Professional Documents
Culture Documents
MECHANICAL PRINCIPLES This shows a definite procedure of thought and instrumentation to produce a lasting restoration that will not fail under normal circumstances. The mechanical factor included in cavity preparation is basically concerned with the retention of the restoration and the continued vitality and function of the tooth.
1234567-
Location and extent of carious lesion. Position of pits & fissures dictate outline form. Relationship of self cleansable areas to outline form. Preservation of healthy and vital tooth structure. Restorative material. Esthetics. Functional requirements of the restoration,or improving occlusal relationships, even when the involved tooth structure is not faulty. 8- The desired cavosurface marginal configuration of the proposed restoration.
Conservation of tooth structure is of almost importance and must be considered repeatedly during the design of a cavity preparation. Two separate cavities should not be united unless the separating ridge is less than 0.5mm. (e.g. oblique ridge in upper molars or transverse Ridge in lower 1st premolars).
Enamel which has been undermined by caries must be removed to insure that the cavo-surface enamel (that enamel at the cavity margins) will be supported by sound dentin. Unsupported enamel (Undermined Enamel) should be removed during cavity preparation, since it is liable to fracture creating open marginal areas which may lead to secondary decay. An exception to this may be noted at this time. With the introduction of the acid etch technique for composite
resins, unsupported enamel is not always removed but may be retained for esthetic reasons. Marginal ridges should be encroached upon as minimally as possible in order that their strength is preserved.
Occlusal outline of upper and lower molars with marginal ridges parallel to outer tooth surface to preserve enough thickness to these marginal ridges.
The dentist must design the cavity so that all margins are located in areas easily cleansed by the patient. These areas are found on smooth surfaces above the height of contour, occlusal cusp inclines, incisal edges and cusp tips.
5- Restorative material
Individual properties of each material utilized to restore teeth demand certain design factors that must be incorporated into each cavity preparation. Cavity preparations in teeth have been more or less designed to meet the needs of amalgam, with block-shaped cavities, edges with butt joints (The marginal strength (also called "edge-strength") of dental cement and amalgam is relatively weak, so their cavosurface margins must be prepared at an angle of approximately 90 with the tooth surface provide maximum
edge strength for both the restorative material and the enamel), and undercuts to lock into the cavity. Because amalgam as a metal is an excellent thermal conductor, cavity preparations should be made shallow. A restoration that is too shallow, however, has tendency to fracture because amalgam is a material that is quite brittle. Preparations therefore are made so the amalgam will be in the range of 2mm thick. When carious dentin penetrates beyond this depth, a liner or cement base may be placed. To compensate for the brittleness of the material, all cavities are more or less mortised into the tooth. Flat walls parallel with or perpendicular to the tooth surface compose the form of these box-like preparations. Anchorage of the material is achieved by parallelism of opposing walls or by slight undercuts in dentin. Placing a bevel and etching the enamel at the cavosurface angle of composite resin preparations improve the marginal seal. In some cases, the bevel may also aid in improving the contour and esthetic qualities of the composite resin restorations. Cohesive gold restorations require a beveled cavosurface angle in the cavity preparation because the malleting forces needed to place the cohesive gold may fracture enamel rods from the unbeveled cavosurface angle, a beveled margin also allows for the best marginal adaptation and finish. Cast gold restorations require even more beveling than cohesive gold restorations, since this imparts a better marginal seal. Cast gold has sufficient strength to be used to veneer or cap the tooth, while amalgam cannot be used in this way, The physical properties of the restorative material will, therefore, determine the position and configuration of the cavosurface margin.
6- Esthetics.
It is important to maximize the conservation of tooth structure, because the natural tooth is the most esthetic. Should esthetics be compromised, then an esthetic material must be used.
to capping the cusp. If the extension is 2/3, the cusp-capping procedure is most often the proper procedure, which removes the margin from the area of masticatory stresses. 4-Restrict the pulpal depth of the preparation to a maximum of 0.2mm into dentin. To be as conservative as possible,the preparation for a occlusal surface pit&fissure lesion is first prepared to a depth of 1.5mm,as measured at the central fissure. 5-When 2 pit &fissure preparations have less than 0.5m of sound tooth structure beween them, they should be joined to eliminate a weakenamel wall between them. SMOOTH-SURFACE LESIONS occur in 2 locations: Proximal surfaces. The gingival portion of the facial and lingual surfaces. When the proximal surface of a tooth is involved and requires restoration, the proximal outline of the cavity preparation is influenced by: Class II, III & IV smooth surface lesions 1. Extent of carious involvement. 2. The type of restorative material to be used. 3. Area of contact with adjacent tooth/teeth. 4. Accessibility of the proximal margins for placement and finishing of the restoration and for subsequent cleansing by the patient. 5. Height of the gingival tissue. 6. Occlusion with teeth of the opposite arch.
Regardless of the restorative material to be used, the gingival pointangles (points X & Y) will be located in the same position facially & lingually on the proximal surface being restored. Variation in proximal outline due to the restorative material is in the direction which the planes of the facial & lingual proximal walls follow as they proceed occlusally from points X & Y.
On the proximal surface, the facial and lingual outlines for amalgam restorations are parallel to the long axis of the tooth and parallel to each other occluso-gingivally. For the gold inlay, the facial and "lingual outlines diverge as they proceed occlusally from points X & Y to allow withdrawal of the wax pattern. SPECIAL CONDITIONS THAT NEED Reduced or restricted extensions for smooth-surface tooth preparations are: proximal contours and root proximity, esthetic requirements, and the use of some tooth preparations for composite restorations. Increased extensions for smooth-surface tooth preparations are: mental or physical handicaps, advanced pt. age, partial dentures abutments, extra means of retention &resistance form and the need to adjust tooth contours.
Resistance form:
Primary resistance form may be defined as that shape and placement of the preparation walls that best enable both the restoration and the tooth to withstand, with out fracture, masticatory forces delivered principally in the
PRINCIPLES 1- Use the box shape with a relatively flat floor,which helps the tooth resist occlusal loading by virtue of being at right angles to those forces of mastication that are directed in the long axis of the tooth. 2- To restrict the extension of the external walls(keep as small as possible) to allow strong cusp and ridge areas to remain with enough dentin support 3- To have a slight rounding of internal line angles to reduce stress concentrations in tooth structure. 4- To cap week cusps and envelope enough week tooth structure to resist fracture of the tooth by forces directed both in the long axis and obliquely 5- To provide enough thickness of restorative materials to prevent their fracture under load. 6- To bond the material to tooth structure whenever indicated.
The factors that contribute to resistance form include: 1. Areas included within the outline form. 2. Cavity wall angulations. 3. Cavity preparation depth. 4. Internal line angles. 5. Type of restorative material used.
1- Areas included:
Features of resistance form and how to achieve it: The more minimal the surface area of the restoration exposed to occlusal stresses, the less liable it will be to deterioration and displacement.
Excessive facio-lingual width weakens the cusps and exposes unnecessarily increased surface area of the restoration to stress. Surface enamel becomes undermined when caries reaches the dentinoenamel junction and extends laterally along the junction before penetrating deeper into the dentin. Enamel unsupported by sound dentin tends to fracture (cleave) under occlusal stresses and must therefore be removed. A basic rule guides the reduction of the cusps during initial tooth preparation is: cusp reduction should be considered when the out line extends half the distance from a primary groove to a cusp tip, and is mandatory if it extends two thirds this distance.
Well defined internal line angles delineate the walls of the cavity preparation, aid in establishing uniform depth, and contribute to retention form by preventing rotation of the restoration. Resistance to rotational displacement of a restoration is increased by definite line angles. However, present, dental research indicates that occlusal stresses are not dissipated within the restorative material and are concentrated at the line angles of the cavity preparation; therefore rounding (coving) internal line angles reduce stress concentration. Fracture resistance of the tooth: Photo elastic stress investigations indicate that the form of the buccopulpal and lingopulpal line angles in a class II cavity preparation is of considerable importance. Concentration of stress at sharp line angle when an opposing cusp applies force on the restoration and the tooth will lead to a definite possibility of fracture through the cusp. Line angles such as the pulpo-axial should be slightly rounded to minimize stress concentration in the restoration.
Fracture resistance of the restoration: In class II amalgam restoration if the axiopulpal line angle is left as a
sharp right angle it creates a concentration of stress in the amalgam when occlusal force is applied.
Caries Pattern
Brittle materials that have low tensile strengths, such as amalgam and cements, require good box form and strict adherence to proper preparation.
Less brittle materials such as composite resins can be used in shallower or rounded preparations when other means of retention are used in addition to wall friction. Cast gold restorations also utilize box form, but the vertical walls must be divergent enough to allow insertion and withdrawal of the restoration. Resistance to proximal displacement of amalgam restorations is sometimes obtained by placing grooves into the facial and lingual proximal walls at the depth of the axial wall. Grooves are sometimes countersunk into the dentin of other cavity walls where additional resistance form is required. A dovetail is formed by flaring a portion of a cavity preparation so that it is wider than the isthmus of the preparation and provides mechanical resistance to proximal displacement of two-surface restorations (i.e. Class II on posterior teeth and lingual-proximal restorations on anterior teeth).
Occlusal lock (dove tail)
Retentive grooves
In many cases resistance and retention forms are often established during the same procedure in cavity preparation. Together, they prevent displacement of the restoration and fracture of both restoration and tooth structure under occlusal stresses. Retention forms influenced by the following factors:-
Axial retentive groove depth as influenced by buccolingual extension, A. small cavity with minimal extension, no axial groove required, B. cavity begin to wrap around the tooth, proximal retentive grooves indicated to lock the restoration into position, C. large cavity extending around to cover a portion of the buccal and lingual surface. Note; any further extension or increased buccolingual angle would justify placement of a pin.
3- Auxiliary:
Dovetails, parallel grooves, pins and etching of enamel are additional methods that may be used to enhance retention with certain types of restorative materials. A dovetail is a constriction in the outline form of a preparation that prevents displacement of the restoration toward a proximal surface of the tooth. Dovetails are mainly used on the occlusal surfaces of posterior teeth to prevent mesial or distal displacement of amalgam and cast restorations. Parallel grooves are used to increase retention of cast gold restorations, The grooves must be parallel to the path of insertion of the casting. They act by increasing the surface area of the preparation and by undercutting some of the surfaces that are parallel to the path of insertion. Occasionally, additional retention may be obtained through the use of pins carefully placed into the dentin within a cavity preparation. Pins are usually reserved for use in extensive cavity preparations.
Pins are small diameter screws and wires that are used to attach a restorative material directly to dentin. Nonparallel pins are used with amalgam restorations. Parallel pins are sometimes a part of cast restorations and must parallel the path of insertion. Retentive devices, such as points, grooves and pins are placed in the dentin just inside the dentino-enamel junction. They should not be placed in the enamel or at the DEJ which will undermine the enamel and seriously weaken it. The internal boundary for these retentive devices is the ideal position of the pulpal and axial walls. Retention should not be placed in interjacent dentin. When the pulpal and axial walls do not have their ideal depths and contours due to extensive carious destruction or fracture of the tooth, retention is, nevertheless, placed just within dentin and with respect to the ideal position of the pulpal and axial walls. This placement prevents undue weakening of the tooth and the possibility of exposing the pulp. The recent trends in conservative restorative dentistry reduce the dependence on the mechanical interlocking (retention) of the restorative material into the cavity because it leads to unnecessary tooth cutting and destruction to create dove tails, undercuts, grooves, etc. Instead they reduce the cavity size and tooth cutting as much as possible (just remove caries) and depends on the new generation of adhesive materials capable of boding all restorative materials to tooth structure (enamel and dentin) as for example "Bonded Amalgam Restorations" and "Composite Bonded Restorations" or
even "Glass ionomer Restorations (GIC)". "Adhesion form instead of resistance form and retention form" By these new concepts the restorative material becomes an integral part of the tooth increasing its overall strength and fracture resistance to masticatory forces.
The use of a "proxitector" for protection of adjacent tooth during proximal cavity preparation. (also a matrix band can be used for the same purpose)
Location of cavity margins: Cavity margins must be located where they can be properly restored and finished. Their location must allow also for subsequent polishing and cleansing of the restoration.
the extent that some of the usual preparation landmarks become obliterated. 4) Gross caries: so much of the tooth is curiously involved that most, or all, of the normal landmarks have been destroyed. Small lesions The removal of small carious lesions should present no problem to the operator as they lie within the area included by the ideal preparation. Moderate lesions The removal of moderate sized carious lesions is initiated by utilizing Black's principles of outline, resistance and retention form. This will usually complete the preparation except for localized areas of decay. The removal of the remaining decay is best accomplished with a round bur in the slow speed hand piece. The largest round bur that will fit into the carious area should be selected. The blades of a slowly rotating large round bur act as many spoon excavators and the carious material can be carefully planed away. The larger burs also have fewer tendencies to penetrate tooth structure because of their greater bearing area. This technique is utilized until all the soft, crumbly material has been removed. Check the area with an explorer or spoon excavator to establish that all the remaining tooth structure is hard. Dental caries in dentin and enamel progresses in several "zones". Not all of the dentinal "zones" warrant removal. Clinically, the criterion followed is hardness. If the dentin feels hard or crisp to the touch of an explorer or spoon excavator, then it need not be removed. Only those areas which are soft should be removed. The entire wall or floor should not be reduced to include one localized carious area.
Entry is made into tooth in conventional manner with a high speed fissure bur.
Ideal depth and width are established, ignoring the carious tooth structure.
Decay extending beyond the limits of the ideal preparation is removed with the largest round bur that will fit into the area.
The caries removal process should begin peripherally in the DEJ areas. As the carious dentin is removed peripherally, the bur is worked into the deeper areas. Often it is necessary to enlarge the occlusal opening to gain both visual and 'mechanical access
Decay in areas involving potential exposures, such as the axial and pulpal walls, should be removed last.
After all decay has been removed, the preparation is reeval-ated for undermined enamel, resistance form, and retention form.
All undermined enamel areas should be removed with the high speed fissure bur and an attempt made to reestablish lost retention and resistance form.
The pulpal should be flattened only at ideal depth. Any pulpal floor destruction beyond ideal depth should be left and not smoothed.
Large lesions: The removal of decay from large carious lesions can usually be accomplished within the sequence of Black1s principles. The basic cavity outline is established utilizing the high speed handpiece with a carbide bur. Any undermined enamel that remains is removed at this time. In addition to removing weakened tooth structure, this procedure will also afford access for the next step which is decay removal. Caries removal begins in those areas where there is the least chance of pulp exposure, (peripherally) and continues centrally until all the affected dentin has been removed. Should an exposure then occur, it will in all probability be after all or nearly all the decay has been removed. This is advantageous for two reasons: 1) the exposure site will be relatively clean with no carious material remaining, and 2) it will be unnecessary to subject the tooth to the additional trauma of decay material after treatment of the exposure site. Following caries removal some of the steps of cavity preparation may have to be repeated to ensure proper cavity preparation design and assure smooth cavity margins. Gross lesions: The removal of decay becomes the first of Black's steps to be performed in the gross caries situation. The situation becomes more complicated, since the amount of destruction often leaves the operator without anatomical landmarks, and the chances for an exposure are much greater. Caries removal again starts peripherally. As sound dentin is reached laterally, it followed to the central areas. The affected dentin in the pulp horn areas is removed last, for the reasons described earlier. If the removal of decay exposes more undermined enamel, it should be removed to satisfy the requirement of resistance form. After complete caries removal, the proper outline form is established with all margins in easily cleansable areas. It may be necessary to achieve retention form through dovetails, grooves, pins, etc.
Diagram showing Cavo-surface angle > 270: (B) which gives a strong enamel margin. (A) restoration margin angle.
A 90 cavo-surface angle (butt joint) provides maximum strength for enamel margin and amalgam. A 45 cavo-surface angle (bevel) provides best structure of enamel rods at margins for acid etching, bonding and composite restoration.
More recently a modified concept of the stages or steps of cavity preparation has been proposed. In an academic setting, the student should be instructed to accomplish tooth preparation in two stages which are:
A- Initial stage: I- Outline form: Step 1: outline form and initial depth:
Establishing the outline form means: i. Placing the preparation margins in the positions they will occupy in the final preparation except for finishing enamel walls and margins. ii. Preparing an initial depth of 0.2 to 0.5mm pulpally of the DEJ
iii.
position or 1.5mm cavity depth at central groove. Depth of the axial wall in smooth surface lesions shouldn't exceed 0.2 to 0.8mm deep into dentin. The outline form must be traced before any mechanical alteration to the tooth is begun.
Because retention needs are related to the restorative material used, the principles of primary retention form vary depending on the material. 1. Amalgam restoration in most class I and all class II conventional preparations, the material is retained in the tooth by developing external tooth walls that converge occlusally. The facial and lingual walls of the occlusal portion of the preparation, as well as the proximal portion, converge toward the occlusal surface. The occlusal convergence of the proximal portion has several advantages in addition to producing retention. It allows slight facial and/or lingual extension of the proximal portion of the preparation in the gingival area while conserving the marginal ridge, thus reducing the forces of mastication on critical areas of the restoration. 2. Adhesion systems provide some retention by micromechanically bonding amalgam to tooth structure and also reducing or eliminating microleakage. However, until longevity studies demonstrate that bonding systems provide complete retention form, traditional retention features should be provided for amalgam restorations. Composite restorations primarily are retained in the tooth by a microchemical bond that develops between the material and etched and primed tooth structure. In such restorations, the enamel and dentin are etched by an acid and the dentin is primed with a dentin bonding agent. These procedures are discussed in a subsequent. 3. Glass ionomer cement is retained by chemical adhesion to tooth structure.
Step 5: Removal of any remaining enamel pit or fissure infected dentin and/or old restorative material if indicated.
In dentin, as caries progresses an area of decalcification precedes the penetration of microorganisms. This area of decalcification often appears discolored in comparison with undisturbed dentin, yet, it doesnt exhibit the soft texture of caries. This dentin condition may be termed "affected dentin"
and differs from "infected dentin" in that it has not been significantly invaded by microorganisms. It is accepted and appropriate practice to allow affected dentin to remain in a prepared tooth. '"Caries-disclosing" dyes may aid that decision. Fortunately the decision does not require exactness, for it is not necessary that all dentin invaded by microorganisms be removed. In shallow or moderately deep lesions, the removal of the masses of microorganisms and subsequent sealing of the preparation by a restoration at best destroy those comparatively few remaining microorganisms and at worst reduce them to inactivity or dormancy. When a pulpal or axial wall has been established at the proper initial tooth preparation position and a small amount of infected carious material remains, only this material should be removed, leaving a rounded, concave area in the wall. The level or position of the wall peripheral to the caries removal depression should not be altered. It is more expedient to remove extensive caries early in the tooth preparation before time and effort are spent in doing a tooth preparation for a certain restorative material that is then deemed inadequately for satisfactory restoration of the tooth. In one appointment, infected dentin is removed from several teeth and temporary restorations are placed. After all the teeth containing extensive caries are so treated, then individual teeth are restored definitively. This procedure stops the progress of caries and is often referred to as the caries control technique. Large areas of soft caries usually are best removed with spoon excavators by flaking up the caries around the periphery of the infected mass and peeling it off in layers. The bulk of this material is thus easily removed in few large pieces.
i.
ii. iii.
iv.
Vertically oriented retention locks and retention grooves are used to provide additional retention for proximal portions of some tooth preparations. Horizontally oriented retention grooves are prepared in most class V preparations for amalgam Pins, slots, steps and amalgam pins, when the need for increased retention form is unusually great; several other features may be incorporated into the preparation. The use of pins and slots increase both retention and resistance forms, while steps and amalgam pins do it to a lesser extent. Beveled enamel margins increase both the surface area of etchable enamel and maximize the effectiveness of the bond by etching more enamel rods.
gradual increase in composite thickness from the margin to the bulk of the restoration. 3. The marginal seal may be enhanced. The restorative material is the primary factor dictating the desired smooth or rough enamel wall. The prepared walls of inlay or onlay preparations require a very smooth surface to permit undistorted impressions and close adaptation of the casting to the enamel margins (fine sand-paper disks). Prepared walls and margins of composite restoration can be roughened using coarse diamond stones to increase surface area for bonding. When using amalgam restorative materials, a very smooth preparation walls are not as desirable as for cast restorations (a rougher surface prepared wall markedly improves resistance to marginal leakage). High speed can lead to overextension of margins, grooved walls and/or rounded cavosunacfe angles, especially on proximal margins. If this method is used, plain-cut fissure burs produce the finest surface; these burs produce a smoother surface than cross-cut burs, diamonds, or carborundum stones. The planning action of razor-sharp hand instrument can result in smooth enamel wall, although it may not be as smooth as that achieved with other instruments, Hand instruments such as enamel hatchets and marginal trimmers may be used in planning enamel walls, cleaving enamel and establishing enamel bevels.
deposition of corrosive products at the interface of the preparation wall in an amalgam. Zinc oxide-eugenol cement has significant germicidal properties over an extended period of time. Therefore some protection from further carious action is afforded by some restorative materials (glass lonomer cement GIC). The routine use of specific sterilization medicaments should no longer be a strong consideration. However, the use of dentin bonding agents (for bonded restorations) and sealers (for non-bonded restorations) to effect a dentin tubular seal is recognized. Eliminating bacterial penetration is so important that the use of dentin bonding agents or sealers will likely become unaffected.
Patient Factors; 1. 2. 3. 4. The patient's knowledge and appreciation of good dental health. The patient's economic status. The patient's age. Whether or not adequate isolation of the operating site can be obtained. 5. Caries in this patient, is it reversible (incipient) or irreversible (cavitated); active or not. (Caries risk assessment). Conservative Factors: 1. While one of the primary objectives of operative dentistry is to repair the damage from dental caries, the preservation of the vitality and integrity of the tooth is paramount. 2. The pulp should not be subjected to unnecessary abuse. 3. The less tooth structure removed the less potential damage that may occur to the pulp. 4. The smaller the tooth preparation, the easier it is to retain the restorative material in the tooth. 5. Examples of conservative tooth preparation features: Minimal extensions of the tooth preparations, especially faciolingually and pulpally. Supragingival margins and Rounded internal line angles. Only uncoalescent fissures are excised, enameloplasty and fissure sealant instead of extension for prevention. Material Factors: 1. An amalgam restoration requires a specific mechanical tooth preparation for resistance and retention. 2. An indirect cast metal restoration also requires a specific
tooth preparation form that provides: Draw or draft to provide seating. A beveled cavosurface configuration, 3. Adhesive composite restorations or GIC do not typically require tooth preparations as precise as those for amalgam and cast metal restorations. 4. Ceramic inlay restorations do require specific preparation depths and wall designs but do not require complex cavosurface marginal configurations. 5. Bonded amalgam restoration still requires the same tooth preparation as for non-adhesive amalgam restoration.