Complex Amalgam

Restorations
Introduction

Complex posterior restorations are used to

replace missing tooth structure of teeth that have
fractured or are severely involved with caries or
existing restorative material.
These restorations usually involve the
replacement of one or more missing cusps, and
often, they utilize a bonding technique.
 Amalgam is easy to use and has a high
compressive strength, excellent wear resistance,
and a proven long-term clinical performance.
However, it is metallic (unesthetic), requires a
retentive tooth preparation, and does not seal or
strengthen the tooth.
Indications

 Complex posterior amalgam restorations should

be considered when:
i. Large amounts of tooth structure are missing.
ii. One or more cusps need capping.
Uses

 Complex amalgam restorations can be used as:

i. Definitive final restorations.
ii. Foundations.
iii. Control restorations in teeth that have a
questionable pulpal or periodontal prognosis.
iv. Control restorations in teeth with acute or severe
caries.
Factors affect selection

i. Resistance and retention forms.

ii. Status and prognosis of the tooth.
iii. Role of the tooth in overall treatment plan.
iv. Occlusion, esthetics, and economics.
v. Age and health of the patient.
i. Resistance and Retention forms

 In a weakened tooth, the conventional retention and

resistance forms are not adequate because of insufficient
tooth structure.
 So it is restored by either:
i. Indirect restoration (the best).
ii. An amalgam restoration with auxiliary retention and
resistance features.
i. Resistance and Retention forms

• Auxiliary retention features: pins, slots, grooves.

• Auxiliary resistance features: pins, slots, box-like forms.
 The need for auxiliary retention and resistance features
depend on the amount of tooth structure remained and the
tooth being restored.
ii. Status and Prognosis of the tooth

 Teeth with questionable pulpal or periodontal conditions are

treated initially with a control restoration.
 A control restoration helps:
i. Protect the pulp from the oral cavity (fluids, bacteria, thermal
changes)
ii. Provide an anatomic contour which provide healthier gingiva.
iii. Facilitate control of caries and plaque.
iv. Provide some resistance against tooth fracture.
ii. Status and Prognosis of the tooth

 The status and prognosis of the tooth determine the

size, number, and placement of retention features.
• Large restorations: require more retention.
• Deep cavities, and small teeth : require care in size,
number , and locations of retention features.
iii. Role of the tooth in overall
treatment plan
 The choice of restorative material for a tooth is influenced
by it’s role in the overall treatment plan.
 For examples:
• Complex amalgam restorations can be selected for teeth
that will be abutments for FDPs.
• Indirect restoration is preferable than a complex amalgam
restorations on teeth that will be abutments for RPDs.
iv. Occlusion, Esthetics, & Economics

 Occlusion:

• Complex amalgam restorations can be used as

interim restorations in teeth that require occlusal
alterations e.g.: changes in vertical dimensions.
iv. Occlusion, Esthetics, & Economics

 Esthetics:

• When esthetics is of primary consideration,

complex amalgam restoration is not the treatment
of choice.
iv. Occlusion, Esthetics, & Economics

 Economics:

• When the cost of the treatment is a major factor

for the patient, a complex amalgam restoration
may be an alternative for indirect restoration if
adequate retention and resistance forms can be
obtained.
v. Age and Health of the patient

 Forsome older or debilitated patients a complex

amalgam restorations may be the preferred treatment
over the more expensive and time-consuming indirect
restorations.
Contraindications

i. Patients with significant occlusal problems.

ii. Teeth can’t be restored properly with direct restorations.
iii. Teeth in esthetic areas.
Advantages

i- Conservation of tooth structure:

• Preparation for a complex amalgam restoration is more
conservative than preparation for indirect restorations.
ii- Appointment time:
• Less appointment time (one) than indirect restorations
(at least two).
Advantages

iii- Resistance and Retention forms:

• A complex amalgam restoration with cusp coverage
increase the fracture resistance of a weak tooth compared
with amalgam restoration without cusp coverage.
iv- Economics:
• Less costly than indirect restorations.
Disadvantages

i- Tooth anatomy:
• Difficult to achieve proper anatomy, contours and
occlusal contacts.
ii- Resistance form:
• Difficult to develop a proper resistance form.
 There are two types according to retention:

Pin-retained amalgam restoration

Slot-retained amalgam restorations

Slot retained amalgam restorations

a slot is a retention groove in dentin whose length is in a

horizontal plane.
 Slot retention may be used in conjunction with pin
retention, or as an alternative to it.
 Slots are particularly indicated in short clinical crowns
and in cusps that have been reduced 2 to 3 mm for
amalgam.
 Compared with pin placement, more tooth structure is
removed preparing slots.
 However, slots are less likely to create microfractures in the
dentin and to perforate the tooth or penetrate into the pulp.
 Coves and locks can be used to provide additional retention
Tooth preparation for slot retained amalgam restoration

Slot
 length depends on the extent of the tooth preparation

Slots
 are usually placed on the facial, lingual, mesial, and
distal aspects of the preparation.

The
 slot may be continuous or segmented, depending on
the amount of missing tooth structure and whether pins
were used.
a slot is placed in the gingival floor 0.5 mm axial
of the DEJ.
 The slot is at least 0.5 mm in depth and 1 mm or
more in length, depending on the distance
between the vertical walls.
Pin-Retained amalgam
restorations
Definition

 Any restoration required the placement of one or

more pins in dentine to provide adequate retention
and resistance forms.
 Pinsare used whenever adequate resistance and
retention forms cannot be established with slots,
locks, or undercuts only.
Pins are rarely used in anterior teeth, except in
some cases where a proportionally large class
IV is located on the distal surface of a canine,
and involving the distoincisal angle.
The use of pins may be considered for a tooth
that has insufficient enamel present for acid-
etching, and/or insufficient remaining tooth
structure for adequate retention features.
Tooth preparation for pin retained amalgam restoration

 The general initial form is the same as any deep

cavity preparation.
 When caries is extensive, reduction of one or
more of the cusps for capping may be indicated
(capping cusps).
 Ensurethat the final restoration has restored cusps
with a minimal thickness of 2 mm of amalgam for
functional cusps and 1.5 mm of amalgam for non
functional cusps.
 A linercan be applied, if needed, and, if used, should not
extend closer than 1 mm to a slot or a pin.
 Pinsplaced into prepared pinholes (also referred to as pin
channels) provide auxiliary resistance and retention forms.
 Coves, locks, groves and slots might be used to increase
retention.
Types of pins
 Three types of pins:
i. Self-threading: the most frequently used (Most
retentive, But generates vertical and horizontal stress on
dentine, pinhole diameter is smaller than that of the pin)
ii. Friction-locked:(diameter is 0.025mm smaller than that
of the pin)
iii. Cemented : ( preparation diameter is 0.025-0.05mm
wider than the pin used)
Three types of pins. A, Cemented.
B,Friction-locked. C, Self-threading
Self-Threading Pins
Factors affect pin retention

i. Type.
ii. Surface characteristics.
iii. Orientation.
iv. Number
v. Diameter.
vi. Extension into dentin and amalgam.
i- Type

 The-self threading pin is the most retentive, the

friction-locked is intermediate, and the cemented
pin is the least retentive.
 The self-threading pin is 3-6 times more retentive
than the cemented pin.
ii- Surface characteristics

 Thenumber and depth of the elevations (serration

and threads) on the pin influence the retention.
iii- Orientation

 Placing pins in a non-parallel manner increases their

retention.
 Bending pins to improve retention in amalgam is not
desirable because bends may interfere with adequate
condensation of amalgam around the pin and thereby
decrease amalgam retention.
 Bending also may weaken the pin and risk fracturing the
dentin.
 Pins should be bent only to provide for an adequate
amount of amalgam (approximately 1 mm) between the
pin and the external surface of the finished restoration
(both on the tip of the pin and on its lateral surface)
iv- Number:

 In general increasing the number of pins increases their

retention in dentin and amalgam.
 The benefits of increasing the number of pins must be
compared with the following possible problems:
i. Increase crazing of dentine.
ii. Decrease amount of available dentin between pins.
iii. Decrease the strength of amalgam restoration.
v- Diameter

 In general as the diameter increase, the retention

increase.
Vi- Extension into dentin and
amalgam
 Extension into dentin and amalgam should be about
1.5-2 mm to preserve the strength of both amalgam
and dentin.
• Less extension will result in less retention.
• More extension will not increase the retention and it
is contraindicated.
 Asthe number, depth, and diameter of pins
increase, the danger of perforating into pulp or the
external tooth surface increases.
Pin placement factors and techniques

 Pinsize: Four sizes of pins are available, each

with a corresponding color-coded drill
 Two determining factors for selecting the
appropriate size pin are the amount of dentin
available to safely receive the pin and the amount
of retention desired
 Number of pins:
(1) the amount of missing tooth structure
(2) the amount of dentin available to receive pins safely,
(3) the amount of retention required,
(4) the size of the pins.
As a rule, one pin per missing axial line angle should be
used.
 The pinhole should be positioned no closer than 0.5 to 1
mm to the DEJ or no closer than 1 to 1.5 mm to the
external surface of the tooth, whichever distance is
greater.
 the pinhole should be parallel to the adjacent external
surface of the tooth.
 Pinholesshould be prepared on a flat surface that is
perpendicular to the proposed direction of the pinhole.
 Whenever three or more pinholes are placed, they should be
located at different vertical levels on the tooth, if possible.
 Thiswill reduce stresses resulting from pin placement in the
same horizontal plane of the tooth.
 Minimal inter pin distance is 3mm and maximum is 5mm
 Certain clinical locations require extra care in
determining pinhole angulation. The distal of mandibular
molars and the lingual of maxillary molars have been
considered as areas of potential problems because of the
abrupt flaring of the roots just apical to the CEJ.
 Once the pins are placed, evaluate their length. Any
length of pin greater than 2 mm should be removed.
 To remove the excess pin a special bur at high speed is
used, it must be perpendicular to the pin or it might
loosen it.
 After placement, the pin should be tight, immobile, and
not easily withdrawn.
Possible problems with pin placement

 Failure of pin retained restorations

 Fractured drills or fractured pin

 Loose pins

 Penetration into the pulp or external wall perforation

Amalgam foundation

 A foundation is an initial restoration of a severely

involved tooth. The tooth is restored so that the
restorative material (amalgam, composite, or other) will
serve in lieu of tooth structure to provide retention and
resistance forms during the development of the
subsequent final cast restoration.
 Types of foundation retention

1- pin retention.
2- slot retention
3- chamber retention
Chamber Retention. For developing foundations in
multirooted endodontically treated teeth, an alternative
technique has been described by Nayyar
RESTORATIVE TECHNIQUE

1. Use of Desensitizer or Bonding System.

Once the preparation is completed with the necessary resistance
and retention forms incorporated, clean the preparation, with
air/water spray and remove visible moisture without desiccating the
tooth.
To reduce dentin permeability and seal the dentin, either a dentin
desensitizer or dentin bonding system is used as varnish.
Dentin bonding systems are usually recommended for extensive
preparations, particularly with deep excavations, capped cusps, and
in weak teeth
 Mandibular first molar with fractured
distolingual cusp.
 B, Insert wedges.
 C, Initial tooth preparation. D and E,
Excavate any infected dentin; if indicated,
remove any remaining old restorative
materials.
 F, Apply liner and base (if necessary).
Matrix Placement:
 G, Prepare pilot holes.
 H, Align twist drill with external surface of
tooth. I, Prepare pinholes.
 J, Insert Link pins with slow-speed handpiece.
 K, Note depth-limiting shoulder (arrow) of
inserted Link Plus pin.
 L, Use No. '/, bur to shorten pins.
M, Bend pins (if necessary) with bending
tool.
N, Final tooth preparation.
O,Tofflemire retainer and matrix band
applied to prepared tooth.
P, Reflect light to evaluate proxi mal
area of matrix band.
O, Preparation overfilled.
R, Restoration carved.
S, Reflect light to evaluate
adequacy of proximal contact and
contour.
T, Restoration polished.
The matrix must be stable, If not stable during condensation,
a homogeneous restoration may not be developed.
The restoration may be improperly condensed, weak, and
may disintegrate when the matrix is removed, even if pins
are used for retention.
In addition to providing stability, the matrix should extend
beyond the gingival margins of the preparation enough to
provide support for the matrix and to permit appropriate
wedge stabilization.
 the matrix should extend occlusally beyond the marginal
ridge of the adjacent tooth or teeth by 1 to 2 mm.
 Finally:

Inserted the amalgam then contour , finish and polish the

amalgam restoration.
Thank you