fundamentals of tooth

preparation

Dr / Reham M. Attia

Dr. Reham M. Attia

Final Stages of Tooth Preparation

Final Stages of Tooth Preparation
• After initial stages of the preparation, the prepared tooth should
be carefully examined.
• For most of the conservative restorations, after initial stages of
tooth preparation the tooth is ready for restoration except for
some final procedures like varnishing, etching and bonding, etc.

For extensive restorations, some of additional steps may

be required.
The remaining carious portion should be removed only after the
initial tooth preparation has been completed.
It provides two advantages:
1. It allows optimal visibility and convenience form for removal of
remaining carious lesion.
2. Completion of the initial preparation permits immediate
placement of a base and the restoration.

Carious Tissue Removal

After the establishment of external and internal outline form, if
any of the remaining carious tooth structure or defective
restorative material is left in tooth,
it is to be removed in this stage.
if a small amount of carious lesion remains, only this lesion should
be removed, leaving concave, rounded area in the wall.
In the extensive preparations with soft caries, the removal of
carious dentin is done early in initial tooth preparation. It
is better to remove the extensive caries early in tooth preparation
to provide better opportunity to specific needs of retention and
resistance form.
In 2015, The terms
 'non-selective caries removal’,
 'selective caries removal’
 'stepwise excavation’
should be considered as three distinct approaches to managing
deep carious lesions and preserving a vital pulp
Isolate the remaining carious lesion and remove it using the
following instruments:
 Low speed handpiece with the large dull round bur (with no
pressure) that will fit in the carious lesion used with light force
and a wiping motion

 Spoon excavator that will fit in the carious lesion. Use of a large
spoon excavator decreases the chance of a pulpal exposure.

Important notes
 Force for removal of infected dentin should be directed laterally
and not towards the center of the carious lesion
 Start removal of caries from the lateral borders of the lesion
 After removal, confirm it with the explorer applying it laterally.
 Avoid using excessive force with the explorer as it may cause a
pulpal exposure.
 The Peripheral Seal Concept in Adhesive
Dentistry

The specific objectives of

caries removal end point
determination are the
creation of a peripheral
seal zone and the
absolute avoidance of
pulpal exposure while
generating a highly
bonded restoration with
excellent long-term
prognosis.

Deep caries lesion showing the outer carious dentin staining red
and extending to the circumpulpal dentin ( > 5 mm from the
occlusal surface).
By using only visual and tactile methods for deep caries removal,
the pulp is often exposed

Caries removal end points for a deep lesion. The peripheral seal
zone has been created without exposing the pulp. A small
amount of outer carious dentin is left on top of the inner carious
dentin inside the peripheral seal zone.
 Even though it is the hardest tissue
of the human body, the enamel is
the weakest one when undermined.
The prism’s core is stronger than the
interprismatic enamel.

 Therefore, when pushed, it generally

cracks in the interprismatic enamel
following the long axis the prisms. As
it has already been mentioned, while
the undermined enamel can be
preserved when performing an
adhesive restoration, because it is
protected by the restorative
material, for non-adhesive
restorations it is essential its
removal or protection via a base
material.

 The purpose of the finishing of the enamel walls, for an amalgam

restoration, is to remove the irregularities and undermined
enamel prisms left by the initial preparation steps, to ensure that
just full-length enamel prisms remained, creating the best
marginal sealing as possible between the restorative material and
the tooth structure

 The procedure for the removal of the undermined enamel prisms

is called marginal trimming.

 The finishing also must be performed on

the CS angles of the buccal and lingual
walls of proximal boxes, in Class II
preparations, removing the remaining
undermined enamel that was left after
the use of rotary instrument
In order to perform this step on the
CS angle of the gingival wall, in
Class II preparations, the direction
of the prisms has to be followed,
cutting them about 15–20° in
relation to a line perpendicular the
long axis of the tooth, creating a
slightly bevel

Procedures for Finishing the External Walls of the Tooth

Preparation
 Definition: Finishing of a 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.

 Finishing of the enamel margins should be done irrespective of

the restorative material used.

 The finishing of the preparation walls results in

1) Better marginal seal between restoration and tooth structure
2) Increased strength of both tooth structure and restoration at
and near the margins
3) Strong location of the margins
4) Increase in degree of smoothness of the margins.
Features of finished preparation:
 The design of cavosurface angle depends on type of restorative
material being used.

 For example, for amalgam restoration, cavosurface angle of 90

degrees affords maximum strength to tooth restoration.

What about composite restoration ?

 Final Procedures: Cleaning, Inspecting and Sealing

The 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 preparation walls, floors and margins from enamel

and dentin chips resulting during tooth preparation:

 Remove all the debris from the preparation, especially on the

margins, otherwise deposits left on them consequently dissolve,
resulting in microleakage which further can result in secondary
caries.

 Cleaning of preparation can be done by using

 Warm water.
 Immovable particles of debris can be removed with the help of a
small cotton pellet dampened with water or hydrogen peroxide.
.
• Drying the tooth preparation before insertion of the restorative
materials: It can be done using air, dry cotton pellets and
commercial cleaners.

• It is important that tooth is not dehydrated by overuse of air or

hot air.

• Sterilization of preparation walls using very mild alcohol free

disinfectant: Use of mild disinfectant in tooth preparation serves
the purpose of disinfection

 Anionic detergents based on sodium lauryl sulfate, antimicrobial

 agents like 2% chlorhexidine gluconate solution or alkaline
solutions of calcium hydroxide have been used for cavity
cleaning or disinfection.

 The use of a chlorhexidine solution presents also the advantage

of being able to deactivate the dentin matrix metalloproteinase
enzymes (MMP), which are released by the demineralization
promoted by the bacterial acids, responsible for the formation
of the carious lesions.

 Those enzymes are responsible for the hydrolysis of the

exposed collagen, favoring the progression of the carious lesion.

 When chlorhexidine is applied on the cavity for 10–15 s, it is

capable to inactivat of the metalloproteinases
 One option when performing amalgam restorations is to apply
a 2% neutral sodium fluoride solution on the preparation walls.

 This procedure will promote the deposition of calcium fluoride

over the walls, acting as a fluoride reservoir that will be
released if there is a drop in the pH. The application of the
fluoride solution reduces up to 60% of the formation of
secondary caries on the amalgam restoration margins and
interface.
 Overall, however, the effects of the antimicrobial agents can be
only superficial, due to the presence of the residual bacteria
inside the dentin tubules and within the smear layer.

 However, considering what was explained before, the

relevance of the cavity disinfection is questioned anyway.
Sealing the cavity seems more relevance than performing such
disinfection.