Dr. A.

Brodie Operative Dentistry NSU - College of Dental Medicine Section of Cariology and Restorative Dentistry Dental Amalgam as a Direct Restorative Material; Instrumentation, Technique, Safe Handling, Environmental Issues Refer to notes from Dental Biomaterials and readings in Biomaterials text. Refer to assigned readings Chapter 11and Chapter 6 - Fundamentals of Operative Dentistry 3rd Edition. Indications for Amalgam Posterior Teeth -Class I; Replacement restorations -Class II; Complex Class II -Class V -Class VI Anterior Teeth (rarely, if ever) -Class III (distal of canine) Abutment teeth for Removable Partial Dentures. Repair of Amalgam Restorations Clinical repair of deteriorated amalgam restorations Retentive methods: surface sandblasting, resin bonding systems, mechanical retentive undercuts (use of bur) Contraindications for Amalgam Use Mercury Sensitivity true hypersensitivity to mercury is rare. Relative Contraindications: -Esthetically prominent areas. -Small Class I and II restorations that can be properly isolated and restored with resin composite or glass ionomer -Small Class VI restorations Controversy vs. Satisfaction - American Dental Association Survey, ADA News October 20, 2008 Decision-Making for Treatment and Restorative Materials Each patient and each clinical situation must be evaluated on an individual basis to determine the optimum treatment and restorative material.

Clinical Use of Amalgam- Instrumentation and Technique Clinical Considerations for Amalgam Restorations - Occlusion, Local Anesthesia, 1

isolation Mixing the Alloy and the Mercury Amalgamation - the process of mixing liquid mercury with one or more metals. Trituration - process of grinding powder within a liquid. These terms are generally used interchangeably in the dental setting. Optimal material and method to mix the alloy and mercury - Single-use disposable capsules Triturator used with an oscillating motion Primary purpose Trituration times Placement of Amalgam into a prepared area of the tooth- Insertion and Condensation Use of Amalgam carrier and amalgam well The prepared area of the tooth must provide mechanical retention features. Incremental placement - Use smaller, then successively larger condensers (for admixed alloy). - Condensers are most often held utilizing the Modified Pen Grasp. - Condense into the deepest area of tooth preparation first, then incrementally. - Condense with lateral pressure as well as vertical pressure. - Slightly overfill; maintain pressure throughout placement of all increments - Overfilling the tooth preparation with amalgam Burnishing (smoothing, rubbing) of the surface is accomplished with burnishing instruments. Pre-Carve Burnishing - a form of condensation - covers margins - brings mercury rich phase to surface - creates initial primary anatomy - removes gross excess Amalgam Burnishers What are the potential consequences of inadequate precarve burnishing? What are the potential consequences of residual mercury remaining in the amalgam? Amalgam Restoration - Carving Goals of Carving - Create correct primary occlusal anatomy for optimum form and function. - Removal of sharp, pitted anatomy, allowing for effective plaque control. Amalgam Carving Instruments Amalgam Carving Technique Part of the carving instrument blade must rest part on unprepared tooth structure,

part on amalgam. Cutting edge of the carver is perpendicular to the cavosurface margin. The instrument moves parallel to the cavosurface margin. Use larger carver before smaller carver. Evaluate occlusion Post-Carve Burnishing Purpose Technique Use of a dry or water-damp cotton ball or cotton roll Finishing and Polishing Finishing and Polishing procedures not always needed. Indications: marginal discrepancy, improve contour, correct very rough surface Timing Class I Amalgam Restoration- Operative Laboratory Projects Occlusolingual ( e.g on maxillary molars) Occlusofacial (or occlusobuccal e.g. on mandibular molars) Final Amalgam Restoration Criteria for a successful restoration Anatomically correct (good primary anatomy)- grooves, fossae, ridges. No marginal voids or ditches. No excess. Smooth surfaces. In harmony with adjacent and opposing occlusion. Biomaterials and Clinical Properties of Amalgam Alloy Composition Silver Tin Copper Zinc Particle type - Lathe cut, Spherical, Admixed Mercury Purpose of the mercury Properties of amalgam: - Type of amalgam - Type of amalgam - Trituration - Condensation - Presence of moisture Corrosion 3

Chemical Corrosion Electrochemical Corrosion - Galvanic corrosion - Crevice corrosion (concentration cell) - Stress corrosion Marginal Fracture Amalgam is a brittle material; risk of bulk fracture, low edge strength. High copper amalgams display less marginal fracture than low copper amalgams Marginal Fracture and Tooth Preparation Tooth preparation must provide a minimum depth for bulk thickness of amalgam to resist marginal and bulk fracture (1-2 mm, generally minimum 1.5 mm). Tooth preparation must provide cavosurface angle of 90 (butt joint margin). Tooth preparation must provide mechanical retentive features ( e.g. convergent opposing walls). Material Properties of Amalgam Compressive Strength Tensile Strength Shear Strength Wear Resistance -relatively high, wear rate similar to tooth Creep Solubility Radiopacity Thermal conductivity Coefficient of thermal expansion Corrosion Types of Corrosion Galvanic Corrosion Pitting Corrosion Stress Corrosion Tarnish Microleakage and Corrosion Creep Definition What affects creep? Increased or residual mercury increases creep. Under or over trituration increases creep. Increased copper decreases creep. Increased condensation decreases creep.

Creep and Zinc Zinc-containing high-copper amalgams do not exhibit the phenomenon of delayed expansion. BUT isolation to prevent any moisture contamination is important for both zinccontaining and zinc-free amalgam restorations, because contamination of dental amalgam with moisture will create porosity in the restoration, which will decrease strength and increase both corrosion and creep.

Effect of Material Properties on the resulting Amalgam Restoration Effect of Alloy Composition Silver Tin Copper Zinc Mercury Effect of Particle Shape Effect of Particle Size Effect of Trituration Overtrituration Undertrituration Effect of Condensation Decreased condensation pressure will: -decrease strength -decrease adaptation to walls and margins. -increase delayed expansion, increase creep -increase corrosion Size of Condenser head Effect of Moisture Contamination Moisture contamination (from saliva, etc.) can result in: - increased delayed expansion - decreased compressive strength - in a zinc-containing alloy, severe expansion, pain, sensitivity Effect of Carving 5

Marginal Defects: Marginal deficiency ditched margin, submarginated, open margin Marginal excess flash, excess Effect of Burnishing,Carving, Finishing and Polishing Burnishing (prior to carving) Finishing and Polishing Maximizing the Properties of Amalgam Ideal conditions resulting in an ideal amalgam

Safety in Handling Amalgam, Environmental Concerns and Practice Recommendations Public Awareness and Perceptions Environmental Concerns - the dental office, amalgam scrap, waste water. Forms of mercury Amalgam separators in dental offices Mercury Mercury in industry Mercury in fish Principles of Amalgam Handling and Safety Mercury vapor point of entry of mercury vapor is through the lungs. Who is at greatest risk? Sources of Mercury Vapor Freshly triturated amalgam. Placement of amalgam restorations. Removal of amalgam restorations. Droplets from leaky capsules. Contaminated work surfaces and flooring. Heat sterilization of amalgam-contaminated instruments. Correct handling therefore relates to minimizing vapor Proper disposal of Amalgam - use only sealed amalgam scrap containers - amalgam containers contain old fixer solution - OSHA regulatory policies must be adhered to - Amalgam spills may occur; prompt cleanup, correct OSHA and EPA policies

must be followed. Symptoms of Mercury Toxicity Inhalation Eyes, Skin, Ingestion First Aid MSDS sheets Amalgam/Mercury - Contamination of water lines - EPA , other environmental initiatives gaining ground in order to reduce the amount of mercury entering waste water lines - Reducing mercury with all safe handling procedures Environmental Protection Agency and Amalgam Separators - Currently endorsed for dental practices on a voluntary basis. - EPA may monitor use of amalgam separators in dental practices, but does not regulate. - Best Management Practices aim to reduce or prevent release of mercury into POTWs Public Owned Treatment Works NSU guidelines for scrap Amalgam - Non-contact- amalgam which is mixed but not used. - Contact Amalgam from the operatory, contact with patient, extracted teeth. - Empty amalgam capsules - Chair side traps- are checked every 3 months by engineering - All sources- should be placed in separate containers marked biohazardous scrap amalgam. What is the ADA (American Dental Association) best management practice recommendation regarding handling of amalgam waste? Public Concerns and Awareness Evidence Toxic risk Allergic risk T W.H.O. and ADA (and FDA): removal of amalgam on grounds of improving health and curing diseases JAMA April 2006 Neuropsychological and Renal Effects of Dental Amalgam in Children Informed Consent Advantages and Disadvantages of Amalgam Advantages Relatively long-lasting 7

Easy handling Wear resistant Cost-effective Marginal seal Disadvantages Unesthetic Thermal conductivity Marginal fracture/Bulk fracture Exposure of dental personnel to mercury Public/patient concern regarding mercury. Future? Resin-based materials Non-amalgam alloys Risks of other direct restorative materials?

References Phillips Science of Dental Materials 11th Edition, Anusavice, Saunders 2003. ADA Best Management Practices for Amalgam Waste, March 2004, ADA Environmental Issues in Dentistry mercury. Fan, et al. International Dental Journal (1997)47, 105-109 Environmental Hazard Evaluation of Scrap Amalgam. Fan, et al. Dental Materials 8:359-361, November 1992 Purchasing, installing and operating dental amalgam separators. McManus, Fan. JADA, Vol. 134, August 2003, 1054-1065 Dental Mercury Hygiene Recommendations. ADA Council on Scientific Affairs. JADA, Vol. 134, November 2003, 1498-1499 Contemporary Orthodontics, 3rd Edition, Proffitt, Mosby 2000. Contemporary Implant Dentistry, 2nd Edition, Carl E. Misch, 1999 McCrackens Removable Partial Prosthodontics, 11th Edition, Carr, et al, Mosby, Elsevier 2005 Restorative Dental Materials, 11th Edition, Craig & Powers, Mosby, 2002 Sturdevants Art and Science of Operative Dentistry, 4th Edition, Roberson, Heymann, and Swift, Mosby 2002. ADA Proposed ANSI/ADA Specification No. 109, June 2006 Neuropsychological and Renal Effects of Dental Amalgam in Children. Bellinger, et al. Journal of the American Medical Association (2006) Journal of Operative Dentistry March/April 2006 Dental Amalgam and Multiple Sclerosis: A Systematic Review and MetaAnalysis; . Aminzadeh Bsc Pharm, DDS, Etminan PharmD, MSc ; Journal of Public Health Dentistry 67 (1), 6466. Winter 2007

ADA Positions & Statements ADA Statement on Dental Amalgam; Revised April 2007; www.ADA.org ADA www.ADA.org/prof/resources/topics/amalgam_economic_impact.pdf Craig, Robert G.. Restorative Dental Materials, 11th Edition. Elsevier, 2002. 4.5.2 Environmental Pollution 121 ( 2003) 321-326 www.ada.org/goto/amalgambmp http://edocket.access.gpo.gov/2008/E8-21484.htm