustained relief, a fluoride-containing varnish Recent trends to treat dentin
(example sodium fluoride and stannous fluoride) can hypersensitivity
reduce the hypersensitivity because fluoride decreases the
dentinal permeability by precipitating calcium fluoride 1. Arginine-based Product Pro-ArginTM
crystals in the tubules. Pro-Argin is available as home care toothpaste that can
be indicated in association with the in-office treatment. It
2. Dentin Bonding Agents uses arginine, an amino acid, bicarbonate (pH buffer), and
Dentin bonding agents can be applied to seal the dentinal calcium carbonate as source of calcium. Its mechanism of
tubules. 5% glutaraldehyde when combined with 35% action is based on the role that saliva plays an important
HEMA causes coagulation of proteins inside the dentinal role in reducing the dentin hypersensitivity. Arginine is
tubules. positively charged, it binds to negatively charged tubules,
thus attracting a calcium rich layer from saliva to infiltrate
3. Oxalates and block the dentinal tubules. This dentin plug is rich in
phosphate, calcium, and carbonate, and reduces the flow
oxalates precipitate and occlude the open dentinal of dentinal fluid in the tubules. It is applied by slow speed
tubules. They react with calcium ions of dentin and form handpiece on exposed dentin. It provides the instant relief.
calcium oxalate crystals inside the dentinal tubules as well
as on the surface of dentin. 3% potassium oxalate reduces 2. Laser
hypersensitivity but it should not be used for long time as
it can cause gastric irritation. The laser therapy has been proposed for treatment of
dentin hypersensitivity because it is painless for the
4. Gingival Grafts patient. Mechanisms of action performed by different
types of laser are:
Gingival grafts are indicated in cases where gingival ◆◆ Occlusion of dentinal tubules, for example, Nd-YAG.
recession is progressive and treatment is not responding ◆◆ Alteration of nerve transmission, e.g. GaAlAs
to conventional methods. ◆◆ Deposition of insoluble salts in dentinal tubules, e.g.
Er:YAG laser.
5. Anti-inflammatory ◆◆ Coagulation of proteins within the tubules and blocking
0.5% solution of prednisolone on exposed root surface the fluid movement.
induces remineralization resulting in occlusion of dentinal
tubules. 3. Bioglass
It contains calcium sodium phosphosilicate bioactive
6. Fluoride Iontophoresis glass and comes under the trade name of NovaMin. In this,
Iontophoresis is a term applied to the use of an electrical silica is the main component which acts as nucleation site
potential to transfer ions into the body for therapeutic for precipitation of calcium and phosphate. When applied
purposes. The objective of fluoride iontophoresis is to on dentin, it forms the apatite layer which occludes the
drive fluoride ions more deeply into the dentinal tubules tubule.
that cannot be achieved with topical application of fluoride
alone. 4. Casein Phosphate
The casein phosphopeptide (CPP) contains phosphoseryl
Homeopathy sequences which get attached and stabilized with
amorphous calcium phosphate (ACP). The stabilized CPP–
Propolis
ACP prevents the dissolution of calcium and phosphate ions
Propolis is a natural, nontoxic, and resinous substance, and maintains a supersaturated solution of bioavailable
which is collected by honey bees from sprouts, exudates calcium and phosphates. Various studies have shown
of trees, and other accessible parts of the plants. that CPP–ACP can effectively remineralize the enamel
Chemically, propolis consists of about 50–60% resins, subsurface lesions. Due to its remineralizing capacity, it is
30–40% wax, 5–10% essential oils, etc. Propolis exhibits used to prevent and treat dentin hypersensitvity.
5. Nanodentistry a. Hydrodynamic theory.

b. In-office treatment of dentin hypersensitivity.
Nanomaterials are those materials with component less
than 100 nm in dimension. Recently, nano-hydroxy,
VIVA QUESTIONS
apatite paste technology has been developed in dentistry
for the remineralization of carious lesions and treatment 1. Which is most accepted theory of dentin
of dentin hypersensitivity. Nano-HAP uniformly occludes hypersensitivity?
the dentinal tubules with a dentinal plug and forms a 2. Dentinal fluid movement activates mechanoreceptors
protective layer on the surface of the dentine, thus reducing of which fiber.
the dentin hypersensitivity, which is shown in Figure 27.4. 3. Right handed tooth brushers affects which quadrant/
side.
4. Which teeth are affected the most in dentin
hypersensitivity?
5. Discuss the incidence of dentin hypersensitivity.
6. What are predisposing factors of dentin
hypersensitivity?
7. Discuss differential diagnosis of dentin
hypersensitivity.
8. Discuss differential diagnosis of dentin hyper
sensitivity.
9. What is mechanism of action of CCP-ACP?
10. Discuss the LASERs in hypersensitivity treatment.
11. What is mechanism of action of hot/cold stimulus
with respect to fluid movement?
Fig. 27.4: Nano-HA occludes the dentinal tubules BIBLIOGRAPHY

uniformly by forming dentinal plug.
1. Addy M. Dentin hypersensitivity: new perspectives on an old
problem. Int Dent J. 2002;52:367-75.
Conclusion 2. Addy M, Mostafa P, Newcombe RG. Dentin hypersensitivity: The
Dentin hypersensitivity is common yet difficult to diagnose. distribution of recession, sensitivity and plaque. J Dent. 1987;
15:242-8.
Thorough history and clinical examination can help to
3. Dababneh R, Khouri A, Addy M. Dentin hypersensitivity: An
differentially diagnose it from other conditions causing enigma? A review of terminology, epidemiology, mechanisms,
dental pain and sensitivity. Once diagnosed, the main aetiology and management. Br Dent J. 1999;187:606-11.
aim should be implementing the preventive strategies by 4. Hussain RAH, Dannan A, Al-Ahmad MN, et al. Propolis
eliminating the predisposing factors for causing dentin Treatment for dental sensitivity after tooth bleaching. IJIR. 2016;
hypersensitivity. Depending upon the severity, clinical 2(5):143-6.
5. Karim BF, Gillam DG. The efficacy of strontium and potassium
management may include both at home therapies and in
toothpastes in treating dentin hypersensitivity: a systematic
office treatment. review. Int J Dent. 2013; 2013:573258.
7. Miglani S, Aggarwal V, Ahuja B. Dentin hypersensitivity: recent
EXAMINER’S CHOICE QUESTIONS trends in management. J Conserv Dent. 2010;13(4):218-24.
6. Orchardson R, Gillam DG. Managing dentin hypersensitivity. J
1. Define dentin hypersensitivity. Am Dent Assoc. 2006;137(7):990-8.
2. How will you manage a case of dentin hypersensitivity? 8. Schmidlin PR, Sahrmann P. Current management of dentin
3. Write short notes on: hypersensitivity. Clin Oral Investig. 2012;17(S1):55-9.
Chapter
28
Tooth Whitening
Chapter Outline
Introduction Bleaching of Vital Teeth

Classification of Discoloration Vital Bleaching Techniques
Bleaching Bleaching of Nonvital Teeth
Bleaching Agents Effects of Bleaching Agents on Tooth and its Supporting
Mechanism of bleaching Structures
Introduction Classification of Discoloration

Teeth are polychromatic so color varies among the gingival, Color of the teeth is influenced by a combination of their
incisal, and cervical areas according to the thickness, intrinsic color and presence of any extrinsic stains on
reflections of different colors, translucency, and thickness the tooth surface. Intrinsic tooth color is associated with
of enamel and color of dentin (Fig. 28.1). Thickness of light scattering and adsorption properties of enamel and
enamel is greater at the occlusal/incisal third of the tooth dentin, where dentin plays a major role in determining
and thinner at the cervical third. That is why, teeth are the overall shade. Extrinsic stains form due to smoking,
darker on cervical one-third than at middle or incisal dietary intake of tannin-rich foods, use of some cationic
one-third. Normal color of primary teeth is bluish white, agents like chlorhexidine, or metal salts like tin and iron.
whereas color of permanent teeth is grayish yellow, grayish So, discoloration of teeth can be classified as:
white, or yellowish white. With age, the color of teeth ◆◆ Intrinsic discoloration
changes to more yellow or grayish yellow due to increase in ◆◆ Extrinsic discoloration
dentin thickness and decrease in enamel thickness. ◆◆ Combination of both.
Intrinsic Stains
1. Preeruptive Causes
These are incorporated into the deeper layers of enamel
and dentin during odontogenesis and alter the develop
ment and appearance of the enamel and dentin.
i. Alkaptonuria: Dark-brown pigmentation of primary
teeth is commonly seen in alkaptonuria.
ii. Hematological disorders:
◆◆ Erythroblastosis fetalis: In this, stain is usually green,
brown, or bluish in color.
◆◆ Congenital porphyria: It is an inborn error of porphyrin
metabolism, characterized by overproduction of
uroporphyrin. Teeth show red or purplish discoloration.
Fig. 28.1: Normal anatomical landmarks of tooth: A. Cervical margin, ◆◆ Sickle cell anemia: In this, stain is green, brown, or
B. Body of tooth, C. Incisal edge, and D. Translucency of enamel. bluish in color.
iii. Diseases of enamel and dentin—Amelogenesis

imperfecta (AI): It comprises a group of conditions that
demonstrate developmental alteration in the structure of
the enamel in the absence of asystemic disorders.
iv. Fluorosis: Fluorosis staining manifests white opaque
areas on teeth, yellow to brown discoloration, moderate
and severe changes showing pitting, and brownish
discoloration of surface (Fig. 28.2).
◆◆ Vitamin D deficiency results in white patch hypoplasia
in teeth.
◆◆ Vitamin C deficiency along with vitamin A deficiency
during formative periods of dentition resulting in
pitting type appearance of teeth.
v. Dentinogenesis imperfecta (DI): Color of teeth in DI
varies from gray to brownish violet to yellowish brown with Fig. 28.4: Discolored maxillary central and lateral incisors.
a characteristic usual translucent or opalescent hue.
vi. Tetracycline and minocycline: Chelation of tetracycline
molecule with calcium in hydroxyapatite crystals forms
tetracycline orthophosphate which is responsible for
discolored teeth (Fig. 28.3).
2. Posteruptive Causes
i. Pulpal changes: In pulp necrosis, disintegration products
enter dentinal tubules and cause discoloration (Fig. 28.4).
Fig. 28.5: Discolored appearance of teeth due to caries.
ii. Dental caries: In general, teeth present a discolored

appearance around areas of bacterial stagnation and
leaking restorations (Fig. 28.5).
iii. Restorative materials and dental procedures:
Discoloration can also result from the use of endodontic
Fig. 28.2: Clinical picture showing fluorosis of teeth in form of
hypomineralized brownish discoloration. sealers and restorative materials.
iv. Aging: Secondary and tertiary dentin deposits with
aging, pulp stones cause changes in the color of teeth
(Fig. 28.6).
Extrinsic Stains
Daily Acquired Stains
◆◆ Plaque: Pellicle and plaque on tooth surface give rise to
yellowish appearance of teeth.
◆◆ Food and beverages: Tea, coffee, red wine, curry, and
colas if taken in excess cause discoloration.
◆◆ Tobacco use: It results in brown to black appearance of
Fig. 28.3: Photograph showing tetracycline stains. teeth.
Tooth Whitening 369
◆◆ When mixed with superoxol, it decomposes into sodium
metaborate, water, and oxygen.
Carbamide Peroxide
◆◆ Also known as urea hydrogen peroxide.
◆◆ Used in concentrations ranging from 3% to 45%.
◆◆ It decomposes into urea, ammonia, carbon dioxide,
and hydrogen peroxide.
◆◆ Carbopol (polyacrylic acid polymer) is used as a thicke
ning agent. It prolongs the release of active peroxide.
Fig. 28.6: Discoloration of teeth resulting from tooth wear and aging. ◆◆ For gel preparations—glycerin, propylene glycol,
sodium stannate, citric acid, and flavoring agents are
◆◆ Swimmer’s calculus: It is yellow to dark brown stain added.
present on facial and lingual surfaces of anterior teeth.
It occurs due to prolonged exposure to pool water. Mechanism of bleaching
◆◆ Chlorhexidine stain: The stains produced by use of
chlorhexidine are yellowish brown to brownish in Mechanism of bleaching is mainly linked to degradation
nature. of high-molecular weight complex organic molecules that
reflect a specific wavelength of light, which is responsible
Bleaching for color of stain (Fig. 28.7). Resulting degradation
products are of lower molecular weight and composed of
Bleaching is a procedure which involves lightening of the less complex molecules that reflect less light, resulting in a
color of a tooth through the application of a chemical agent reduction or elimination of discoloration.
to oxidize the organic pigmentation in the tooth.
Bleaching agents BLEACHING OF VITAL TEETH

These are powerful oxidizing chemicals that lighten the Indications Contraindications
stains of teeth, thereby restoring their normal color. • Age-related Teeth with:
Different types of bleaching agents are available discolorations • Insufficient enamel for bleaching
commercially. These bleaching agents may contain the • Mild generalized • Cracks and fracture lines
following components. staining • Inadequate or defective restorations
• Mild tetracycline • Large pulp chamber
staining • Extensive restorations
Hydrogen Peroxide • Mild fluorosis • Severe fluorosis and pitting
◆◆ Used in concentration ranging from 5% to 35%. • Acquired superficial hypoplasia
◆◆ H2O2 has low molecular weight so can penetrate dentin, stains from smoking • Noncompliant patients
and breakdown into water and releases perhydroxyl tobacco • Severe tetracycline staining with
• Color changes related banding
ions and nascent oxygen which are responsible for to pulpal trauma or • Sensitivity to heat, cold, or sweets
bleaching action. necrosis • In patients with bulimia nervosa
◆◆ Bleaching action of H2O2 is accelerated by heat, light, or
in combination with sodium perborate.
◆◆ It is clear, colorless, and odorless liquid stored in
lightproof bottles.
◆◆ If stored properly, its shelf-life is 3–4 months but
decomposes rapidly in presence of organic debris and
an open air.
◆◆ Should be handled carefully to prevent direct contact
with mucous membrane.
◆◆ Can be used alone or in combination with sodium
perborate.
Sodium Perborate
◆◆ Available as white powder in granular form.
◆◆ Mainly three types: sodium perborate monohydrate,
trihydrate, and tetrahydrate and these three types vary
in oxygen content. Fig. 28.7: Schematic representation of mechanism of bleaching.
Flowchart 28.1: Bleaching technique.
Vital Bleaching Techniques ◆◆ This will allow pulp to settle. Figures 28.9A and B show
(Flowchart 28.1) before and after photographs of vital tooth bleaching.
1. In-office Bleaching: Advantages Disadvantages
i. Thermocatalytic Vital Tooth Bleaching • Patient preference • More chair time

• Less time than overall time • More frequent and longer
Procedure: needed for home bleaching appointment
◆◆ Pumice the teeth to clean off any debris present on the • Patient motivation • Dehydration of teeth
tooth surface. • Protection of soft tissues • Safety considerations.
• More expensive
◆◆ Isolate the teeth with rubber dam and protect the gingival
tissues with orabase or vaseline. Protect patient’s eyes
ii. Nonthermocatalytic bleaching
with sunglasses.
◆◆ Saturate the cotton or gauze piece with bleaching In this technique, heat source is not used.
solution (30–35% H2O2) and place it on the teeth.
◆◆ Expose the teeth using plasma arc light or laser light Commonly used solutions for bleaching
(Fig. 28.8). The temperature of device should be main Name Composition
tained between 52°C and 60°C (125–140°F). Superoxol 5 parts H2O2:1 part ether
◆◆ Change solution in between after every 4–5 minutes. McInnes solution • 5 parts of HCl (36%) (etches the enamel)
The treatment time should not exceed 30 minutes. • 1 part of 0.2% ether (cleans the tooth
◆◆ Remove solution with the help of wet gauge. surface)
◆◆ Remove solution and irrigate teeth thoroughly with • 5 parts of 30% H2O2 (bleaches the
warm water. enamel)
◆◆ Polish teeth and apply neutral sodium fluoride gel. Modified McInnes • H2O2 (30%)
◆◆ Instruct the patient to use fluoride rinse on daily basis. solution (in this • NaOH (20%) because of its highly
sodium hydroxide alkaline nature, it dissolves calcium of
◆◆ Second and third appointment is given after 3–6 weeks.
is added in the tooth at slower rate
solution) • Mix 1 part of H2O2 and 1 part of NaOH
along with ether (0.2%)
Steps:
◆◆ Perform thorough oral prophylaxis, and isolate the teeth
using rubber dam.
◆◆ Apply drop-by-drop superoxol solution taking care not
to spill it.
◆◆ Wash the teeth with warm water and reapply the
bleaching agent until the desired color is achieved.
◆◆ Wash the teeth and polish them.
iii. Microabrasion
It is a procedure in which a microscopic layer of enamel
is simultaneously eroded and abraded with a special
Fig. 28.8: Thermocatalytic technique of bleaching for vital teeth. compound (usually contains 18% of hydrochloric acid)
Tooth Whitening 371
A B
Figs. 28.9A and B: (A) Preoperative vital tooth bleaching; (B) Postoperative vital tooth bleaching.
leaving a perfectly intact enamel surface behind (Figs. 2. Home Bleaching Technique/Night-guard
28.9A and B). Bleaching
Protocol:
◆◆ Clinically evaluate the teeth. Commonly used Solutions for Night-guard Bleaching
◆◆ Clean teeth with rubber cup and prophylaxis paste. ◆◆ 10% carbamide peroxide with/without carbopol
◆◆ Apply petroleum jelly to the tissues and isolate the area ◆◆ 15% carbamide peroxide
with rubber dam. ◆◆ Hydrogen peroxide (1–10%).
◆◆ Apply microabrasion material on tooth surface at
interval of 60 seconds with intermittent rinsing. Steps of Tray Fabrication
◆◆ Repeat the procedure if necessary. Check the teeth
when wet. ◆◆ Take the impression and make a stone model.
◆◆ Rinse teeth for 30 seconds and dry. ◆◆ Trim the model.
◆◆ Apply topical fluoride to the teeth for 4 minutes. ◆◆ Place the stock-out resin and cure it.
◆◆ Re-evaluate the color of the teeth. More than one visit ◆◆ Apply separating media.
may be necessary sometimes. ◆◆ Choose the tray sheet material of 0.3 mm thickness
made up of flexible.
Advantages Disadvantages ◆◆ Cast the plastic in vacuum tray forming machines and
• Minimum discomfort to • Not effective for deeper stains get the tray as per patient model (Fig. 28.10A).
patient • Removes enamel layer ◆◆ Trim the tray just beyond the gingival margins.
• Less chair side time • Yellow discoloration of teeth ◆◆ Check the tray for correct fit, retention, and
• Useful in removing superficial has been reported in some
overextension.
stains cases after treatment.
• Resultant tooth surface is ◆◆ Demonstrate the amount of bleaching material to be
shiny and smooth in nature. placed.
Treatment regimen:
iv. Laser-assisted Bleaching Technique ◆◆ After routine tooth brushing, patient is instructed to
This technique achieves power bleaching process with place small amount of bleaching gel into the tray to
the help of efficient energy source with minimum side cover the facial surfaces of the teeth (Figs. 28.10B and
effects. Laser whitening gel contains thermally absorbed C). After seating tray in mouth, the extra material is
crystals, fumed silica, and 35% H2O2. In this, gel is applied carefully wiped away.
and is activated by light source which in further activates ◆◆ While removing the tray, patient is asked to remove the
the crystals present in gel, allowing dissociation of oxygen tray from second molar region in peeling action. This is
and therefore better penetration into enamel matrix. The done to avoid injury to soft tissues.
following lasers have been approved by the FDA for tooth ◆◆ Patient is instructed to rinse off the bleaching agent and
bleaching: clean the tray.
◆◆ Argon laser ◆◆ Duration of treatment depends upon original discolo
◆◆ CO2 laser ration, time of application of tray, patient compliance,
◆◆ GaAlAs diode laser. and time of bleaching.
B C
Figs. 28.10A to C: Photograph showing bleaching trays: (A) Bleaching tray; (B) Instruct the patient to place small amount
of bleaching gel in tray; (C) Bleaching tray applied.
◆◆ Patient is recalled for periodic checkups for assessing ◆◆ Heat the bleaching solution using heated instrument
bleaching process. like hot burnisher.
◆◆ Replenish the bleaching solution, and repeat this
Advantages Disadvantages procedure 4–5 times till the desired tooth color is
• Simple method for patients • Patient compliance is achieved.
to use mandatory ◆◆ Wash the tooth with water and seal the chamber using
• Simple for dentists to monitor • Tooth sensitivity dry cotton and temporary restorations.
• Less chair side time and • Gingival irritation can occur ◆◆ Recall the patient after 1–3 weeks.
cost-effective • Chances of abuse by using
◆◆ Do the permanent restoration of tooth using suitable
• Patients can bleach their excessive amount of bleach
composite resins afterward.
teeth at their convenience. for too many hours per day
• Altered taste sensation.
Walking Bleach/intracoronal Bleaching
Bleaching of Nonvital Teeth It involves use of chemical agents within the coronal
portion of an endodontically treated tooth to remove tooth
Indications Contraindications discoloration.
Discolorations due to pulp • Presence of cracks and craze lines Steps:
necrosis or intrapulpal • Extensive restorations ◆◆ Take the radiographs to assess the quality of obturation.
hemorrhage. • Unpredictable prognosis of tooth. If found unsatisfactory, retreatment should be done.
◆◆ Evaluate the quality and shade of restoration, if present.
Prerequisites for Nonvital Bleaching If restoration is defective, replace it.
◆◆ Evaluate tooth color with shade guide.
◆◆ Three-dimensional obturation of root canal system ◆◆ Isolate the tooth with rubber dam.
◆◆ Absence of periapical lesion ◆◆ Prepare the access cavity, remove the coronal gutta-
◆◆ Asymptomatic teeth. percha, expose the dentin, and refine the cavity
(Fig. 28.11A).
Thermocatalytic Technique of Bleaching for ◆◆ Place mechanical barriers of 2 mm thick, preferably
of glass ionomer cement, zinc phosphate, IRM,
Nonvital Teeth
polycarboxylate cement, or MTA on root canal filling
◆◆ Isolate the tooth to be treated using rubber dam. material (Fig. 28.11B). The coronal height of barrier
◆◆ Clean the pulp chamber, and remove 2 mm of gutta- should protect the dentinal tubules and conform to the
percha below cementoenamel junction. Cover it with external epithelial attachment.
glass ionomer cement to prevent diffusion of bleaching ◆◆ Now mix sodium perborate with an inert liquid (local
material into the dentinal tubules in cervical area. anesthetic, saline, or water) and place this paste into
◆◆ Place freshly prepared superoxol (30% H2O2) in the pulp pulp chamber (Fig. 28.11C). In case of severe stains,
chamber and on labial surface carefully by syringe. add 3% hydrogen peroxide to make a paste.
Tooth Whitening 373
A B C
Figs. 28.11A to C: (A) Removal of coronal gutta-percha using rotary instrument; (B) Placement of protective barrier over gutta-percha;
(C) Placement of bleaching mixture into pulp chamber and sealing of cavity using temporary restoration.
◆◆ After removing the excess bleaching paste, place a Studies have shown a reduction in enamel bond strength
temporary restoration over it. Apply pressure with when bonding procedure is carried out immediately or up
the gloved finger against the tooth until the filling has to 1 week after vital bleaching. This is because of presence of
set because filling may get displaced due to release of residual oxygen, which inhibits its free radical polymerization
oxygen. and interferes with resin bonding. Sodium ascorbate is a
◆◆ Recall the patient after 1–2 weeks, repeat the treatment buffered form of vitamin C which consists of 90% ascorbic
until desired shade is achieved. acid bound to 10% sodium. It is a powerful antioxidant used
Restore access cavity with composite after 2 weeks weeks. for removal of residual oxygen after bleaching.
Figures 28.12A to F show the walking bleach procedure of
nonvital maxillary central incisors. 3. Effects on Dentin
Complications of Intracoronal Bleaching Bleaching has shown to cause uniform change in color
through dentin.
◆◆ External root resorption.
◆◆ Chemical burns if using 30–35% H2O2, therefore,
gingiva should be protected using petroleum jelly or 4. Effects on Pulp
cocoa butter Studies have shown that 3% solution of H2O2 can cause
◆◆ Decrease bond strength of composite because of transient reduction in pulpal blood flow and occlusion of
presence of residual oxygen following bleaching pulpal blood vessels.
procedure.
5. Cervical Resorption
Effects of Bleaching Agents More serious side effects such as external root resorption
on Tooth and its Supporting may occur when a higher than 30% concentration of
Structures hydrogen peroxide is used in combination with heat.
1. Tooth Hypersensitivity 6. Mucosal Irritation

Tooth sensitivity is common side effect of external tooth
bleaching. Higher incidences of tooth sensitivity (67–78%) A high concentration of hydrogen peroxide (30–35%) is
are seen after in-office bleaching with hydrogen peroxide caustic to mucous membrane and may cause burns and
in combination with heat. bleaching of the gingiva.
2. Effects on Enamel 7. Toxicity

Studies have shown that 10% carbamide peroxide signi The acute effects of hydrogen peroxide ingestion are
ficantly decreased enamel hardness. But application dependent on the amount and concentration of hydrogen
of fluoride showed improved remineralization after peroxide solution ingested. Signs and symptoms usually
bleaching. seen are ulceration of the buccal mucosa, esophagus and
A B
C D
E F
Figs. 28.12A to F: Walking bleach of maxillary arch: (A) Preoperative photograph showing discolored and nonvital maxillary central incisors;
(B) Removal of gutta-percha from coronal part of crown; (C) Glass ionomer cement placed as mechanical barrier; (D) Bleaching agnent placed in
access cavity, temporized; (E) Postoperative; (F) After direct composite built up of maxillary central incisors.
stomach, nausea, vomiting, abdominal distention, and going for more invasive procedure like veneering or
sore throat. full ceramic coverage, depending upon specific case.
It can be performed in office or at home as per patient’s
requirements. However, as with any dental procedure,
Conclusion
bleaching involves risks. Clinician should inform their
Bleaching is safe, economical, conservative, and effective patients about the possible changes that may occur on their
method of decoloring the stained teeth due to various dental tissues and restorations after bleaching procedure
reasons. It should always be given a thought before so as to compare risk versus benefit of the procedure.
Tooth Whitening 375
Examiner’s Choice Questions 8. What are the etiological factors responsible for
discoloration of teeth?
1. What are different etiological factors responsible for 9. What are the contraindications of bleaching?
discoloration of teeth? 10. Which blood disorders causes discoloration of teeth?
2. Define bleaching. Explain the mechanism of bleaching
11. What is the mechanism of bleaching?
and classify different bleaching procedures.
12. Name few bleaching techniques.
3. How will you bleach a nonvital central incisor tooth?
13. Which acid is used in microabrasion?
4. Enumerate the causes of discoloration of teeth? What
methods are used to achieve normal color of teeth? 14. What are the suggestions for safer bleaching of
Describe the methods used to bleach the vital teeth. endodontically treated teeth?
5. Write short notes on: 15. Which laser is used to activate the in-office bleaching
a. Contraindication of bleaching. solution?
b. Nightguard vital bleaching technique. 16. What are the indications and contraindications
c. Walking bleach. of Home bleaching technique/night guard vital
d. In-office bleach. bleaching?
e. Effects of bleaching on teeth. 17. What is microabrasion?
18. What is walking bleach?
VIVA QUESTIONS
1. What is the effect of bleaching on vital teeth? Bibliography
2. What are commonly used solution for night-guard 1. Goldstein RE. Bleaching teeth: new materials—new role. J Am
bleaching? Dent Assoc. 1987;116:44E-52.
3. What is the composition of McInnes solution? 2. Haywood VB, Heymann HO. Nightguard vital bleaching: how
4. Name the gel preparation of bleaching agent. safe is it? Quintessence Int. 1991;22:515-23.
5. What are the effects of bleaching on teeth? 3. Haywood VB. Historical development of whiteners: clinical
safety and efficacy. Dent Update. 1997;24:98-104.
6. What is the major effect of bleaching solution on
4. Laser assisted bleaching: an update. J Am Dent Assoc.
composite? 1998;129:1484-7.
7. What is the effect of concentration of hydrogen 5. Watts A, Addy M. Tooth discolouration and staining: a review of
peroxide (30–35%)? the literature. Br Dent J. 2001;190:309-16.
Chapter
29
Minimally Intervention Dentistry
Chapter Outline
Introduction Principles of Minimal Intervention

Definition
Introduction
Till the middle of the 19th century, the exact etiology of
dental caries was not known. Tooth preparations were
designed without specifications. Materials used at that
time had little standardization which resulted in their poor
performance. Black advised placement of the margins in
“self-cleansable areas”. This led to the term “extension for
prevention”, which could be summarized as “the removal
of the enamel margin by cutting from a point of greater
liability to a point of lesser liability to recurrence of caries”.
But this traditional restorative approach does not help in
management of complex restorative challenges such as
erosion, abrasion, demineralization, rampant caries, sound
and decayed retained roots, recurrent caries, etc. Minimum
intervention dentistry (MID) is the modern approach for Fig. 29.1: Diagrammatic representation of minimal intervention
management of caries. This approach starts with diagnosis approach.
and risk assessment of caries so as to allow proper treat-
ment decision. The main goal of minimal intervention is to PRINCIPLES OF MINIMAL INTERVENTION
increase the life of the teeth, which was restored with less
intervention. Now the concept is “prevention of extension” The current philosophy of minimal invasive dentistry is to
rather than “extension for prevention”. combine aesthetics, prevention, adhesion, and restoration
to remove a carious lesion in the least invasive manner.
Definition Principles of minimal intervention dentistry as given by
Tyas et al. are:
Minimum intervention dentistry is defined as a philosophy 1. Early caries diagnosis
of professional care concerned with the first occurrence, 2. Classification of caries depth and progression
early detection, and earliest possible cure of the disease 3. Assessment of individual caries risk (high, moderate,
on microlevels followed by minimally invasive treatment and low)
to repair irreversible damage caused by that disease. 4. Reduction in cariogenic bacteria to eliminate the risk of
Minimal intervention approach includes (Fig. 29.1): further demineralization and cavitation and arresting
1. Identifying the caries of active lesions
2. Early intervention 5. Remineralization of early lesions
3. Prevention. 6. Minimal surgical intervention of caries lesions
Minimally Intervention Dentistry 377
7. Repair rather than the replacement of defective Secondly, the classification identifies carious lesions
restorations according to various sizes:
8. Assessing disease management outcomes at regular ◆◆ Size 0: Carious lesion without cavitation can be
intervals. remineralized
◆◆ Size 1: Small cavitation, just beyond healing through
1. Early Diagnosis remineralization
◆◆ Size 2: Moderate cavitation not extended to cusps
Goal of minimally intervention dentistry is to halt the ◆◆ Size 3: Enlarged cavitation with at least one cusp
disease first and then to restore lost structure and function. which is undermined and which needs protection from
To achieve this goal, an accurate diagnosis of the disease occlusal load
is mandatory. Based on minimal intervention theory, ◆◆ Size 4: Extensive decay with at least one lost cusp or
caries starts with imbalance between remineralization incisal edge.
and demineralization of tooth surface and progresses
into initial reversible lesion (noncavitated) and later
Viva Voce
irreversible lesion (cavitated). It is important to note that
caries activity cannot be determined at one stage only, it Difference between caries classification given by GV Black
has to be monitored over the time by taking radiographs and G Mount
and doing clinical checkups. Recent developments MI classification of G Mount
in technologies like electrical conductance methods, GV Black classification (1997)
quantitative laser fluorescence, laser fluorescence, tuned- Provision of specifications Direct recommendation
aperture computed tomography, and optical coherence for preconceived for appropriate treatment
tomography have helped in early diagnosis of the lesion. preparation designs for according to classification
For complete diagnosis along with detection of the carious amalgam code
lesion, one should also assess the caries activity which is Preparation designs do Considers both site as
more important aspect. not take extent of active well as size of the carious
caries into various tooth lesion
tissues
2. Caries Classification Based on Site
and Size of Lesion
Minimally invasive procedure mandates that “leave the
Because of importance of site and size of carious lesions groove intact unless there is caries on the surface, even
for treatment, Mount et al. gave a new classification of if it is stained”. If groove is intact, it can be sealed at the
dental caries by combining both site and size of the lesion end of the procedure. For treatment of proximal caries,
(Fig. 29.2). Basis of classification system given by Mount
conservative “slot” preparation can be made instead of
and Hume is that it is only essential to make entry into the
design given by Black.
lesions and remove areas which are infected and tooth is
Teeth requiring replacement of a cusp can be restored
broken down to an extent where remineralization is not
using indirect composite or porcelain restorations. These
possible.
large, indirect aesthetic restorations can be prepared with
minimal destruction of additional sound tooth structure.
These restorations can be fabricated using either indirect
laboratory techniques or using computer-aided design
and computer-assisted manufacturing (CAD/CAM).
Philosophy of minimal surgical intervention also involves
anterior aesthetic procedures (e.g. diastema closure)
rather than aggressively preparing the tooth for a porcelain
laminate or full coverage porcelain crown.
3. Assessment of Caries Risk

Assessment of individual caries risk is one of the
Fig. 29.2: Caries classification according to size and site. important tools which helps the clinician to make a
respective treatment plan for each individual. In caries
Firstly, lesions are classified according to their location: risk assessment, one identifies the children/patients who
◆◆ Site 1: Pits and fissures are at higher risk for dental caries and thus require more
◆◆ Site 2: Contact area between two teeth dental care than the individuals with low or moderate
◆◆ Site 3: Cervical area in contact with gingival tissues. caries risk.
Categories of patients on the basis of risk of development of

caries
Low risk Moderate risk High risk
1. No caries in last 1. One carious 1. ≥2 carious lesions
years lesion in last in last 3 years
2. Sealed pit and years 2. Deep pits and
fissure 2. Deep pits and fissure
3. Good oral fissures 3. No/little fluoride
hygiene 3. Fair oral hygiene exposure
4. Appropriate 4. White spots/ 4. Poor oral hygiene
fluoride use interproximal 5. Frequent sugar
5. Regular dental radiolucencies intake
visits 5. Orthodontic 6. Inadequate saliva
treatment flow
7. Irregular dental
visits
Following factors are commonly seen in patients with

high-risk caries:
1. Status of oral hygiene:
Fig. 29.3: Cycle of demineralization and remineralization.
•• Poor oral hygiene
•• Nonfluoridated toothpaste
5. Remineralization of Initial Lesions
•• Low frequency of tooth cleaning
•• Orthodontic treatment and Reduction in Cariogenic Bacteria
•• Partial dentures. Dental caries passes through the series of demineralization
2. Dental history: and remineralization cycles depending on the
•• History of multiple restorations microenvironment (Fig. 29.3). When the pH is less than
•• Frequent replacement of restorations. 5.5, demineralization occurs. In a neutral environment,
the hydroxyapatite of the enamel is in equilibrium with
3. Medical factors:
saliva which is saturated with calcium and phosphate
•• Medications causing xerostomia ions. At or below pH 5.5, H+ ions produced by the bacterial
•• Gastric reflux metabolites react preferentially with the phosphate group
•• Sugar-containing medication of the enamel crystals, converting PO42– ion to HPO42– ion
•• Sjögren’s syndrome. which, once formed, can no more form the crystal lattice;
4. Behavioral factors: at the same time, H+ ions are buffered. This leads to enamel
•• Bottle feeding at night dissolution, termed as demineralization, which marks the
•• Eating disorders beginning of early enamel caries.
•• Frequent intake of snacks
•• More intake of sticky foods. Indications of Remineralization
5. Socioeconomic factors: ◆◆ An adjunct preventive therapy to reduce caries in high-
•• Low education status risk patients
•• Poverty ◆◆ To repair enamel in cases involving white-spot lesions
•• No fluoride supplements. ◆◆ Reduce dental erosion in patients with gastric reflux or
other disorders
◆◆ To reduce decalcification in orthodontic patients and
after teeth whitening
4. Decreasing the Risk of Further
◆◆ Desensitize sensitive teeth.
Demineralization and Arresting
Active Lesion Requirements of an Ideal Remineralizing Agent
According to minimal invasive dentistry, depending on ◆◆ It should diffuse into the subsurface or deliver calcium
the patient’s risk factors, a number of suitable agents and and phosphate into the subsurface
therapies can be applied like fluoride toothpastes, gels, ◆◆ It should be able to work at an acidic pH
varnishes, mouth rinses, xylitol gum, diet counseling, and ◆◆ It should be effective in patients with xerostomia
casein derivatives to reduce the rate of progress of tooth ◆◆ Should not favor calculus formation
demineralization. ◆◆ Boosts the remineralizing properties of saliva.
Different Remineralizing Agents phosphosilicate. it is technically described as an inorganic
amorphous calcium sodium phosphosilicate (CSPS).
1. Fluoride NovaMin®, a trade name for bioactive glass, is manufactured
Arnold, in 1957, was first to mention the posteruptive by NovaMin® Technologies Inc. Its mechanism of action is
effects of fluorides in drinking water and topical fluoride in shown in Figure 29.5.
caries prevention. Four mechanisms are involved by which
fluoride increases caries resistance, viz. increased enamel
resistance, increased rate of maturation, remineralization
of incipient caries, interference with microorganisms, and
improved tooth morphology (Figs. 29.4A and B).
Enamel is dissolved by lowering of pH in dental plaque
due to acid production every time sugar is ingested. However,
if fluoride is present in the biofilm fluid, and pH is not lower
than the critical pH, hydroxyapatite (HA) is dissolved and
at the same time, fluorapatite is formed. This indirect effect
of fluoride in reducing enamel demineralization occurs
when the pH drop is complemented by its natural effect on
remineralization.
Fig. 29.5: Mechanism of action of bioactive glass.
Need for Nonfluoridated Remineralizing
Agents 3. Casein Phosphopeptide-amorphous Calcium
1. Fluoride is highly effective on smooth-surface caries, its Phosphate
effect is limited on pit and fissure caries.
2. toxicity of fluorides increases with inadequate nutrition. CPP-ACP is acronym for a complex of casein phosph
3. If used in limits, fluoride shows no problems, but in opeptides and amorphous calcium phosphate. CPPs are
some parts of world, it has been suggested to reduce the group of peptides derived from casein. Casein is the part of
fluoride exposure. protein which naturally occurs in milk. CPP is responsible
4. Many countries do not have fluoridated products. for high availability of Ca2+ from milk. In normal state,
All these limitations have prompted researchers to look calcium phosphate forms a crystalline structure at neutral
for nonfluoridated alternatives for remineralization. pH and thus becomes insoluble. But CPP keeps calcium
and phosphorus in ionic form (amorphous state). In this
2. Bioactive Glasses state, calcium and phosphate ions can enter the tooth
NovaMin®: Bioactive glass (Bioglass) was invented by enamel and thus promote remineralization of tooth.
Dr Larry Hench in 1960s. It contains calcium sodium Proposed mechanism of anticariogenicity for the CPP-ACP
is that it localizes ACP in dental plaque, which buffers the
free calcium and phosphate ion activities, thereby helping
to maintain a state of supersaturation with respect to tooth
enamel thus depressing demineralization and promoting
remineralization (Fig. 29.6). CPP-ACP technology has
been trademarked as GC Tooth Mousse (topical crème)
and RecaldentTM (chewing gum) (Figs. 29.7A to C).
A
Figs. 29.4A and B: Mechanism of: (A) Demineralization; and

(B) Remineralization by fluorides. Fig. 29.6: Role of CPP-ACP in remineralization process.
A B C
Figs. 29.7A to C: (A) Tooth mousse (topical crème); (B) Trident sugar-free gum; (C) RecaldentTM chewing gum.
4. Tricalcium phosphate (TCP) (Clinpro Tooth

Crème) (Fig. 29.8)
TCP is a new hybrid material created with a milling
technique that fuses beta-tricalcium phosphate and
sodium lauryl sulfate or fumaric acid. This results in a
“functionalized” calcium and a “free” phosphate, so as to
increase the efficacy of fluoride remineralization. When
Fig. 29.9: ACP Technology (Enamelon, Enamel Care).
it is used in toothpaste formulations, a protective barrier
is created around the calcium, allowing it to coexist with
the fluoride ions. When TCP comes into contact with reacting with each other before use. The current sources
saliva, the protective barrier breaks down, making the of calcium and phosphorus are two salts—calcium sulfate
calcium, phosphate and fluoride ions available to the and dipotassium phosphate. When these two salts are
teeth for remineralization. Fluoride and calcium ions then mixed, they rapidly form ACP that can precipitate onto
react with weakened enamel to provide a better seed for the tooth surface. This precipitated ACP can then readily
enhanced mineral growth relative to fluoride alone. dissolve into the saliva and can be available for tooth
remineralization.
6. Sugar Substitutes—Xylitol (Figs. 29.10A and B)

Xylitol is naturally occurring sweetener in same category
as sorbitol and mannitol. It is found in fibers of trees, fruits,
and vegetables.
Fig. 29.8: Tricalcium phosphate (TCP) (Clinpro Tooth Creme).

(Courtesy: 3M ESPE).
5. ACP Technology (Enamelon, Enamel Care)

(Fig. 29.9)
ACP technology requires a two-phase delivery system A A
to keep the calcium and phosphorus components from Figs. 29.10A and B: Xylitol.
Mechanism of action: It cannot be fermented by plaque
bacteria because S. mutans do not metabolize xylitol. It
inhibits growth and metabolism of S. mutans and reduces
dental plaque. This causes reduction in acid production
and thus reduction in dental caries (Fig. 29.11).
Fig. 29.12: Nanohydroxyapatite particles penetrate beneath the

enamel surface and provide replacement of calcium and phosphate
ions, thus helping in remineralization.
calcium ions which are then available for remineralization

to remineralize the tooth surface.
10. Ozone
Ozone is a chemical compound consisting of three oxygen
atoms (O3, triatomic oxygen). Ozone therapy is also
Fig. 29.11: Mechanism of action of xylitol. proposed to stimulate remineralization of incipient caries
following treatment for a period of about 6–8 weeks.
7. Grape Seed Extract
6. Minimal Intervention of Cavitated
Grape seed extract (GSE) has high proanthocyanidins Lesions
(PA) content. PA-treated collagen matrices are nontoxic
and inhibit the enzymatic activity of glucosyltransferase The modern concept of restorative dentistry is based on
and amylase, which results in decrease in the caries. conservation and has concentrated on the importance
Application of grape seed extract has shown to increase of preservation of sound tooth structure by conservative
remineralization by depositing minerals on the lesion means of tooth preparation.
surface by forming insoluble complexes when mixed with
phosphate buffer. Rationale of Minimal Tooth Preparation
8. Nanohydroxyapatite i. Early diagnosis of caries by newer diagnostic methods.
ii. Understanding of gradation of mineral loss from
Carbonated hydroxyapatite nanocrystals are synthesized center of lesion to peripheral part. This means that
with biomimetic characteristics for composition, structure, partly demineralized structure need not to be removed
size, and morphology. These nanohydroxyapatite particles because remineralization is possible in this area.
penetrate beneath below the surface of the enamel iii. Understanding of ion migration which takes place
providing replacement of calcium and phosphate ions both in and out of tooth structure. So, if remineralizing
to areas from which minerals have dissolved, thereby agent is applied, noncavitated lesions can be reversed.
remineralizing the demineralized enamel and restoring its iv. Evolution of adhesive dentistry allows minimal
integrity (Fig. 29.12). tooth preparation, reduces microleakage at tooth
restoration interface, and offers reinforcement to the
9. Calcium Carbonate Carrier—SensiStat tooth structure.
SensiStat technology was developed by Dr Israel Kleinberg v. Development and evolution of restorative material
of New York. SensiStat technology is made of arginine which is capable of ion exchange, can act as
bicarbonate, an amino acid complex, and calcium anticariogenic material and can remineralize the
carbonate. Arginine complex is responsible for holding tooth structure.
the calcium carbonate particles to the tooth surface and Micropreparation burs like fissurotomy burs, smart burs
allows the calcium carbonate to slowly dissolve and release like polymer burs are used for modern tooth preparations.
4. Tunnel Preparation
Tunnel preparation is removal of proximal caries via access
in occlusal surface. It is also called as internal oblique
preparation/internal fossa preparation.
It is indicated if carious lesion is more than 2.5 mm from
the marginal ridge. In this, access to carious lesion is made
from the occlusal surface, while preserving the marginal
ridge. For tooth preparation, small tapered bur with long
shank is directed at the lesion and the preparation is
A B
completed using small round burs and hand instruments
Figs. 29.13A and B: (A) Tooth preparation using straight fissure bur; (Fig. 29.14). So, by tunnel preparation, marginal ridge
(B). Tooth preparation using fissurotomy tapered bur allows minimal
is preserved, normal contact area is not disturbed but it
removal of tooth structure.
is highly technique sensitive with more chances of pulp
exposure and uncertain caries removal.
Minimally Invasive Treatment Options for
Cavitated Lesions
1. Fissurotomy
It is ultraconservative tooth preparation using fissurotomy
bur of head length of 2.5 mm and diameter of 0.6 mm, 0.7
mm, and 1.1 mm. by this, width of prepared cavity comes
1/8th to 1/10th intercuspal distance, i.e. narrow and
conservative. It is later restored with flowable composite.
Length of bur head allows the bur tip to cut just below DEJ
and not further, tapered shape allows the cutting tip to
encounter very few dentinal tubules (Figs. 29.13A and B).
2. Chemomechanical Caries Removal

Fig. 29.14: Tunnel preparation.
Chemomechanical caries removal (CMCR) involves the
selective removal of carious dentin. Reagents commonly
available in market are Caridex and Carisolv. Caridex 5. Box and Slot Preparations
consists of two solutions, viz. solution I containing Box and slot preparations are conservative preparations
sodium hypochlorite, and solution II containing glycine, which involve removal of the marginal ridge, but the
aminobutyric acid, sodium chloride, and sodium preparation does not include the occlusal pits and fissures.
hydroxide. The two solutions are mixed immediately If proximal lesion is close to marginal ridge, entry in lesion
before use and solution is applied by using an applicator is made through outer slope of ridge and contacts are not
until the sound dentin appears. It consists of mixture of disturbed as far as possible (Figs. 29.15A and B).
amino acids and 05% sodium bicarbonate. The resultant
high pH reacts with denatured collagen in carious dentin 6. Tooth Preparations Using Air Abrasion
which removes softened dentin.
In this technique, kinetic energy is used to remove carious
lesion. Here, powerful fine stream of aluminium oxide
3. Pit and Fissure Sealants and Preventive Resin
particles is directed against the target tooth surface.
Restorations The abrasive particles hit the tooth with high velocity
A pit and fissure sealant is a material which is placed and a small amount of tooth structure is removed. The
in deep pits and fissures of newly erupted teeth so as to size of particles ranges from 27 µm to 50 µm targeted at
prevent development of caries. Materials used for pit and air pressure of 40–160 psi at the distance of 0.5–2 mm
fissure sealants are composite resins, compomers, and from target area. Air abrasion is indicated for removal of
fluoride-releasing sealants. Preventive resin restorations superficial enamel defects, enamel surface defects, and
are placed in teeth with the rationale that placement of a for surface preparations of abrasion lesions. Air abrasion
resin sealant isolates the carious lesion from the surface is not indicated in patients with dust allergy, asthma,
biofilm. But use of preventive resin restorations should be chronic obstructive lung disease, open wounds, advanced
limited to fissures where lesion is confined to the enamel periodontal disease, fresh extractions, and recent
only. placement of orthodontic appliances.
A B
Figs. 29.15A and B: (A) Box-only Class II composite preparation; (B) Slot preparation.
7. Tooth Preparation Using Lasers 7. Repair instead of Replacement of

Commonly used lasers for tooth preparation are erbium: the Restoration
yttrium-aluminium-garnet lasers and erbium, chromium: Repair of defective restorations rather than replacement
yttrium-scandium-gallium-garnet lasers. Lasers have has advantage of saving the tooth structure, patient-chair
shown to remove caries selectively while leaving the sound time, and places minimal trauma on pulp of the tooth. The
enamel and dentin intact. Advantages of laser preparation decision to repair rather than replace a restoration should
include no vibration, little noise, no smell, and conservative be based on the patient’s risk of developing caries, the
tooth preparation with minimal discomfort, so no need of professional’s judgment of advantages versus risks, and
local anesthesia. conservative principles of tooth preparation.
When treating an old restoration, one should consider
8. Tooth Preparation by ozone the following options before performing their replacement:
◆◆ Recontour and/or polish
It is mainly indicated to treat primary root carious lesions, ◆◆ Seal the margins
pits and fissures, and early carious lesions around crown ◆◆ Repair any local defect
and bridges. Various dental ozone devices like HealOzone ◆◆ Replace restoration.
and Dent Ozone units are available, these dental ozone When any of following occurs, old restoration is
units deliver ozone gas at preset concentration. At the end considered for replacement rather than repair (Figs.
of 30–60 seconds of ozone exposure, a mineral wash is 29.17A and B):
placed over the treated area to initiate the remineralization ◆◆ Secondary caries which cannot be removed during
process (Fig. 29.16). repair procedure
◆◆ Need for aesthetics
◆◆ Presence of pulpal pathology
◆◆ Fractured restoration.
8. Disease Control
We know that dental caries is an infectious disease.
Different efforts which must be made in order to decrease
the incidence of caries include identification and
monitoring of bacteria, diet analysis and modification,
and use of topical fluorides and antimicrobial agents. For
caries control, caries vaccines and bacterial replacement
therapy have also come up in the show.
Vital Pulp Therapy

Fig. 29.16: Dental ozone machine. In minimally intervention dentistry for deep carious
(Courtesy: Kavo India) lesions, vital pulp therapy is indicated which involves
A1
B1
A2 B2
Figs. 29.17A and B: Repair of the old restoration; (A1) A discolored lateral incisor with composite restorations needs repair only; (A2) lateral
incisor after polishing only; (B1) defective retoration with secondary caries needs replacement; (B2) Postoperative photograph showing replace-
ment of restoration.
(Courtesy: Priya Titus).
stepwise remineralization using biocompatible dental c. Minimal invasive options for carious lesions.
materials. Before initiating the treatment, clinician d. Various tooth remineralization agents.
must determine the extent of decay and the feasibility of
vital pulp therapy. Only the minimal marginal enamel VIVA QUESTIONS
is removed to enter the carious lesion and remove the
1. Define minimal intervention dentistry.
infected dentin.
2. What are principles of minimum intervention
dentistry?
Conclusion 3. What is difference between caries classification given
Minimal intervention dentistry is the natural evolution of by GV Black and G Mount?
dentistry. As new materials and techniques are developed, 4. What are requirements of an ideal remineralizing
dentistry is changed to make the use of most conservative agent?
techniques. In general, the minimally intervention 5. What is bioactive glass?
dentistry should fulfil the following objectives of dental 6. What is full form of CPP-ACP?
care, which involve: 7. What is mechanism of action of xylitol?
◆◆ Categorizing the patients for risk of developing dental 8. What is fissurotomy?
caries depending upon existing oral health conditions. 9. What is chemomechanical caries removal?
10. What is tunnel preparation?
◆◆ Applying aggressive caries preventive measures like
11. Discuss tooth preparation using air abrasion.
implementation of fluoride therapy, antimicrobial
12. Discuss tooth preparation by lasers.
therapy, diet modification, and calcium supplemen
tation to reduce the caries risk. bibliography
◆◆ Conservative use of intervention procedures.
1. Azarpazhooh A, Limeback H. Clinical efficacy of casein
derivatives: a systematic review of the literature. J Am Dent
EXAMINER’S CHOICE QUESTIONs Assoc. 2008;139(7):915-24.
2. Christensen GJ. The advantages of minimally invasive dentistry.
1. Write in detail about the concept of minimal J Am Dent Assoc. 2005;136(11):1563-5.
intervention dentistry. 3. Cury JA, Tenuta LM. Enamel remineralization: controlling the
2. Write short notes on: caries disease or treating the early caries lesions? Braz Oral Res.
2009;23 (Suppl 1):23-30.
a. Concepts of minimal intervention dentistry. 4. Ericson D. What is minimally invasive dentistry? Oral Health
b. Mount and Hume classification of caries. Prev Dent. 2004;2 (Suppl 1):287-92.
5. Frencken JE, Pilot T, Songpaisan Y, et al. Atraumatic restorative 10. Reynolds EC. Calcium phosphate-based remineralization
treatment (ART): rationale, technique, and development. J systems: scientific evidence? Aus Dent J. 2008;53(3):268-73.
Public Health Dent. 1996;56(3 Spec No):135-40. 11. Smales RJ, Yip HK. The atraumatic restorative treatment (ART)
6. Karlinsey RL, Mackey AC, Walker ER, et al. Remineralization approach for the management of dental caries. Quintessence
potential of 5000 ppm fluoride dentifrices evaluated in a pH Int. 2002;33(6):427-32.
cycling model. J Dent Oral Hyg. 2010;2(1):1-6. 12. Strand GV, Nordbø H, Leirskar J, et al. Tunnel restorations
7. Llena C, Forner L, Baca P. Anticariogenicity of casein phospho placed in routine practice and observed for 24 to 54 months.
peptide-amorphous calcium phosphate: a review of the Quintessence Int. 2000;31(7):453-60.
literature. J Contemp Dent Pract. 2009;10(3):1-9. 13. Ten Cate JM, Featherstone JD. Mechanistic aspects of the
8. Mickenautsch S, Rudolph MJ, Oganbodede EO, et al. The interactions between fluoride and dental enamel. Crit Rev Oral
impact of the ART approach on the treatment profile in a Biol Med. 1991;2(3):283-96.
mobile dental system (MDS) in South Africa. Int Dent J. 1999; 14. Van Loveren C. The antimicrobial action of fluoride and its role
49(3):132-8. in caries inhibition. J Dent Res. 1990;69 (Spec No):676-81.
9. Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. 15. Walsh LJ. The current status of tooth crèmes for enamel
J Am Dent Assoc. 2003;134(1):87-95. remineralization. Dental Inc. 2009;2(6):38-42.
Chapter
30
Noncarious Lesions of Teeth
Chapter Outline
Introduction Localized Nonhereditary Enamel Hypocalcification

Attrition Localized Nonhereditary Dentin Hypoplasia
Abrasion Localized Nonhereditary Dentin Hypocalcification
Erosion Amelogenesis Imperfecta
Abfraction Dentinogenesis Imperfecta
Localized Nonhereditary Enamel Hypoplasia
INTRODUCTION Traditionally, attrition of teeth was seen in the older

age group as a sign of the natural aging phenomenon.
Tooth surface loss is a process that results in noncarious However, numerous contradicting studies have reported
lesions. Several categories of tooth surface loss exist it to be increasingly seen in the young adults and mostly
including erosion, attrition, abrasion, and abfraction, etc. linked to bruxing activity.
There can be many causes of these conditions including
bruxism, clenching, dietary factors, habits, lifestyle,
incorrect tooth brushing, abrasive dentifrices, craniofacial
Etiology of Attrition
complex, iatrogenic dentistry, and aging. Determining the Attrition of teeth is a normal physiological process.
etiology of tooth surface loss can be difficult but is possible However, several factors can cause excessive or
through observation of the pattern of tooth surface loss pathological occlusal wear.
on the teeth and is necessary to treat. Management of this ◆◆ Parafunctional habits: Bruxism is a parafunctional,
process includes prevention, tooth remineralization, and nonproductive habit of grinding or clenching the upper
active treatment by restoring the involved teeth. Treatment and lower teeth against each other and is destructive in
can range from minimally invasive and adhesive dentistry, nature.
to full mouth rehabilitation, to restore the lost vertical ◆◆ Developmental anomalies: Amelogenesis imperfecta
height. and dentinogenesis imperfecta predispose teeth to
rapid wear.
◆◆ Iatrogenic: Occlusal prematurities due to faulty
Attrition restorations can be uncomfortable for the patient
Definition which can make him grind his teeth against each other.
Coarse porcelain restorations against natural teeth can
Attrition may be defined as the physiologic wearing away expedite the rate of wear.
of a tooth as a result of tooth-to-tooth contact during ◆◆ Occupation: Attrition can occur when a person is
mastication, and parafunctional movements. It is most exposed to an atmosphere of abrasive dust and cannot
often seen on the occlusal, incisal, and proximal surfaces of avoid getting the material into his/her mouth.
teeth not on other surfaces unless a very unusual occlusal ◆◆ Sex: Attrition is more prevalently seen in males as
relation or malocclusion exists. The rate of attrition compared to females. This could be due to the strong
depends on the amount of load applied and the mineral masseter muscle activity, greater muscle fiber mass,
content of the tooth. and stronger ligaments.
Noncarious Lesions of Teeth 387
Clinical Features (Figs. 30.1A and B) ABRASION
◆◆ There is appearance of a small polished facet on a cusp Definition
tips or ridges or a slight flattening of incisal edges.
◆◆ Attrition may be entirely asymptomatic, or there may be Abrasion is a pathologic wearing away of tooth surface
dentin hypersensitivity secondary to loss of the enamel through some abnormal mechanical process, habits, and
layer, or tenderness of the periodontal ligaments caused abrasive substance. Abrasion usually occurs on exposed
by occlusal trauma. root surfaces of teeth, but under certain circumstances
◆◆ A yellow appearance of the tooth surface may be due it may be seen on other surfaces, such as on incisal or
to the enamel being worn away, exposing the darker proximal surfaces.
yellower dentin layer underneath.
◆◆ Altered occlusion due to decrease in vertical height or Etiology of Abrasion
occlusal vertical dimension.
Various etiological factors are:
◆◆ Compromised periodontal support can result in tooth
◆◆ Faulty oral hygiene practice: The common cause of
mobility and drifting of teeth.
abrasion is the faulty use of toothbrush carrying dental
◆◆ Loss in posterior and occlusal stability, so mechanical
abrasive. Toothbrush can cause wear of cementum and
failure of restoration occurs.
dentin if it is injudiciously used particularly in hori-
zontal direction rather than in vertical direction.
Management of Attrition ◆◆ Abnormal oral habits: Abrasion can be caused due to
◆◆ Counseling by a trained psychologist, meditation, yoga, certain habits like:
and deep breathing exercises are advised to better i. Habitual holding of pins in teeth may result in
handle stressful situations. notching of incisal edges of maxillary incisors.
◆◆ An occlusal splint made in hard acrylic resin is ii. Chewing tobacco can cause generalized occluding
prescribed when generalized attrition is present due to surface abrasion.
bruxism. iii. Forcing toothpicks, interdental stimulator, or solid
◆◆ Habit breaking appliances can be given to the patients. plaque control devices interproximally can cause
Chemotherapeutic agents that are prescribed include proximal surface abrasion.
muscle relaxants and nonsteroidal anti-inflammatory
drugs (NSAIDs) to relieve the symptoms. Clinical Features (Fig. 30.2)
◆◆ Occlusal prematurities should be corrected.
◆◆ Abrasive lesion may be linear in outline following
the path of brush bristles, peripheries are angularly
Restorative Treatment
demarcated from adjacent tooth surface.
To prevent wear of opposing natural dentition, metal ◆◆ It is V-shaped or wedge-shaped defect on the CEJ in
occlusal surface of high noble content like gold alloys is teeth with some gingival recession with angle of the V
preferred. being sharp one.
A B
Figs. 30.1A and B: (A) Clinical picture of attrition showing worn off and polished facets on occlusal surfaces;
(B) Photograph showing attrition of teeth.
microorganisms. The loss of tooth structure is inconsistent

to the age of the patient. The teeth may be hypersensitive
to temperature changes and touch. Caries is generally an
uncommon occurrence in patients with erosion.
Etiology of Erosion
1. Intrinsic erosion: It occurs due to involvement of
endogenous acids, mainly due to regurgitation of gastric
acid into the oral cavity. This may occur in following
conditions:
•• Eating disorders like anorexia nervosa and bulimia
nervosa
•• Vomiting
•• Recurrent vomiting
•• Psychogenic vomiting syndrome
Fig. 30.2: Abrasion caveties present on maxillary canine, •• Drug-induced vomiting
1st and 2nd premolars showing wedge-shaped defects.
•• Pregnancy morning sickness
•• Gastrointestinal disorder
◆◆ Exposed dentin is smooth, polished, and it rarely has •• Peptic ulcer
any plaque accumulation or carious activity. •• Chronic alcoholism.
◆◆ Most commonly seen toothbrush abrasions are 2. Extrinsic erosion: Occurs due to acids from:
unilateral in nature. i. Environmental origin like professional wine
◆◆ Lesion may be extremely sensitive. tasters, battery, electroplating chemical manu
facturer, and swimmers.
ii. Dietary origin: It is by high intake of citrus fruit
Management of Abrasion
and juices, carbonated beverages, and pickled
After confirming the diagnosis, treatment of abrasion foods.
should be pursued in the following sequence: iii. Medicinal origin: Aspirin, vitamin C, iron tonics,
◆◆ Knowing the causative factors, first correct or replace and acidic mouthwashes can cause extrinsic
the iatrogenic factors and then proceed with restorative erosion.
treatment.
◆◆ If the lesions are multiple, shallow (<0.5 mm in dentin), Clinical Features
and wide, there is no need to restore them. If they
involve cementum or enamel only, there is need to ◆◆ Erosion affects upper teeth more than lower teeth,
restore them. especially attacking the facial surface of cuspids and
◆◆ If a restoration is not indicated, edges of the defect premolars. The lower anterior teeth facially are a
should be contoured as smooth in non-demarcating common location for erosion.
pattern for esthetics and plaque control reasons. The ◆◆ These are rounded lesions with no demarcation so
tooth surface then should be treated with fluoride explorer can easily pass without interruption between
solution to improve its caries resistance. However, if lesions and surrounding teeth (Fig. 30.3).
the lesion is wedge- or V-shaped and exceeds 0.5 mm ◆◆ Surface of lesion is glazed. Wear of nonoccluding
into dentin, it should be restored with GIC or composite surfaces occurs.
resin. ◆◆ Loss of surface characteristics of enamel in young
◆◆ If the involved teeth are extremely sensitive, it is children.
preferable to desensitize exposed dentin using fluoride ◆◆ Dentin sensitivity to physical, chemical, and mechanical
solution application (8–30% sodium or stannous stimuli may be present.
fluoride for 4–8 minutes), or iontophoresis using an ◆◆ Teeth with erosion do not tend to retain plaque.
electrolyte containing fluoride ions.
Management of Erosion
EROSION ◆◆ Reduce the frequency and intake of acid.
◆◆ Use of sodium bicarbonate mouthrinse in patients with
Definition
gastric regurgitation.
Erosion can be defined as the loss of tooth structure ◆◆ Increase the flow of saliva by using sugarless chewing
resulting from chemical process in the absence of specific gum.
Etiology of Abfraction
◆◆ When a tooth is hyperoccluded, the masticatory forces
are transmitted to this tooth, which transfers this energy
to the cervical region.
◆◆ Lateral force produces compressive stress on the side
toward which the tooth bends and the tensile stress is
on the other side. These stresses create microfractures
in the enamel or dentin at the cervical region. These
fractures are perpendicular to the long axis of the tooth
leading to a localized defect around the CEJ (Figs.
30.4A and B).
The lesion is formed by combined bending and
deformations. This leads to alternating tensile and
compressive stresses, resulting in weakening of the enamel
Fig. 30.3: Clinical picture of erosion. and dentin. If the forces reach up to a fatigue limit, the tooth
cracks or breaks. At the same time, the opposite region is
◆◆ Remineralization of tooth surfaces with fluoride under compressive stress. When the direction of the force
applications. changes, the tooth bends in the opposite direction, and
◆◆ Recommend the use of soft toothbrushes and dentifrices the stresses correspondingly reverse at this cervical area.
low in abrasiveness in a gentle manner. Thus, side-to-side bending of the tooth results in fatigue
◆◆ Construction of an occlusal guard is recommended if and fracture of the most flexed zone. These interocclusal
bruxism habit is present. forces create physical microfractures or abfractions at the
cervical region (Flowchart 30.1).
ABFRACTION
Clinical Features
Grippo coined the term “abfraction” to define the loss of
dental tissues caused by stress-induced noncarious lesions. ◆◆ Abfraction is very common on the anterior and
Abreak means “to break away” and the term is derived from premolar teeth, because of their smaller size on buccal
the Latin words “ab”, or “away” and “fractio”, or “breaking”. or lingual surfaces due to the direction of the occlusal
Here, tooth substance loss occurs due to biomechanical or incisal loads.
loading forces that result in flexure and ultimate fatigue of ◆◆ Abfraction lesion appears as a wedge-shaped defect
enamel and dentin at a location away from loading. with sharp line angles (Fig. 30.5). In the early stages,
A B
Figs. 30.4A and B: Abfraction. Fracture of tooth due to lateral forces.
Flowchart 30.1: Loss of tooth structure in abfraction. ionomer cements (GICs), resin-modified GICs (RMGICs),
compomers, composite resins, and a combination of the
techniques.
Noncarious cervical lesions show an increased
amount of sclerotic dentin, low permeability, and
hypermineralization making surface unsuitable for
adhesive bonding agents. in such teeth, retention for
restorations with a lower elastic modulus may be better
than that for a material with a higher elastic modulus, for
example, microfilled composites have greater elasticity
than hybrid composites, so preferred in these cases.
LOCALIZED NONHEREDITARY ENAMEL

HYPOPLASIA
During amelogenesis, ameloblasts that are responsible
for formation of enamel, if they are injured, it will result in
defective formation of enamel matrix. This will ultimately
results in defective enamel formation. When the teeth
erupt, these defects will be evident in the crown portion of
the tooth and this is called localized nonhereditary enamel
hypoplasia.
Teeth commonly affected are central incisor, lateral
incisor, cuspid, and 1st molar since these are the teeth
which usually form within 1 year of birth.
it may appear as minor irregular crack or fracture line
in cervical region of the tooth. But in later stages, it
appears as groove extending into the dentin.
Etiology
◆◆ Systemic disorders: These mainly include nutritional
deficiency such as deficiencies of vitamin A, C, and D
and hypocalcemia. Certain exanthematous diseases
like measles, chickenpox, and scarlet fever may lead to
enamel hypoplasia.
◆◆ Congenital syphilis: Enamel hypoplasia due to
syphilis is pathogenic and usually affects maxillary
and mandibular incisors and first molars called
“Hutchinson’s teeth”.
◆◆ Birth injuries: If birth is traumatic, then there may
be alteration of formation of enamel which leads to
enamel hypoplasia. 1st permanent molar may be a
type of enamel hypoplasia indicating trauma/change of
environment at the time of birth.
Fig. 30.5: Wedge-shaped lesion in abfraction. ◆◆ Localized infection: These include periapical infections
of the preceding deciduous tooth (Turner’s hypoplasia),
traumatic intrusion of the preceding tooth, etc.
Management of Abfraction ◆◆ Fluorides: Mottled enamel—ingestion of fluoride
When an abfraction lesion is less than 1 mm in depth, only containing drinking water during the time of tooth
monitoring at regular intervals is sufficient. Restoration formation may cause mottled enamel. The severity of
of noncarious lesions improves the maintenance of oral mottling increases with increasing amount of fluoride in
hygiene, decreases tooth sensitivity, improves esthetics, water. High concentration of fluoride, i.e. above 1 ppm
and strengthens the teeth. Occlusal adjustments, occlusal affects the ameloblast in the formative shape. Enamel
splints, and elimination of parafunctional habits may hypoplasia may range from white flecks to pitting and
also be of help. Materials used for restorations are glass brownish staining of enamel (Fig. 30.6).
◆◆ These areas are chalky and can be easily stained.
◆◆ The shades of teeth may range from chalky to yellow or
brown, dark brown, and/or grayish.
◆◆ If extensive, these lesions may predispose to attrition or
abrasion. Also, the enamel can be chipped if the lesion
involves the entire surface of a tooth.
Management
◆◆ If diagnosed early, when the enamel is still intact,
mineralization process should be initiated. This proce-
dure can be done using periodic fluoride applications,
fluoride iontophoresis, and strict prevention of plaque
accumulation.
◆◆ In some cases, composite veneering, bleaching, lami-
Fig. 30.6: Discoloration due to fluorosis.
nated veneering, PFM crowns, or all-ceramic crowns
can be treatment of choice.
Management
Treatment will vary depending on the extent of hypoplasia LOCALIZED NONHEREDITARY DENTIN
and its location. HYPOPLASIA
◆◆ If the defects are of minimum size, such as isolated pits,
then selective odontomy can be performed. However, Differentiation of cells of odontoblast results in formation
if odontomy and esthetic contouring cannot produce of the dentin. Odontoblasts are very specialized cells.
desirable results, then veneering with composite resin Their function and products (dentin) can be disturbed
may be done. by environmental irritation, leading to deficient or
◆◆ If lesions are discolored and sufficient amount of complete absence of dentin matrix deposition. But, unlike
enamel is present, vital tooth bleaching of the teeth may ameloblasts which are irreplaceable cells, odontoblasts
be a treatment of choice but after selective odontomy, are replaceable cells. If ameloblasts are damaged, it means
which will remove some of the discolored area. no enamel in that area but in odontoblasts, there will be no
◆◆ If lesion is completely disfiguring, both in color and dentin temporarily but dentin deposition will be resumed
contour and involved surface area is not an occluding as soon as other cells of pulp start depositing it. In these
one, laminated direct or indirect tooth-colored resinous cases, defect will be isolated within the dentin substance
or ceramic veneers are treatment of choice. and this situation does not require any treatment.
Such defects may go unnoticed even during cavity
preparations. However, if these defects are sizeable and
LOCALIZED NONHEREDITARY ENAMEL exposed during cavity preparations, treatment consists of
HYPOCALCIFICATION intermediary basing to bring the pulpal floor at same level.
These are the defects of the enamel which are ectodermal
in origin. These usually occur when ameloblasts are injured LOCALIZED NONHEREDITARY DENTIN
during mineralization of enamel. If mineralization of HYPOCALCIFICATION
enamel matrix is affected in the calcification stage, it leads
to nonhereditary enamel hypocalcification. The highest In some cases, during the formative stage, if odontoblasts
incidence of hypocalcification is on the anterior teeth of are disturbed, it may result in total absence or faulty depo-
the upper and lower jaws. Hypocalcification manifests sition of dentin. If dentin matrix is deposited and fails to
frequently as “opaque, i.e. not transmitting light”, opacity calcify, it will results in localized dentin hypocalcification.
with white, yellow, or brown colors in the form of small Dentin in such cases is soft, easily penetrable, and less
or large white dots and might be symmetrically bilateral resilient. The most common example of this is interglobular
on the left and right sides caused by systemic factors. It dentin. Most of the time, lesion is unnoticed even during
is caused by shortage of organic matrix absorption and cavity preparations. In cases of severe involvement,
restriction of matrix mineralization. It can also be caused treatment consists of removal of defect followed by
by calcium deficiency in children with low blood calcium. intermediary basing prior to permanent restoration.
Clinical Features AMELOGENESIS IMPERFECTA

◆◆ The affected teeth will have soft enamel which can be These lesions result from genetically determined abnor-
easily removed with a diagnostic instrument. malities in the formative stage of enamel unassociated
with evidence of biochemical or systemic diseases. They ii. In hypocalcific type (Fig. 30.8):
may be hypocalcification, hereditary generalized, local- −− Enamel is usually stained yellow or black. It may be
ized hypoplasia, hypomaturation, or pigmented hypoma- chalky in early stages of life.
turation. The abnormality could be in the matrix formation −− Enamel is soft in consistency and get scrapped off
leading to hypoplasia or it could be in the mineralization easily.
leading to hypomineralization.
Clinical Features
Amelogenesis imperfecta affects only one type of dentition
and only enamel because it is an ectodermal disturbance.
i. In hypoplasia type (Figs. 30.7A and B):
−− Small teeth with short roots, small pulp chamber,
and root canal.
−− Delayed eruption of teeth.
−− Sometime, enamel has glassy appearance due to
lack of prisms.
−− Change in teeth color from yellow to dark brown. Fig. 30.8: Hypocalcification.
−− Teeth with irregular shape and abnormal texture.
−− Unsealed or exposed areas. iii. In hypomaturation: Enamel can be pierced by an
−− Erosion and abrasion along the edge of the affected explorer point under firm pressure and can be lost
tooth. away by chipping from underlying normal appearing
−− Extreme tooth sensitivity to hot or cold liquids. dentin.
−− Pain in the mouth due to secondary infections. iv. Hypomaturation-hypoplastic taurodontism:
−− Enamel may be discolored, wrinkled, or yellow −− Clinically, crown appears white/yellow-brown
with signs of severe occlusal wear. mottled.
−− Teeth appear smaller than normal and they lack
proximal contacts. The enamel thickness is less.
The crowns appear to have hypomineralized areas
and pits.
Management
Early diagnosis is a key to relatively successful treatment.
Selective odontomy is done for esthetically reshaping
of the teeth. Full veneers with metallic based or cast
restorations for posterior teeth and all ceramic restorations
for anterior teeth can be given. Preventive interventions,
such as professional cleaning, the use of antimicrobial oral
rinses (e.g. chlorhexidine), and excellent oral hygiene help
A
to achieve healthy soft tissue prior to and after restorative
care.
DENTINOGENESIS IMPERFECTA
Dentinogenesis imperfecta comprises a group of auto
somal dominant genetic conditions characterized by
abnormal dentin structure affecting both deciduous and
permanent teeth.
a. Shield’s Classification of Dentinogenesis

Imperfecta (DGI-I)
B
Dentinogenesis imperfecta type I
Figs. 30.7A and B: Hypoplasia. Case of amelogenesis imperfecta
(A) Before treatment; (B) After treatment. Individuals with DGI-I also have osteogenesis imperfecta.
(Courtesy: Priya Titus). The teeth are amber and translucent and show significant
attrition. Radiographically, teeth have short, constricted knowledge regarding long-term results. Cases should be
roots and dentin hypertrophy leading to pulpal obliteration reviewed annually and new study casts and photographs
either before or just after eruption. should be assessed.
◆◆ Clinical and radiographic examination of abutments
Dentinogenesis Imperfecta Type II should be performed to check for caries and wear facet.
Risk of cementation failure is present due to differential
The dental features of DGI-II are similar to those of wear, bruxism, and short clinical crowns.
DGI-I but osteogenesis imperfecta may not be present.
Characteristic feature is presence of bulbous crowns.
Conclusion
Dentinogenesis Imperfecta Type III Noncarious tooth surface loss is a normal physiological
process occurring throughout life, but it can often become
The clinical features are variable and resemble those seen
a problem affecting function and esthetics. Noncarious
in DGI-I and II but primary teeth show multiple pulp
lesions can be abrasion, attrition, erosion, abfraction,
exposures and radiographically, they appear “shell” teeth, enamel, and dentin hypoplasia, etc. Early detection of
i.e. teeth which appear hollow due to hypotrophy of the these lesions is of utmost important for the prevention of
dentin. serious irreversible damages to an individual’s dentition.
Diagnosis, prevention, and treatment of noncarious
b. Clinical Features tooth lesions should be based on their multifactorial
◆◆ Color of teeth may range from gray, brown, and yellow- causes. Priority should be prevention of the lesion by
reducing or inhibiting the causative factors. Restoration
brown to violet, but they exhibit a characterized unusual
of noncarious lesions provides easy maintenance of oral
translucency or opalescent hue.
hygiene, maintains aesthetics, function, and reinforce
◆◆ Enamel gets easily chipped because of the defective
the teeth.
dentinoenamel junction.
◆◆ Crowns are overcontoured. Roots are short slender.
◆◆ Severe attrition may be present. EXAMINER’S CHOICE QUESTIONS
◆◆ Dentin will contain lot of interglobular dentin. 1. Explain abfraction in detail
◆◆ Root canal and pulp chamber space is obliterated. 2. What are clinical features of attrition? How will you
◆◆ Dentin hardness and resilience is half of that of normal treat a case of attrition of teeth
dentin. 3. Define abrasion. Write in detail about etiology, clinical
◆◆ Decay, if initiated, spreads laterally. features and treatment of abrasion.
c. Radiographic Features Viva QUESTIONS

For types I and II, there is partial or complete obliteration 1. What are the most common cervical lesions?
of pulp chamber and root canal with continued formation 2. Name the wedge-shaped defects.
of dentin. In type III, there is appearance of shell teeth, 3. Name the broad and saucer-shaped lesion.
enamel of normal thickness but dentin is very thin with 4. Which restorative material is best to restore cervical
enormous pulp chamber. lesions?
5. What is differential diagnosis of noncarious cervical
d. Management lesions?
6. Define attrition.
◆◆ Two possible treatment modalities can be used like
selective odontomy and permanent full veneering 7. Discuss etiological factors for attrition.
procedures. As the teeth are very weak, permanent full 8. Define abrasion.
cast crown should be given. There should not be any 9. Discuss etiological factors for abrasion.
attempt to use intracanal or intraradicular retention 10. Discuss management of abrasion.
modes. Only extracoronal retention modes can be used 11. Define erosion.
for veneers. 12. What are etiological factors for erosion?
◆◆ Splinting between these teeth may be considered to 13. Discuss management of erosion.
avoid root fracture. 14. Define abfraction.
Maintenance phase of noncarious lesions: Regular 15. What are etiological factors for abfraction?
follow-up of treated cases is necessary as there is lack of 16. How will manage a case of abfraction?
BIBLIOGRAPHY 3. Bishop K, Kelleher M, Briggs P, et al. Wear now? An update on

the etiology of tooth wear. Quintessence Int. 1997;28(5):305-13.
1. Addy M, Shellis RP. Interaction between attrition, abrasion and 4. Eccles JD. Tooth surface loss from abrasion, attrition and
erosion in tooth wear. Monogr Oral Sci. 2006;20:17-31. erosion. Dent Update. 1982;9(7):373-4.
2. Arens U, Oral Health Task Force. Tooth wear. In: Arens U (Ed). 5. Levitch LC, Bader JD, Shugars DA, et al. Non-carious cervical
Oral Health, Diet and Other Factors: The Report of the British lesions. J Dent. 1994;22(4):195-207.
Nutrition Foundation’s Task Force. Amsterdam: Elsevier; 1999. 6. Shafer WG, Hine MK, Levy BM, et al. Textbook of Oral Pathology,
pp. 60-2. 4th edition. Philadelphia: Saunders; 1983. pp. 160-1.
Chapter
31
Dental Ceramics
Chapter Outline
Introduction Disadvantages of Dental Ceramics

Definitions Metal ceramic Restorations
History Conventional Method of Fabrication of Pfm Restorations
Classification All-ceramic System
Composition All-ceramic Restorations
Properties of Ceramic Porcelain Laminate Veneers
Methods of Strengthening Porcelain All-ceramic Crowns
Advantages of Dental Ceramics Fabrication of Ceramic Restorations
Introduction Definitions
The term Ceramic comes from the Greek word “keramos” Ceramic
which means burnt earth. Ceramic compounds is an
inorganic compound of, nonmetallic materials which are An inorganic compound with nonmetallic properties
made by heating of raw materials at high temperature. typically composed of metallic or semi-metallic and
Porcelain is a type of ceramic. nonmetallic elements; for example, porcelain and glasses.
Ceramics are now a days popular due to the demand
for aesthetics and durability of the restorations. Dental Dental Ceramic
ceramics mainly consist of glasses, porcelains, and highly
An inorganic compound with nonmetallic properties
crystalline structures. physical and mechanical properties
typically composed of oxygen and one or more metallic
of ceramics are much closer to enamel than those of
or semi-metallic elements, e.g. aluminium, calcium,
acrylic resins and metals. Ceramics have coefficient of
magnesium, and zirconium, etc. that is formulated to
thermal expansion very close to that of tooth, excellent produce the ceramic-based prosthesis.
wear resistance and durability, all these qualities make
ceramics as a choice of restorations in areas demanding
aesthetics and durability. Though ceramics are strong, Feldspathic Porcelain
resilient, and temperature resistant, but these are brittle A ceramic which consists of a glass matrix phase and one
and thus may fracture when flexed, or when quickly or more crystalline phases like leucite.
heated and cooled. Commonly used ceramic materials
are feldspathic porcelain, castable ceramic (Dicor), and
Glass Ceramic
new machinable glass ceramic (Dicor MGC) used with
CEREC systems. While seating on the prepared tooth, the A ceramic composed of a glass matrix phase and at least
cementing surface of the ceramic restoration is etched one crystalline phase which are formed by controlled
which aids in removal of all the glossy matrix. crystallization of the glass.
Glaze Ceramic 1965 Mclean and Hughes

A special ceramic powder when mixed with a liquid, Improved the fracture resistance by
applied to a ceramic surface and heated to an appropriate introducing aluminous porcelain
temperature for a sufficient time, forms a smooth glossy 1984 Adair and Grossman
layer on ceramic surface. Introduction of castable glass ceramic (Dicor)
Metal Ceramic Restoration Classification

Restoration made with a metal substrate to which
porcelain is bonded for esthetic enhancement with an 1. According to Fusion Temperature
intermediate metal oxide layer. ◆◆High-fusing ceramics—1300°C (2372°F)
◆◆Medium-fusing ceramics—1101–1300°C (2013–2372°F)
Aluminous Porcelain ◆◆Low-fusing ceramics—850–1100°C (1562–2012°F)
A ceramic consisting of a glass matrix phase and at least ◆◆Ultra low-fusing ceramics—<850°C (1562°F).
35% volume alumina. High and medium fusing are used for production of
denture teeth. Low and ultra low fusing are used for crown
Body Porcelain and bridge construction.
A veneering ceramic used for ceramic or metal ceramic
restoration. 2. According to Method of Firing
◆◆ Atmospheric firing
Castable Ceramic ◆◆ Vacuum firing (lowers the porosity).
A glass or other ceramic especially used for casting into a
refractory mold to produce a core coping or framework for 3. According to Crystalline Phase in Ceramics
a ceramic restoration. ◆◆ Alumina based, for example—Optec HSP
◆◆ Feldspar based, for example—conventional ceramics
CAD-CAM Ceramic ◆◆ Leucite based, for example—IPS Empress
This type of ceramic is used for making whole or part of ◆◆ Spinel based, for example—In-Ceram Spinel.
an all-ceramic restoration by means of a computer-aided
design (CAD) and computer-aided manufacturing (CAM) 4. According to Application
process.
◆◆ Ceramic as veneers over metal crowns and fixed partial
dentures
History
◆◆ All ceramic veneer, crowns, inlays, and onlays
1728 Pierre Fauchard ◆◆ Ceramic denture teeth.
Suggested the use of porcelain in dentistry
1789 Duchateau and DeChemant 5. According to Fabrication Technique
Introduced porcelain tooth material for
bridge work and denture ◆◆ Sintered, for example—metal ceramic
1808 Fonzi ◆◆ Cast for example—castable ceramic
Terra metallic porcelain (held in place by ◆◆ Machined, for example—CEREC, Vitablocs
platinum foil) ◆◆ Heat pressed, for example—IPS Empress
1837 Ash ◆◆ Slip casting, for example—In-Ceram.
Improved version of porcelain tooth material
1900–1905 Introduction of first electric porcelain 6. According to Composition
furnace ◆◆ Pure alumina
1903 Dr Charles Land ◆◆ Pure zirconia
Introduction of first ceramic crown using ◆◆ Silica glass
platinum foil matrix and high fusing ◆◆ Leucite-based glass ceramic
porcelain ◆◆ Lithia-based glass ceramic.
1962 Weinstein and Weinstein
Introduction of porcelain fused to metal
restorations Composition
1963 Vita Dental porcelains are basically glassy materials. Molten
Commercial production of porcelain glass solidifies with liquid structure rather than crystalline
Dental Ceramics 397
structure during cooling. The structure thus formed is Medium- and Low-fusing Ceramics
known as vitreous and process is known as vitrification.
The principal anion which is responsible for forming Medium- and low-fusing ceramics are formed by process
known as fritting and product obtained is termed as frit.
bonds with multivalent cations such as silicon and boron
Basic ingredients for medium- and low-fusing ceramics
is O2– ion. These ions are considered as glass formers. Other
are same as those of high fusing but, in addition, certain
oxides such as potassium, sodium, calcium, or aluminium
glass modifiers are also added.
oxides are added in glass to obtain additional desirable
properties (Fig. 31.1).
Glass Modifiers
◆◆ Most commonly used glass modifiers are potassium,
sodium, and calcium oxides. These modify the
properties of ceramics by interrupting glass network.
◆◆ Act as fluxes and reduce the softening temperature of
glass.
◆◆ Lower the viscosity of glass and increase thermal
expansion.
If used in excess, glass modifiers reduce chemical dura
bility and crystallization of glass during firing.
Intermediate Oxides
◆◆ Most commonly used is aluminium oxide (Al2O3).
◆◆ Lower the softening temperature along with viscosity of
Fig. 31.1: Composition of dental porcelain. glass.
Boric Oxide (B2O3)

High-fusing Porcelains
◆◆ Acts as glass former as well as glass modifier.
Basic ingredients of these types of porcelains are:
◆◆ Lowers the melting point and viscosity of glass.
◆◆ Feldspar ◆◆ Matrix of B2O3 is formed by three-dimensional
◆◆ Kaolin (clay) arrangement of BO3 triangles.
◆◆ Quartz.
Opacifying Agents
Feldspar
Most commonly used agents are zirconium oxide, titanium
◆◆ Primary constituent and is present in concentration of oxide, and cerium oxide.
75–80%.
◆◆ Sodium or potassium form is mainly used but in dental, Coloring Agents/Pigments
potassium feldspar is preferred because of increased
Various coloring agents are used to obtain various shades
resistance to pyroplastic flow and increased viscosity. needed to simulate natural teeth, mimic markings like
◆◆ Undergoes incongruent melting at 1150–1530°C to enamel craze lines, decalcification spots, and to create
form a liquid and crystalline material, i.e. potassium gingival effects (Table 31.1).
aluminosilicate known as leucite.
Table 31.1: Different colors produced by use of metal oxides in
Kaolin ceramics.
◆◆ Present in concentration of 4–5% Metallic pigments Color
◆◆ Acts as binder Ferric oxide Brown
◆◆ It is opaque and lowers the translucency of porcelain.
Titanium oxide Yellowish brown
Manganese oxide Lavender
Quartz
Cobalt oxide Blue
◆◆ Present in concentration of 13–14% Nickel oxide Brown
◆◆ Acts as strengthener
Chromium-alumina Pink
◆◆ Provides strength, firmness and increases translucency
Copper oxide Green
of porcelain.
Glaze and add-on porcelains

These are uncolored glass powders which mature at lower
temperatures than that of restoration and coefficient of
thermal expansion is slightly lesser than ceramic body.
these are used for producing final finishing and simple
corrections on tooth.
properties of ceramic
Biological Properties A B
Figs. 31.2A and B: Diagrammatic representation of (A) Before;
It is biocompatible, inert in nature, so no interaction with (B) After ion exchange process in porcelain.
surrounding tissues.
stresses. This is available under commercial name GC
Chemical Properties Tuf-coat (GC).
Insoluble in oral fluids and resists acid etching.
Hydrofluoric acid and stannous fluoride can cause surface 2. Dispersion Strengthening
roughness.
Dispersion strengthening is a process in which
Mechanical Properties strengthening is done with dispersed phase of different
material with the capability of blocking a crack from
It has high hardness, can cause wearing of opposing propagating the material. Dispersion strengthening of
teeth. High compressive strength, low tensile strength, ceramics can be obtained by increasing the crystal content
and fracture toughness, making it brittle in nature, so bulk of alumina, leucite, and zirconia. For example, if alumina is
thickness is required to avoid fracture. High modulus of added to glass, the glass is toughened and strengthened as
elasticity makes it a stiff material. crack cannot pass through tough crystalline particle such
as alumina easily, while it can pass through glass easily.
Interfacial Properties
It does not bond chemically to dental cements. 3. Thermal Tempering
Thermal Properties It is the most common method for strengthening glass. This
process creates residual compressive stresses in the glass
Ceramic has low thermal conductivity. Coefficient of by heating and when it is in molten state, it is immediately
thermal expansion is similar to enamel and dentin. quenched. This quenching (rapid cooling) produces a
rigid glass surrounding a soft molten metal. For dental
Aesthetic Properties use, ceramics are quenched (rapid cooled) in silicone oils
Excellent aesthetics, color matching. or other special liquids.
Manipulation 4. Reduce the Number of Firing Cycles

Technique sensitive, requires skilled operator and special Main function of firing cycle is to sinter the powder
equipment for manipulation. particles together and produce a relatively smooth surface.
Several chemical reactions occur at the time of firing
Methods of Strengthening Porcelain cycles. If number of firing cycles is increased, the leucite
content of porcelain also increases which further increases
1. Chemical Strengthening/Ion Exchange the coefficient of thermal expansion of porcelain. The
expansion mismatch between porcelain and metal creates
This is one of the effective methods of introducing residual
stresses on cooling which can cause crack formation in the
compressive stresses into surface of a ceramic. Chemical
porcelain. Thus, reduction in number of firing cycles can
strengthening is usually carried out by replacing small-
help in reducing crack formation.
sized cations in the surface layer with large-sized cations
while matrix remains the same. This is also known as 5. Developing Residual Compressive Stresses
low temperature ionic crowding. Sodium ions present
in the matrix are replaced by large size potassium ions This is also one of the important methods for developing
by placing porcelain crown in bath of potassium nitrate residual compressive stresses in the ceramic. In metal
(Figs. 31.2A and B). The potassium ion is 35% larger in ceramic crowns, metal should have high coefficient of
size than sodium ion, so, creates residual compressive thermal expansion than porcelain so that on cooling, metal
Dental Ceramics 399
contracts slightly more than that of porcelain, creates is the main concern. In metal ceramic restoration,
stresses and provides strength to porcelain. This rule also advantages of aesthetics of porcelain and strength of metal
applies to all ceramic systems in which inner layer (core) are combined.
has high coefficient of thermal expansion than outer
layers, creating stresses and strengthening the porcelain. Requirements for Metal Ceramic Restorations
◆◆ Porcelain and alloys should be able to form a strong
6. Transformation Toughening bond since the most common cause for the failure of
metal ceramic restoration is debonding of porcelain
In this process, small and tough particles like alumina,
from the metal.
leucite, and lithium disilicate are uniformly dispersed in the
◆◆ Both porcelain and alloy should have almost similar
matrix so that cracks cannot pass through these crystals. In coefficient of thermal expansion so that porcelain
case of zirconia-based ceramics, zirconia crystals undergo does not crack or separate from alloy on cooling.
change from tetragonal crystal to monoclinic phase upon ◆◆ Low fusion temperature of ceramic and high fusion
stressing and cause transformation toughening. temperature of alloy (at least 100°C more than that of
ceramic) so as to avoid distortion of metal coping.
7. Proper Glazing of Porcelain ◆◆ Alloy should have a high modulus of elasticity so
removal of number of surface flaws by glazing and proper that it can share greater proportion of stress than the
polishing improves the strength of porcelain. adjacent porcelain.
◆◆ Adequate stiffness, sag resistance, and strength of the
8. Adhesive Bonding of Ceramic Restorations alloy.
adhesive bonding of ceramic restorations by resin luting Composition of Metal Ceramic Alloys and
cements strengthens the ceramic restoration.
Ceramics
Advantages of dental ceramics Metal ceramic alloys used are:
◆◆ Noble metal alloys:
◆◆ Highly aesthetic with excellent color matching and •• High gold alloys
translucency •• Gold-platinum-palladium alloys.
◆◆ No display of metal ◆◆ Low gold alloys:
◆◆ Biocompatible •• Gold-palladium alloys
◆◆ Strong once bonded to tooth •• Gold-palladium-silver alloys.
◆◆ Does not stain ◆◆ Silver-palladium alloys
◆◆ Low thermal conductivity/insulation ◆◆ Base metal alloys:
◆◆ High abrasion resistance due to their hardness •• Nickel-chromium alloys
◆◆ Durable •• Cobalt-chromium alloys.
◆◆ Low coefficient of thermal expansion.
Porcelain-metal Bond
Disadvantages of dental ceramics
There are generally two types of bonding present between
◆◆ Fragile and brittle metal and ceramic:
◆◆ Costlier than amalgam or composite
◆◆ Abrade the opposing tooth 1. Micromechanical Bonding
◆◆ Finishing of the margins is difficult in the less accessible
interproximal areas Fused ceramic flows over the metal coping and adapts to
◆◆ Need special and expensive laboratory equipments minute irregularities present on metal surface and form
◆◆ Very technique sensitive micromechanical bonds. Irregularities present on metal
◆◆ Accurate occlusion can be difficult to achieve surface should be uniform without any sharp line angles so
◆◆ Takes two appointments as to avoid stress concentration which can result in fracture
◆◆ Intraoral finishing and polishing is a time-consuming of porcelain. This ability of the fused porcelain to intimately
procedure and difficult. adapt to the metal surface is called “wetting”. Irregularities
on the coping surface can be produced by sand blasting.
Metal Ceramic Restorations
2. Chemical Bonding
All ceramic restorations, though look very natural, but are
very brittle and tend to fracture. Metal restorations are very Chemical bonding occurs between the ceramic and
strong but they cannot be used in areas where aesthetics the surface oxide layer present on the base metals, such
as iron, indium, and tin of gold alloys. Fused porcelain 1. Condensation of Porcelain
diffuses into the metallic oxide layer and vice versa.
in this, porcelain powder is mixed with distilled water or any
In metal ceramic bonding: other binder and applied onto the metal surface. First of all,
◆◆ Metal should not interact with ceramic as it will visibly opaque layer is placed, then dentin and enamel porcelain
discolor it and affect the aesthetics. are applied on metal framework. Condensation is done by
◆◆ Metal-porcelain bond must be durable and stable at maximum incorporation of porcelain powder so as to have
interface to withstand masticatory stresses. minimum voids. It can be done by following ways:
In a metal ceramic restoration, on the labial side, the
thickness of the metal is about 0.3–0.4 mm which is covered Vibration Method
with opaque porcelain of about 0.3–0.4 mm thickness.
Body porcelain is about 1 mm thick on the labial side and In this, wet porcelain mixture is applied with spatula and
the transparent porcelain is about 0.3–0.5 mm thick at vibrated gently till particles join together. Mild vibrations
incisal third. At the middle-third of the crown, it is about help in packing the wet powder densely. Excess water is
0.2–0.3 mm thick and at the cervical third, it is about 0.1 removed using tissue paper. This is most useful method in
mm thick (Fig. 31.3). removing excess water from the mixture.
Spatulation Method
In this method, a small spatula is used to smoothen the
wet powder and the wet particles condense together by
which the excess water comes on the surface from where it
can be removed using tissue paper.
Brush Technique
In this method, dry porcelain powder is applied on wet
porcelain surface with the help of a brush. The dry powder
absorbs the excess water from wet porcelain making
particles join together.
Fig. 31.3: Metal ceramic restoration. 2. Preheating/Drying

In this, porcelain tray is placed in front of preheated
Conventional Method of furnace at 650°C for 5 minutes for low-fusing porcelain
Fabrication of Pfm Restorations and 480°C for 8 minutes for high-fusing porcelain till it
reaches leathery or green state.
Significance
◆◆ Increase in strength by removal of excess water.
◆◆ Prevention of sudden production of steam which could
cause voids or fractures.
3. Sintering or Firing
Porcelain restorations are fired in ceramic furnace by
following methods:
Temperature Controlled
In this, furnace temperature is raised at constant rate until
required temperature is reached.
Temperature Time Control Method

In this, furnace temperature is raised at a given rate until
preset temperature is reached. After this, temperature is
maintained for specific time till final stage is reached.
Dental Ceramics 401
Different media like air, vacuum, and diffusible gas can Significance
be used for firing porcelain.
◆◆ Overfiring: it occurs due to firing at temperature higher
than required for firing or due to longer firing time. It
Air Firing increases chances of slumping (forming a globule
It traps air producing voids, pits, and surface roughness. of ceramic rather than definite shape) and reduces
It reduces the strength and optical properties of ceramic. strength due to formation of undesired crystalline
phases (devitrification).
Vacuum Firing ◆◆ Underfiring: Porcelain will attain chalky white color
overlying its shade. This occurs because light is
It produces dense porcelain with smooth surface, high scattered and reflected at the boundaries between the
strength, and translucency. particles and at the surface of porosity.
Diffusible Gas 4. Cooling

Helium, hydrogen, or steam is substituted for ordinary After firing is done, porcelain is cooled. It is always
furnace. preferable to do cooling slowly since rapid cooling may
result in crazing or cracking of the surface. Slow cooling
Mechanism
is done by placing the restoration under a glass cover to
◆◆ During initial firing temperature, voids are occupied protect it from cold wind and dirt contamination.
by atmosphere of furnace. As the temperature begin to
increase, the porcelain particles bond at their point of
contact.
5. Checking Fit on the Working Cast
◆◆ As temperature is further raised, sintered glass flows Final restoration is tried on working cast. Adjustments are
to fill the air spaces. Porcelain particles fuse together made with diamond stones and discs. After all corrections
by sintering forming a continuous mass. It results in are made, restoration becomes ready for surface treatment.
decrease in volume called as firing shrinkage.
◆◆ With further sintering, gaps between particles become 6. Surface Treatment
porosities. Viscosity of glass is low enough for it to flow
Restoration is surface treated by self-glazing and add-on
due to its own surface tension. So, as the firing proceeds,
glaze, polishing and custom staining.
voids attain spherical shape.
◆◆ In final firing stage—the voids will rise to surface and Glazing
disappear.
Glazes are uncolored glass powders which mature at
lower temperature than that of restoration. The coefficient
Stages of Porcelain Maturity of thermal expansion of glaze is lesser than ceramic body.
A series of stages of maturation in the firing of ceramic Glaze layer is kept at least 50 microns thick. Purpose of
materials occur depending upon degree of pyrochemical glazing:
reaction and sintering shrinkage occurring before glazing, ◆◆ Reduction of surface flaws
viz. low, medium, and high bisque stage. ◆◆ Sealing of surface porosities
◆◆ Increase in porcelain strength as it prevents crack
propagation
Low Bisque Stage ◆◆ Reduces plaque accumulation.
In low bisque stage, porcelain is very porous, and it readily
absorbs water. Particles lack strength, and porcelain shows Types of Glazing
minimal shrinkage during this stage. ◆◆ Self-glazing: In this technique, the completed resto
ration is heated to the glazing temperature. This results
Medium Bisque Stage in formation of a glossy film by a viscous flow on the
Surface is still porous, and flow of glass grain is increased. porcelain surface.
Entrapped air attains sphere shape. There is definite ◆◆ Add-on glazing: In add-on glazing, the uncolored
shrinkage in this stage. glasses with fusion temperature lesser than porcelain
restoration are used which form an external glossy layer.
Self-glazing is preferred over add-on glaze because
High Bisque Stage
add-on glaze produces unnatural glossy appearance.
Porcelain shows smooth surface and attains adequate Moreover, it is difficult to apply and has less durability, low
shrinkage. Now, the porcelain is very strength. chemical durability, and causes shade modification.
Failures of Metal Ceramic 4. Pressable Ceramic

Restorations (Fig. 31.4) IPS empress 1 and 2
Most of the metal ceramic restorations fail because of
bond fracture at the metal oxide interface. Other reasons 5. Machinable Ceramic
for failure of metal ceramic restorations are: ◆◆ CEREC, Vitablocs Mark I and II
◆◆ Fusion of porcelain grains inside the coping. ◆◆ Dicor MGC
◆◆ Thin margins of metal buckle due to contraction of ◆◆ Celay
porcelain.
◆◆ Elastic deformation of nonrigid metal structure. 1. Traditional Powder Slurry Ceramic/Sintered
◆◆ Casting contamination by low-fusing alloy components
All Ceramics
from the metallic die.
◆◆ Forceful fitting may result in elastic deformation of the These are supplied in powders which are mixed with
metal and breakdown in porcelain bond. distilled water to form “slurry”. This slurry formed can be
built up in different layers on a die to form the restoration.
This type of ceramic can be classified in two types:
a. Alumina Reinforced Ceramic

This type of ceramic is based on dispersion strengthening—
one of the methods used for strengthening of ceramic.
Alumina crystals are dispersed uniformly in a glass matrix
to increase strength, toughness, and elasticity of the
material. In case of aluminous ceramic, the concentration of
alumina crystals and glass powder are mixed and prefritted
at 1,200°C. Then, this crystal glass mixture is grounded and
incorporated into glass matrix; for example, Hi-Ceram.
b. Leucite Reinforced Ceramic

In this type, leucite crystals (potassium aluminosilicate) are
Fig. 31.4: Fracture in a metal ceramic restoration. dispersed in glassy matrix. Leucite is added in feldspathic
porcelain to match the thermal contraction of ceramic to
the metal but it also acts as reinforcing filler because of very
All-ceramic system
high tensile strength. The leucite and glassy components
To overcome the disadvantages of porcelain fused to metal, are fused together and baked at 1,020°C to form the ceramic.
all-ceramic materials have been introduced with new These ceramics have high strength and good translucency.
techniques and technologies. Due to new advancements In addition, surface stains or pigments can also be added to
in technology, all-ceramic systems have high strength and enhance aesthetics; for example, Optec-HSP.
precision fit close to that of ceramo-metal in addition to
aesthetics. 2. Castable Ceramic
These are supplied as solid ceramic ingots which are
Classification of All-ceramic Systems heat treated under controlled conditions (ceramming)
using lost wax and centrifugal casting technique. In 1984,
1. Traditional Powder Slurry Ceramic castable ceramic was marketed under the name DICOR.
◆◆ Alumina reinforced ceramic (Hi-ceram)
◆◆ Leucite reinforced ceramic (Optec-HSP) Fabrication Technique
◆◆ Die is waxed up, invested, and burnt out.
2. Infiltrated Ceramic ◆◆ Ceramic ingot is heated at 1,350°C and casted using
◆◆ In-ceram centrifugal casting technique.
◆◆ In-ceram spinel ◆◆ Ceramming process—crown is heated at 1,075°C for 10
hours for controlled crystallization, i.e. evenly uniform
3. Castable Ceramic distribution of tiny crystals throughout the body of
Dicor glass, thus enhancing mechanical properties.
Dental Ceramics 403
◆◆ Final shade of crown is applied to the surface of ◆◆ SLIP is painted onto the die with brush. Water is
restoration. removed by capillary action of porous gypsum leaving
behind the layer of solid alumina.
Advantages ◆◆ Sintering is done at 1,120°C for 10 hours.
◆◆ Lanthanum alumina silicate glass powder is applied to
◆◆ Satisfactory marginal fit
the core and fired at 1,100°C for up to 5 hours. Molten
◆◆ High strength and improved surface hardness
glass flows into the pores by capillary diffusion.
◆◆ Highly aesthetics as mica crystals which form the crystal
◆◆ Excess glass is removed and final core is veneered using
phase have matching the index of refraction to the glass
dentin and enamel porcelain.
phase
For example, In-Ceram, In-Ceram Spinel, and In-Ceram
◆◆ Chameleon effect, i.e. restoration takes the shade of
Zirconia.
adjacent tooth and luting cement.
In-Ceram
Disadvantage
Composition: This type of ceramic is available in two
Surface stains may get removed after occlusal adjustments. components:
1. Powder: Aluminium oxide
3. Pressable Ceramic 2. Low viscosity glass.
In this, aluminium oxide is fabricated on a porous
These materials are supplied as solid ceramic ingots which substrate in which low viscosity glass is heated at high
are melted and pressed into the mold created by lost wax
temperature, to be infiltrated in this matrix.
technique.
In-Ceram Spinel
Technique
In this, spinel (aluminium and magnesium oxide) is
◆◆ Die is waxed up, invested, and placed in specialized used as the core material. It has better translucency than
mold which has aluminium plunger. In-Ceram (high opacity due to higher concentration of
◆◆ After burnout, ceramic ingot is placed under the alumina crystals).
plunger and heated to 1,150°C and plunger presses the This type of ceramic can be used for both anterior and
molten ceramic into the mold. posterior crowns.
◆◆ Final shade is adjusted by staining or veneering.
5. Machinable Ceramic
Examples
These ceramics are supplied in the form of ceramic blocks
◆◆ IPS Empress I—it contains 35–45% volume leucite as of various shades (Fig. 31.5). Later on, these blocks are
crystalline phase. It shows porosity and has flexural fabricated into inlays, onlays, or crowns with the help of
strength. CAD-CAM or copy milling.
◆◆ IPS Empress II—it contains 65% volume lithium
disilicate as main crystalline phase. It has less porosity
and high flexural strength than Empress I.
◆◆ IPS e.max Press—it was introduced in 2005. It contains
enhanced lithium disilicate press ceramic material
when compared to Empress II, so have better aesthetics
and physical properties.
4. Infiltrated/Slip Cast Ceramics

These materials have powder which consist of alumina or
spinel (magnesium aluminium oxide) forming a porous
infrastructure and a glass which is then infiltrated at high
temperature into this porous structure.
Fig. 31.5: Machinable ceramic.
Technique
CAD-CAM (Fig. 31.6)
◆◆ Die is prepared.
◆◆ Aluminium powder is mixed with water to produce This method utilizes the process chain of scanning and
suspension called as SLIP. milling to produce final restoration in one single visit.
properties similar to that of Dicor ceramic except for

less translucency.
◆◆ Procera AllCeram: This type of crown contains sintered
and highly packed aluminium oxide (99.9%) crystals as
core material which is combined as AllCeram veneering
porcelain. This is one of the hardest ceramics used in
dentistry for anterior and posterior crowns, inlays, and
onlays.
ALL-CERAMIC RESTORATIONS
1. Ceramic Inlays and Onlays (Fig. 31.7)
For patients demanding aesthetic restorations, ceramic
inlays and onlays provide a durable alternative to posterior
composite resins restorations.
Fig. 31.6: CAD-CAM machine.
Prepared tooth is scanned and digital data is processed

by the computer. After that the restoration is designed and
machined from machinable ceramic block with the help of
computer-assisted milling machine.
Copy Milling
Die is prepared, over which the resin pattern of tooth
preparation is made. This pattern is copied and machined
from a ceramic block using photographic device known as
optical scanner.
Advantages
◆◆ A single appointment restoration.
◆◆ Conventional impression, multiple sittings, and tempo
rary restorations are not required.
◆◆ Quality of the ceramic restorative material is very good.
Blocks of very good quality machinable ceramics are used
Fig. 31.7: Ceramic inlays and onlays.
for milling. They come in various natural tooth shades.
◆◆ A natural looking restoration having excellent aesthetics.
Indications
◆◆ Results in a restoration which is nonabrasive, biocom
patible, and resistant to plaque. 1. Aesthetics is main concern
2. Patient having good oral hygiene
Disadvantages
3. Suitable for large preparations
◆◆ High cost of the equipment
4. When accessibility and isolation of tooth are easy to
◆◆ Special training is required
achieve
◆◆ More conservative tooth preparation is required
5. When preparation margins are on enamel and sound
◆◆ Computer prepares rough occlusal anatomy without
tooth structure making it feasible for bonding.
consideration of opposing occlusal anatomy
6. When undercuts are not present in tooth preparation
◆◆ Requires final occlusal adjustments.
Examples:
◆◆ Vitablocs Mark I and II: These have similar properties Contraindications
to feldspathic porcelain and are developed by 1. In patients with poor oral hygiene and multiple active
CEREC-CAD system. Vitablocs Mark II has high caries
strength than Vitablocs Mark I. These materials can be 2. Because of their brittle nature, they are contraindicated
used for inlays, onlays, and crowns. in patients with excessive occlusal loading, such as
◆◆ Dicor MGC: The CAD-CAM ceramic dicor MGC has bruxers
high concentration of tetrasilic fluormica crystals (i.e. 3. When moisture control is difficult to achieve
70%) than castable Dicor ceramic (i.e. 55%). It has 4. Inadequate enamel for bonding
Dental Ceramics 405
5. When marked undercuts are present in the tooth ◆◆ During final tooth preparation, coarse diamond
preparation. preparation points are used. Always remove the
undermined or weakened enamel.
Advantages ◆◆ Do the central groove reduction (approximately 1.5–2
1. Excellent aesthetics mm) following the anatomy of the unprepared tooth.
2. Low thermal conductivity This provides additional bulk for the ceramic so as to
3. Durable have strength. The outline form should avoid occlusal
4. Chemically inert contacts.
5. Low coefficient of thermal expansion ◆◆ There should be at least 1.5 mm of clearance in all
6. Biocompatible. excursions to prevent ceramic fracture.
◆◆ Preparation walls should exhibit 6–8° of occlusal
Disadvantages divergence per wall. Increased degree of taper in
ceramics is given because ceramic restorations are
1. More expensive than amalgam or composite adhesively bonded to tooth structure, restoration should
2. Requires special and expensive laboratory equipment passively seat in the tooth preparation (Fig. 31.8).
3. Takes two appointments ◆◆ Extend the proximal box to have a minimum of 0.6 mm
4. Intraoral finishing and polishing is a time consuming of clearance for impression making.
procedure ◆◆ Isthmus width should be minimum of 1.5 mm to
5. Fragile and brittle, so, can fracture during try in or prevent fracture (Fig. 31.8).
cementation. ◆◆ Margins of the preparation should be kept supragingival
6. Abrasive to the opposing enamel. so as to have sufficient enamel for bonding.
◆◆ The width of the gingival floor of the box should be
Tooth Preparation approximately 1.0 mm.
Before applying the rubber dam, mark and assess the ◆◆ All internal line and point angles should be rounded
occlusal contact relationship with articulating film. To and preparation walls should be smooth and even.
avoid chipping or wear off the luting resin, avoid placement ◆◆ If cusps are undermined or fractured, cusp capping is
of the margins of the restoration at a centric contact. recommended. For this, 1.5–2 mm of cusp height should
be reduced and hollow ground bevel is placed on facial
Outline Form and lingual margins away from occlusal contact.
Outline form is usually governed by the existing restoration ◆◆ All cavosurface margins should be made butt angled
and caries. or they should present a hollow ground chamfer in
◆◆ It is grossly similar to that for conventional metal inlays an attempt to create an invisible margin (Fig. 31.8).
and onlays except that bevels and flares are not given Bevels are contraindicated because bulk of restoration
here. In initial tooth preparation, the carbide burs are is needed to prevent fracture. A distinct heavy chamfer
used. is recommended for ceramic onlay margins.
◆◆ Bur should be held tapering to make straight facial and ◆◆ Provide pulp protection by placing resin modified glass
lingual walls that diverge occlusally (10° taper) to allow ionomer cement base in excavated tissue in the gingival
the easy insertion and removal of restoration. wall.
Fig. 31.8: Tooth preparation for ceramic inlay showing divergent preparation of tooth walls, 1.5–2 mm depth of cavity,
widened isthmus, butt angle or hollow ground chamfer line.
◆◆ Refine the margins with finishing burs and hand instru Cementation
ments, do trimming of any excess glass ionomer base
because smooth, distinct margins are needed to achieve ◆◆ Apply rubber dam for isolation of the tooth.
a precisely fitting ceramic restoration. ◆◆ Do pumice prophylaxis to remove any surface deposits.
Table 31.2 shows the differences between tooth ◆◆ Etch the prepared tooth surface using 37% phosphoric
preparation for cast metal inlay/onlay and ceramic inlay/ acid for 15 seconds rinse, wash and dry it.
onlay. ◆◆ Apply two thin coats of bonding agents and light cure it.
◆◆ Etch the internal surface of inlay/onlay with 10%
Table 31.2: Differences between cast metal and ceramic inlays and hydrofluoric acid for 1 minute rinse, wash and dry it.
onlays.
◆◆ Apply silane coupling agent on etched porcelain
Sl. Cast metal inlays Ceramic inlays and surface.
No. Feature and onlays ceramic onlays ◆◆ Apply luting resin onto the fitting surface of restoration
1. Bulk Less bulk needed More bulk and and position the restoration onto the prepared tooth.
clearance required
◆◆ Remove excess of cement and light cure the resin
2. Bevels Bevels necessary Bevels contraindicated cement for 1 minute.
3. Cervico- 2–5 degrees per 6–10 degrees of occlusal ◆◆ Remove small excess using blade or fluted bur. Finish
occlusal wall divergence margins of restoration and polish using rubber cup/
divergence
silicon cusp disc and diamond polishing paste.
4. Pulpal floor Flat and Need not be flat and Figures 31.9A and B show the management of maxillary
perpendicular to perpendicular to the long
the long axis of axis of the tooth; if the second molar by ceramic onlay.
the tooth cavity is shallow, pulpal
floor should be indented
in central fossa region
Porcelain Laminate Veneers
parallel to the cuspal Ceramic veneers became popular in 1980s; they are the
inclines
most aesthetic materials which can restore shape, shade,
5. Internal line Well-defined Rounded internal line and size of enamel. Laminate veneer is a conservative
angles internal line and and point angles alternative to full coverage crown for improving
point angles
appearance of anterior teeth.
6. Isthmus 1.5–2.0 mm of Minimum 2.0 mm width
width isthmus width is required
Indications (Fig. 31.10)
7. Cavosurface 140–150° 90° butt joint
angle (30–40° marginal 1. To improve dicolorations like tetracycline stains,
metal) fluorosis, and devitalized teeth, etc.
8. Cusp Functional cusp: 1 Functional cusp: 1.5 mm 2. Repair of chipped/fractured teeth
reduction mm–1.5 mm –2 mm 3. To close diastema between teeth
A B
Figs. 31.9A and B: (A) Preoperative management of maxillary second molar by ceramic onlay;
(B) Postoperative photograph of maxillay second molar.
(Courtesy: Mohan Bhuvaneswaran).
Dental Ceramics 407
reduction of 0.3–0.5 mm labial reduction should
be carried out. For this, place depth grooves on
enamel surface using depth cutting diamond.
Using tapered bur, reduce the facial enamel
surface to the depth of the groove. Take care
to limit the reduction with in the enamel and it
should follow the contour of the tooth.
ii. Interproximal reduction: It is done by using
Fig. 31.10: Indications for porcelain laminate veneers. tapered diamond extending interproximal
margins half way into contact areas. This provides
proximal translucency of veneer, porcelain
4. To correct malformations of anterior teeth like peg bulk in proximal areas and mask interproximal
laterals margins of veneer.
5. To improve aesthetics of anterior teeth iii. Incisal modification: There are four types of
6. To lengthen anterior teeth incisal preparation designs (Figs. 31.11 A to D):
7. To correct enamel hypoplasia and hypocalcifications. a. Window preparation/feathered incisal
edge: In this veneer is taken close to but not
Contraindications up to incisal edge. This has advantage of
◆◆ Inadequate enamel for bonding retaining natural enamel over incisal edge
◆◆ In patients with bruxism and abnormal oral habits but has disadvantage of weakening of incisal
◆◆ Poor quality enamel available for bonding. edge.
◆◆ Severe crowding of teeth b. Incisal bevel: In this, bucco-palatal bevel is
◆◆ Cost issues prepared across full width of the preparation
◆◆ Deciduous teeth. and there is some reduction of incisal length
of the tooth. This gives better control over
incisal aesthetics and positive seating of
Advantages
veneer.
Excellent aesthetics and color matching. c. Incisal lingual wrap preparation: In this,
◆◆ Chemically inert, so resistant to fluid absorption prepare 0.5 mm depth cut grooves in incisal
◆◆ Biocompatible in nature edge and then reduce the incisal tooth
◆◆ Good abrasion resistance. structure using tapered diamond. Then
reduce mesio-incisal and disto-incisal
Disadvantages
◆◆ Fragile and brittle in nature
◆◆ Difficult to repair or modify after cementation
◆◆ More expensive than amalgam or composite
◆◆ Need special and expensive laboratory equipment
◆◆ Intraoral finishing and polishing is a time-consuming
procedure
◆◆ Highly technique sensitive
A B
◆◆ Needs precise tooth preparation.
Tooth Preparation for Ceramic Veneer

Conventional porcelain veneer is a thin piece of porcelain
which is bonded to the labial surface of a tooth. Porcelain
is durable, translucent, strong, natural looking and highly
aesthetic material. It is done in two appointments
1st Appointment
1. Tooth preparation: Tooth preparation for porcelain C D
veneer has following aspects: Figs. 31.11A to D: Incisal modifications for ceramic veneer. (A) Win-
i. Labial reduction: Thickness of ceramic laminate dow preparation; (B) Incisal bevel; (C) Incisal lingual wrap preparation;
ceramic veneer should be 0.5 mm, so, uniform (D) Incisal butt joint preparation.
corners an additional 0.5 mm. then extend Seating of Restoration

the incisal chamfer to palatal surface. Lingual 1. Apply luting resin on to the prepared tooth and fitting
chamfer line should avoid occlusal contact surface of veneer and seat the veneer with firm finger
on interface of porcelain and tooth structure. pressure and hold in place while extra cement is
Contact should either be all on ceramic or on removed.
tooth structure. 2. Color stability of light curing resins is better than
d. Incisal butt joint preparation: In this, dual cure or self-cure resins. Dual cure resins contain
prepare 0.5 mm depth cut grooves in incisal tertiary amines which may undergo long-term color
edge and then reduce the incisal tooth change with overall darkening, thus contraindicated
structure using tapered diamond. Then round with veneers due to their thin and translucent nature.
the facial incisal line. 3. Light cure the resin cement for at least 60 seconds
iv. Cervical definition: Place chamfer or beveled from facial, lingual and incisal surfaces.
shoulder gingival finish line in enamel so as to 4. Remove small excess of set bonding material using
have strongest bond to enamel. Finish line is sharp carver. finish margins of restoration and polish
placed 0.1–0.2 mm gingival sulcus for optimal using rubber cup/silicon cusp disc and diamond
aesthetics. polishing paste.
2. Impression: If possible leave retraction cord in place Figures 31.12 and 31.13 show management of diastema
during impression. Use polysiloxane or polyether and malpositioned teeth with ceramic veneers.
material for impression because multiple pours
are needed for laboratory procedures. To minimize ALL-CERAMIC CROWNS
tearing of impression in lingual areas, place soft wax
in these areas. Now-a-days, popularity for all ceramic crowns has
3. Temporary veneer: These are made by composites, increased because these are stronger, more reliable,
kept supragingival, out of occlusion and bonded by translucent and more aesthetically pleasing than tradi
spot etching and bonding. tional porcelain fused to metal crowns. These crowns are
4. Shade selection: after cleaning the teeth with pumice best suited for patients who are allergic to metals.
and water, check shade of hydrated teeth in natural
light source and also match with shade and type of Indications
luting agent.
◆◆ In areas with a high aesthetic demand where a more
2nd Appointment conservative restoration would be inadequate.
◆◆ In teeth with proximal and/or facial caries that cannot
Preparation of Veneer be restored with composite resin.
1. Etch the internal surface of veneer with 10% ◆◆ In teeth with sufficient coronal structure to support the
hydrofluoric acid for 90 seconds rinse and dry it. restoration especially in the incisal area.
2. Apply silane coupling agent on etched surface of veneer
and allow it to set for 60 seconds. Do not rinse it. Place it
in light proof box until ready to cement on tooth. Contraindications
Preparation of Tooth ◆◆ When a more conservative restoration can be used.
1. Remove temporary ◆◆ In posterior teeth with increased occlusal load and
2. Evaluate the fit and aesthetics reduced esthetic requirement where metal ceramics
3. Apply rubber dam for isolation and clean all tooth crowns are preferred.
surfaces with rubber cup and pumice/water mix and ◆◆ If occlusal loading is unfavorable.
rinse thoroughly. ◆◆ If sufficient enamel is not present to provide adequate
4. Place mylar strip between adjacent teeth to minimize bonding.
etching and placement of adhesive on adjacent teeth.
In case of multiple teeth, place two veneers at a time, Advantages
the usual sequence is both central first, then lateral
and canine on one side and finally lateral and canine ◆◆ Excellent aesthetics
on opposite side. ◆◆ Translucency similar to that of natural tooth structure
5. Etch the prepared tooth surface using 35% phosphoric ◆◆ Biocompatibility
acid for 15–20 seconds rinse and dry it. ◆◆ Lack of reinforcement by a metal substructure that
6. Apply two thin coats of bonding agent, air thin it and permits slightly more conservative reduction of the
then light cure. facial surface than with the metal ceramic crown.
Dental Ceramics 409
A B C
D E F G
H I J
K L M
Figs. 31.12A to M: (A) Preoperative photograph; (B) Tooth preparation; (C) Application of retraction cord and taking impression; (D) Fabri-
cated veneers; (E) Isolation of teeth for cementation; (F) Application of 10% hydrofluoric acid; (G) After rinsing, application of silanating agent;
(H) Frosted appearance after etching; (I) Application of bonding agent on prepared tooth surface; (J) Application of luting cement on veneer;
(K) Cementation of veneers on central incisors; (L) Cementation of veneers on lateral incisors; (M) Postoperative photograph.
(Courtesy: Priya Titus).
Disadvantages Tooth Preparation

◆◆ Comparatively less strength of the restoration because Occlusal Reduction
of the absence of a reinforcing metal substructure. ◆◆ Ideally, there should be 1.5–2 mm of clearance incisally/
◆◆ Requires more tooth cutting because of the need for a occlusally for porcelain in all excursive movements of
shoulder type margin circumferentially. the mandible. This results in an aesthetically pleasing
◆◆ Difficult to achieve well-fitting margins in some cases. restoration with adequate strength.
◆◆ Place depth grooves in the occlusal surface of
◆◆ Cannot be modified once prepared.
approximately 1.3 mm depth (to compensate for
◆◆ Proper preparation design is essential to ensure additional loss of tooth structure during finishing).
mechanical success. ◆◆ The depth grooves should be directed perpendicular to
◆◆ Needs butt joint cavosurface angle to minimize the risk the long axis of the opposing tooth to provide adequate
of fracture. bulk for the porcelain crown.
◆◆ The preparation should provide adequate support for
the porcelain along its entire incisal edge. Therefore, it Facial Reduction
cannot be given in severely damaged tooth. ◆◆ Place depth grooves and reduce the facial surface. The
◆◆ These restorations are not supportive as retainers for a depth of these grooves should be approximately 0.8
fixed partial denture. mm to allow finishing.
A B
C D
Figs. 31.13A to D: (A) Preoperative photograph; (B) Preparation of teeth for veneers;
(C) Occlusal view of tooth preparations; (D) Postoperative photograph.
(Courtesy: Mohan Bhuvaneswaran).
◆◆ One depth groove is placed in the middle of the facial ◆◆ Avoid making a sloping shoulder which may result in
wall and one each in the mesiobuccal and distobuccal unfavorable loading of the porcelain and thus tensile
line angles. failure.
◆◆ At a time, reduce half of the facial surface. Keep the ◆◆ Take care that no unsupported enamel remains to
cervical component parallel to path of withdrawal and avoid fracture.
an incisal component parallel to the original contour of ◆◆ The completed chamfer should be 1 mm wide, smooth,
the tooth. continuous, and free of any rough edges.
Lingual Reduction Finishing

◆◆ Place depth grooves and reduce the lingual surface. ◆◆ Finish and smoothen the prepared surfaces.
The depth of these grooves should be approximately 0.8 ◆◆ There should not be sharp line angles which can cause
mm to allow finishing. fracture because of wedging action.
◆◆ Use the football-shaped diamond for lingual reduction. ◆◆ Do marginal refinement if needed.
◆◆ Do the lingual reduction until a clearance of 1 mm in all
mandibular excursive movements is achieved.
◆◆ Do the shoulder preparation, from the center of the Cementation
lingual wall toward the proximal, until the lingual ◆◆ Apply rubber dam for isolation of tooth.
shoulder meets the facial shoulder forming a uniform ◆◆ Do pumice prophylaxis to remove any surface deposits.
margin. ◆◆ Etch the prepared tooth surface using phosphoric acid
for 15 seconds wash and dry it.
Chamfer Preparation ◆◆ Apply two thin coats of bonding agents and light cure it.
◆◆ For subgingival margins, do the chamfer preparation ◆◆ Etch the internal surface of crown with 10% hydrofluoric
after placing the retraction cord. acid for 1 minute wash and dry it.
Dental Ceramics 411
◆◆ Apply silane coupling agent on etched surface. ◆◆ Remove the restoration from refractory die and then fit
◆◆ Apply luting resin onto the fitting surface of crown and on to master die
position the crown onto the prepared tooth. ◆◆ Do final adjustments, finishing, and polishing.
◆◆ Remove excess of cement and light cure the resin
cement for 1 minute. Lost Wax Technique
◆◆ Remove small excess using blade or fluted bur. Finish
◆◆ Complete the tooth preparation, take the impression,
margins of crown and polish using rubber cup/silicon
and pour “master” die and cast using die stone.
cusp disc and diamond polishing paste.
◆◆ Make a wax pattern and invest it with phosphate
bonded investment.
Fabrication of Ceramic ◆◆ Burn out the wax using a wax eliminating furnace.
Restorations ◆◆ Heat the transparent casting glass at 1100°C till the
casting glass is turned into white, opaque, and semi-
Techniques used for fabrication of ceramic restorations
crystalline material. A special casting machine is used
are:
to melt the glass ingot.
◆◆ Firing on platinum foil
◆◆ The molten glass is slowly cast into the mold using
◆◆ Using refractory techniques
centrifugal casting machine. After cooling, clean the
◆◆ Lost wax technique
restoration of all the investment material.
◆◆ Machined restoration using CAD-CAM technology.
◆◆ Seat the restoration on master die and working cast for
adjustment of contour and finishing.
Firing on Platinum Foil ◆◆ After final fitting is confirmed, final adjustment and
Ceramic inlays and onlays are commonly fabricated by finishing procedures are done, shading porcelains are
firing dental porcelains on refractory dies. Firing is the applied, and fired for better color matching and final
oldest method among different fabrication techniques. finishing and glazing is done.
This is no longer preferred nowadays. In this technique,
platinum foil is adapted over the die. Feldspathic porcelain Machined Restorations Using CAD-CAM
is applied over the layer of platinum foil. Then along with ◆◆ After completion of the tooth preparation, a scanning
foil, porcelain layer is removed from the die and fired in device collects the information on the shape and
oven. Before cementation, remove the platinum foil. size of the preparation. This step is called as “optical
impression”. A video image of the prepared tooth is
Advantages displayed to ensure proper positioning of the scanning
◆◆ Ease of fabrication device.
◆◆ Easy accessibility in proximal areas of preparation. ◆◆ The system projects an image of the tooth preparation
and surrounding structures on a monitor.
Disadvantages ◆◆ Once the restoration has been designed, the computer
directs a micromilling device (CAM portion of the
◆◆ More chances of inaccuracies
system) to mill the restoration out of a ceramic block.
◆◆ Technique sensitive.
These blocks of “machinable ceramics” especially used
for CAM devices are fabricated under ideal conditions.
Fabrication Using Refractory Die The blocks are among the strongest ceramics available
This is most commonly used method for fabricating inlays, for use with physical properties almost similar to that
onlays, and veneers. of enamel.
◆◆ The restoration is then removed from the milling device,
Steps ready for try-in and cementation.
◆◆ Complete the tooth preparation as per requirement.
◆◆ Take the final impression, wash and remove excess
Conclusion
water from the impression surface using cotton pellets. Ceramics have been used in dentistry because of their
◆◆ Pour the impression using type IV stone and prepare excellent aesthetics, biocompatibility, and durability,
“master” working cast. though they have problems of being expensive, technique
◆◆ Die is duplicated very accurately in refractory invest sensitive, and require precise laboratory procedures. In the
ment material which can withstand porcelain firing last few decades, there have been tremendous advances
temperature. in the mechanical properties, methods of fabrication,
◆◆ Mix the porcelain powder with distilled water or binder and their bonding techniques which have increased
provided by manufacturer, pour it in the desired form the range and scope for use of ceramics in dentistry like
on the refractory die. inlays, onlays, veneers, and crowns. Newer all ceramic
restorations come with their own advantages and Bibliography

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Chapter
32
Evidence-based Dentistry
Chapter Outline
Introduction Steps of Evidence-based dentistry

What is Evidence-based Dentistry? Application of Evidence‐based Dentistry from Research Clinical
Definition of Evidence-based Dentistry Practice
Need of Evidence-based Dentistry Who Get Benefits from Evidence-based Dentistry?
Introduction that is answered through collection, appraisal, and analysis

of published and unpublished research. Systematic
In today’s world, dentistry is changing at a surprising rate.
reviews are conducted by a collaborative team of experts
Each new day, we are overwhelmed with information on
in a clinical discipline and methodologists trained in
new procedures, materials, and techniques. Out of these,
searching, appraising, and summarizing all evidence. The
few procedures, techniques, and materials have undergone
team defines a clinically focused question relevant to the
controlled clinical research. Keeping up-to-date with the
provision of care. The team conducts a systematic search
latest advancement in dentistry and managing patients
for an evidence that may help in answering the question.
with complex needs, is a bit challenging for practicing
Then, statistical methods are used for pooling suitable
dentists.
quantitative data. This approach results in better quality
Dentistry has evolved through three phases. The three
reviews of the evidence that are less subject to biases.
phases are:
The practice-related element in EBD is the clinician’s
1. Age of expertise: Knowledge gained through the
integration of the resulting knowledge with clinical expertise
experience.
and patient preferences to determine the treatment to be
2. Age of professionalism: Knowledge gained through
recommended to individual patients (Fig. 32.1).
experience. It is maintained and disseminated.
3. Age of evidence: Currently, evidence-based practice
is required for development of clinical practice.
What is evidence-based dentistry?

Evidence-based dentistry (EBD) incorporates the
“conscientious, explicit, and judicious use of current best
evidence in making decisions about the care of individual
patients.” Thus, EBD is basically comprised of two
elements, one research-related and one practice-related.
The research-related element is the synthesis of available
evidence in the most objective way possible, such as a
systematic review. Systematic reviews are “summaries
of available scientific evidence in which studies are
collected, evaluated, and synthesized in accordance with
an organized, structured set of methods”. Like original
research projects, systematic reviews start with a hypothesis Fig. 32.1: Concept of evidence-based dentistry.
Definition Of EVIDENCE-BASED
DENTISTRY
David sackett (founder person for evidence-based
practice) has defined EBD as “an integrated individual
clinical expertize with best available external clinical
evidence from systematic research”.
American Dental Association (ADA) has defined EBD as
“An approach to oral healthcare that requires the judicious
integration of systematic assessments of clinically
relevant scientific evidence, relating to patient’s oral and
medical conditions and history, together with dentist’s
clinical expertise and the patient’s treatment needs and
preferences”.
Need of Evidence-Based Dentistry

The world in which we practice dentistry has changed at a
great rate due to two phenomena—information explosion Fig. 32.2: Different studies and tools used to achieve best
and consumer movement. In addition, the nature of the evidence available.
relationship between the patient and the clinician has
changed; patients actively take part in decision-making
◆◆ Use relevant information, if needed to conduct research
process which is due to knowledge gained from internet. ◆◆ Utilize the relevant information results of research into
Traditionally, the primary sources of information were clinical practice
teachers, textbooks, journal articles, but nowadays trend ◆◆ Evaluate the effect of incorporated changes on
has grown towards e-sources. To provide the best known healthcare outcomes.
treatment to patients, the practice of EBD has become Steps involved in practicing EBD are shown in
inevitable. The primary aim and the most valuable Flowchart 32.1.
application of the evidence-based approach to the
practice of dentistry is “to encourage the ordinary dental Flowchart 32.1: Steps involved in practicing
practitioner in primary dental care to look for and make evidence-based dentistry.
sense of the evidence available to apply it to everyday
problems.” Incorporating EBD to clinical practice helps in
formulating a clear question related to a patient problem,
finding the evidence quickly and efficiently, evaluating
its credibility and usefulness, and aiming to help dentists
overcome the first of those barriers. Thus we can say that
evidence-based dentistry:
◆◆ Helps in bridging the gap between clinical knowledge
that is commonly practiced and dental knowledge that
derives from research and clinical trials, etc.
◆◆ Helps the dentist in deciding the etiology of the disease
and effective treatment for the disease.
◆◆ Helps in reducing variations of patient’s care.
◆◆ Helps in updating the knowledge of practitioner.
◆◆ Helps in utilizing the best possible treatment available Framing Clinical Questions
for patient.
This step helps in effective and efficient searching for
clinical problem. Mostly clinical questions framed are too
Steps of evidence-based dentistry broad. To focus on the clinical conditions, we generally
(Fig. 32.2) prefer PICO format.
◆◆ Identify the clinical problem
◆◆ Frame/ask clinical questions related to the problem PICO Format
◆◆ Search for evidence to find pertinent literature P — The patient or problem
◆◆ Critical appraisal of literature available I — Intervention
Evidence-based Dentistry 415
C — Comparison are based on the scientific process of research (evidence-
O — Outcome based research) like basic, applied, and clinical research.
Purpose of using PICO in Framing Questions It is an art as it draws on the experience and personal
◆◆ Helps in focusing the clinician to the most important observation of the clinician. There are following benefits of
single issue related to clinical problem. applying the evidence‐based method in clinical practice:
◆◆ Helps in directing the patient to identify what actually i. It can improve the quality of patient management
the problem is. And what are the outcomes if specific ii. It can create a higher standard of practice
type of treatment is given to the patient? iii. There is a need for dentistry to be more compatible
◆◆ Helps in simplifying the search related to clinical problem. with medicine that has embraced the evidence-based
◆◆ How clinical questions are framed? philosophy.
◆◆ Collecting clinical findings properly. Clinicians can incorporate evidence-based methods in
◆◆ Selection and interpretation of diagnostic tests. patient care as follows:
◆◆ Select treatment which is more beneficial. Identify a clinical situation: Clinicians are faced with
◆◆ Methods which prevent or reduce the risk of disease. different challenges everyday in patient care. Some are
◆◆ Educate the patient about its after effects. more common and are solved routinely, while others
are less common and require more research to treat. In a
Search and Evaluate the Evidence periodontal practice, it is common to see patients who are
taking calcium channel blockers, for example, nifedipine,
Search and evaluate the best evidence available. To achieve showing signs of gingival enlargement.
this, various studies and tools can be used (Fig. 31.2). Another example is dealing the case of dental implants.
Different methods for searching evidence: Clinicians should exercise caution while treating patients
A. Comparative studies: who smoke and those with untreated periodontal disease,
i. Prospective studies: poor oral hygiene, and uncontrolled systematic diseases.
a. Randomized controlled trials
b. Nonrandomized controlled trials
c. Cohort study WHO GET BENEFITS FROM EVIDENCE-
ii. Retrospective studies: BASED DENTISTRY?
a. Case control study The ultimate beneficiaries of EBD are patients who will
B. Descriptive studies: reap the rewards of better care. Dentists are also benefited
i. Cross-sectional study from EBD. Clinicians can provide better healthcare taking
ii. Case report care of evidence-based results to predicate their clinical
iii. Case series. decisions. Researchers are benefited by being called upon
Systematic review and meta-analysis using two or to do the clinical testing necessary before new products
more randomized clinical trials are accepted as the best are placed on the market.
level of evidence. It is considered as the “Gold standard”.
Systematic reviews are outline of existing evidence on a
Clinical Applications
specific topic. This review is more focused than narrative
literature review and given by team of experts. Meta- The information gathered by critical evaluation of evidence
analysis is often used with systematic review. It combines is noted and assessed by its application to clinical practice
the several individual studies into one analysis. and patient care. Certain points that should be taken into
Advantages of evidence‐based approach compared care while applying information on the patient are:
with other assessment methods: ◆◆ Diagnosis: Diagnostic tests which are required should
◆◆ Objective be easily available, accurate, and affordable from
◆◆ Scientifically sound patient point of view.
◆◆ Patient-focused ◆◆ Prognosis: The information in the article should
◆◆ Incorporates clinical experience be clearly depicting outcome after treatment. The
◆◆ Stresses good judgment outcome/result is whether treatment is sufficient
◆◆ Is thorough and comprehensive enough for patient to reassure or not.
◆◆ Uses transparent methodology. ◆◆ Therapy: The knowledge gained from evidence should
be used in improvement of therapy to the patient.
APPLICATION OF EVIDENCE‐BASED ◆◆ Prevention: Methods/techniques should be used to
prevent the disease further.
DENTISTRY FROM RESEARCH CLINICAL
Problems in implementation of evidence-based
PRACTICE dentistry (given by Richards and Lawrence 1998):
Dentistry is not just a science but also an art. It is a science ◆◆ Amount of evidence available
because the fundamental building blocks of knowledge ◆◆ Quality of evidence
◆◆ Dissemination of evidence viva questions

◆◆ Clinical practice based on authority rather than practice.
1. What is evidence-based dentistry?
2. Define evidence-based dentistry.
CONCLUSION
3. Why there is need for evidence-based dentistry?
Evidence-based dentistry helps in providing interpretation 4. What are different steps of evidence-based dentistry?
and application of various research findings. In other words, 5. What is PICO?
they join the clinical research and the real practice dentistry. 6. What is purpose of using PICO in framing questions?
Also, it provides the logic to treatment whenever there is 7. What are advantages of evidence-based approach
some legal issue regarding procedure. To practice EBD, the compared with other assessment methods?
clinician must have up-to-date knowledge regarding new 8. Who gets benefits from evidence-based dentistry?
technologies and developments. EBD approach empowers
clinicians to question and consider the use of the current bibliography
best evidence in decision-making on the management of
individual patients. It offers many benefits ranging from 1. Bero L, Grilli R, Grimshaw JM, et al. Closing the gap between
research and practice. BMJ. 1998;317(7156):465-8.
more efficient and effective healthcare delivery to improve
2. Bickley S, Harrison J. How to find the evidence. J Orthod. 2003;30:
treatment standards and outcomes. 72-8.
3. Bader J, Ismail A, Clarkson J. Evidence-based dentistry and the
EXAMINER’S CHOICE QUESTIONs dental research community. J Dent Res. 1999;78(9).
4. Faggion CM Jr, Tu YK. Evidence-based dentistry: a model for
1. Write short note on evidence-based dentistry. clinical practice. J Dent Educ. 2007;71(6):825-31.
2. What is PICO format? 5. Sutherland SE. The building blocks of evidence-based dentistry.
3. What are advantages of evidence-based dentistry? J Can Dent Assoc. 2000;66(5):241-4.
Chapter
33
Nanotechnology in Dentistry
Chapter Outline
Introduction Nanotechnology in Dentistry

History Applications of Nanotechnology in Dentistry
Definitions Barriers for Nanotechnology
Approaches in Nanotechnology
INTRODUCTION disease, relieving pain, and preserving and improving

dental health using nanostructured material.
Necessity is the mother of invention which has led to the
introduction of nanotechnology, a technology that deals Nanomaterials: These are materials with less than 100
with structures ranging in size of 100 nanometers or nm particles existing in different forms and shapes. They
smaller in at least one dimension and developing material are categorized according to their dimensions into: Zero
and devices within that size. dimension (nanoparticles), one dimension (nanorods),
two dimension (thin films) and three dimension
(nanocones) (Figs. 33.1A to D). Nanomaterials have small
HISTORY
size, larger surface area, high surface energy, etc.
The term nanotechnology is derived from the Greek word
“nanos” meaning dwarf. The term nanotechnology was
introduced by Norio Taniguchi in 1974, when he referred APPROACHES IN NANOTECHNOLOGY
to a “production technique to get extra high accuracy and Following approaches are applied for synthesis of
ultrafine dimensions”. The term nanodentistry was first nanoparticles (Fig. 33.2):
popularized in 2000 by research scientist Robert Freitas.
He developed visions using nanorobots for orthodontics,
1. Top-down Approach
dentition regeneration, nanomaterials, and robots in
dentifrices–dentifrobots. Although most of his ideas were Particles are synthesized in the conventional manner and
and remain science fiction, these ideas are gradually made smaller by grinding or milling.
being realized into practice. Today, many applications of
nanoscale technology are known and used in the field of 2. Bottom-up approach
dentistry.
nanoparticles are synthesized by direct molecular
synthesis and bonding, i.e. they are synthesized from
DEFINITIONS
molecular level.
Nanotechnology: It is defined as the multidisciplinary
science of the creation of materials, devices and systems at 3. Functional Approach
the nanoscale level.
does not give importance to the method of production
Nanodentistry: It is the science and technology of of a nanoparticle, rather, it emphasizes on production of
diagnosing, treating and preventing oral and dental nanoparticle with a specific use
A B C D
Figs. 33.1A to D: Classification of nanomaterials. (A) Zero-dimension (nanoparticles); (B) One-dimension (nanorods);
(C) Two-dimension (thin films); (D) Three-dimension (nanocones).
5. Reduced mortality and morbidity rates associated

with certain oral diseases
6. Better outcome of the treatment procedures.
Disadvantages of Nanodentistry
1. Many ethical issues to deal with
2. Toxicity associated with the nanoparticles is harmful
to human beings and environment.
Applications of nanotechnology in
dentistry (Fig. 33.3)
1. Preventive Dentistry
Development of nano-toothbrush by incorporating
nanogold or nanosilver colloidal particles between
toothbrush bristles showed better plaque removal. nano-
modified toothpastes (calcium carbonate nanoparticles
and nanosized sodium trimetaphosphate) and mouth
Fig. 33.2: Synthesis of nanomaterials.
wash solutions (with nanofluorides) help reducing the
caries activity and dentine permeability and promote
Nanotechnology in dentistry remineralization of incipient caries. Nanorobots used
in mouthwash or toothpaste can patrol all supragingival
Nanotechnology when combined with dentistry forms
nanodentistry which is being applied in different areas
like manufacturing of dental materials, prevention of
dental caries and periodontal disease, management of
dentine hypersensitivity, oral cancer, and endodontic
diseases.
Advantages of Nanodentistry
1. Nanodental materials are made available with optimal
hardness, flexural strength, modulus of elasticity,
translucency durability, and excellent handling
properties.
2. Superior aesthetics
3. Accurate and quick diagnosis of oral diseases with
newer diagnostic equipment
4. Reduced time of treatment with faster healing
properties Fig. 33.3: Applications of nanomaterials in dentistry.
Nanotechnology in Dentistry 419
and subgingival surfaces, metabolizing trapped organic 7. Dentin hypersensitivity
matter into harmless and odorless vapors and performing
Reconstructive dental nanorobots can selectively and
continuous calculus debridement. Thus, properly planned
precisely occlude the dentinal tubules in as less as 100
dentifrobots can identify and destroy pathogenic bacteria
seconds, thus rapidly reduce the dentin hypersensitivity.
present in the plaque, allowing the harmless species of oral
microflora to increase in a healthy ecosystem. With the use
of this kind of daily care, using dentifrobots can result in 3. Endodontics
prevention of tooth decay and gingival disease. i. Nanoparticles as Antimicrobial Agents
because of polycationic or polyanionic nature, nano
2. Restorative Dentistry
particles efficiently remove bacterial biofilms, disinfect
1. Nanocomposites the canals by removing residual microbes from the canal
and increase the antibacterial action of the intracanal
Nanocomposites have shown superior mechanical
medicaments.
properties like hardness, strength, aesthetics, and lower
Nanoparticles bind the targeted bacterial cell
polymerization shrinkage along with good handling
properties. Examples of nanocomposites are Filtek DEB, membrane by electrostatic forces, causing an alteration
Filtek Translucent (3M ESPE), and Tetric Evoceram in the membrane potential, depolarization and ultimately
(Dentsply). loss of membrane integrity, and subsequently bacterial
cell death. Other mechanism is that nanoparticles produce
2. Nano-Glass Ionomer Cement (GIC) oxygen free-radicals which block the protein function, and
destroy DNA (Figs. 33.4A and B).
i. Addition of nanoapatite or nanofluorapatite to powder
of GIC improves the compressive, tensile, and flexural
strengths of the set cement.
ii. Addition of nano-sized fillers and bioceramic particles
to resin-modified glass ionomer cements (RMGICs)
have shown to improve adhesion, aesthetics, fluoride
release, mechanical, and physical properties of
nano-RMGICs.
3. Nanoceramics
The organically modified ceramic nanoparticles contain
a polysiloxane backbone. These are inorganic-organic
hybrid particles where inorganic part, siloxane, and A B
organic part, methacrylate, combine with resin matrix. It Figs. 33.4A and B: Schematic representation of antibacterial
improves resistance to microcrack propagation which are mechanisms of nanoparticles. (A) Toxicity by production of oxygen
reflected or absorbed by the nanoceramic particles. free radical, (B) Nanoparticles attach to bacterial cell membrane
causing toxicity by cell membrane damage.
4. Nano-bonding Agents
Nano-bonding agents contain nanoparticles dispersed in ii. Nanotechnology-based Root-end Sealant
the solution. Silica nanofillers present in solution improve
Nanomaterial enhanced retrofill polymers (NERPs) offer
bond strength values.
improved strength, bonding, and adaptability to tooth
5. Coating agents structure when compared to conventional materials.
Pellets of NERP containing chlorhexidine show drug
These agents contain light-activated nanosized fillers release capabilities, thus favorable in cases of apical
which are used as coating over the composite, glass infection.
ionomer cements, and veneers. Due to presence of
nanofillers, these offer excellent polish, thus, prevent 4. Surgical interventions
staining, increases abrasion and wear resistance.
i. Nanoanesthesia
6. Tooth Whitening Agents To achieve nanoanesthesia, a colloidal suspension
Calcium peroxide nanoparticles show deeper penetration containing millions of active analgesic micrometer sized
in the tooth by micro and nano cracks, thus having longer dental nanorobot particles is placed on the patient’s
surface contact, consequently better tooth whitening. gingiva. On coming in contact with the surface of the
crown or mucosa, the nanorobots reach dentin by nanorobots can help in decreasing the need for fixed
migrating into the gingival sulcus. On reaching the orthodontic therapy.
dentin, the nanorobots enter dentinal tubules and then
toward pulp. This movement of nanorobots is guided 7. Periodontics
by a combination of chemical gradients, temperature
differentials, and position of navigation, all controlled i. Periodontal Bone Grafts
by onboard nanocomputer as directed by the dentist. It
With both microporosity and nanoporosity, these grafts
takes about 2 minutes for nanorobots to reach pulp. On
have greater surface area compared to other bone grafts,
reaching pulp, the dentist commands the analgesic dental
letting better bone regeneration.
nanorobots to shut down all sensitivity in selected tooth
that requires treatment. This causes immediate anesthesia
of that tooth. After completion of the procedure, the ii. Bone replacement materials
dentist commands the nanorobots via same datalinks to Hydroxyapatite nanoparticles [example Ostim (Osartis
restore all sensation. GmbH, Germany), and Vitoss (Orthovita, Inc. USA)] are
used to repair bone defects. These biomaterials have better
ii. Nanoneedles handling properties, increased flow, and intermingle well
These are used to perform the surgery on a single living with host bone.
cell and are nanometer wide in dimension, for example,
Sandvik Bioline, RK 91tm needles. iii. Nanomaterials for Periodontal Drug Delivery
iii. Detection and Treatment of Oral Cancer Nanomaterials have been tried successfully in local drug
delivery systems. These nanomaterials are made up of
Dendrimer nanoparticles used as drug delivery vehicles
biodegradable polymer that allows the drug delivery to
target the tumors with large doses of anticancer drugs.
the site-specific region of the tooth at regular intervals
Quantum dots can be used as photosensitizers and
as these materials disintegrate. For example, Arestin is
carriers. They can bind to the antibody present on the
a nanomaterial in which tetracycline is incorporated
surface of the target cell and when stimulated by UV light,
they give rise to reactive oxygen species and thus are lethal into microspheres for drug delivery by local means to
to the target cell. Thus, they can be used in treatment of periodontal pocket.
cancer.
Barriers for Nanotechnology
5. Prosthodontics Following issues are required to deal for successful
i. Nanoimpression implementation of nanotechnology:
1. Biological issues: biocompatibility with human body
Nanofillers integrated in the vinylpolysiloxanes produce a
and development of biofriendly nanomaterial.
unique addition siloxane impression material which has
2. Engineering issues: Mass production technique and
better flow and hydrophilic properties; hence, fewer voids
precised positioning, manipulation, and assembling
at margin and enhanced precise detailing.
of molecular scale parts.
3. Social issues: Public acceptance, ethics, cost factor,
ii. Removable Partial Denture
and human safety are main concerns.
Incorporation of carbon nanotubes into heat cure
monomer reduces the polymerization shrinkage and
improves the mechanical properties.
CONCLUSION
Nanotechnology provides solutions to many problems of
iii. Nanotitanium implants mankind, but it comes with its own problems because “The
smaller the particles, the more toxic they become”. Thus,
Nanotitanium implants are highly compatible with bone
science and applications of nanotechnology are constantly
and provide 20 times faster bonding along with improved
evolving as we see new products being introduced
strength, biocompatibility, longevity, and wear resistance.
into the market. Though, nanomaterials have superior
mechanical and physical properties, they come with
6. Orthodontics their own problems. Research to improve upon existing
The orthodontic nanorobots directly have an impact on nanomaterials is still ongoing, with future directions
periodontium, thus allow painless tooth movements towards more efficient and cost effective availability of
within few minutes to hours. Therefore, use of these nanomaterials.
Nanotechnology in Dentistry 421
EXAMINER’S CHOICE QUESTIONs bibliography

1. Write short note on nanodentistry with its future 1. Freitas RA Jr. Nanodentistry. J Am Dent Assoc. 2000;131(11):
aspects. 1559-65.
2. Freitas RA Jr. Nanotechnology, nanomedicine and nanosurgery.
2. Write a short note on nanotechnology in restorative
Int J Surg. 2005;3(4):243-6.
dentistry.
3. Frietas RA. Nanodentistry. JADA. 2000;131:1559-65.
4. Goracci G, Mori G. Micromorphological aspects of dentin.
viva questions Minerva Stomatol. 1995;44(9):377-87.
5. Mitra SB, Wu D, Holmes BN, et al. An application of nanotechno
1. Define nanotechnology. logy in advance dental materials. J Am Dent Assoc. 2003;134(10):
2. What are nanoimpressions? 1382-90.
3. What are nanoceramics? 6. Patil M, Mehta DS, Guvva S. Future impact of nanotechnology
4. What is bottom-up and top-down approach? on medicine and dentistry. J Indian Soc Periodontol. 2008;12(2):
5. What is role of nanotechnology in preventive dentistry? 34-40.
Chapter
34
Lasers in Operative Dentistry
Chapter Outline
Introduction Laser Interaction with Biological Tissues

History Laser Safety in Dental Practice
Classification of Laser Applications of Lasers in Operative Dentistry
Principles of Laser Beam Advantages and disadvantages of lasers
Laser Physics
Introduction
1979 Adrian and Gross Sterilization of dental instruments
Lasers in dentistry are considered to be a new technology by argon laser
which is being used in clinical dentistry to overcome 1994 Morita Nd:YAG laser in endodontics
some of the drawbacks posed by conventional dental 1998 Mazeki et al. Root canal shaping with Er:YAG
procedures. This technology was first used for dental laser
application in 1960 but its use has rapidly increased in the
last few decades.
Laser is an acronym for “Light Amplification by Classification of Laser
Stimulated Emission of Radiation.” The application of lasers
is almost in every field of human endeavor from medicine, 1. Based on the Wavelength of the Beam
science and technology to business and entertainment over (Fig. 34.1)
the past few years. The first laser or maser as it was initially
called, developed by Theodore H Maiman in 1960. Maser ◆◆ Ultraviolet rays: 140–400 nm
like laser is an acronym for “Microwave amplification by ◆◆ Visible light: 400–700 nm
stimulated emission of radiation.” This laser constructed ◆◆ Infrared: 700 to microwave spectrum.
by Maiman was a pulsed ruby laser.
History
1917 Albert Einstein Theory of spontaneous emission

of radiation
1960 Theodore Maiman First demonstrated laser function
and developed working laser
device known as ruby laser
1964 Stern, Sognnaes Laser in dentistry
and Goldman
1965 Leon Goldman Exposure of vital tooth to laser
1966 Lobene et al. Use of CO2 lasers in dentistry
1974 Yamamoto et al. Nd:YAG in prevention of caries Fig. 34.1: Schematic representation of electromagnetic spectrum
showing lasers of different wavelengths.
Lasers in Operative Dentistry 423
2. Based on Penetration Power of beam
◆◆ Hard: Increased penetration power; for example,
Nd:YAG, argon
◆◆ Soft lasers: Decreased penetration power; for example,
diode, GA-As, He-Ne lasers.
3. Based on pulsing
◆◆ Pulsed: The beam is not continuous, i.e. it is of short
duration
◆◆ Nonpulsed: The beam is continuous and is of fixed
duration. Fig. 34.3: Collimated and uncollimated beam.
4. According to Type of Laser Material Used Laser Physics

◆◆ Gas lasers: CO2 lasers, argon lasers, He-Ne lasers The basic units or quanta of light are called photons.
◆◆ Liquid lasers: Ions of rare earth or organic fluorescent Photons behave like tiny wavelets similar to sound wave
dyes are dissolved in a liquid, for example, dye lasers pulses. If a photon is absorbed, its energy is not destroyed
◆◆ Solid state lasers: Ruby lasers, Nd:YAG lasers but rather used to increase the energy level of the absorbing
◆◆ Semiconductor lasers: Gallium, Arsenide. atom. The photon then ceases to exist and an electron
within the atom jumps to a higher energy level. This atom
Principles of Laser Beam is thus pumped up to an excited state from the resting
ground state. In the excited state, the atom is unstable
The common principle on which all lasers work is the
and will soon spontaneously decay back to the ground
generation of monochromatic, coherent, and collimated
state, releasing stored energy in the form of an emitted
radiation by a suitable laser medium in an optical
photon. This process is called spontaneous emission. The
resonator (Fig. 34.2).
spontaneously emitted photon has a longer wavelength
and less energy than the absorbed photon. The difference
in the energy is usually turned into heat (Fig. 34.4).
The process of lasing occurs when an excited atom can
be stimulated to emit a photon before the process occurs
spontaneously. When an atom in the excited state becomes
irradiated with a photon of light energy of the same
wavelength and frequency that was previously absorbed,
as it returns to its resting state, it will emit two photons of
light energy in the same direction in spatial and temporal
phase. This is the stimulated emission of radiation.
Fig. 34.2: Common principles on which all lasers work is generation

of monochromatic, coherent, and collimated beam.
Monochromatic: Light produced by a particular laser is

of a characteristic wavelength. It is important to have this
property to attain high spectral power density of the laser.
Coherence: A laser produces light waves that are identical

in physical shape and size.
Collimation: Collimation refers to the beam having

Fig. 34.4: Spontaneous emission occurs when electron makes un-
specific spatial boundaries. These boundaries ensure that
stimulated transition to lower energy levels. Stimulated emission oc-
there is a constant beam size and shape that is emitted curs when an incoming photon induces the electron to change energy
from the laser unit (Fig. 34.3). levels.
If a collection of atoms is more that are pumped up 4. Optical cavity: In this, all the other components of
into the excited state than remain in the resting state, laser are housed. An optical cavity is at the center of
the spontaneous emission of a photon of one atom will the device. The core of cavity is comprised of chemical
stimulate the release of a second photon, and these two elements, molecules, or compounds and is called the
photons will trigger the release of two more photons. active medium.
These four then yield eight, eight yields sixteen and the 5. Optical mirror: These are totally reflective and
cascading reaction follows to produce a brief intense flash partially transmissive mirrors placed parallel to
of a monochromatic and coherent light. each other. These act as optical resonator reflecting
the waves back and forth and help to collimate and
Basic Components of Laser (Fig. 34.5) amplify the laser beam.
1. Laser medium or active medium: This consists of 6. Lens: It helps in convergence of light to a focal point.
chemicals that are used to fill the optical cavity. The The size and shape of the lens determine the focal
active medium contains atoms which can emit light by length and spot size. Spot size measures the surface
stimulated emission. The active medium can be solid, area on which laser beam is concentrated. It is directly
liquid, gas, and plasma. Lasers are generally named related to efficiency. Smaller spot size is ideal for
for material of active medium which can be container
incision and bigger one for ablation and hemostatic
of gas, a crystal, or a solid-state semiconductor.
procedures. Laser beam can be focused through a
2. Excitation mechanism: Pump energy into active
lens to achieve a converging beam which has high
medium by one or more of three basic methods:
Optical, electrical, or chemical. intensity to form a focal spot. When the laser is moved
3. Optical resonator: lasers reflect the laser beam away from the tissue and away from the focal point,
through active medium for amplification. They also the beam is defocused, becomes more divergent, and
help to prevent the scattering of radiation in the therefore, delivers less energy to the target site (Fig.
optical cavity. 34.6).
Fig. 34.5: Schematic representation of gas or solid, active-medium laser. At each side of optical cavity (contains chemicals which can emit light
stimulated emission) two mirrors are there parallel to each other which act as optical resonator reflecting the waves back and forth and help to
collimate and amplify the laser beam. Other components are cooling system and focusing lenses.
Fig. 34.6: Closer is the laser beam to the target, smaller is the spot size. As the laser is moved away from the focus, the beam gets divergent and
spot size increases.
Laser Interaction with Biological Thermal effects of laser irradiation at different temperature
Tissues range
Temperature Temperature Temperature Temperature
When laser interacts with the tissues, it can be absorbed, <60°C >60°C <100°C >100°C
reflected, scattered or transmitted (Fig. 34.7). The type
• Tissue Protein • Tissue • Super
of interaction between a laser beam and any tissue is hyperthermia denaturation dehydra heating
determined by the wavelength of the laser beam, the • Enzymatic tion causes
operation mode of the laser, the amount of energy applied, changes • Blanching vapori
and tissue characteristics. • Edema of tissue zation
1. Absorption: Here specific molecules in the tissue • Tissue
ablation
known as chromophores absorb photons and produce and
photochemical, photothermal, photomechanical, and shrinkage
photoelectrical effects.
iii. Photomechanical interaction: Laser energy can
be converted into acoustical energy which upon
impact creates a shock wave that disrupts the target
tissue.
iv. Photoelectrical interaction: This includes photo
plasmolysis which explains how tissue is removed by
formation of electrically charged ions which exist in a
semigaseous high-energy state.
Laser Safety in Dental Practice

The surgical lasers currently used in dentistry generally
fall in class IV category which is considered the most
hazardous group of lasers. Following hazards are seen with
Fig. 34.7: When light encounters matter, it can be reflected, scat- lasers in dentistry:
tered, absorbed, or transmitted.
1. Ocular hazards: Retinal and corneal injury occurs
either by direct emission from the laser.
2. Reflection: The laser beam gets reflected back with no 2. Tissue hazards: Temperature rise of 21°C above
absorption and interaction with tissues. This reflected normal body temperature can cause denaturation
beam results in undesirable effects of laser. of cellular enzymes which interrupt basic metabolic
3. Transmission: In this, laser energy can pass through processes.
superficial tissues to interact with deeper tissues. 3. Environmental hazards: These nonbeam hazards can
Nd:YAG and diode lasers show deeper penetration
be production of smoke, toxic gases, and chemicals.
due to tissue transmission.
4. Electrical hazards: These can occur in form of electric
4. Scattering: Once the laser energy enters the target
shock, fire, or explosion. To avoid an electrical hazard,
tissue, it scatters in different directions. This property
is not helpful but can help with its biostimulative the operatory must be kept dry.
properties sometimes.
Following photobiologic actions occur when laser is Precautions to be taken while
used: Using Lasers
i. Photochemical effects: The basis of the photochemical
effect is the absorption of the laser light without any 1. Both patient and operator should wear safety goggles
thermal effect leading to change in the chemical (Fig. 34.8). These glasses block the laser from getting
and physical properties of atoms and molecules. into eye.
Photochemical effects include biostimulation, that 2. Lock the door during the treatment.
is, stimulatory effect of lasers on biochemical and 3. Never look directly into the laser beam.
molecular processes that normally occur in the tissues 4. Never point the laser hand piece at any person except
such as healing and repair. at the treated area.
ii. Photothermal interaction: In this interaction, laser 5. Never use the laser in the presence of flammable
light energy absorbed by tissue substances and anesthetics.
molecules become transformed into heat energy 6. Never step on or abruptly bend the fibre optic cable.
which produces the tissue effect. 7. Never move the laser machine during operation.
wavelength are absorbed by the bacteria of tooth which

give fluorescence called laser-induced fluorescence.
The instrument’s digital display indicates the number of
bacteria in this area of the tooth and it may correspond
to the extent of decay. It helps in early detection of fissure
caries and calculus.
2. Thermal Testing
In this, pulsed Nd:YAG laser is applied on the tooth. Pain
produced by laser is mild and tolerable when compared to
conventional pulp tester.
Fig. 34.8: Protective eyewear for use of laser. 3. Cavity preparation

Nowadays, lasers with similar wavelengths in the middle
Applications of Lasers in Operative infrared region of the electromagnetic spectrum are being
dentistry used commonly for cavity preparation and caries removal.
The Er:YAG laser and Er,Cr:YSGG can perform precise cavity
1. Caries detection preparation by photothermal and photoablation effects (Fig.
34.11). Laser beam vaporizes the water present in enamel
The Diagnodent is based on the principle that bacterial
and dentin, resulting in microexplosions in hydroxyapatite.
metabolites within caries produce fluorescence which is
This forms microcraters on the tooth surface.
enhanced by laser light (Figs. 34.9 and 34.10). It is used
for caries detection by emitting a nonionizing laser beam
at a wavelength of 655 nm towards a specific darkened Conventional cavity
Laser cavity preparation preparation
groove on patient’s tooth. Here, photons of this laser
• No vibration and less noise • Produce vibration and
• Lasers cut at a point of their tip noise
which is to be used with up and • Burs produce abrasive
down motion cutting from their sides
• Rough edges that need hand and at the end
instruments like excavators to • Produces smooth edges
remove the ablation products • Produces a smear layer
• Removes smear layer • More traumatic to patient
• Less traumatic to patient • Burs cut at sides and at
• Prepares highly conservative end
cavity • Considered unsafe in
• Considered safe in cases of cases of sudden patient
Fig. 34.9: Schematic representation of Diagnodent. unexpected patient movement movement
A B
Figs. 34.10A and B: (A) Tip of explorer does not detect the cavity until cavity is large enough; (B) Diagnodent can
detect caries even at early stage.
1. Low Output Power Lasers
(He-Ne and Ga-Al-As lasers) where laser energy is
transmitted through enamel or dentin to reach pulp tissue,
blocking the A or C-fibers.
2. Middle Output Power Lasers
(Nd:YAG and CO2 lasers) which mainly seal the dentinal
tubules and reduce the permeability.
9. CAD/CAM Technology
In this technology, instead of conventional intraoral
impression materials, laser scanners take an optical
impression of a prepared tooth and take a bite registration
Fig. 34.11: Laser beam produces precised and clean cavity cutting to form a three-dimensional image. This enables the
with minimal tooth loss. dentist to take an optical impression and create a computer
file with this data. Based on this data, a virtual model is
created from which an accurate master model is made.
4. Disinfection of Prepared Cavities This model is sent to the laboratory for fabricating the final
lasers can be used for disinfection of prepared cavities restoration.
by photoactivation. Use of tolonium chloride along with
visible red light laser releases nascent oxygen which 10. Restoration Removal
destroys the bacterial cell wall and thus destroys residual The Er:YAG laser can remove cement, composite resin, and
microorganisms of the prepared cavity. glass ionomer by ablation effect. Lasers should not be used
to remove the amalgam restorations due to risk of release of
5. Caries Prevention mercury vapor. Gold crowns, cast restorations, and ceramic
An increased temperature is necessary to achieve the restorations cannot be removed by laser because of low
photothermal effect and increasing the resistance of absorption of these materials and reflection of the laser
light.
enamel to acid attack. Laser application decreases the
enamel solubility by promoting the thermal decomposition
11. Deep Caries Management
of the more soluble carbonate hydroxyapatite into the
less soluble hydroxyapatite, by changing its crystalline Lasers have advantages of less chair side time,
structure. noninvasive, and enhanced patient cooperation in deep
caries management. For direct and indirect pulp capping,
6. Etching Nd:YAG, Ga-As, argon laser, and CO2 are commonly used
lasers.
Laser causes etching of enamel and dentin by micro
explosions during hard tissue ablation which results in 12. Sterilization of Instruments
microscopic and macroscopic irregularities. However, it has
been shown that etching effects produced by Er:YAG laser Argon, CO2 and Nd:YAG lasers have been used successfully
are inferior to that of conventional phosphoric acid etching. to sterilize dental instruments.
7. Photopolymerization 13. Teeth Whitening

The whitening effect of the laser is achieved by a chemical
The argon laser (488 nm blue) is used for initiation of
oxidation process. Once the laser energy is applied,
polymerization of the composite resins by activating
H2O2 breaks down to H2O and free oxygen radical which
camphorquinone, a photoinitiator that causes polymeri
combines with and thus removes stain molecules. The
zation of the resin composites. Laser curing light causes
energy of CO2 laser is emitted in the form of heat. This
greater depth and degree of cure of composites, but it
energy can enhance the effect of the whitening after initial
causes rise in temperature, rapid polymerization, and
argon laser process.
affects adjacent restorations.
14. Gingival Tissue Management
8. Treatment of Dentin Hypersensitivity CO2, Nd:YAG, argon, and diode lasers can be used for
The lasers used for the treatment of dentin hypersensitivity gingival tissue retraction, removal of gingival overgrowth,
are divided into two groups: and contouring of gingiva during restorative procedures.
Advantages and disadvantages of 2. Describe in detail the use of lasers in conservative

lasers dentistry.
Advantages Disadvantages a. Common principles on which laser work
• Lasers are less painful thus, • Laser cannot be maneuvered b. Tissue effects of laser
reduce the need for local around cavities which are
c. Principles of laser
anesthesia present between two teeth or
• Do not pose the fear of drill in large cavities d. Laser safety.
• Produce less swelling and • Even after laser application,
bleeding conventional drill is still
• Prepare very conservative required for the bite viva questions
cavity without pain and adjustment, and for shaping
anxiety and polishing the restoration
1. What are different laser delivery system?
• Laser treatment is expensive 2. What are different laser emission modes?
• Laser can cause eye injury, if 3. What are possible mechanisms of action of laser?
not handled properly 4. What are the uses of lasers in operative dentistry?
• Procedure is time consuming
5. What are common hard tissue lasers used in operative
• Proper training is required to
practice laser dentistry dentistry?
6. What are the advantages of laser over conventional
cavity preparation?
Conclusion
7. Which laser is having wavelength closer to
If used cautiously and ethically, lasers can be an essential camphoroquinone initiator in composite resin?
tool in many dental treatments. With the introduction 8. What are common laser hazards?
of lasers in dentistry, the complex procedures have
become easier and time saving. Thus, the ability to care
for patients has improved. A few dentists are aware of this Bibliography
new technology, but others continue to use conventional 1. Coluzzi D, Convissar R. Lasers in clinical dentistry. Dental
instruments. Lasers are able to perform many restorative Clinics of North America. 2004;48(4):533.
procedures without the fear of drill, pain, anxiety, swelling, 2. Kakodkar G, Ataide I, Pavaskar R. Lasers in conservative
dentistry: an overview. J of clin and diagnost Resear. 2012;6(3):
and bleeding. In near future, it is expected that laser
533-6.
technologies will become an indispensable part of dental 3. Moritz A. Oral laser applications. Berlin: Quintessence Verlags;
practice. 2006.
4. Schwarz F, Arweiler N, Georg T, et al. Desensitizing effects of
Examiner’s Choice Questions an Er:YAG laser on hypersensitive dentine. J Clin Periodontol.
2002;29(3):211-15.
1. Define and classify lasers. Write briefly on laser 5. Todea CDM. Laser applications in conservative dentistry. TMJ.
physics and types of lasers. 2004;54(4):392-405.
Annexures
Annexure 1: Mechanical Properties of Different Restorative Materials
COMPRESSIVE STRESS Shear Stress

If a body is placed under a load that tends to compress or A shear stress is produced by twisting action on a material.
shorten it, the internal resistance to such a load is called a It occurs when two sets of forces are directed parallel to
compressive stress. each other but not along the same straight line.
Material Compressive strength (Mpa) Material Shear strength (MPa)

Enamel 400 Enamel 90
Dentin 297 Dentin 138
Amalgam 310–483 Amalgam 188
Glass ionomer cement 200 Zinc phosphate cement 13
Zinc phosphate cement 117 Porcelain 111
Composites 200–345
Porcelain 150
FLEXURAL (BENDING) STRESS
Flexural stress is produced by bending forces in restoration
Tensile Stress or prosthesis in one of the following two ways:
1. By subjecting an FPD to 3 point loading whereby the
A tensile stress is caused by a load that tends to stretch or end points are fixed and a force is applied between
elongate a body. Because, most dental materials are quite these end points.
brittle, they tend to fracture when subjected to tensile 2. By subjecting a cantilevered structure to a load along
stress like flexural loading. any part of unsupported section.
Material Ultimate tensile strength (MPa) Material Flexural strength (MPa)
Enamel 10 Amalgam 124
Dentin 106 Resin composite 139
Amalgam 32 Porcelain 65
Resin modified glass ionomer 42–68
Glass ionomer cement 18
Zinc phosphate cement 8
ELASTIC MODULUS (Young’s modulus)
Composites 45
Porcelain 25
It describes the relative stiffness or rigidity of a material
which is measured by the slope of elastic region of stress
Gold alloy 448
strain graph.
The proportional limit, compressive strength and Material KHN (kg/mm3)

modulus of elasticity of enamel are more than that of
Enamel 343
dentin, this makes enamel stiffer and brittle than dentin.
Thus, dentin is capable of sustaining plastic deformation Dentin 68
under compressive stresses before it fractures. Amalgam 110
Zinc phosphate cement 40
Elastic modulus GPa*
Material (1 gigapascal =103 MPa) Gold alloy 22
Enamel 84.1 Feldspathic porcelain 460
Dentin 18.3 Silicon carbide abrasive 2480
Amalgam 27.6
Resin composite 16.6
Thermal Conductivity
Porcelain 69.0 It is the amount of heat in calories or joules passing per
Gold (type IV) alloy 99.3
second through a body 1cm thick, 1cm2 cross-sectional
area when the temperature difference is 1°C. Metallic
filling materials should have same thermal conductivity as
IMPACT STRENGTH of tooth.
It is defined as the energy required to fracture a material
Material Thermal conductivity J/sec/cm2 (C/cm)
under an impact force. A material with low elastic
modulus and high tensile strength is more resistant to Enamel 0.0092
impact forces. Dentin 0.0063
Dental amalgam 0.23
Material Elastic modulus Tensile strength
Zinc phosphate cement 0.012
Amalgam 21 gpa 27–55 mpa
Resin composite 0.011
Composite 17 gpa 30–90 mpa
Porcelain 0.010
Porcelain 40 gpa 50–100 mpa
Gold 2.97
TOUGHNESS
THERMAL COEFFICIENT OF EXPANSION
It is defined as the amount of elastic and plastic deformation
energy required to fracture a material. Toughness increases The change in length per unit length of the material for a
with increase in strength and ductility. Thus a tough 1°C change in temperature is called the linear coefficient
material is generally strong but a strong material is not of thermal expansion(α).
necessarily tough.
Clinical importance
Material Fracture Toughness (MN/m)
1. The tooth and the restorative materials to prevent
Enamel 0.7–1.3
marginal leakage. This will lead to breakage of marginal
Dentin 3.1 seal between the filling and the cavity wall.
Amalgam 1.3–1.6
Material α (ppm/K)
Composite 1.4–2.3
Enamel 11.4
Porcelain 0.9–1.0
Dentin 8.3
Hardness Amalgam 25
Composite 14–50
Hardness is the resistance to indentation. Factors related
to hardness are compressive strength, proportional limit, Aluminous porcelain 6.6
and ductility. Gold 14
Annexures 431
Annexure 2: Department of Conservative Dentistry and Endodontics
CASE RECORD SHEET

Patient Name:................................................................................................................................................................................
OPD No.:........................................................................................ Age/Sex:..................................................................................
Date: ........................................................................................... Occupation:............................................................................
Marital status: Married/Single.................................................... Address/Contact No.:............................................................
1. Dental History
Chief complaint:...........................................................................................................................................................................
History of present illness:...........................................................................................................................................................
Past dental history:......................................................................................................................................................................
Medical history:............................................................................................................................................................................
Any disease related to
Cardiovascular: Yes/No............................................................... Hepatic: Yes/No.....................................................................
Respiratory: Yes/No...................................................................... Renal: Yes/No.........................................................................
Gastrointestinal: Yes/No.............................................................. Endocrine: Yes/No.................................................................
Neural: Yes/No ..............................................................................................................................................................................
If yes, give details: .........................................................................................................................................................................
Have you been hospitalized/operated:................................................................................................ Yes/No...........................
If yes, give details:..........................................................................................................................................................................
Do you have any history of abnormal bleeding with trauma or dental procedures:....................... Yes/No...........................
If yes, give details:..........................................................................................................................................................................
Are you pregnant?................................................................................................................................. Yes/No...........................
1st trimester: 2nd trimester: 3rd trimester

Allergy to: .....................................................................................................................................................................................
2. Clinical Examination
A. Intraoral Examination
i. Hard tissue examination
Total No. of teeth present:.............................................................................................................................................................
Decayed teeth:...............................................................................................................................................................................
Missing teeth:.................................................................................................................................................................................
Filled teeth:....................................................................................................................................................................................
Fractured teeth:.............................................................................................................................................................................
Discolored teeth:...........................................................................................................................................................................
Attrition:.........................................................................................................................................................................................
Abrasion:........................................................................................................................................................................................
Erosion:..........................................................................................................................................................................................
Mobility:.........................................................................................................................................................................................
Crowding/spacing:........................................................................................................................................................................
Molar occlusion:............................................................................................................................................................................
ii. Soft tissue examination:

Sinus Opening:..............................................................................................................................................................................
Swelling:.........................................................................................................................................................................................
Inspection:.....................................................................................................................................................................................
Palpation:.......................................................................................................................................................................................
Percussion:.....................................................................................................................................................................................
B. Extraoral Examination
Swelling:.........................................................................................................................................................................................
Lymph node enlargement:...........................................................................................................................................................
Sinus opening if any:...................................................................................................................................................................
C. Provisional Diagnosis
D. Clinical Tests
i. Pulp vitality test:
a. Thermal test:
b. Electric pulp test:
c. Other pulp vitality test, if any:
ii. Percussion test:
iii. Radiological Examination:
E. Other Tests:
F. Laboratory Investigations:
G. Final Diagnosis:
H. Prognosis:
Good/ Fair/ Poor/ Doubtful
I. Treatment Plan:
J. Postoperative Evaluation and Follow Up

i. 1 month
ii. 3 months
iii. 6 months
iv. 1 year
Signature
Annexures 433
CONSENT FORM
1. The doctor has explained my dental condition, the proposed procedure, I understand the probable outcome of the
procedure.
2. The doctor has explained relevant treatment options, their associated risks and prognosis to procedure.
3. I understand that photographs taken during the procedure are for academic purpose.
4. I understand the details of the procedure and in case of any unexpected complication during or subsequent to
treatment, will not hold either the treating doctor or the hospital authority responsible.
5. I am willing to undergo the treatment.
Signature
(Parent/ Guardian, if minor)
Date Treatment done Medications Signature

INDEX
Page numbers followed by f refer to figure, fc refer to flowchart, and t refer to table.
A abrasive technique 82 foundation 235, 235f

bubbles 268, 268f insertion of 213, 219
Abfraction 338, 389, 389f presence of 268 manipulation, faulty 217
etiology of 389 remedies of 268 marginal ditching of 112, 215, 215f
management of 390 firing 401 phase down of 222
Abrasion 338, 387 pressure casting machine 265 pins 107
cavities 388f rotor contra-angle handpiece 83, 83f depth in 227, 232
defect 300 turbine handpiece 82 form of 107f
etiology of 387 water syringe 129 preparation of 235f
management of 388 Alcohol flame, heating on 241 placement of 231
resistance 353 Alcoholism, chronic 388 polishing of 214, 219
Abrasive Alkaptonuria 367 properties of 195
classification of 91 All-ceramic resistance form of 217f
disks 93f crowns 408 restoration 193, 206f, 218, 223, 317f
instrument 68, 91, 92 restorations 404 class II cavity preparation for 204
parts of 91f system 402 class III cavity preparation for 210
particle classification of 402 class VI cavity preparation for 212, 212f
density of 91 Allergy 111, 149 failures of 215, 216
hardness of 92 All-in-one system 281, 282 fracture of 216f
shape and size of 91 Alloy 193, 399 life of 215
rotary instruments 93f high fusion temperature of 399 poor anatomic contour of 215f
surface, clogging of 92 selection of 217 proximal box for 209f
Absorbents 128 strength of 399 removal of old 219
Absorption 425 temperature of 269 steps for 212
Abutment tooth 210f types of 197, 214 retention of 105f, 107f
modifications for 209 Alum 135 slot preparation for 208f
Acetylene 266 Alumina 348 strength of 225
Acid etching 15, 277, 286 reinforced ceramic 402 structure of 196f
Acidogenic theory 39 Aluminium 189 sufficient thickness of 210f
Acidulated phosphate fluoride gel 61f chloride 135 tooth preparation for 257, 318
Acrylic restorations 192 collars 161, 162f trituration of 219
indirect 187 cylinder 187 types of 198
Actinobacillus 55 foil incisor corner matrix 164, 164f wars 221
Actinomyces viscosus 42, 55 oxide 82, 94 current status of 221
Active-medium laser 424f shell crowns 192 Amalgamation reaction 196
Actodehydrogenase gene 64 Aluminosilicate polyacrylate 347 Amalgamator 213f
Additives 264 Alveolar bone 20 Amalgapin 234
Adhesion 274, 295, 351, 353 density of 36f Amelogenesis imperfecta 368, 391, 392f
mechanism of 274, 351, 352f Alveolar crest group 20 after treatment 392f
types of 274f Alveolar irritation 95 before treatment 392f
Adhesives 274 Amalgam 193, 194, 218, 229, 319 American Dental Association 8, 193, 311, 414
advantages of 273 alloy American Society of Dental Surgeons 221
dentistry 4 composition of 195t Amorphous calcium phosphate technology
indications for 273 constituents of 194f 365, 380, 380f
Admixed alloy 194, 196 selection of 212 Anatomic matrix 162
Adsorption 274 type of 214t band, placement of 160, 160f
Aesthetic 239, 250, 329, 339, 353, 354 and composite restoration, preparation for Angle former excavator 74f
considerations 208 319t Angle’s classification 28f
contouring 338 blues 112, 216 Angular system 7
dental proportion, recurring 334, 334f capsule 212f Anorexia nervosa 388
dentistry 288, 337 carrier 76, 77f Anterior composite restorations, tooth
improvement procedures 300 carving of 231 preparation for 307
properties 398 condensation of 219 Antianxiety
reasons 257 dimensional changes in 196f, 197f agents and sedatives 131
requirement 208 factors affecting dimensional changes of drugs, premedication using 153
treatment plan 338 197 Anti-inflammatory corticosteroids 364
Air finishing of 214 Antimicrobial agents 40, 419
abrasion, tooth preparation using 382 fluoridated 201 Antiretraction valves 146
Antisepsis 139 Bleaching 126f, 369, 374 Burnisher 77, 77f

Antisialagogues 130 agents 369 egg-shaped 77f
Arginine-based product pro-argin 365 effects of 373 Butane tetracarboxylic acid 295
Argon laser 371 mechanism of 369, 369f Butt joint, lack of 217
curing unit 306 mixture, placement of 373f
Aseptic technique 139 sensitivity 363
Atraumatic restorative treatment technique solutions for 370
C
357 technique 370fc Calcium 381
Attrition 250, 386 laser assisted 371 aluminate glass ionomer cements 349
etiology of 386 trays 372f carbonate carrier 381
management of 387 Blood vessels 20 fluoride 348
Autoclaving Body porcelain 396 hydroxide 179, 183, 187
advantages of 143 Boiling water 146 placement of 182f
disadvantages of 143 Bond strength 295 ion migration 44
packaging of 143 Bonded amalgam sodium phosphosilicate 379
Autocure glass ionomer cement, setting bonding mechanism of 200f Canine 6f, 22, 44
reaction of 350 system 200 guided occlusion 33f
Automate II mechanical device 164 Bonding 274, 301, 303, 312f Carbamide peroxide 369
Automatic mallet 245 agent, application of 286, 305f, 310f, 311f, Carbide burs 145
Automatrix 316f, 341f Carbohydrate
bands 164 indications of 200 in caries formation, role of 40fc
placement of 165 mechanism of 200, 280, 280f, 281, 281f intake, frequency of 41
removal of 165 Bone replacement materials 420 Caridex 65
Auxiliary slice preparation 253, 253f Boric oxide 397 Caries 338
Axial wall 99f Bottle caries 49 activity tests 57
Box preparation 253, 253f acute 47
B Box-only class II composite preparation 383f advanced 49
Brinell hardness number 237 arrested 47
Bacillus Brittle material 199 backward 48
stearothermophilus 144 Broken drill 233, 233f balance
subtilis 144 Brush 92, 93f concept 40
Back-pressure porosity 269, 270 technique 400 theory 40f
Bacteria 42 Bruxism 27 chronic 47
cariogenic 378 Bruxomania 27 classification 377, 377f
Bacterial metabolites 42 Buccal WHO system of 49
Ball burnisher 77f aspect 25, 25f compound 48
Baltimore College of Dental Surgery 1 corridor 334, 334f detection 426
Band 155 cusps 29f, 30 recent methods of 52
material, types of 155 embrasures 24, 24f development of 378
removal of 158 extension 204f diagnosis of secondary 55
Barium 348 groove 28 early childhood 49
Barrier technique 140 surfaces, caries of 50 evaluation of 111
Bases 354 vestibular spaces 120 excavation 181
Beam Bulimia nervosa 388 extent of 48, 207, 357f
penetration power of 423 Bulk method 241 incipient interproximal 51f
wavelength of 422 Bur lesion in secondary 55f
Beaver tail 77 low incidence of 250
angle of 359f
Bennett’s movement 31, 32f moderate 49
blade 86, 89f
prevention 427
Beveled tooth preparation 302, 302f, 308, 308f, bulk of 88f
current methods of 63
309, 311f, 312f classifications of 84
genetic modalities in 63
steps of 311f design 86, 86f, 87t
primary 47, 47f
Bevels 252 modifications in 85
progression, speed of 47
functions of 252 end-cutting 85, 88
removal using air abrasion 65
types of 252, 252f factors affecting cutting efficiency of 88
risk, assessment of 57, 377
Bicarbonate 42 flutes of 89f secondary 47, 47f, 50, 51f, 54, 154f, 216, 322
Bilayered technique 358 head severe 49
Bin-angled chisel 75, 75f designs of 85f simple 48
Binary alloys 194 diameter, correlation of 86t smooth surface 43, 46, 46f
Bioactive glass 349, 379 visual contact with 89 spread, pathway of 48
Bioaggregate 183, 184 heat treatment of 88 vaccine 64
Biodentine 183, 184 latch type 84f development of 64
Bioglass 365 length of 87f rationale of 64
Biological tissues 425 neck diameter of 88 Cariology 39
Birth injuries 390 parts of 84 Carious dentin
Bisphenol A-glycidyl methacrylate 275, 289, size 86 dyes for detection of 52
313 spiral crosscuts of 88f removal of remaining 203
Blades, number of 88 tooth 86 Carious enamel, dyes for detection of 52
Bland clamps 122 types of 84f, 85 Carious lesion, management of deep 181
Index 437
Carious tooth, restoration of 3 Centrifugal casting machine 265, 265f Class II tooth preparation 100f, 242, 300, 316
Carvers 75, 77, 77f Centripetal build-up technique 305, 305f conservative 172f
Casein Ceramic 339, 395 design, factors affecting 207
phosphate 365 crystalline phase in 396 Class III amalgam 211f
phosphopeptide 365 infiltrated 402, 403 Class III cavity 238
amorphous calcium phosphate 350, inlays 180, 326t, 404, 404f, 406, 406t preparation 100
379 tooth preparation for 405f Class III dental caries 48f
Cast gold inserts 165 Class III direct composite restorations 163
alloys 249 low fusion temperature of 399 Class III preparation, steps of conventional
classification of 249 metal oxides in 397t 308f
components of 248 onlays 180, 404, 404f, 406, 406f, 406t Class III tooth preparation 99f, 101f, 211f, 242,
inlay, cavity preparation of 257t organically modified 295 307, 355
pins 226 properties of 398 conventional 307
restorations 180 restorations Class IV cavity preparation 100, 101f, 309
Cast metal 406t adhesive bonding of 399 Class IV dental caries 48f
inlay 406 fabrication of 411 Class IV tooth preparation, conventional 309
basic design of 251 veneers 344, 344f, 345 Class V amalgam restoration, cavity
onlay 258, 406 cementation of 344 preparation of 211f
restoration 248, 250, 254f, 255, 255f, 260 incisal modification for 407f Class V cavity 238
techniques of fabrication of 248 tooth preparation for 407 preparation 101, 211
Castable ceramic 396, 402 Cermet cement 348 rules for 104
veneers 344 Cervical Class V dental caries 48f
Casting burnout 51, 51f Class V lesions, restorations of 354
cementation of 267 embrasure 336, 336f Class V tooth preparation 101f, 244, 245, 245f,
cleaning of 266 lesions 338 309, 355
defects 267 margin 367f conventional 309
distortion of 267 matrices 164f steps of 244f
machines 265 resorption 373 Class VI cavity 238
pressure 269 Chairside infection control 147 Class VI dental caries 48f
Cavity Chamfer preparation 410 Class VI lesions with amalgam 212
configuration 299 Class VI tooth preparations 300
Cheek retractor 130, 130f
liners 179 Clenching 27
Chemical
Cleoid
preparation 202f, 355, 426 bonding 399
carver, sharpening of 81f
conventional 426 indicators 144
discoid 75
deep 179f properties 398
carver 76f
final 203, 207, 211, 211f solution, contents of 144
CO2 laser 371
instruments for 255 strengthening 398 Cobalt oxide 397
stages of 101 vapor 142 Cobblestone appearance 276, 276f
steps of 102, 212 deposition diamond burs 90, 90f Collimated beam 423f
sealers 178 pressure sterilization 142, 144 Collimation 423
Cavosurface angle 99f, 217 Chemiclave 144 Colony-forming units 146
design of 108 Chemicomechanical methods 135 Comfort control syringe 151, 152f
margin 99 Chemicoparasitic theory 39 Communicable diseases 111
Cellophane 155, 163 Chemomechanical caries removal 64, 382 Compaction
Cells 20 Chicken pox 111 energy of 246
membrane Chisels 74 objective of 245
bacterial 419f Chlorhexidine 40, 296 Complex amalgam restorations 234
damage 419f gluconate 59 Complex tooth preparation 98, 98f
Cellular elements 18 impregnated glass ionomer cement 350 Compomers 295
Celluloid 163 Chromium alumina 397 composition of 295
crowns 187 Class I amalgam preparation 204f Composite
Cellulose Class I cavity preparation 99, 202 adhesive, failures of 285f
acetate 163, 191 steps of 203f, 316f aesthetic of 298, 339
nitrate 163 Class I dental caries 48f antibacterial 296
Cement Class I direct composite restorations, small-to- build up
manipulation of 189, 356 moderate 314, 315f procedure 343f
spatulas 76, 76f Class I tooth preparation 242, 242f, 300, 314, using putty index 343f
Cementation 406, 410 315f, 355, 355f classes of 299f
Cemented pins 226 Class II cast metal inlays, cavity preparation classification of 291
advantages of 226 of 255 conventional class IV preparation for 309
disadvantages of 226 Class II cavity preparation 100 factors affecting water absorption of 298
Cementoenamel junction 13, 207 steps of 206f failure, minimize chances of 322
Cementum 19 Class II composite tooth preparation 165, 318, gun 303, 304f
Centers for Disease Control and Prevention 319f inlay 326t
141, 145 Class II dental caries 48f restoration 327f
Central nervous system 153 Class II design, modifications in 208, 208f light-cured 290t
Centric holding cusp 29, 30 Class II gold inlays 256f, 257 placement 301, 303, 304f
Centric relation 27 indications for 250 instruments for 303
interference 33, 33f Class II inlay restoration 257 techniques 304
resin 180, 295 Cross-arch intraoral finger rest 79f composition 331
instruments 77 Crown emergencies 117
matrices used for 303 coronal part of 374f engine 81
placing 286 forms 191 floss 59, 59f, 124
polymerization of 301 matrices, transparent 162 foot engine 2
restoration 288, 301, 317f, 319, 322 placement 364 handpiece, sterilization of 145
defective 311f Crystalline 240 history 57, 110, 378
different failures of 321f gold 240 mercury hygiene 220
failures of 318 types of 240 midline 331
finishing of 307, 307f Curing light, intensity of 300 evaluation of 331f
generations of 291 Cusp 29f office 219, 220
instruments for 77f and fossa apposition 29f ozone machine 383f
moderate class I direct 315f, 316f capping 210, 255, 258 papilla, cells of 18
moderate-to-large class I direct 315 for amalgam, steps of 210f plaque 1
polishing of 301 features of posterior 29 porcelain, composition of 397f
posterior 310 functional 29, 260 practice, laser safety in 425
repair of 322 gliding 30 procedures 368
tooth preparation for 318 reduction 258f, 260 performing 116f
second-generation 291 significance nonsupporting 30 prophylaxis 59
shade of 299 supporting 29 pulp 18, 18f, 177
types of 290, 290t, 292 Cuspal replacement 355 effect of caries on 176
veneers, processed 342 Cutting instruments 69, 75 stones 261
Composi-tight bevels in 71 tape 59, 124
3D soft face ring 167, 168f nature of 177 unit waterlines 146
matrix 167, 167f sterilization of 146
Compressive strength 197, 198, 201 Dentifrices 94, 364
Computer-aided design and computer-aided D Dentin 15, 16t, 229, 232f
manufacturing Decayed tooth, treatment of 1 adhesive
ceramic 396 Deciduous dentition 6f sealers 364
machine 404f Deep caries 308f systems 278
technology 427 management 427 adventitious 16
Condensation technique 197 Deep carious lesion 184f, 238 affected 18, 46, 46t, 106, 106t
Condenser, types of 76f, 214 Defective enamel, incomplete removal of 217 bonding 18, 277
Condylar guidance 31 Defense cells 18 agent 278, 279, 282, 282f, 285f, 365
Cone Defense dentin 16 failures of 285
bur, inverted 85 Demineralization success of 286
socket handle 69 cycle of 378 chambers 234
Conflicts regarding amalgam, history of 218 mechanism of 379f color 15
Conservative dentistry 91 Dental composition of 277f
Conservative tooth preparation, modified aesthetics, elements of 329 conditioning of 278
303f, 309, 310 amalgam 57, 193, 218 deep 284
Constituent metals 195 alloys 193 demineralized 285f
Contact rings, principles of 166 generations of 194 diseases of 368
Convenience form 106, 203, 355, 356 history of 194 eburnation of 17
Conventional tooth preparation 308, 317f phase down of 221, 222 effects on 373
indications for 302 safe 220 fracture 225
Coolants, use of 177 burs 84 functions of 17
Copper 59, 195, 248 sterilization of 145 hardness of 16
amalgam alloys 198t care, quality of 114 hypersensitivity 18, 361, 363fc, 364-366,
band 133 caries 3, 3f, 39, 59t, 363 419
application of 133f classification of 46 diagnosis of 363
matrix 162f clinical presentation of 43 differential diagnosis of 363t
collars 161, 162f diagnosis of 50 etiology of 363fc
oxide 397 etiology of 40 management of 364f
wire 174, 174f histopathology of 44 mechanism of 362f
Core build up 354 management of 64 prevention of 364
after endodontic treatment 226 ozone treatment of 65 theories of 361
Coronal gutta-percha, removal of 373f prevention of 58 treatment of 427
Coronal tissue, extensive loss of 127 radiographic classification of 49, 49f hypoplasia 3
Corrosion 198, 199 cements 187 infected 18, 46, 46t, 106, 106t
control of 142 ceramics intratubular permeability of 277f
Corundum 94 advantages of 399 normal 46
Cotton roll and disadvantages of 399 permeability 18, 176, 277, 364
cellulose wafers 128 chair 115 pin depth in 227, 232
gauze pieces 128f positions 116 primary 16, 17f, 17t
Coupling agents 290, 290f clinic, reduce mercury exposure in 219f proximal caries in 43f
Cove, preparation of 234f composite safe bur 89
Crab claw separator 171, 171f composition of 289 secondary 16, 17f, 17t
Cracked tooth syndrome 363 particle size distribution in 289f shade 305f
Index 439
structure of 16 Discolored maxillary management of 3
superficial 284 central incisors 368f permeability 15
support 17 lateral incisors 368f proximal caries in 43f
surface 278 Disinfectant systems 146 removal of superficial 104f
transparent 46 Disinfection 139 rods 13f, 14f
types of 232 methods of 146 unsupported 217
Dentinal Distal bevel instruments 71 selective etch of 305f
caries 45 Distal gingival margin trimmer 75f spindles 14
zones of 45, 45f Distofacial grooves 28 strength 15
changes, advanced 45 Distortion 267 structure of 12
hypersensitivity 361 Double cord technique 134 thickness of 12, 13f, 14
tubules 16, 16f, 362f Double wedging technique 172, 173f translucency of 367f
Dentinoenamel junction 14, 14f, 229f Dry dentin 277, 278f translucent gray color of 13f
Dentinogenesis imperfecta 368, 392, 393 Dry heat 142 tufts 14, 14f
Dentistry sterilization 142, 143 walls and margins, finishing of 204, 207
applications of advantages of 144 Enamelon 380, 380f
nanomaterials in 418f disadvantages of 144 Enameloplasty 104, 104f
nanotechnology in 418 Dye enhanced laser fluorescence 54 Endodontics 354, 419
beginning of 5 Dye penetration method 52 Endoscopic filtered fluorescence method 53
four handed 117 Epoxy resins 261
laser in 422 Erosion 238, 388
nanotechnology in 417, 418 E clinical picture of 389f
practicing evidence-based 414fc defect 300
E sound 332
preventive 418 etiology of 388
Eating disorders 388
steps of evidence-based 414 Erythroblastosis fetalis 367
Ectopic eruptions 338
Dentition, types of 6 Etchant 275f
Eighth-generation dentin-bonding agent 282,
Desensitizing agents, classification of 364 application of 63f, 311f, 316f, 341f, 343f
282f
Diagnodent 54, 54f, 426f Etched enamel rods 276f
Elasticity
Diamond burs 145 Etched porcelain veneers 343
high modulus of 399
Diamond instruments 91, 93 Etching 276, 301, 303, 427
modulus of 298, 325
Diastema 338 effects of 276
Electric
closure 377 mechanism of 276
annealer 242
management of 342f Ethanol 146
engine 82
Dicalcium phosphate dihydrate 62 Ethoxybenzoic acid reinforced cement 188
Die fabrication 326 melting units 266
Electrical conductance measurement 53 composition of 188
Diet 41f Ethyl silica-bonded investment 264
chemical nature of 41 Electrical hazards 425
Electromallet compaction 245 Ethylene oxide sterilization 142, 144
vitamin content of 41 Ethylenediamine tetraacetic acid 275
Diffusion 42, 274 Electron beam irradiation 323
Electronic dental anesthesia 151, 152, 152f Eugenol cement 188
Digital dental radiography 52 Evidence-based dentistry 413-415
Digital imaging fiberoptic transillumination 53 mechanism of 152
Electrosurgery 135, 136 application of 415
Dipentaerythritol pentaacrylate
rules for 136 concept of 413f
monophosphate 275
Elliot separator 171 implementation of 415
Direct composite restorations 313f
placement of 171f Explorers, types of 73f
advantages of 300
Embrasure 24 Extensive tooth
disadvantages of 301
functions of 25 involvement 250
large class I 317f
Emergency temporary restorations 354 loss 225
Direct composite veneers 341f, 344
Emery 94 Extracellular components 18
Direct filling gold 57, 106, 237
Enamel 12, 16t Extracoronal preparations 187, 191
classification of 239fc
bevel 302 Extraoral examination 111
compaction of 245, 245f
bluish color of 13f Extraoral factors 56
restoration 243f
bonding 277 Extraoral finger rest 79
advantages of 237
steps for 276 Extraoral finishing 250
care 380, 380f Extraoral palm
indications of 238
caries 44 down finger rest 79f
steps of 246
incipient 44 up finger rest 79f
Direct partial veneers 340
Direct pins 226 zones of 44, 44f Extraoral polishing 250
types of 227f color of 13 Extrinsic
Direct posterior composite restorations composition of 12, 275f discoloration 367
contraindications for 313 contiguous 48f erosion 388
indications for 311 diseases of 368 stains 368
Direct pulp capping 182, 183f, 183fc, 184f effects on 373 Eye
Direct resin 344 etching, pattern of 276f injuries 95
composites 325 functions of 15 wear 95, 140f
restorations 320f hardness of 13
Direct stimulation theory 361, 362f hatchet 75, 75f F
Direct veneer technique 340 hypoplasia 50t, 112
Discoloration, classification of 367 lamellae 14, 14f F sound 332
Fabrication Fissurotomy burs 90, 90f, 382 Gingival

method of 340 Fixed orthodontic appliances 175 bevel 257
technique 396, 402 Flame, zones of 266, 266f embrasure 24, 24f
using refractory die 411 Flare 252 extension 258f
Face modified 253 floor 99f, 105, 105f
mask 140 preparation, modified 253f grafts 365
profile, horizontal 330f primary 252, 253f health 336
shield 140 secondary 253, 253f level and harmony 336, 336f
Facial Flat bands 158 margin 104f
analysis 329f Flexi dam 121 apical 336f
asymmetry 111 Fluor protector 61f deep 172f
composition 329 Fluorapatite crystals, formation of 60f trimmer 71f, 75
cusps 30f marginal hatchet 75
Fluoridated salt 62
embrasure 28 retraction 136, 136f
Fluoride 60, 348, 379, 379f, 390
midline 330, 331f cord 133, 133f, 134f
bombs 48
pulp horn 209f tissue 120
effects of 60
reduction 409 management 131, 132, 137, 427
surfaces, cervical third of 23 in dentifrice, concentration of 62
iontophoresis 365 retraction 132
Faciolingual extensions, tooth requires less Gingivitis 33
103f products 60
recharge 351 Giomer 295, 349
Fats 58 Glass ionomer
Feathered incisal edge 407 cycle 352f
based adhesive system 285
Federation Dentaire Internationale System 9 release 295, 351, 352f
cement 57, 63, 179, 180, 187, 347, 350, 352f,
Feldspar 397 supplements 62
356f, 360, 374f
Feldspathic porcelain 395 syndrome 48
advantages of 353
Fender wedges 168, 168f varnish 60, 61f, 365
classification of 347
Fermentable source, nature of 42 Fluorosis 13f, 112, 368, 391f
contraindications of 355
Ferric oxide 397 Flute ends, design of 89
conventional 348, 349, 349f
Ferric sulfate 135 Food and Drug Administration 218
Ferrier design 244 Foot engiene 81 indications of 354
Ferrier double bow separator 173, 174f Formaldehyde 146 nanotechnology in 350
Fiberoptic handpiece 89, 89f Fossa apposition 29 placement of 355f
Fiberoptic transillumination 52 Four-number formula 70f proline-containing 350
Fibers 19 Fourth-generation properties of 351
apical 20 bonding agents 279, 280, 280f restorations 57f
interradicular 20 composites 291 self-hardening 349
orientation of 324f Fracture setting reaction of 350, 350f
reinforced
line 112, 216 clinical applications of 357
composites 324f
within tooth 233f powder, composition of 348
glass ionomer cement 350
Friction grip bur 84f resin-modified 351
Fibroblasts 18
Friction locked pins 226 setting reaction of resin-modified 351, 351f
Fibrous gold 239
Fifth-generation advantages of 227 Glaze ceramic 396
composites 291 disadvantages of 227 Glazing 322, 401
dentin-bonding agent 280, 280f, 281f Frosty white appearance 276 purposes of 322
Files 75, 75f Fulguration 136 types of 401
Fillers 289 Fully set cement, structure of 350, 351f Glutaraldehyde 60, 146
particle size 291 Fusion temperature 396 Glycerophosphoric acid dimethacrylate 275
types of 300 Gnarled enamel 13, 14f
Finger rests 78 Gold 237, 248
Finishing and polishing 214, 266, 357
G compaction of 246
carbide burs 93f dent 241
GaALAs diode laser 371
instruments 68, 92 factors affecting compaction of 245
Gallium amalgam 200
procedure 231 foil 218, 239
restorations, properties of 201
Finishing burs 92 carbonized 240
Galvanic corrosion 198, 198f
Firing cycles, reduce number of 398 corrugated 240
Galvanism 199, 218
First amalgam war 218, 221 cylinder 240, 240f
Gas
First mandibular molar with inlay, restoration laminated 240
diffusible 401 granular 241
of 259f
inclusion porosity 269, 270 in dentistry, future of 247
First molar, caries in 111f
First-generation contact ring lasers 423 noncohesive form of 241
disadvantages of 167 Gaseous defects 269, 270 pellets 240
systems 166 Gastroesophageal reflux disease 363, 364 properties of 237
First-generation dentin-bonding systems 279 Gastrointestinal disorder 388 restoration 198f, 242f
Fissure 314f Gate control’s theory 152 semicohesive form of 241
bur, tooth preparation using straight 382f Geobacillus stearothermophilus 144 sheets 239f
lesions 103f Ghost image 72 storage of 241
sealants Gingiva 126f, 155 types of 239
types of 62 remove 136f Golden proportion, rule of 334, 334f
use of 62 retraction of 133f Graham Mount’s classification 49, 50t
Index 441
Gravity convection 143 Hot air oven 143 Inorganic components 284
Grid system 7 Hot spot 269 Instrument 71
Grooves, placement of 256 porosity 269 advantages of balancing of 69
Guards, advantages of 79 Human dentition comprising incisors 6f balancing of 70f
Gustafson’s method 17 Hunter-Schreger bands 14 classification of 141
Gutta-percha 187 Hutchinson’s tooth 390 contact forming 165, 165f
composition of 187 Hybrid cord packing 134f
placement of protective barrier over 373f composite resins 293 designs 71
removal of 374f layer 283 exchange 118
stick 175, 175f, 187f formation 277f for dry heat, packaging of 143
GV black classification 68 properties of 283 formula 69
Gypsum-bonded investment 264, 265 zones of 283, 283f
grasps 77
Hybridization 283
motions 71
Hybridoid layer 283
H Hydrodynamic theory 362, 362f
processing
cycle 142fc
Hand Hydrofluoric acid 409f
Hydrogen peroxide 369 procedures 142
condensation 245 sterilization 427
cutting instrument 68, 73 Hydroxyapatite 379
Hydroxyethyl methacrylate 275 classification of 141t
parts of 68, 69f
Hygroscopic low heat technique 265 Interdental brushes 59, 59f
hygiene 141
Hypermobility 33f Interdental contact area and point 335
instrument 303, 304f
Hypnosis 153 Interfacial properties 398
parts of 68
sharpening of 80 Hypomaturation 392 Interim restoration 186, 199
mallet method 245 hypoplastic taurodontism 392 objective of 186
mixing method 356f Hypomineralization 112 purposes of 186
Handpiece 81 Hypoplasia 338, 392, 392f requirements of 186
evolution of 81 Hypoplastic defects 238, 300 Interpin distance 229, 231
sterilization 145 Hyposalivation, causes of 43 Interprismatic enamel, removal of 276f
types of 83 Interproximal contact
area 335, 335f
Handwashing I point 335
instructions 141
technique of 141f Iatrogenic sensitivity 363 Interproximal spaces 25, 25f
Hard laser 423 Immunization 141 Interpupillary line 330
Hard tissue 65 Impression 408 Intertubular dentin 16, 16f
components 331 Incisal bevel 407, 407f Intracoronal bleaching 372
examination 111 Incisal butt joint preparation 407f, 408 complications of 373
Hat dam 125 Incisal edge 367f Intracoronal preparation 187
Hatchet 75, 94 midway upper and lower lip 332f Intraoral finger rest 78
Head cap 140, 140f positions 331 conventional 79f
Heart murmurs 110 Incisal embrasures 24, 24f, 333f, 335, 336f Intraoral lignocaine patch 151
Heat Incisal lengths 331 Intratubular permeability 277, 277f
generation 234 Incisal lingual wrap preparation 407, 407f Intrinsic
polymerization 323 Incisor 22 erosion 388
production 177 central 333f stains 367
Heavy occlusal stresses 239, 300 trauma 28 Iodine 60
Hematological disorders 367 Incremental layering technique 304, 304f Iodophors 146
Hepatic dysfunction 150 Indirect composites, classification of 323 Ion
Hepatitis 111 Indirect resin composite 322, 325 exchange 398
Herpes simplex 111 inlay restoration 326f leaching phase 350
High bisque stage 401 restorations 322 releasing composites 296
High caries Indirect restorations, foundation for 225 Isolation, adequate 286
index 250 Indirect wax pattern method 262 Isopropyl alcohol 146
risk 57, 354 Indium 195 Isthmus, narrow 217
susceptibility 300 liquid alloy 201 Itaconic acid 348
High compressive strength 199 Infection control 139, 146 Ivory matrix
High copper alloy 194, 195, 195t objective of 140 band retainer no 8 156
High heat thermal expansion technique 265 rationale for 139 holder no. 1 155
High linear coefficient of thermal expansion Ingraham design 244 retainers no.1 and 8 155
301 Inhalation sedation 153
High smile line 337, 337f Initial cavity preparation 202, 204, 210, 211
High viscosity autocure glass ionomers 349 stage 102 J
Hoe excavator 73, 74f Initiator-activator system 290t
Jaw design, basis of 122
Hollenback carver 214 Inlay 250
Hollow ground bevel 252 preparation, steps of 255
Home bleaching technique 371 restoration, X-ray after 327f K
Honeycomb appearance 276, 276f taper 251, 251f
Honing machine 80 In-office bleaching 370 Kaolin 397
Horizontal layering technique 304 In-office treatment procedure 365 Keyes triad 40, 41f
L Localized infection 390 Marginal ridge 24, 24f

Localized nonhereditary dentin restoration of 24f
Labial hypocalcification 391 Marzouk’s classification 68
aspect 25, 25f hypoplasia 391 Mass, homogenous 213f
embrasures 24 Localized nonhereditary enamel Mat foil 241
reduction 407 hypocalcification 391 Mat gold 240
Lactobacillus 55 hypoplasia 390 Materials, heat treatment of 68
acidophilus 42 Lock 234 Matrix 155, 156
test 58 preparation 234f adaptation, defective 218
zeae 64 Loma linda design 244 application 301, 303
Laminate restoration technique 358 Long bevel 252 classification of 156t
Lanthanum 348 Long loop electrode 136f compositions 291
Laser 64, 66, 137, 364, 365, 422 Loose pins 233 compound supported 155, 160
advantages of 428 Lost wax technique 411 custom-made 155
basic components of 424 Low bisque stage 401 functions of 155
beam 427f Low caloric sweeteners 58 ideal requirements of 155
principles of 423 Low copper alloy 194, 195, 195t intercellular 20
cavity preparation 426 Low fracture resistance 354 parts of 155
classification of 422 Low fusing ceramics 397 placement 170, 231
disadvantages of 428 Low mercury alloy 200 removal of 231
fluorescence, qualitative 53 Low microleakage 300 retainerless system 164
interaction 425 Low output power lasers 427 strips 163f
irradiation, thermal effects of 425 Low smile line 337, 337f systems, recent advances in 165
material used, types of 423 Low temperature ionic crowding 398 transparent 155
medium 424 Low thermal conductivity 300 Matrix band
physics 423 Low viscosity 349 application of 213
Lathe-cut low copper alloys 196 Low volume evacuator 129, 129f placement of
Leathery tissues 65 Low wear resistance 301, 354 S-shaped 161f
Lens 424 Lower incisors 44 T-shaped 161f
Lesion Lower lip, curvature of 337f S-shaped 161
body of 44 Lower tooth T-shaped 161
large size of 238 Maxilla 6
lingual inclines of 34
Less internal stresses 251 Maxillary anesthesia 150
mesial inclines of 34
Less technique sensitive 354 Maxillary anterior tooth
Lubricant 123
Lesser interpin distance generates 232f incisal edge of 337f
Lung irritation 95
Leucite reinforced ceramic 402 reshaping of 339f
Luting agents 354
Ligature wire 174, 174f restoration of class V lesion 313f
Luting cement 300
Light cure composites 299 Maxillary arch 28f, 116
Light emitting diode unit 306 walking bleach of 374f
Light source and resin 300 M Maxillary canine 334, 388f
Light stimulated emission 424f Maxillary central incisor 311f, 334, 335f, 337f
Light transmitting wedges 172, 172f M sound 331 fractured 3f
Light-emitting diode 306f Machinable ceramic 402, 403, 403f restoration of 310f
Liners 178, 179f, 354 Macrofilled composites 292 class V lesion 313f
Lingual cusps 30, 30f Magic foamcord 36, 137, 137f Maxillary first molar 28, 209
Lingual embrasures 24, 24f Maleic acid 348 conservative preparation for 209
Lingual extension 204f Malocclusion 27 Maxillary incisors
Lingual reduction 410 Mandible 32f, 120 display of 332f
Lingual surfaces border movements of 32 partial direct veneer of 340f
caries of 50 gliding movement in 31f Maxillary lateral incisor 334
cervical third of 23 rotational movement in 30f, 31f restoration of class V lesion 313f
middle third of 23 translation in 31f Maxillary molars 257
Lingual vestibular spaces 120 movement of 31f oblique ridge in 257
Lingual walls 210f Mandibular anesthesia 150 Maxillary posterior tooth 78
Link series 228 Mandibular arch 28f Maxillary premolars 334
Lips 120 Mandibular first molar 51f, 184f, 314f Maxillary second molar 406f
Liquid 348, 349 class I cavity of 243f preoperative management of 406f
composition of 188, 189, 191, 348 class II cavity preparation of 104f Maxillary second premolar with inlay,
dam 125 Mandibular first premolar 209, 257 restoration of 259f
lasers 423 conservative preparation for 209 Maxillary tooth 29f, 30, 33f, 332f
rubber dam 126f Mandibular midline, deviation of 331f buccal surfaces of 334f
system, manipulation of 188 Mandibular movements 30 functional cusps of 29f
Liquidam 321f variable 30 non-functional cusps of 30f
application of 321f Mandibular tooth 29f, 30, 33f, 332f pin placement for 230t
Load, application of 88 functional cusps of 29f worn off incisal edges of 343f
Local anesthesia 149, 151, 151f, 301 non-functional cusps of 30f Mechanical vacuum investing 264
recent advances in 151 pin placement for 230t Medication 111
wand system of 151, 151f Manganese oxide 397 Medium bisque stage 401
Local anesthetic agent, composition of 150 Marginal degradation 199 Medium fusing ceramics 397
Index 443
Medium smile line 337, 337f Minimally intervention dentistry 376 National Institute of Health 218
Melting alloy 265 Minimally invasive National Institute on Standard and Technology
Melting range 249 dentistry, world congress of 1 199
Mercuroscopic expansion 197 treatment 382 Natural gas 265
consequences of 197 Minimum intervention dentistry 376 Neck 85
Mercury 212 Minimum occlusal thickness 105 Needle-free anesthesia 151
alloy ratio 212 Minocycline 368 Nerve
contaminated Miracle mix 348f desensitization 364
instruments, cleaning of 219 Mirror for indirect visualization, use of 72f fiber 20
waste, disposal of 219 Modeling compound 124 primary 362f
elemental 218 Modern adhesives, classification of 279, 284 Nib 69
exposure 219 Moist dentin 277, 286 Nickel oxide 397
forms of 218 Moist heat sterilization 142 Night-guard bleaching 371
free direct filling alloy 199 autoclave for 143f solutions for 371
Moist sterilization 143
hygiene 218 Nitrofurans 60
Moisture control
inorganic 218 Nitrogen atmosphere 323
advantages of 120
poisoning, acute 220 Nitrous oxide 153
difficult 300
storage of 219 Noble metal
methods of 120
toxicity 220 absence of 194
Molar 6f, 22, 24f
levels of 220 conservative preparation for 209f alloys 194
vapours, monitoring of 220 relationship 29 presence of 194
Mesenchymal cells, undifferentiated 18 Molded abrasive 92f Noncarious lesions
Mesial bevel instruments 71 Molten alloy, impact of 269 clinical examination of 112
Mesial gingival margin trimmer 75, 75f Moulded abrasive instrument set 92, 92f maintenance phase of 393
Mesiobuccal cusp 28 Mouth breathers 355 Noncarious tooth surface loss 393
Mesiodistal extension, extensive 217 Mouth mask 140f Noncentric cusp 30
Metal ceramic Mouth mirror 71 Noncord technique 137
alloys and ceramics, composition of 399 cone socket handle of 69f Noncutting instruments 69
bonding 400 sizes of 72, 72f Nonfluoridated remineralizing agents 379
Metal ceramic restoration 396, 399, 400f surfaces of 72f Nonfunctional contacts 27
failures of 402 Mouth prop 130, 130f Non-functional cusps 30
fracture in 402f Mouthrinse 60, 61f Non-noble metal alloys 194
requirements for 399 Mucosal irritation 373 Nonsteroidal anti-inflammatory drugs 387
Metal ions 59 Mucosal route 64 Nonsupporting cusp 30
Metal reinforced glass ionomer cements 348 Multiple amalgam restoration 112f Nonthermocatalytic bleaching 370
Metal restorations, faulty veneers in 345 Multiple carious tooth 111f Nontransparent matrices 155
Metal sprue formers 263 Multiple tooth isolation 121 Nonvital bleaching, prerequisites for 372
Metallic pigments 397 Mumps 111 Nonvital maxillary central incisors 374f
Metallic shim stock film 35, 35f Muscle relaxants 131 Nonvital tooth, bleaching of 372
Methacryloxyethyl trimellitate anhydride 275 Musculoskeletal disorders 119 N-phenylglycine-glycidyl methacrylate 275
Methacryloyloxydecyl dihydrogen phosphate Mylar strips 163
275
O
Methacryloyloxydecyl pyridinium bromide N
296 Oblique fibers 20
Methacryloyloxydodecyl pyridinium bromide Nanoanesthesia 419 Occlusal analysis system, T-scan 35
275, 296 Nano-bonding agents 419 Occlusal bevels 257
Methyl methacrylate 289 Nanoceramics 419 Occlusal caries 51f
Microabrasion 126f, 370 Nanocomposites 297, 419 Occlusal contact 27
Microfilled composites 57, 293 Nanodentistry 366, 417
Occlusal convergence, lack of 217
Microflora 41f advantages of 418
Occlusal disharmony 250
Microhybrid composites 293 disadvantages of 418
Occlusal embrasures 24
Microleakage 198, 201, 225, 234, 251, 299 Nanofill composites 293
Occlusal fissures 14, 14f
Nano-glass ionomer cement 419
around margins 325 Occlusal forces
Nanohybrid composites 293
Micromechanical bonding 399 direction of 36, 36f
Nanohydroxyapatite 381, 381f
Micromotor 83 duration of 36
Nanoimpression 420
contra-angle handpiece 83f frequency of 36
Nanoleakage 299
handpiece, conventional 231 Nanomaterial magnitude of 36
Microporosity 269 classification of 418f Occlusal instability, signs of 33
Middle output power lasers 427 enhanced retrofill polymers 419 Occlusal interferences 28, 33
Minamata convention 221 synthesis of 418f Occlusal outline form 255, 259
on mercury, intervention of 222t Nanoneedles 420 Occlusal pit 14, 14f
Mineral trioxide aggregate 183 Nanoparticles, antibacterial mechanisms of Occlusal preparation 317f
Minikin 228 419f Occlusal problems 226
Minim pin 228 Nanotechnology 417, 418 Occlusal reduction 409
Minimal intervention barriers for 420 Occlusal schemes 32
approach 376 Nanotitanium implants 420 Occlusal surfaces, caries of 50
principles of 376 Nasolabial angle 330, 330f Occlusion 27
Minimal tooth preparation, rationale of 381 National Institute for Dental Research 218 acute trauma from 36, 36f
centric 27 P Pin 232, 254

correction of 250 amalgam restorations, cavity preparation of
examination 113 Packable composites, properties of 294 229
indicators 35, 35f Packaging material 142t diameter 231
Occult caries 48 Pain 153 in amalgam, factors affecting retention of
Ocular hazards 425 control of 149 231
Odontoblastic transduction theory 362, 362f methods of 153 insertion of 230
management protocol 149 length 229
Odontoblasts 18
Palaquium 187 control for 231
Old restorative materials 207
Palatal cusps 29f nonparallel 226
Omni matrix 159, 159f
Palatal shell fabrication 341f number of 229, 231
Onlay 250
Palladium 195, 248 orientation 232
contraindications for 259 Palm grasp 78, 78f
indications for 258 placement of 233f
modified 78 point 184f
Opacifying agents 397 Palmer notation 10 restoration interface 233
Open sandwich technique 358 Palodent bitine 166, 166f retained restoration 225, 235f, 271
Operative dentistry 1, 3f, 27, 33, 337 Paper-carried abrasives 93 size 229
adhesion in 273 Parachlorometaxylenol 141 tooth interface 233
applications of lasers in 426 Parafunctional contacts 27 types of 226-228, 228f, 231
evolution of 2t Partial denture, removable 420 Pin in dentin
factors of occlusion affecting 29 Paste-paste system 188, 356 and amalgam, depth of 227t
field of 1 Pear-shaped bur 85 factors affecting retention of 231
indications of 3 Pen grasp Pin placement
infection control in 139 inverted 78, 78f
location of 229, 230f
instruments in 67 modified 77, 78f
principles of 229
laser in 422 Peptic ulcer 388
techniques of 229
occlusion in 27 Periapical periodontitis 363
Pinhole 229f
pain management in 149 Pericoronitis 363
diameter of 227
purpose of 4 Periodontal
porosity 269, 270
rotary speed ranges in 83t bone grafts 420
preparation of 229
scope of 4 disease 154f
factors affecting 229
drug delivery, nanomaterials for 420
smile designing in 329 Pin-retained cast restorations, indications for
fibers 20
Operator’s eyewear 119 271
ligament
Optical cavity 424 Pin-retained restorations
fibers 20, 20f, 170
Optical mirror 424 complications of 232
space, widening of 36f
Optical resonator 424 failures of 232
perforation 233, 233f
Optra dam 125, 125f soft tissue grafting 364 Pit 314f
Oral cancer tissue injury 36 lesions 103f
detection of 420 Periodontics 420 types of 61
treatment of 420 Periodontium 24, 36, 36f use of 62
Oral cavity 6, 39 examination of 112 Pit and fissure 43f
Oral environment, components of 120 protection of 23f caries 43, 46, 46f
Oral habits, abnormal 387 significance of 21 lesions 102
Oral hygiene 59 Periradicular tissue 19 Pit and fissure sealant 313, 354, 382
practice, faulty 387 Peritubular dentin 16, 16f contraindications for 63t
status of 378 Permanent dentition 6, 6f indications for 63t
Oral lichen planus 199 FDI tooth notation system for 9f placement of 63f
universal tooth notation system for 8f Placing bonded amalgam, technique of 200
Oral prophylaxis 301
zsigmondy-palmer tooth notation system Plaque, microbial composition of 41
Ordinary hatchet 73, 73f
for 7f Plasma arc curing 306f
Organic components 284
Permanent tooth 7-9, 10t unit 306
Organic mercury 218
Personal protection equipment 140 Plastic deformation 197
Original fissurotomy 90
Philips and Lutz classification 291 Plastic filling instrument 76, 76f
Ormocer, components of 296f
Phonetics 331, 332f Plastic matrix strips 163
Orthodontics 420 Plastic rubber dam clamp 122f
Phosphate 348
Outer dentin 18 Plastic wedges 171, 172f
bonded investment 264, 265
Overextended cavity preparation 217 Platinized gold foil 240
ions 381f
Overfiring 401 Platinum 248
Phosphor imaging system 52
Overgloves 141 Phosphoric acid 189 foil, firing on 411
Overheating 242 Photochemical effects 425 Plugging dentinal tubules 364
Oversized temporary crowns 175 Photoelectrical interaction 425 Pneumatic condenser 245
Over-triturated mix 213 Photomechanical interaction 425 Polishing 246
Oxalates 365 Photopolymerization 427 advantages of 214
Oxides, intermediate 397 Photothermal interaction 425 Polyacrylic acid 348
Oxygen 265, 266 Pickling 266 Polycarbonate crown forms 191
free radical, production of 419f Piece method 241 Polycarboxylate cement 180
Ozone 381 Piggyback wedging 173 Polychromatic layering technique 306
therapy, technique of 65 technique 173f Polymer bur 89
Index 445
Polymer reinforced zinc oxide-eugenol cement Prosthodontics 420 RecaldentTM chewing gum 380f
188 Protection, removal of 256 Recurrent caries 47, 47f, 54, 112, 216
composition of 188 Protective eyewear 140, 426f Recurrent vomiting 388
Polymer rigid inorganic matrix material 294, Protective gown 140 Reduce demineralizing factors 58
350 Protein precipitation 364 Reduce water stagnation 146
Polymerization 324, 325 Proteolysis-chelation theory 40 Refractory material 264
method 291 Proteolytic theory 40 Regional nerve block 150
rate 298 Protrusive interference 34, 35f Remaining dentin thickness 18, 177, 177f, 178
shrinkage 297, 297f, 301, 325 Protrusive movement 31 Remineralization
techniques 323 Proximal box preparation 255, 259 cycle of 378f
Poor oral hygiene 300 Proximal contact mechanism of 379f
Poor periodontal condition 238 areas 25 Remineralizing agents 379
Porcelain types of 25 Replacement dentin 16
aluminous 396 Proximal ditch out 317f technique 358
condensation of 400 Proximal margins extending subgingivally 250 Residual air 270
high-fusing 397 Proximal surfaces, caries of 50 Residual caries 49, 49f
laminate veneers 406 Proximal tooth preparation 104f, 160f Residual stresses after curing 325
indications for 407f Psychogenic vomiting syndrome 388 Resin 263
maturity, stages of 401 Pulp 12 bonding agent 179
metal bond 399 capping chemicals 275
proper glazing of 399 agent, ideal requirements of 183 coated amalgam 202
Porphyria, congenital 367 indirect 181, 182f composites, second-generation indirect
Posselt’s envelope 32, 32f materials used for 183, 183f 324
Posselt’s motion 32, 32f cavity 19 dentin inter-penetration 280
Postcarve burnishing 214 chamber 19 matrix 289, 290, 295
Postcementation pain, prevent 267 consists 18 modified glass ionomer 57
Postendodontic restoration 199 dentin complex 18 cement 180, 348, 349f
Posterior tooth 6, 23, 25f, 26f effects on 373 reinforced layer 283
contact area protection 106, 176, 178, 203, 207, 218, 229, restorations, preventive 314f, 382
buccolingually in 26f 286, 301, 302, 355 sealants, placement of 63
labiolingually in 26f materials used for 178 thickness 300
occlusal aspect of 15f methods of 180t Resistance form 260, 355
Post-restorative protective agents, classification of 178 primary 104, 202, 205
failures 218 substance of 18 Restoration
pain 218 Pulpal changes 368 adjoining 209
Powder 348, 349 Pulpal damage 94 building of 246, 246f
diamond abrasive 91, 91f prevention of 184 conservative composite 314, 314f
gold 241 Pulpal floor 99f, 105 factors affecting cavity design for 97
liquid system 356 deepening of 210f failures of 105f
system, manipulation of 188 two-level 207 faulty 216f
Preamalgamated alloys 195 variable depth of 302 finishing of 246, 247f
Precarve burnishing 214 Pulpal injury, prevent 184 fractured 363
objective of 214 Pulpal irritants 176
Precontoured bands 158 gingival margin of 137
Pulpal penetration 233, 233f indications of 212
Precontoured sectional matrix bands 167 Pulpal protection 355
sizes of 167f intermediate 354
Pulpal trauma 94 minimum occlusal thickness, types of 105
Predentin 16 Pulpitis 363
Pregnancy morning sickness 388 paving of 246
dentistogenic 177 polishing of 170
Premolar 6f, 22, 24f Pure gold, density of 237
Pressable ceramic 402, 403 premature fracture of 218
Putty index 312f, 341f previous 55fc
Pressure 177 Pyromellitic acid diethylmethacrylate 275
Previous defective restoration repair of old 384f
repair of 3, 3f replacement of 383
replacement of 3, 3f Q retention of 107f
Primary cutting edge angle, measurement seating of 408
of 70f Quadrant dentistry 113, 114f stamp technique of 318, 321f
Primary dentition 8f Quaternary alloys 194 types of 105, 180
FDI tooth notation system for 9f Quenching 266 Restorative dentistry 149, 419
zsigmondy-palmer tooth notation system abrasive in 94
Restorative instruments 76
for 7f R Restorative intervention, indications of 97
Primary tooth 7, 8
Prismless layer 14 Radiolucent 354 Restorative material 57, 180, 184, 364, 368
Proanthocyanidins 381 Radiopacity 298, 353 removal of old 106
Probiotic approach 64 Rampant caries 47, 47f thickness of 104
Procera allceram 404 Ramping curing 298 Restorative treatment 3f, 363, 387
Professional topical fluorides 60 Rapid heating rate 268 Restoring proximal areas, consequences of 154
Prophylactic antibiotic 110 Rapid tooth separation 170 Retainer 155, 156
Propolis 365 Reactive dentin 16 number 122
Prosthetic composites 322 Rebonding, purposes of 322 removal of 158
Retainerless automatrix system, components Rubber dam frame 123 Shank 69, 84
of 165f types of 123f design 84
Retention form 105, 260, 355, 356 Rubber dam punch 123 Sharp axiopulpal line angle 217
primary 105, 203, 207 holes 124f Sharp instruments, advantages of 80
Retention grooves 107 working end of 124f Sharp tip corners, rounding of 85
Retentive clamps 122 Rubber dam sheet 121, 124f, 133, 174 Sharpey’s fibers 19
Retraction cord 133 color of 121f Sharpness tests 81
application of 409f thickness of 121 Sheets 239
placement of 134, 134f Rubber-ended rotary tools 93 Shield’s classification 392
removal of 134 Shielded nippers 164
technique 134 Short bevel 252
Reverse smile line 337 S
Shoulder, formation of 246, 246f
Rickett’s line 330f S sound 332 Sickle cell anemia 367
Rickett’s plane, evaluation of 330 Saliva 40, 42, 120 Side-cutting bur 88
Rigidity 155 components of 42, 42t Silica 348
modulus of 249 ejector 129, 129f Silver 195, 248, 296
Ring sectional matrix system 167 flow of 60 nitrate 62
Rolled cotton twills 133 flow rate 42 Silver alloy
Root canal 19 functions of 42, 42t admix glass ionomer cement 348
treated 112f pH of 42 consolidated 201
Root caries 44, 46, 47f, 55, 56f, 300 quality of 60 Silver amalgam 180, 202, 257
differential diagnosis of 56t quantity of 42, 60 cavity preparation of 257f
features of 56 viscosity of 43 indications of 198
histopathology of 46 test 58 phases of 196t
restoration of 354 Salivary buffering capacity test 58 recent advances in 199
tooth management of 57fc Salivary components 42 Simple box preparation 208
treatment of 57 Salivary flow test, unstimulated 58 indications of 208
Root surface Sand 94 Simple tooth preparation 97, 98f
butt joint on 302 Sandwich technique 357, 358, 358f Single bevel instruments 71, 71f
caries of 44, 50, 51f, 308f closed 358 Single cord technique 134
lesion 258, 258f indications of 358 Single tooth isolation 121
Root-end sealant, nanotechnology-based 419 steps of 358 Six molars 6
Rotary curettage 135 synonyms of 358
Sixth generation
technique 135f types of 358
composites 292
Rotary cutting instruments 68, 81, 94 Saucer shaped preparation 317, 318f
dentin-bonding agent 281, 281f
in dentistry, development of 82t Sclerotic dentin 17
Skin lesions 111
Rotary cutting, types of 81 Scooped-out preparation 317, 318f
Skinners 288, 291
Rotary denttage 135 Scrap amalgam, disposal of 219
Skirt 254
Rotary gingitage 135 Scrape test 81
Slice preparation 253, 253f
Rotary instruments, recent advances in 89 Sealant
Slip cast ceramics 403
Rotated tooth 208, 209 application of 63f
light curing of 63f Slot 107, 234, 254
Rotational movement 31f
Second amalgam war 221 Slot preparation 208, 234, 318, 318f
Rough tooth preparation walls 302
Second generation indications of 208
Round bur 85
dentin-bonding systems 279 Slow maturation 350
Round steel bur, large sized 106
rings 167 Small knurled nut 157
Round wedge 171, 172f
Secondary trauma 37f Small particle-filled composites 292
Rubber cups 93f
from occlusion 37 Smart bur 89
Rubber dam 121, 126, 133
Sectional matrices and contact rings, Smart composites 296
accessories 121, 123
advantages of 167 Smart prep burs 89, 90f
advantages of using 121
Selective etch 312f use of 106
application of 15, 128t
contraindications of 121 Self-cure composites, mixing for 299 Smear layer 18, 283, 284f
designs of 125 Self-etch components of 284
disadvantages of 121 adhesive 281 dissolving adhesives 285
equipments 121 primer 281 modifying agents 284
forceps 123, 123f Self-glazing 401 removing dentin adhesives 285
isolation using 312f Self-healing composites 297 Smile design 331
isolation with 121 Self-sealing ability 199 soft tissue component of 336
napkin 125, 125f Self-shearing pin 228 vital elements of 331
placement of 125, 126f, 127 Self-threading pin 227 Smile line 336, 337f
methods of 126 advantages of 227 inverse 337
removal of 128 disadvantages of 227 Sodium
template 123, 124f Semiconductor lasers 423 aluminium fluoride 348
Rubber dam clamp 122 Separating rubber ring 174, 174f dodecyl sulfate 60
accidental aspiration of 124f Set amalgam, structure of 196 fluoride gel 61f
classification of 122 Setting reaction 189, 191, 201, 295 hypochlorite 146
shapes of 122f Shallow cavity preparation 217 perborate 369
sizes of 122f Shallow, management of 181 Soft lasers 423
Index 447
Soft tissue 12, 95 Surface contact 28 Tofflemire retainer 158
component 331 Surface contamination 274 and band, removal of 158
examination 111 Surface energy 274 head of 157f
Soft-start polymerization 298 Surface protection 357 modifications in 159
Soldering, steps of 267 Surface texture 298 parts of 157, 157f
Solid state lasers 423 Surgical diathermy 135 placement of 158, 159f
Solidification shrinkage Synthetic diamond 94 Tofflemire universal matrix band retainer 157
defects 269 Synthetic silicon carbide 94 Tongue 120
porosity 269 Syphilis, congenital 390 Tooth 40, 41f, 75, 87f, 232, 367
Solubility 191, 299, 353 Syringe 303 alignment of 29
Sorbitol 58 Systemic diseases 43 anatomy 225
Spatulation method 400 Systemic disorders 390 angle 87
Spaulding classification 141, 141t Systemic health 43, 110 anterior 23, 25f, 26f
Spectrum, electromagnetic 422f Systemic immunization 64 attrition of 387f, 338
Spherical alloy 195 biochemical structures of 41
Spheroidal alloy 195 body of 367f
Spiro orthocarbonates 296 T brown discoloration of 13f
Split dam technique 127 caries of 50
Tactile examination 50
indications of 127 chemical altering 60
Tannic acid 135
Split increment horizontal technique 304, 305f chipped 363
Taper, concept of 251
Sponge 240 color of 13, 367
Tapering-fissure bur 85
Spontaneous emission 423, 423f contour of 23
Tarnish 198
Spoon excavator 71f, 74, 74f deciduous 9, 10t
Tartaric acid 348
circumferential bevel in 71f dimensions 333
Temperature time control method 400
Sprue diameter 263 discoloration 338
Temporary restoration 260, 373f
Sprue former display, degree of 331
Temporary veneer 408
angulation of 263 filled 112f
Tensile strength 198, 237, 325
attachment of 263, 263f fluorosis of 368f
Terminal hinge axis 30
purpose of 263 for cementation, isolation of 409f
Ternary alloys 194
ranges, diameter of 263 for veneers, preparation of 410f
Tertiary dentin 15, 16, 17f, 17t
types of 263 form, physiology of 22
formation 177
Sprue length 263, 263f fracture of 297f, 338, 389f
Testing caries vaccine 64
Spruing wax pattern 263 fractured cusp 199
Tetracycline 368 functions of 22
Stainless steel 155
burs 84 stains 112, 368f gingival aspect of 126f
crowns 187, 191 Thermal conductivity 198 hypersensitivity 373
Stamp cusp 29 Thermal expansion 399 inclinations 335, 335f
Stamp technique 320f coefficient of 198, 237, 249, 288, 297 innermost portion of 12
Standard bur head sizes 86t Thermal properties 398 isolation of 316f, 343f
Standard pin 228 Thermal tempering 398 joint 285f
Steam heat sterilization 142, 143 Thermal testing 426 long axis of 206f, 244f, 251
Steel burs 145 Thermocatalytic vital tooth bleaching 370, malalignment of 103f, 338
Stephan curve 42f 370f, 371 malformations 338
Sterilization 139, 155 Third amalgam war 221 malpositioned 127
method 141, 142, 142t, 145, 145t Third-generation management 55fc
monitoring of 144 composites 291 margins, exposes prepared 133f
Sterilizing conditions 145 dentin-bonding systems 279 material, conservation of 225
Stiffness, adequate 399 Thread mate system 228, 231 mousse 380f
Straight bur 84f plus, advantages of 228 nomenclature 6
Straight chisel 74, 74f Three way syringe 130f noncarious lesions of 386
Straight handpiece shank 83, 85 Three-body wear 298 normal anatomical landmarks of 367f
Straight knife electrode 136f Three-number formula 70, 70f notation
Straight-fissure bur 85 Three-site technique 304 method of 7
Streptococcus mutans 42, 55 Throat shield 130 systems 7
Stress-bearing areas 355 Thumb grasp 78, 78f occluding 267f
Stresses 232, 232f modified 78 occlusal relationship of 113f
Striae of Retzius 14 Thumbnail test 81 of restoration, fracture of 216
Strontium 59, 348 Thyroid disease 150 overcontouring of 23
fluorosilicate glass 295 Tie formation 246, 246f position of 41
Sturdevant 288 Tin 195 preparation 63f, 97, 102, 107t, 170, 184,
Subgingival caries 300 oxide 94 255, 256f, 301, 302, 305f, 310,
Subtransparent dentin 46 Tissue 310f, 316f, 325, 325f, 341f, 344,
Successive cusp build-up technique 305, 305f coagulants 135 355, 382f, 383, 405, 407-409, 409f
Suck-back porosity 269 contraction 135 burs for 255f
prevention of 270f hazards 425 compound 98, 98f
Sugar substitutes 380 Titanium oxide 397 conservative 302, 353
Sulcular enlargement 136f Tofflemire bands, types of 158f designs of 100t, 302
Sulcus opening, expasyl technique for 137f Tofflemire matrices 155 dimensions of 73
Supraperiosteal infiltration 150 indications of 158 effect of 177
external walls of 98f Tripoli 94 bleaching 339f, 369

final stages of 106 Triturated mix, normal 213 postoperative 371f
finishing external walls of 107 Trituration time 197 preoperative 371f
for onlay, steps of 259, 260f Tuberculosis 111 Vitamin
internal walls of 98f Tungsten carbide burs 84, 84f A 41
management of class II 320f Tungsten-quartz halogen 306 B 41
modified 309, 310 curing unit 306f C 41
class III 309 Tunnel preparation 359, 382, 382f D 41
objective of 97 steps of 359f K 41
occlusal view of 410f Turbid dentin 46 Vitrification 397
principles of 97, 242 Turner’s hypoplasia 390 Voids 112, 216
purpose of 97 Tweezer 73, 73f Vomiting 388
recent advances in 4 Twist drills 230f drug-induced 388
types of 100, 107, 156t Two-body wear 298
preserving of 5 Two-digit system 9
prognosis of 239 Two-in-one design 228 W
protective functional form of 23
restoration of 308f Walking bleach 372
resulting, discoloration of 369f U Wall banking 246, 246f
separation of 170 Ultrasonic 82 Washing and drying 63f
fender wedges for 168f cleaner 142, 142f Water 189, 348
methods of 170 instruments 68 absorption 298
reason for 170 Ultraviolet films 268, 268f
set of 6 absorbers 291 causes of 268
structure 12, 89f, 191, 300, 382f illumination 52 hardening glass ionomer cements 349
conservation of 300, 302 light curing 290t mixed glass ionomer cements 349
loss of 390fc rays 422 purification system 146
noncarious loss of 3, 3f Unaesthetic 199, 251 samples 146
removal, instruments for 68 Uncollimated beam 423f sensitivity 352, 354
surface 49, 72f Un-etched enamel rods 276f turbine handpiece 82
external 229f Unicompositional high copper alloy 196 Waterlines, care of 146
loss 386 Unilateral balanced occlusion 32, 32f Wax 263
number of 48 Universal numbering system 10 distortion 268f
translucency of 12 Universal tooth notation system 8f up 312f
types of 22, 22t Unstimulated saliva, resting pH of 58 Wax pattern 264, 268f
undercontouring of 23 Upper tooth 34
walls, divergent preparation of 405f burnout of 264
Urethane dimethacrylate 275, 289, 295 fabrication 262
wear and aging 369f
whitening 339, 367, 427 investment of 263f
agents 419 V removal of 264
with deep pit and fissure 104f washing of 264
V sound 332 Weakened tooth structure 199
with inlay, restoration of 258
Vaccine 64 Wear resistance 298, 298f, 325
Toothbrushing 59
Vacuum firing 401 Wedelstaedt chisel 71, 74, 74f
motions of 59f
Valvular defects 110 Wedge 171
Tooth-colored polycarbonate crowns 187
Vanguard electronic caries detector 53
Topical anesthesia 150 placement of 172
Varnish 178, 178f, 365
Torch melting 265 principle 170
thickness of 178
Toxic substance 178t techniques 172
effect of 178 Vaseline, application of 321f
types of 171, 172, 172t
Toxicity 373 Vasoconstrictors 135
wedging 173
Traditional powder slurry ceramic 402 Veneer 340
technique 173f
Transcutaneous electrical nerve stimulation fabricated 409f
Wedjet rubber dam cord 124f
152, 152f preparation of 344, 408
Wet dentin 278f
local anesthesia 151 repair of 344
Whether alloy 194
Transfer infectious diseases 95 technique, indirect 342
types of 340 White spots 43
Transseptal fibers 20 Wide isthmus 217
Trauma Vertical face profile 330f
Vertical layering technique 304 Window matrix 162, 163f
chronic 36, 37f
Vibration method 400 Window preparation 342, 407
from occlusion 36
Vickers hardness number 325 Wingless clamp 122f
Traumatic injuries 3
Virtual dental patient 36 Wooden sticks 59, 59f
Tray fabrication, steps of 371
Trendelenburg position 117, 117f Visible light 290f, 422 Wooden wedge 133, 171
Triangular wedge 171, 172f curing 290 placement of 133f
Tricalcium phosphate 380, 380f Visual examination 50 Working area
Trichloroacetic acid 135 Visual tactile method 50 visibility of 118
Triclosan 60 Vital bleaching techniques 370 zones of 117
Trident sugar-free gum 380f Vital pulp therapy 383 Working cast 261, 401
Triethylene glycol dimethacrylate 275, 289 Vital signs 111 Working die 261
Triple-beveled instrument 71 Vital tooth Working interference 34f
Index 449
Wrench system 173 Z Zinc oxide-eugenol cement 187
Wrought precious metal pins 226 manipulation of 188, 188f
Zenith point 335, 335f setting reaction of 188, 189f
Zinc phosphate 189
X Zinc 59, 189, 195, 248
cement 180, 187, 189
chloride 62
Xeroradiography 53 containing alloys 194 Zinc polycarboxylate cement 187, 190, 190f
Xerostomia 40, 355 content 194 manipulation of 191
Xylitol 40, 58, 58f, 380, 380f free alloys 194 Zircon 94
mechanism of action of 381f oxide-eugenol 179, 182f, 187, 187f Zirconomer 349
powder, composition of 188 Zsigmondy-palmer
polyacrylate cement 190 notation 10
Y presence of 197 system 7
Young permanent tooth 250 silicophosphate cements, properties of 190

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Textbook of

Amit Garg MDS

The Health Sciences Publisher

Textbook of Operative Dentistry

Amit Garg MDS Neetu Jindal MDS

Anil Chandra MDS Nikhil Bahuguna MDS

Deepak Mehta MDS PhD Nisha Garg MDS

Jojo Kottoor MDS Poonam Bogra MDS

Pranav Nayyar MDS

Priya Titus Singh BDS

Renu Aggarwal MDS Tom Jm Dienya MDSC (Endo) FADI FICD

Roma Turetskiy Varinder Goyal MDS

Sandhya Punia MDS Vinisha Pandey MDS

Sanjay Miglani MDS FISDR Yogesh Gupta MDS

Hyeon-Cheol Henry Kim DDS MS PhD

1. Introduction to Operative Dentistry 1 Clinical Presentation of Dental Caries 43

Purpose of Tooth Preparation 97 13. Infection Control in Operative Dentistry 139

Enamel Bonding 275 Advantages of Glass Ionomer Cements 353

24. Composite Restorations 288 27. Dentin Hypersensitivity 361

 Introduction  Objectives/Purpose of Operative Dentistry

Table 1.1: Evolution of operative dentistry.

Era Year Major inventions/events

INDICATIONS of operative dentistry

Fig. 1.3: Fractured maxillary central incisor can be corrected by

Fig. 1.1: Dental caries.

2. Noncarious loss of tooth structure: Treatment of

Fig. 1.4: Operative dentistry is needed for aesthetic improvement.

Fig. 1.2: Noncarious loss of tooth structure requiring restorative

Scope of operative dentistry

 Introduction  Tooth Notation Systems

INTRODUCTION Between six and twenty-four months of a baby life,

Fig. 2.1: Human dentition comprising incisors, canines,

Disadvantages ◆◆ If teeth have been extracted or missing, they are also

Table 2.1: Permanent teeth.

Table 2.2: Deciduous teeth.

Advantages Zsigmondy Palmer and FDI system of tooth notations

Introduction Dental Pulp

Introduction Significance: Poorly mineralized enamel appears whiter

Fig. 3.3A: Translucent gray or bluish color of enamel

Fig. 3.1: Enamel rods showing keyhole pattern.

decreases gradually from cusps or incisal edges to cervical

Fig. 3.3B: Fluorosis showing brown discoloration of teeth.

Significance: Spindles serve as pain receptors, therefore

Fig. 3.5: Schematic representation of enamel lamellae, enamel tufts

teeth, only 1/3rd of fracture resistance is present when

2. Periodontal Ligament Nerve Fibers

Cells and Intercellular Matrix

 Introduction  Functions of Teeth

introduction Table 4.1: Types of teeth and their functions.

4. Protection of Supporting Tissues

ii. Undercontouring: It means too little contouring, so

Fig. 4.4: Common faults that occur during the restoration

Fig. 4.3: Marginal ridge (orange arrow) in molar and premolar.

i. Labial/buccal and Lingual Embrasures iii. Gingival Embrasure

Fig. 4.6: Embrassure. x–depicts a correct embrasure form; y–depicts B

◆◆ If embrasure size is enlarged, food impaction occurs

Improper proximal contact area can result in:

Viva Voce Bibliography

 Introduction  Occlusal Schemes

INTRODUCTION Operative dentistry follows the concept of functional

Anterior-Posterior Interarch Interarch Tooth Relationships

Functional Cusp/Supporting Cusp/Stamp Cusp/

Characteristic Features of Supporting Cusps

◆◆ Outer incline has the potential for contact.

Introduction Objectives/Purpose of Operative Dentistry

Introduction Tooth Notation Systems

Introduction Dental Pulp

Introduction Functions of Teeth

Introduction Occlusal Schemes

Introduction Diagnosis of Dental Caries

Introduction Restorative Instruments