Operative PDF

amalgam
1-22
miscellaneous
85-95
96-99
bases/liners/cements
23-36
pins
caries
37-43
rubber dam
100-102
composite
44-57
sealants/fluoride
103-113
gold
58-76
terms
114-124
instruments/burs
77-84
amal
All Class HI lesions should be filled with col1lPosite resh'l bedluse they are
esthetically important.
both the statement and the reason are correct and related
both the statement and the reason are correct but not related
the statement is correct, but the reason is not
the statement is not correct, but the reason is correct
neither the statement nor the reason is correct
copyright C> 20132014 Dental Decks
OPERATIVE
amal
The ideal amount of dentin required between an amalgam restoration and
the pulp for insulation is:
0.5 mm
1.0 mm
2.0 mm
3.0 mm
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*** Think closely, distolingual Class III lesions are relatively nonesthetic and Nattiona! Board questions consider the best material to be amalgam or direct gold.
Composite resin is not recommended for Class III lesions on the distal-lingual aspect of
canines (use either amalgam or direct gold). Composite material will not maintain the
mesiodistal dimension of the tooth. Note: This may not be entirely true today due to the
fact that there are much better wear-resistant resins than in the past. However, for National
Board questions composite is not recommended for this situation.
A lingual approach is made when preparing a Class III dental amalgam preparation for the
distal surface of a canine because a lingual approach preserves the esthetic value of the
facial surface.
Remember:
A bite-wing radiograph is the best method to diagnose incipient carious lesions on
the distal surface of canine teeth .
A diagnostic aid to be used as a last resort to confirm the presence of a carious lesion ,
on the proximal surface of an anterior tooth is mechanical separation (usually with a
wedge).
Rule of thumb: When two teeth adj acent to each other have Class III lesions, you should
prepare the larger one first and fill the smaller one first. Access to the preps and shade
matching are easier when you do both at the same appointment.
2.0 mm -
(1.0 - 1.5 mm is acceptable but not ideal)
*** Thermal insulator- resists the transfer of heat. Amalgam is a poor thermal insulator
this is why a base of either calcium hydroxide or zinc oxide-eugenol is placed under
amalgam restorations (to provide thermal protection).
'of Restorative
/ Chanlcteristic
Direct Gold
Close adaptation to cavity walls
Very good
Amalgam
Good. .....
'.
Composite
Good
Coefficient oftherinal expansion similar to tooth structure, Very good

Chemically acceptable to hard., and soft
"
<:
of Irritation to gingival
..
"
High edge strerigth "
'
,""
,',
"
Clinical10ngevity
'"
"
High abrasion resistance
"
Permanently restores M-D

Withstands masticatory
Imitates
'
"
,"
Irisohibility in oral fluids
versatilitY in:
,:,
Non-corrodingin
'
'0
-:
tooth color
Ease of manipulation and placement

Thermal and electrical inSulator:
Very good
Gdodo
poor, "
Excellent
Excellenf .:'
Good
Very good
Good:
Fair
9pod, .. ',,','
Fair
.,,'
..
"
Poor
..
Fair
..,.7,' , Good
,
Good
Poor
"
Very good
..
"
'
Poor
Very good
'".
",
Very good
Good
G"00 d , '. ',,',
Poor
". N/A
,co,
..
Very good
Fair
Fair
',.,
':
,.,'."",
':'
"
:,
'0'
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Good
Poor
,
Fair
Good
Fair
Poor
Poor
Good,
Very good
Poor
,Popr
Good
,;."
Poor
Very good
amal
A patient comes in claiming that their holistic doctor told hhn that he. has an
allergy to mercury and needs only white fillings. Your best response is:
there is no such thing as a mercury allergy; plus, there is no mercury in amalgam

fillings
you might have mercury allergy, but that is very rare; plUS, there is no mercury in
amalgam fillings
there is no such thing as a mercury allergy; plus, with proper isolation and technique,
your exposure will be minimal
you might have a mercury allergy, but that is very rare; plus, with proper isolation and
technique, your exposure will be minimal
3
copyright Ii) 2013-2014 - Dental Decks
OPERATIVE
amal
Which of the following are similarities between amalgam Class II restorations
and inlayClass II restorations?
Select all that apply.
occlusal isthmus width

depth into dentin
convergent walls on the occlusal surface
axiopulpalline angle shape
gingival wall form
internal line angles
4
copyright Ii) 201 3-2014 - Dental Decks
OPERATIVE
r
you might have a mercury allergy, but that is very rare; plus, with
proper isolation and technique your exposure will be minimal
The amount of mercury remaining in a set amalgam restoration is related to how much of
the mercury-rich matrix is left in the amalgam after condensation. The key is to minimize
the amount of matrix that forms during the reaction. By condensing the amalgam mixture in the cavity preparation, the mercury-rich matrix will come to the surface and be removed by subsequent condensing and carving. The final amalgam restoration will be
composed of mostly residual alloy and very little of the mercury-rich matrix.
The amount of mercury remaining in dental amalgam after condensation directly affects:
(1) the porosity of the restoration, (2) the compressive strength of the restoration, (3) the corrosive resistance of the restoration, and (4) the surface finish of the restoration.
Mercury is used to initiate the reaction with the alloy. Although an amalgam restoration
is nontoxic, mercury is poisonous. Free mercury, in the form of vapor or liquid droplets, represents a significant health hazard in the dental office. The greatest potential hazard of
chronic mercury toxicity comes from inhalation of mercury vapor. The vaporization is most
likely to occur during condensation of the amalgam (always use high speed suction).
Note: Mercury hypersensitivity (allergy) is very rare (1 in 100 million).
Important point concerning condensation pressure: The area of the condenser point and
the force exerted on it by the operator govern the condensation pressure. The smaller the
condenser point, the greater is the pressure exerted on the amalgam.
occlusal isthmus width

depth into dentin
axiopulpalline angle shape
Form a reverse bevel at the axial

gingival line angle, into the
gingival wall
Important: The gingival margin should clear the contact area to allow for adequate finishing of the enamel margins and placement of a matrix band.
amal
You would prefer your assistant overtriturate the amalgam rather than
undertriturate it. This is because an overtriturated amalgam will still have
optimal strength.
both statements are true

both statements are false
the first statement is true, the second is false
the first statement is false, the second is true
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OPERATIVE
amal
Class V amalgam restorations rarely require retentive grooves,but if they are
used, they are placed at the incisoaxial and gingivoaxialline angles.

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OPERATIVE

The longer the trituration time, the smaller the setting expansion. If the trituration is carried to the extent that the amalgam appears shiny and wet, the strength will be maximal
and the smooth, carved surface will retain its luster long after polishing. A properly triturated amalgam appears shiny, wet, smooth, and homogeneous.
Inadequate trituration results in an amalgam mix that has a low strength and a rough surface that will accelerate corrosion. An undertriturated amalgam mixture will appear dry
and grainy. Condensing this mixture will result in poor adaptation to the walls of the
preparation, lacrimation between condensed increments, and reduced strength.
Remember: An overtriturated mix is preferable to an undertriturated mix.
1. The discolored, corroded, superficial layer frequently seen on the surface of
a dental amalgam restoration is most likely a sulfide.
2. When carving an amalgam restoration, be sure to trim the margins with a
sharp instrument that rests on tooth structure (this will prevent "ditching" the
margins).
3. If an amalgam" chips" when you are carving it, the reason for this is that the
amalgam was condensed after its working time had elapsed.
*** Class V amalgam restorations commonly require and utilize retention grooves.
The retention form for a Class V amalgam preparation is provided by the gingival retention groove placed along the gingivoaxialline angle and the incisal retention groove
placed along the incisoaxialline angle. 0.25 mm is the depth of the groove-retention
The outline form for the classical Class V amalgam preparation is a deformed trapezoid
(sometimes called "kidney-shaped"}. The outline form is determined by the location and
size of the carious area.
gingival margin will be less deeper
The nonparallel mesial and distal walls ofthe preparation are straight and parallel to the
transitional line angles. The direction of these walls is determined by the direction of the
enamel walls (as is the decay pattern).
The occlusal and gingival walls of the preparation should be gently curved arcs as determined by the contour of the free margin of the gingival tissue. Note: These arcs should
be as parallel to each other as possible.
Important points:
1. The occlusal arc will normally be the longer of the two.
2. The gingival margin will normally be at, or slightly below, the margin of the free gingIva.
3. For incipient lesions, the axial wall should be uniformly deep into dentin.
amal
Delayed expansion of alllaigarrrrestoratiolls is.associatedwHhwhich two
factors?
..
insufficient trituration and condensation

high residual mercury
the contamination of the amalgam by moisture during trituration and condensation
the failure to use a cavity varnish
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amal
Proper condensation and carving makes an amalgam restoration stronger
because it removes the mercury-rich matrix.
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OPERATIVE
insufficient trituration and condensation

the contamination of the amalgam by moisture during trituration and condensation
*** Important: The contamination of the amalgam by moisture during trituration and condensation is
unquestionably the principal cause of failures.
If moisture is incorporated into an alloy that contains zinc, the water reacts with the zinc to produce hydrogen gas. The resulting pressure from the liberated gas produces severe expansion of the amalgam. This
results in the following clinical manifestations:
The amalgam protrudes from the cavity preparation
Postoperative pain
Excessive corrosion
Important points to remember regarding amalgam:
1. The compressive strength is' greatly reduced when amalgam is contaminated with moisture. The
compressive strength of high-copper amalgam is similar to tooth structure.
2.The most important problem for amalgam restorations is that they have different coefficients of
thermal expansion/contraction (amalgam = 25 ppm;oC) compared to tooth structure (10 ppm/C).
During reductions in intraoral temperature, there is a strong tendency at the margins for amalgam
restorations to contract away from the margins and allow marginal leakage of intraoral fluids (percolation) that are later expelled when the temperature returns to normal.
3. The tensile strength of amalgam is about one-fifth to one-eighth of its compressive strength, that
is why enamel is needed to support amalgam at the margins of restorations. Note: It is more abrasionresistant than composite resin or unfilled resin.
4. Amalgam is brittle and has a low edge strength.
5. Amalgam is a high thermal conductor and a poor thermal insulator.
6. High-copper amalgams exhibit no clinically relevant creep or flow.
7. You need a minimum thickness of 0.75 mm (in axial areas) to 1.5 to 2 mm (in areas of occlusal
contact) for adequate compressive strength .
The most important consideration in the strength of the amalgam is the mercury content.
If the mercury content exceeds 55%, a dramatic loss in strength results. Amalgam restorations that contain mercury levels of about 55% exhibit a high incidence of marginal breakdown, fracture,and corrosion, and the surface finish of the restoration is not good.
Factors that influence the final mercury content of a restoration:
Original mercury-alloy ratio: specific to each product but generally less than 1: 1 so
that amalgam contains 43% to 50% mercury
Amount of trituration
Condensation pressure and time involved in carrying out condensation
Very important: Removing the mercury-rich matrix by proper condensation and carving produces a stronger and more corrosion-resistant amalgam because it minimizes the
formation of the matrix phases of amalgam, which are the least desirable parts of the set
material.
amal
Which phase of theamalgam reaction is prone to corrosion in clinical restorations?
gamma
gamma-one
gamma-two
gamma-three
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amal
When preparing a Class II amalgam restoration, all surface angles should be
approximately 90 degrees.
However, the internal angles should be

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OPERATIVE
------- gamma-two
The reaction that occurs between the alloy particles and the mercury can be summarized as follows:
Silver-tin alloy + Mercury
Ag3Sn
Hg
(gamma)
--t
Silver-tin alloy
Ag3 Sn
(gamma)
+ Silver-mercury + Tin-mercury
Ag2Hg3
(gamma-one)
Sn8Hg
(gamma-two)
Gamma is the umeacted alloy. It is the strongest, and corrodes the least, and forms 30% of volume
of set amalgam. Gamma-one is the matrix for umeacted alloy and is the second strongest phase.
It Forms 60% of volume of set amalgam. Gamma-two is the weakest and softest phase. It is also
the most susceptible to corrosion in the mouth and forms 10% of the volume of the set amalgam.
The volume of the gamma-two phase decreases with time due to corrosion.
The key difference between the low-copper and the high-copper amalgams is that the low-copper
amalgams contain the gamma-two phase, which is not present in the high-copper amalgams. Instead, the high-copper amalgams contain the CU6SnS phase. Since the gamma-two phase corrodes
faster than the CU6SnS phase, the gamma-two phase containing low-copper amalgams develops
micro- porosities due to corrosion faster than the high-copper amalgams. These porosities weaken
the amalgam margins and explain why marginal defects (chipped margins) are more often seen
around low-copper amalgams. This explains why high-copper amalgams should be used rather than
the low-copper amalgams.
1. Smaller particle size results in higher strength, lower flow, and better carvability.
2. Spherical amalgams high in copper usually have the best tensile and compressive.
characteristics.
3. Copper contents over 6% ("high-copper" alloys) eliminate the gamma-two phase
by forming a copper-tin (Cu6Sns) phase reSUlting in superior properties.
4. Amalgam has a coefficient of thermal expansion approximately twice that of tooth
structure.
S.The tensile strength of amalgam is about one-fifth to one-eighth of its compressive
strength.

General properties of Class II amalgam preparations:
All walls should meet the surface of the tooth at a 90 angle (butt joint}.
Occlusal dovetail: provides resistance to proximal displacement.
Pulpal floor should be flat same as Class 1.
The buccal and lingual walls of the proximal section should converge occlusally - the extension of these walls is determined primarily by the position of the adjacent teeth in relation to the tooth being restored.
The buccal, lingual, and gingival walls should be extended into the embrasures enough
to allow easy cleaning - areas of lessened caries susceptibility.
The axiopulpal line angle is beveled to reduce concentration of stresses - resistance
form.
Retention grooves are placed in the axiobuccal and axiolingualline angles and extend-ed
to the height of the axial wall- resistance to dislodgement.
Lingually, it is often necessary to create a reverse curve in the outline. A reverse curve
is a curve put into the buccal or lingual wall so the wall meets the external surface of the
tooth at a 90 angle.
Note: Class II amalgam preps have independent retention and resistance form for both the
proximal box and occlusal portion of the preparation.
Important: When caries is extensive, reduction of one or more of the cusps for capping may
be indicated. When the facial (or lingual) extension is two-thirds from the primary groove toward the cusp tip, reduction of the cusp(s) for amalgam capping is mandatory for the development of adequate resistance form. Note: The final restoration has to have restored cusps with
a minimal thickness of 2 mm of amalgam for functional cusps and 1.5 mm of amalgam for
nonfunctional cusps.
Reverse curve:
preserves
triangular ridge of
the
cusp (prep goes
around it)
b- facilitates
formation of a 90
degree angle
between proximal
wall(s) and the
tangent of the
proximal surface.
amal
Beveling the gingival cavosurface margin of the proximal box of a Class II
amalgam preparation on a permanent tooth:
should result in a long bevel

is contraindicated because of the low edge strength of amalgam
should remove unsupported enamel that may fracture
is unnecessary since the tooth structure in this area is strong
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OPERATIVE
amal
Which tooth requires special attention when preparing the occlusal aspect
for a restoration?
mandibular first bicuspid

mandibular second bicuspid
maxillary first molar
maxillary first bicuspid
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should remove unsupported enamel which may fracture
*** The gingival cavosurface margin is beveled only if it is in the enamel. Beveling is not
necessary if the gingival margin is within cementum.
The gingival cavosurface margin should be beveled to remove any unsupported enamel.
The bevel is usually placed with a gingival margin trimmer. This gingival margin must be
below any existing contact with the adjacent tooth in order to allow proper finishing of the
gingival margin.
1. The bevel is no steeper than necessary to ensure full-length enamel rods forming the gingival margin and is no wider than the enamel.
2. Remember: Enamel rods in the gingival third of the primary teeth extend
occlusally from the DEJ, eliminating the need in Class II preparations for the
gingival bevel that is required in permanent teeth.
3. Primary molar teeth have marked cervical constriction. Therefore, when
preparing the proximal portion of a Class II cavity prep, a satisfactory gingival
seat may be difficult to obtain if the prep extends too deeply gingivally.
mandibular first bicuspid
The key to this question is the angulation of the preparation. The bur should be tilted lingually to prevent encroachment on the facial pulp horn and also to maintain dentinal
support of the lingual cusp. The pulpal floor should be parallel to the occlusal plane of the
tooth facio lingually.
Note: Pulpal floor slopes to coincide with the slope (height) ofthe cusps.
Remember: Anesthesia is necessary for restorative preps that involve or extend past the
DEJ, as sensitivity will be present.
amal
All four waUs, of a, Class I amalgam, preparaHonshould
cause divergencEl! prevents
margin,,1
be,.
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amal
The matrix band should be r",moved after condensation of the amalgam but
prior to the final carving of the restoration. This is becausethewedge compensates for the thickness of the matrix band.
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r
Important:
Only two walls of a Class I amalgam preparation should diverge, the mesial and distal. The buccal and lingual walls of a Class I amalgam preparation should be convergent.
The reason is still true because there are only two marginal ridges per tooth: mesial
and distal
DIVERGING
(Correct)
CONVERGING
(Incorrect)
*** This slight occlusal divergence prevents undermining the marginal ridges of their
dentin support.
1. This divergence of the mesial and distal walls holds true for Class I preparations for direct filling gold and gold inlays as well.
2. For premolars, the distance from the margin of the mesial and distal wall to
the proximal surface must not be less than 1.6 mm. For molars this minimal
distance is 2 mm .
Although the wedge is used to compensate for the thickness of the matrix band, the true reason for
carving after the removal of the band is to gain proper access to all margins of the amalgam restoration.
Important points to remember regarding matrix bands:
The reason for placing the matrix for a Class II amalgam restoration to protrude above the cavity preparation is to allow for overfilling, thus enhancing adequate cavosurface coverage.
Contact areas are always carefully restored in all restorations to protect the gingival tissue. The
matrix band should be burnished into contact with adjacent teeth, this will help ensure contact.
One of the most difficult teeth to adapt the matrix band to is the mesial of a maxillary first
premolar due to its developmental depression (concavity in the cervical third ofthe mesial surface of the crown).
Important: The wedging action between the teeth should provide enough separation to compensate for the thickness of the matrix band. This will ensure a positive contact relationship after the
matrix is removed following the condensation and initial carving of the amalgam.
Common problems associated with amalgam restorations:
Postoperative sensitivity:
- May be caused by inadequate condensation, or lack of proper dentinal sealing
Marginal voids:
- May be caused by inadequate condensation, or amalgam breaking away from margins when
carving
Marginal ridge fractures: may be caused by any of the following:
- Not rounding the axiopulpalline angle in Class II tooth preparations
- Marginal ridge left too high
- Improper occlusal embrasure form
- Improper removal of matrix band
- Overzealous carving of the restoration
j"'"-'
amal
The diagonal slot opening on the Tofflemire matrix retainer (also called the
Universal matrix system) is always placed facing the gingiva.This:
. i
permits easy separation of the retainer from the band in an occlusal direction
allows for better contour of band to tooth
allows for easier wedge placement
is less harmful on the gingiva
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amal
Which of the following are true statements regarding the polishing Of amalgam?
it reduces marginal discrepancy

it should be done about 10 minutes after placement
occlusion should not be checked prior to polishing
it prevents tarnishing of the restoration
it improves the appearance of the restoration
it should be done with a dry polishing powder
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OPERATIVE
permits easy separation of the retainer from the

band in an occlusal direction
In addition, the larger circumference of the 'matrix band is always placed toward the occlusal surface of the tooth, This accommodates for the larger tooth circumference at the
contact level.
The primary function of the matrix band is to restore anatomical contours and contact
areas. Other functions include providing a rigid wall to condense filling material against,
preventing excess filling material from going subgingivally, and to some extent, limiting
moisture contamination during condensation. A properly placed wedge will also protect
the gingival tissue and help reduce moisture leakage into the cavity preparation.
Wedges are inserted from the facial or lingual embrasure, whichever is larger, slightly gingival to the gingival margin. The wedging action between the teeth should provide enough
separation to compensate for the thickness of the matrix band.
Important: When placing a matrix band for a Class II amalgam restoration, the gingivoocclusal width of the band should be trimmed to be at least 1 mm greater than the expected marginal ridge height.
it reduces marginal discrepancy

it prevents tarnishing of the restoration
it improves the appearance of the restoration
The final finish of the amalgam restoration should not be done until after the amalgam is fully
set. It should be delayed for at least 24 hours after condensation and preferably longer (24-48
hours). By waiting, you can be ensured that the reactions between the alloy and mercury will
have been completed and a more corrosion-resistant surface will be created.
Amalgam restorations should be finished and polished for three major reasons: (1) to reduce
marginal discrepancies and to create a more hygienic restoration, (2) to reduce marginal breakdown, which will reduce the chance of recurrent decay, and (3) to prevent tarnishing and to
improve the appearance of the restoration.
Heat generation must be avoided. The use of dry polishing powders and discs can
easily raise the surface temperature above the 60C (140F) danger point. Thus, a wet abrasive powder in a paste form is the agent of choice. Note: Heat will not only damage the pulp
but also draws mercury to the surface of the restoration and an inferior restoration will result.
Final polishing may be accomplished using a rubber cup with flour of pumice followed by a
high-luster agent, such as tin oxide.
Remember: When checking the occlusion on a newly condensed amalgam restoration, the
marks left by the articulating paper should be of the same intensity as other markings in the
same quadrant.
amal
All of the following are true concerning a Class V amalgam preparation
EXCEPT one. Which one is the EXCEPTION?
.
the outline form is determined primarily by the location of the free gingival margin
the mesial, distal, gingival, and incisal walls of the cavity preparation diverge outward
.the retention form is provided by the gingival retention groove along the gingivoaxialline angle and an incisal retention groove along the incisoaxialline angle
a cervical clamp is usually necessary to retract gingival tissues
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OPERATIVE
amal
Which of the following staten,ents in reference to amalgamis false?
increased trituration time will increase compressive strength and decrease setting
expansion
a decrease in particle size will decrease compressive strength and increase setting
expansion
increased condensation pressure will increase compressive strength and decrease
setting expansion
18
OPERATIVE
the outline form is determined primarily by the

location of the free gingival margin
*** This is false; the outline form is determined primarily by the location and size of the
carious lesion.
1. Care must be taken to distinguish the active root-surface carious lesion from
the root-surface lesion that was active but has become inactive (arrested). The
arrested lesion shows eburnated dentin (sclerotic dentin) that has darkened from
extrinsic staining and is firm to the touch of an explorer.
2. The Class V amalgam restoration is used to restore lesions from caries, erosion, and abrasion.
3. Care should be taken not to "ditch" the cementum when finishing and polishing.
4. Occasionally, you will notice that the gingival tissue has receded apically
from the gingival margin of a Class V restoration that was previously polished.
This may be related to irreversible tissue changes caused by inadvertently traumatizing the tissue when the restoration was being polished.
Key point: Be careful.
Remember: Incipient carious lesions are contained entirely within enamel and have not
spread to the underlying dentin. The two options for treatment are:
1. Promote remineralization: with fluoride varnish and self-administered fluoride,
followed by regular monitoring. Note: Incipient carious lesions usually do not progress
rapidly.
2. Place a restoration: be as conservative as possible .
a decrease in particle size will decrease compressive

strength and increase setting expansion
*** The opposite is true.

Dimensional change
Setting Expansion:
- Most amalgam restorations show slight setting expansion, but not of clinical significance.
- The more free mercury, the more setting expansion (and vice versa).
The greater the time of trituration, the less the expansion
The greater the pressure used in condensation, the less the expansion
The smaller the particle size, the less the expansion
Strength:
- Amalgam is brittle but possesses good compressive strength. The most important
consideration in the strength of the amalgam is the mercury content. Mercury content above 55% will cause a marked decrease in strength (should be within 45-53%
by weight).
Higher condensation pressure increases strength
The smaller the particle, the more strength
The longer the trituration time, the more strength
The fewer voids, the more strength
amal
Amalgamrestoratiol1s require an obtuse cavosurfacemarghl becaus,eamalgam isa brittle m,aterial.
'
"
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OPERATIVE
amal
New amalgam alloys are termed "high copper:'
The higher percentage of copper reduces, marginal breakdown.

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OPERATIVE

Remember for the boards: (when this is the answer)
A. The statement is NOT correct
B. Therefore, the reason is obviously not related
C. So, you need to evaluate the reason independently
thus: Amalgam restorations require a 90 cavosurface margin

Amalgam is a brittle material
0
Clinical experience has established that this butt joint margin of enamel and amalgam is
the strongest. Amalgam is a brittle material with low edge strength and tends to chip under
occlusal stress if its angle at the margins is less than 80 0 to 90 0
Outer planes carried into cleans able

area (provides access for finishing
margins). Beveled to result in 40
degree marginal metal

Constituents in Amalgam:
Basic constituents:
Silver (Ag) (40-70%)
- increases strength
- increases expansion
Tin (Sn) 25-27%

Note: Influences the amalgam in an
- decreases expansion opposite manner to silver.
- decreased strength
- increases setting time
Copper (Cu) 6% or less:

Note: New alloys called "high copper" contain 9- ties up tin: reducing gamrna-2 formation 30% copper. These alloys have less marginal break- increases strength
down and are less likely to corrode.
- reduces tarnish and corrosion
- reduces creep: reduces marginal deterioration
Mercury (Hg) 3% max.:
- activates reaction
- only pure metal that is liquid
- spherical alloys
- admixed alloys
require less mercury
require more mercury
- smaller surface area easier to wet
- lathe-cut particles more difficult to wet
- 40% to 45% Hg
- 45% to 50% Hg
Other constituents:
Zinc (Zn) 1% or less: used in manufacturing, decreases oxidation of other elements (sacrificial
anode)
- Provides better clinical performance: less marginal breakdown

- Causes delayed expansion with low eu alloys if contaminated with moisture during condensation
Palladium (Pd) 1% or less: reduced corrosion, greater luster
Indium (In) 1% or less:
- decreases surface tension
- reduces creep and marginal breakdown
reduces amount of mercury necessary - increases strength
reduces emitted mercury vapor
- must be used in admixed alloys
amal
Which of the following statementsare true regarding creep?
creep is a process that happens over time

creep gradually increases the marginal integrity of an amalgam restoration
undertrituration tends to increase the creep rate
overtrituration tends to decrease the creep rate
increasing the condensation pressure decreases the creep rate
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amal
There is no free mercury in triturated amalgam because trituration causes the
alloy to dissolve in the mercury.
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creep is a process that happens over time

undertrituration tends to increase the creep rate
increasing the.condensation pressure decreases the creep
Creep (time-dependent deformation or strain relaxation) is the deformation with time in
response to a constant stress. It has been implicated as one of the main causes for marginal fracture of amalgam restorations.
1. The higher the creep, the greater the degree of marginal deterioration.
2. Creep is time-dependent.
High copper and low mercury content of an amalgam restoration will tend to decrease
creep. Altering the trituration time and condensation pressure can change the creep rate
of an amalgam restoration:
Both undertrituration and overtrituration tend to increase the creep rate
If there is a delay between trituration and condensation, the creep rate increases
Increasing the condensation pressure decreases the creep rate (this will also decrease
the final mercury content of the restoration)
The marginal leakage of an amalgam restoration decreases as the restoration ages. Corrosion products are helpful in reducing marginal leakage around amalgam restorations.
These corrosion products, such as tin oxide and tin sulfide, accumulate in the gap between
the restoration and the tooth, thus providing an excellent seal.
*** There is no free mercury in triturated amalgam because trituration coats the alloy particles with mercury.
The object of trituration is to bring about an amalgamation of the mercury and alloy. Each individual alloy particle is coated with a slight film of oxide that prevents penetration by the mercury. During trituration, this film is rubbed off, and the clean metal is then readily attacked by
the mercury.
Silver Alloys for Dental Amalgams:
Low copper alloys: 4% to 6% or less, traditional alloy
Comminuted (irregular, filing, or lathe-cut)
Spherical particles
High copper alloys: 9% to 30% most common, corrosive resistant
Spherical: sets faster and attains final mechanical properties more rapidly
Comminuted can have zinc or be zinc-free and also can be fine-cut or microcut
Combination (admix) mixture of spherical and comminuted particles
Dispersed-phase alloy was the original admix alloy, mixture of comminuted traditional silver alloy and spherical particles of silver-copper eutectic alloy. Most commonly used alloy
today.
Eutectic alloy is an alloy in which the elements are completely soluble in liquid solution but
separate into distinct areas on solidification.
Note: Once amalgamation occurs, no free (unreacted) mercury is associated with the amalgam
restoration. The restoration has no toxic properties. However, if the amalgam is heated beyond 80C, liquid mercury can form on the surface of the amalgam, and its vapor presents a
health hazard.
bille
What distinguishes a base froma cement frorn a cavity liner?
final application thickness

degree of pulpal protection
biocompatibility of material
degree of hardness
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bille
Which of the following statements are true regarding glass inomer cements?
release fluoride
good chemical adhesion
good thermal insulator
thermal expansion similar to tooth
high solubility after initial setting
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final application thickness

The most important consideration for pulp protection in restorative techniques is the thickness of
the remaining dentin.
In general, cements that are thicker than 2 mm are termed bases and, as such, function to replace
lost dentin structure beneath restorations. A base may be used to provide thermal protection under
metallic restorations, to increase the resistance to the forces of condensation of amalgam, or to
block out undercuts when taking impressions for cast restorations.
The only distinction between a base, a cement, and a cavity liner is their final application thickness:
1. Cements for luting have a desired final film thickness of approximately 15 to 25 microns.
2. Cavity liners (either solution or suspension liners). Liners are materials that are placed as a
thin coating ( have a desired final film thickness of approximately 5 microns) on the surface of
a cavity preparation. Although they provide a barrier to chemical irritants, they are not used for
thermal insulation or to add bulk to a cavity preparation. Furthermore, these materials do not
have sufficient hardness or strength to be used alone in a deep cavity.
3. Bases have a final application thickness of approximately 1 mm to 2 mm (they may be thicker
deppending on the amount ofdentin that has been destroyed). Bases can be considered as restorative substitutes for the dentin that was removed by caries and/or the cavity preparation. They act
as a barrier against chemical irritation, provide thermal insulation, and can resist the condensation forces on a tooth when placing a restoration. Also, the clinician can shape and contour base
materiais after placement into the cavity preparation.
Important: A base should not be used unnecessarily.
Remember: Calcium hydroxide is very effective in promoting the formation of secondary dentin,
which is an important aid in the repair of the pulp.
Note: The selection of appropriate bases and liners to restore the axial wall of a Class II restorations depends on the biological effect required and the thickness of the remaining dentin.
release fluoride
good chemical adhesion
good thermal insulator
thermal expansion similar to tooth
*** This is false; glass ionomer cements have low solubility, lower than zinc phosphates
(which are lower than zinc polycarboxylates).
Glass ionomer cements are hybrids of silicate and polycarboxylate cements designed to
combine the fluoride releasing properties of silicate particles with the chemically adhesive and more biocompatible characteristics of the polyacrylic acid matrix compared
to the extremely acidic matrix of silicate cement.
Advantageous physical properties of glass ionomer cements:
Release of fluoride: anticariogenic
Chemical adhesion to the prepared tooth and certain metals. Micromechanical
bond to composite resins. Important: Chelation of calcium ions on tooth structure
by ionized polyacrylic acid side-groups is the principal mechanism of chemical adhesion to tooth structure.
Biocompatibility is high, thus with enough dentin remaining (0.5-1 mm,) no pulpal
protective agent (calcium hydroxide) is required
Good thermal insulators: equal to that of natural dentin
Thermal expansion is similar to that of tooth structure
After initial setting, they have low solubility in the mouth
Note: Its disadvantage as a cement is that it has a higher cement fIlm thickness than zinc
phosphate cements.
Remember: No lab test of cement has correlated solubility with clinical retention.
bllle
Glass ionomer. cements generally contain f1uoro-alumino.:silica powder.
The
isthe portion responsible for Olle of the major advantages of glass ionomer.
.
.
..
.

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blile
ZOE cements make good temporary sedative restorations because their pH
is very basic.
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Glass ionomer cements are mixed powder-liquid component systems.The powder is a fluoro-alumino-silicate glass
that reacts with a liquid, which is p olyacrylic acid, to form a cement of glass particles surrounded by a matrix of fluoride elements.
Cements can be useed as luting agents:
Zinc phosphate cement: one of the oldest and most widely used cements, zinc phosphate cement, is the standard against which new cements are measured. Advantages: long record of clinical acceptability, high compressive strength, acceptably thin film thickness. Disadvantages: low initial pH, which may lead to postcementation
sensitivity, lack of an ability to bond chemically to tooth structure, and lack of an anticariogenic effect.
Important: Zinc phosphate cement is mixed using the "frozen slab" technique, which greatly extends the working time (by as much as 300%). Note: The pH of newly mixed zinc phosphate cement is under 2 (two layers of
varnish must be applied to protect the pulp) but rises to 5.9 within 24 hours and is nearly neutral at 48 hours.The
film thickness of zinc phosphate is about 25 ).lm.
Zinc polycarboxylate cement: also known as zinc polyacrylate cement, was one ofthe first chemically adhesive dental materials. The adhesive bond is primarily to enamel, although a weaker bond to dentin also forms.
This is due to the fact that bonding appears to be the result of a chelation reaction between the carboxyl groups
of the cement and calcium in the tooth structure; hence, the more highly mineralized the tooth structure, the stronger
the bond. Advantages: kind to the pulp, chemically bonds to tooth structure. Disadvantages: short working time,
requires separate tooth conditioning step prior to cementation. Note: It is more viscous when mixed and has a
shorter working time than does zinc phosphate cement.
Glass ionomer cement: Advantages: chemical bond to enamel and dentin, anticariogenic effect (releases fluoride), coefficient of thermal expansion similar to that of tooth structure, high compressive strength, low solubility. Disadvantages low initial pH which may lead to postcementation sensitivity, sensitivity to both moisture
contamination and desiccation. Note: Its mechanical properties are superior to zinc phosphate and polycarboxylate cements.
Resin-modified glass ionomer luting agents: have properties similar to glass ionomer cements, but have higher
strength and lower solubility. Note: They should not be used with all-ceramic restorations dues to reports of ceramic fracture, most likely the result of expansion from water absorption.
Resin luting agents: are unfilled resins that bond to dentin, which is achieved with organophosphates, (2-hydroxyethyl methacrylate [HEMAV, or 4-methacryloyloxyethyl trimellitate anhydride (4-META).
Advantages: high compressive strength, low solubility. Disadvantages: irritating effects on the pulp, high film
thickness (> 25 mm). Note: As a general rule, resin cements are the best choice for luting ceramic restorations .
*** ZOE cements make good temporary sedative restorations because their pH is about
7 (neutral).
ZOE-eugenol cement is a soft, sedative-type cement. It is used as a sedative or temporary filling material, as an insulative base, and in interim caries treatment. The powder is
zinc oxide and the liquid is eugenol. Eugenol has a palliative effect on the dental pulp,
and this is one of the main advantages of using this type of cement.
A conventional mixture of zinc oxide and eugenol is relatively weak. In recent years, "reinforced" or "improved" ZOE-eugenol
have been introduced (called reinforced
ZOE or ZOE-EBA). In reinforced ZOE (Type III ZOE), the powder is composed of zinc
oxide and finely divided polymer particles (polymethyl methacrylate) in the amount of
20% to 40% by weight. In addition, the zinc oxide powder is surface treated by an
aliphatic monocarboxylic acid, such as propionic acid. Note: This combination of surface treatment and polymer reinforcement results in a material that has good strength and
toughness which markedly improves abrasion resistance. Reinforced ZOE is fine for basing large and complex cavities. This material is able to withstand the pressure of amalgam
condensation and it has minimal effect on the pulp.
Contraindications to the use of ZOE include:
1. On dentin or enamel prior to bonding: compromises bonding.
2. As a base or liner for composite resins: eugenol interferes with polymerization.
3. Patients who are allergic to eugenol (or oil of cloves): this is somewhat common.
4. Direct pulp capping: eugenol is a pulpal irritant when in direct pulpal contact.
Remember: ZOE is soluble in orcH fluids and is difficult to remove from cavity preparations.
bllle
IRM (Intermediate Restorative Materia/) will interfere with subsequent placement ofa resin filling. This is .because .IRM isa form of zinc oxide::eugenot
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bllle
Zinc phosphate cement can cause irreversible pulpal damage because it
shrinks slightly on setting.
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Zinc oxide-eugenol (ZOE) cement is a low-strength base used as a temporary cement filling in the event that the patient will return at a later date for a semipermanent restoration.
The powder is mainly zinc oxide and the liquid is eugenol with olive oil as a plasticizer.
ZOE is not very durable, and it wears away after just a few weeks, but it works to relieve
pain, calm the nerve, and protect the tooth. Note: During the Vietnam War, the US Army
invented a more durable form of ZOE called Intermediate Restorative Material (IRM),
which is fortified with plastic powder.
Uses:
As an intermediate restorative material for both Class I and II restorations.
As a base under nonresin restorations
Restoration of deciduous teeth (when permanent teeth are 2 years or less from eruption)
Restorative emergencies
Advantages:
High strength comparable to zinc phosphate
Excellent abrasion resistance
Good sealing properties
Low solubility
Important: Because of its ZOE composition, IRM will interfere with subsequent placement of a resin filling .
Important: The initial mixture of this cement is very acidic (PH of 3. 5) and can cause
irreversible pulpal damage if a cavity varnish (2 coats) is not placed on the tooth prior
to cementation of the crown.
Note: Zinc phosphate cements shrink more when they are in contact with air; thus, the
cement should not be allowed to dry out.
Zinc phosphate cement is the oldest of the luting cements and thus is the one that has the
longest "track record" and serves as the standard to which newer systems can be compared. It is a powder-liquid system; the powder is mostly zinc oxide (also consists ofmagnesium oxide in the approximate ratio of9 to 1), and the liquid is orthophosphoric acid.
The primary use of zinc phosphate cement is as a luting agent for the cementation cif cast
restorations. It can also be used as a base material when a high compressive strength is
needed.
It has superior strength compared to other cements, and its retention depends on mechanical interlocking (as opposed to glass ionomer and polycarboxylate cements which
adhere to tooth structure by virtue of the polyacrylic acid in the liquid).
1-----, 1. Zinc phosphate cement liquid that has lost some of its water content will
!Note
cause the setting time of the mix to be prolonged.

2. Mixing zinc phosphate cement very rapidly will decrease the final compressive strength of the cement.
b/i/c
Zinc phosphate cements shquld be mixeci on a cool glass sla.b,addil'lg asnlall
amount of powderto the liquid every20 seconds; This isdolle to gain which
of the following advantages.
.
Select all thatapply.
stronger final set

lower solubility
greater viscosity
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b/i/c
Which of the following statements are true regarding
tions?
ionomer restora:-
glass ionomer is often the ideal material of choice for restoring root surface caries in
patients with high caries activity
the best surface finish for a glass ionomer restoration is that obtained against a surface matrix
glass ionomers are somewhat esthetic and polish much better than composites
glass ionomer adheres to mineralized tooth tissue
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stronger final set

lower solubility
*** This is a disadvantage; it will create a material with lower viscosity, allowing it to
flow throughout the metal crown.
Mixing procedure for zinc phosphate cements:
o A cool mixing slab should be used
** Caution: The temperature of the slab should not be below the dew point of the
room.
o Mixing should be started with the addition of a small amount of powder to the liquid. This procedure, along with the cool slab, increases the working time.
o Small increments of powder are added approximately every 20 seconds with vigorous mixing until a creamy consistency is achieved. This will promote a high powderliquid ratio and a superior cementation medium by providing the following:
- a lower viscosity of the mix
- a stronger final set
- a lower solubility of the set cement
*** Important point: The advantages of using the cool slab method are a substantial increase in the working time of the mix on the slab and a shorter setting
time of the mix after placement in the mouth.
glass ionomer is often the ideal material of choice for restoring root
surface caries in patients with high caries activity
o the best surface finish for a glass ionomer restoration is that
btained against a surface matrix
o glass ionomer adheres to mineralized tooth tissue
*** It is true that glass ionomers are somewhat esthetic, however, they do not polish as well
as composites.
Both self-cured and light-cured versions of glass ionomers are available. Light-cured glass
ionomers are preferred because of both the extended working time and their improved physical properties. Because of their limited strength and wear resistance, glass ionomers are indicated generally for the restoration of low stress areas where caries activity potential is of
Significant concern.
Compared to composites, glass ionomers:
o Have a lower compressive strength, tensile strength, and hardness
o Are generally very technique-sensitive because of their high solubility when first mixed
Note: With the newer hybrid or light-cured resin-modified glass ionomers, the above properties have been improved.
Glass ionomers are generally considered the nearly ideal base/liner material because of the
following properties:
o Adhesive bond to tooth structure
o Snap set in the light-cured form (for example, Vitrebond)
o Anticariogenic: due to fluoride release
o Bond to composite: makes for excellent liners for Class V root caries restorations.
*** Sometimes called the "sandwich technique." This technique achieves all the benefits
of the glass ionomer cements plus the high polishability, surface hardness, and strong bond
to enamel of the composite resin.
b/i/e
Which of the following materials eQuid be.used to cementabridge and fill a
cervical lesion?
glass lonomer
zinc oxide-eugenol
zinc polycarboxylate
zinc phosphate
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b/lle
Zinc polycarboxylate cements are rarely usedand marketed, however they
were the first system to chemically bond to tooth structure. .

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glass ionomer
*** Only glass ionomer is used as a cement
agent) and a permanent restorative material. Glass

ionomer cements are often used for root surface carious lesions because of the potential advantage of fluoride release in helping to control the spread of caries.
After the setting, expansion due to water uptake has been observed for some of the newer resin-modified glass ionomer cements (Fuji Duet, Vitremer, and Advance) compared to a regular resin (bis-GMA
or urethane acrylate) cement such as PANAVIA 21, which is a self-cure resin cement, conventional glass
ionomer luting cements, and the old standby zinc phosphate cement. Traditional glass ionomer, phosphate, and resin cements all undergo contraction during setting. The bis-GMA or urethane acrylate resin
cements all undergo polymerization shrinkage during setting. However, the presence of glass filler in
some resin cement materials reduces the shrinkage and can impart radiopacity. Many of the resin cements
are now supplied in the form of dual-cure systems (photo-initiated as well as tertiary amine-peroxide reaction). Such materials include Adherence, Choice, DUO-LINK, Enforce, Lute-It, Nexus, Opal,
RESINOMER, Scotchbond Resin Cement, and Variolink.
Remember: It is important to note that the main function of a luting cement is to provide a non-permeable seal at the margins around the restoration. The marginal cement-filled gaps around inlays, crowns
and bridge abutments can range from 25 to 150flm. Research has shown that the wider the cement gap
at the margin, the greater the cement loss (ditching). A rough cement surface is an ideal site for plaque
accumulation. In such a situation, slow release of fluoride can be a very distinct advantage.
Important: In general, glass ionomer cements tend to have the least erosion, and polycarboxylate cements the most. However, solubility, erosion, and strength are significantly affected by the powder/liquid ratio used.
Note: Zinc oxide-eugenol (ZOE), reinforced ZOE, ZOE-EBA, silicate, and zinc silicophosphate cements
are no longer routinely used to permanently cement restorations. Zinc phosphate cement has been extensively replaced by polycarboxylate or glass ionomer cements. These cements are based on ion cross-linked
polyacrylic acid matrices that have the potential to react chemically with residual powder particles and the
surface of tooth structure.

Zinc polycarboxylate cement was the first system developed with a potential for adhesion to tooth structure via chelation. The polycarboxylate cements are powder/liquid systems. The liquid is an aqueous solution of polyacrylic acid and copolymers. The powder
is zinc oxide and magnesium oxide.
Zinc poly carboxylate cements have a compressive strength slightly lower than that of
zinc phosphate, while the tensile strength is higher. Its final strength depends on the
powder/liquid ratio, with more powder giving greater strength. The strength of the set
material is sufficient for amalgam condensation, and its effect on the pulp is mild enough
to eliminate the need for sublining. Thermal conductivity is low and, thus, the material
gives good protection against thermal stimuli applied to metallic restorations.
An advantage of zinc polycarboxylate cement is that it can bond to tooth structure. This
is attributed to the ability of the carboxylate groups in the polymer molecule to chelate
to calcium in the tooth. The most commonly noted disadvantages of polycarboxylate
cement is its marked thickness and short working time. Currently marketed brands include Durelon (3M ESPE), Liv Carbo (GC America), Hy-Bond Polycarboxylate (Shofu),
and Tylok-Plus (Dentsply/Caulk). The most recent innovation in these cements has been
the development of Durelon Maxicap, an encapsulated version ofDurelon. Because it is
mixed and expressed from a capsule, the traditional difficulties of short working time and
excessive thickness are overcome.
Remember: When cementing a cast restoration, always apply cement to both restoration and the tooth.
b/llc
When using a
cause zinc phosphate cemelits.cue riot
first.1hisis be":
. neither the statement nor the reason is correct
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b/llc
AlAn
base is a base that is typically placed over a calcium hydroxide base that has been placed over a pulp exposure.
primary base
secondary base
direct base
indirect base
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OPERATIVE
It should be emphasized that the use of a base in conjunction with amalgam or gold foil does
not alleviate the need for a varnish as an
in sealing the cavity margins against leakage.
However, the type of base governs the respective order of application of the varnish and the
base. If a zinc phosphate cement base is to be used, then the cavity varnish should be applied to the cavity walls prior to placement of the base. On the other hand, if a biocompatible agent (e.g., a calcium hydroxide, zinc oxide-eugenol, or polycarboxylate cement
base) is employed, then these should be placed against the dentin, and the varnish should
not be applied until the base material has hardened. Important: If varnish is added before a biocompatible base, it may prohibit positive qualities such as eugenol's soothing effect or polycarboxylate's chelation and adhesion.
Zinc phosphate cements provide good pulpal protection from thermal, electrical, and
pressure stimuli, but may damage the pulp as a result of an initial low pH. This, however,
can be of benefit as it provides an antibacterial effect that reduces the number of viable
microorganisms in the cavity floor and, thus, decreases pulpal irritation.
Important: Cements used for bases should be mechanically stronger than when used as
luting agents and are mixed with the maximum powder content that is possible. A low
powder-to-liquid ratio produces a low viscosity cement that is needed for luting agents.
Note: The varnish will reduce the initial microleakage of an amalgam restoration .
secondary base
Bases are classified as either primary or secondary:
Primary bases are placed on the dentin in close proximity to the pulp primarily to provide protection from toxic and thermal irritants. Under amalgam and tooth-colored
restorations, the primary base is usually calcium hydroxide, whereas, under gold restorations, the primary base is usually zinc phosphate cement or zinc polycarboxylate cement.
Glass ionomers are commonly used today, as well.
The most common use of a secondary base is the placement of zinc phosphate cement
over a calcium hydroxide base which has been placed over a pulpal exposure (direct pulp
cap).
*** Bases, in essence, serve as a replacement or substitute for the protective dentin that has
been destroyed by caries and/or cavity preparation. Important: The thickness of thermal insulation required for pulpal protection is 1000 to 2000 11m (1.000-2.000 mm).
Materials that have been employed as bases (bases are typically 1-2 mm thick):
Zinc phosphate cement: remember to seal dentinal tubules with varnish prior to application
Zinc polycarboxylate cement: provides adhesion
ZOE
Glass ionomer cement:provides fluoride release and adhesion
"Hard setting" calcium hydroxide materials: thicker than when used as a liner
Remember: All of the above are suitable as a base under amalgam restorations, however, for
composites, ZOE cannot be used because the eugenol will inhibit the composite setting reaction.
Important: (1) pulpal sensitivity is caused primarily by fluid flow in dentinal tubules; (2) fluid
flow is detected by mechanoreceptors on the edge of the pulp; (3) the reduction in tooth sensitivity with decreased fluid flow in tubules is related to the fourth power of the tubule radius.
b/i/e
Solution liners should not be
under composite restorations because
composites do not reqiJirethe pulpal protection.
the statement is correctr but the reason is not
the statement is not correct r but the reason is correct
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OPERATIVE
b/l/e
Suspension liners, for example calcium hydroxide, harden intraorally by the:
;
chemical reaction of acids and bases

chemical reaction involving polymerization
chemical reaction involving chelation
physical reaction of drying
physical reaction of a sol-gel transformation
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*** Solution liners should not be placed under composite restorations because they will inhibit the
polymerization of the resin. Suspension liners should be used for pulpal protection in this case.
Cavity liners are materials that are placed as thin coatings over exposed dentin. Their main purpose is to
protect the pulp by creating a barrier between the dentin and pulpally irritating agents (i. e., acids from
etchants or cements, restorative materials, etc.) by sealing the dentinal tubules.
Cavity liners are usually classified into two main groups:
1. Solution Liner (Varnish): thin film; typical thickness range is 2 to 5 Ilm (0.002-0.005 mm)
2. Suspension Liner: relatively thin film; typical thickness range is 20 to 25 Ilm (0.020-0.025 mm)
1. Solution liner: thin layer to seal off tubules

- Varnish:
Organic solvent based; water insoluble
1 to 2 Ilm film; used to line cavity up over cavosurface margins
Sets by physical reaction (drying) - just like finger nail polish
Commercial examples: COPALITE, Hydroxyline, Chembar, and Tubilitec
2. Suspension Liner:
Water solvent based; water soluble
20 to 25 Ilm film; used to line only the dentin
Sets by physical reaction (drying)
Commercial examples: Pulp dent and Hypo-Cal
Important: The above cavity liners are now being substituted with the new dentin bonding systems or
dentin sealers (e.g., Gluma or HurriSeal). The dentin bonding systems and dentin sealers are classified
as solution liners.
1. The average lifetime for the integrity of a varnish film is 1 month.
2. A 50% tubule coverage is produced by one thin coating of varnish. Hence, the reason varnishes should be applied in two thin coats.
3. The chemical composition ofCOPALITE contains organic resin, chloroform solvent, acetone solvent, and alcohol solvent.
physical reaction of drying

Dental materials that are designed as pulpal medicaments contain calcium hydroxide or eugenol.
Need depends on extent of cavity preparation:
Shallow = 0.5 mm into dentin (Remaining dentin?: 2 mm, not necessary)
Moderate = 1.0 mm into dentin (Remaining dentin = 0.5-2 mm, possibly necessary)
Deep < 0.5 mm from pulp (Remaining dentin:::: 0.5 mm, necessary)
Objectives for Pulp Medication:
Eliminate acute inflammation (by soothing the nerves)
Prevent chronic inflammation (stimulate secondaryireparative dentin)
Management of Acute Inflammation
Eugenol:
Palliative = mitigates, alleviates, or eases pain
Obtundent = reduces violence or pungency by dulling senses
Delivery:
Released from cement liner or cement base into dentinal tubules
Short-term effect
Management of Chronic Inflammation:
Calcium hydroxide:
Delivery:
Released from suspension liner, cement liner, or cement base
Very basic, dissolves in water, and diffuses to pulp
Accelerates formation of reparative or secondary dentin
Method of action unknown
Characteristics of Calcium hydroxide, Ca(OHh, pastes:
Generates very alkaline solutions, pH = 11.0
Aqueous pastes are viscous and do not wet dry dentin well
Apply without pressure only on concavely excavated dentin
Apply thickness that creates uniform appearance
Set materials are low strength, water soluble, and radiograph poorly
Commercial examples: DYCAL (LD Caulk), LIFE (Kerr), and Light-Cured DYCAL
caries
When removing caries, which ofthe foll()wing layersofdentin are affected,
but not infected, and therefore do not needto be removed? .
turbid dentin
infected dentin
transparent dentin
normal dentin
subtransparent dentin
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caries
The rate of senile.caries is increasing, in part, because of the increase in gingival recession.
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transparent dentin
Zones of carious dentin -- from innermost to outermost:
Zone 1 (normal dentin): totally normal dentin with no bacteria in the tubules.
Zone 2 (sub transparent dentin): zone of demineralization created by the acid from
caries. Damage to the odontoblastic process is evident, however, no bacteria are found
in this zone. Capable of remineralization.
Zone 3 (transparent dentin): softer than normal dentin, shows further demineralization. No bacteria are present. Capable of remineralization provided the pulp remains vital.
Zone 4 (turbid dentin): is the zone of bacterial invasion, tubules are filled with bacteria. Zone is not capable of remineralization and must be removed prior to restoration.
Zone 5 (infected dentin): the outermost zone, consists of decomposed dentin that is
filled with bacteria. Must be totally removed prior to restoration.
Four zones of an incipient lesion in enamel:
l.Translucent zone: the deepest zone, represents the advancing front of the enamel
lesion.
2. The dark zone: does not transmit polarized light. Areas of demineralization and remineralization.
3. The body of the lesion: the largest portion of the incipient lesion. Area of demineralization.
4. The surface zone: relatively unaffected by the caries attack.
The rising incidence of root surface caries (sometimes referred to as senile caries) can be
attributed to the aging of populations and the fact that most adults are retaining more teeth.
In this population, there is increased gingival recession with exposure of root surfaces,
leading to the development of root surface caries. Root surface caries usually appears as
a well-defined discolored area adjacent to the gingival margin, typically near the CEl. It
is found to be softer than the adjacent cementum or dentin. Root surface caries generally
spread more on the surface laterally around the CEJ rather than in depth. In older patients,
rampant caries can be caused by poor oral hygiene, decreased salivary flow, and side effects of medications. On a dental radiograph, root surface caries appears as a cuppedout or crater-shaped radiolucency just below the CEJ. Early lesions may be difficult to
detect on a dental radiograph.
Remember: Glass ionomer is a desirable restorative material for root surface caries
where esthetics is not a major factor.
r-<----!N.9t
1. Residual caries is caries that remain in a completed cavity preparation,

'whether by dentist intention or by accident.
2. Secondary (recurrent) caries is decay appearing at the margins of a restoration and under it.
3. The etiology of root surface caries is currently believed to be the same
as for coronal caries - S. mutans, S. sanguis, A. viscosus, A. naeslundii, Lactobacillus, and Veillonella.
caries
Chronic caries is characterized bywhich ofthe following . .
pain is common
slowly progressing or arrested
common in adults
entrance to the lesion is small
lesion is deep and narrow
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OPERATIVE
caries
-'--_ _-'-- is degraded by
mutans into ____ and-'----_ _-'
thereby causing caries initiation and progression.
sucrose, glucans, lactic acid

glucose, glucans, lactic acid
sucrose, glucose, acetic acid
glucose, sucrose, acetic acid
40
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slowly progressing or arrested

common in adults
Chronic caries is sometimes referred to as slow or arrested caries and is also characterized by the
following:
The lesion is shallow (small lesion)
The entrance to the lesion is wide
Dark pigmentation with leathery consistency
*** Chronic caries should be completely removed when found in enamel and close to
the DEl
"
*** With chronic caries, pain is uncommon
Acute caries, which is sometimes referred to as rampant caries, is characterized by:
The entrance to the lesion is small
The lesion is deep and narrow (large lesion)
Pain may be a feature
Little or no staining
Often multiple, soft-to-the-touch lesions
Most frequently found in children
Rapidly progressing
Note: Changes of the pulp and dentin depend on the rate of the carious progression. The response
of the pulp to carious attack or the trauma of operative procedures depends on the blood supply of
the pulp and its cellular activity.
Defense mechanisms of the pulp (to protect itfrom irritation):
Sclerotic dentin (peritubular dentin formation): initial defense. When it occurs due to the aging
process, it is called physiologic sclerotic dentin. When it occurs due to irritants, it is known as
reactive sclerotic dentin.
Reparative dentin (irritation dentin formation): second line of defense
Its vascularity (inflammation)
sucrose, glucans, lactic acid
*** Sucrose is degraded by Streptococcus mutans into glucans and lactic acid, thereby causing caries initiation and progression.
Pit and fissure caries has the highest prevalence of all dental caries. Smooth surface areas, especially the proximal enamel surfaces immediately gingival to the contact area are the second most susceptible areas to caries. Streptococci and lactobacilli species are common in this
area. The facial and lingual root surfaces may have plaque-containing filamentous actinomyces species that can cause root surface caries. Remember: Lactobacilli species do not
produce the dextran-like, extracellular long-chait). polysaccharides (fructans and glucans) as Lactobaciilus: pit and
do Streptococci species but produces a different extra-polysaccharide called lexan. The way fissure-lexan not dextran
that the lactobacillus species cause dental:caries in the pit and fissure areas is that it gets packed
into those pit and fissure areas, thereby exerting its effect.
Fluoride treatments will dramatically reduce smooth surface caries, although they are not
as effective in preventing pit and fissure caries. Sealing the pits and fissures just after tooth
eruption may be the single most important procedure to help protect these areas from caries
destruction.
Remember:The metabolic acids produced by Streptococcus mutans demineralize the tooth
surface and lead to dental caries. The enzyme glucosyltransferase (GTF) produced by Streptococcus mutans is the key factor in this process. Sucrose is a natural source of energy for this
enzyme, and GTF is the key enzyme that catalyzes the conversion of sucrose to dextran-like,
extracellular long-chain polysaccharides (fructans and glucans), which extrude from the bacterium and stick to the tooth.
Important: Predominant bacteria found in dental plaque:
Streptococcus sanguis (found the earliest) Veillonella, Lactobacilli, and Fusobacterium
Streptococcus mutans, mitis, and salivarius
caries
The initiation of caries requires four entities; chooset:he four entities from the
following choices.
host
bacteria
carbohydrates
saliva
time
41
OPERATIVE
caries
There is
proportion of:
evidence that: tile initiation of dental caries requires a high
lactobacillus within saliva
streptococcus mutans within dental plaque

lactobacillus within dental plaque
streptococcus mutans within saliva
42
OPERATIVE
host
bacteria
carbohydrates
.time
Dental caries is an infectious microbiological disease that results in the localized dissolution of tooth structure. For
caries to occur, a susceptible host (a tooth), microflora with cariogenic potential (plaque), and a suitable substrate (dietalY carbohydrates) all interact to promote the severity of the disease. Note: A certain period of time is also required
for caries to develop.
The greatest percentage of tooth loss in the first two decades of life (except from the natural loss of deciduous teeth)
is due to untreated dental caries. The rate at which the carious destruction of dentin progresses tends to be slower
in older adults than in young persons due to generalized dentinal sclerosis, which occurs with aging.
Protective mechanisms of saliva:
Bacterial clearance: glycoproteins in saliva cause some bacteria to agglutinate and then be removed by swallowing 1.5 L of saliva formed each day.
Direct antibacterial activity: salivary proteins (e.g., lysozyme. lactoperoxidase. lactoferrin. and secretory JgA)
discourage or even kill bacteria..
Buffering capacity: of saliva is major role in caries protection.
Remineralization: calcium, phosphate, potassium, and varying concentrations of fluoride are in saliva and assist with remineralization. Some salivary proteins promote remineralization, these include statherin, cystatins, histatins, and proline-rich proteins.
I. Flnoride and occlusal sealants modify the susceptible host (tooth).Remember: Fluoride provides fluoride ion for remineralization forming fluorapatite, which is more resistant to acid attack than intact hydroxyapatite crystals in enamel.
2. Enamel demineralization occurs at pH 5.5 or below. Remineralization of the damaged tooth structure occurs as the pH rises above 5.5.
3. The prevalence of caries has been declining in children. A decline in adult caries is not as evident.
Fluoridation has received the most credit for the decline in the development of caries.
4. Pregnant patients, compared with similar nonpregnant patients, are likely to have the same degree
of dental caries but more inflamed gingival tissues.
5. To create smooth surface caries, a microorganism must be able to produce dextran-like,
extracellular long-chain polysaccharides (fructans and glucans). This dextran-like material is a similar
product to that which is produced by barnacles to allow them to attach to the bottom of a ship. It is a very
tenacious sticky material. Some members of the streptococci family (i.e., Streptococcus mutans) are able
to produce enough dextran to attach to the tooth's surface.
streptocoCCUS mutans within dental plaque
The first event in the development of caries is the deposit of plaque on the teeth. Dental plaque
is a highly organized gelatinous mass of bacteria that adheres to the tooth surface. Streptococcus
lIlutans produce great amounts of lactic acid (acidogenic), are tolerant of acidic environments
(aciduric), are vigorously stimulated by sucrose, and appear to be the primary organisms associated with dental caries, however, they are not the only organisms required for caries initiation.
Other mutans streptococci species in humans can do this as well (for example. S. sobrinus).
Factors to which the tooth surface is directly exposed,'and which contribute

to the development of dental caries
Facto':
High Risk
Amount of plaque
Large amount of plaque on teeth, meaning many bacteria that can

produce acids (low pH, demineralization)
Large proportion of "cariogenic" types of bacteria, resulting in
lower pH and sticky plaque and also prolonged acid production
Type ofbacyeria
..
..
Type of diet
High sugar frequency resulting in longer time per day with low pH
Frequency ofcarb6hydra.tes
Saliva secretion
....
..
Saliva o';1ffer capacitY

Fluorides
High in carbohydrates, in particular sucrose; "sticky" diet leading to

low pH for a longer time
Reduced salivary flow leading to prolonged sugar clearance time

and to a reduced amount of other saliva protective systems
Low buffer capacity resulting in prolonged time with low pH
Absent: reduced remineralization
Note: Xylitol, which is a natural sugar from birch trees, keeps sucrose molecules from binding
with mutans streptococci. Streptococcus mutans cannot ferment xylitol. Additionally, xylitol causes
the environment to become more alkaline, inhibiting the bacterium's growth.
caries
acidogenic, cariogenic
aciduric, cariostatic
acidogenic, cariostatic
aciduric, cariogenic
43
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comp
UV light curing systems are n() longer used and that is because dual-cure systems fixed the problem ofllincomplete curing:'
44
OPERATIVE
acidogenic, cariogenic
*** Streptococcus mutans are acidogenic and, therefore, cariogenic. This means that these
species produce acid and, therefore, cause the initiation and progression of caries.
Cariogenic bacteria:
Especially members of the mutans streptococci-group (e.g., Streptococcus mutans and
StreptocOCC1jS sobrinus)
Lactobacilli casei
Note: Most current research suggests that the microbial etiology of root caries is very similar to coronal caries. In the past it was thought that Actinomyces species (viscosus and
naeslundii) were most commonly associated with root surface caries.
Essential properties of cariogenic bacteria:
Acidogenic (produce acid) and aciduric (being able to tolerate an acid environment)
*** Note: Lactic acid is formed in large quantities following the degradation of sucrose
by mutans streptococci.
The ability to attach to the tooth surface. Note: Streptococci species have special receptors for adhesion to the surface and also produce a sticky matrix that allows them to cohere
to each other.
The ability to form a protective matrix. Note: Streptococci species produce dextran-like,
extracellular long-chain polysaccharides (fructans and glucans), which extrude from the
bacterium and stick to the tooth, which protects it from being removed from the tooth by
saliva, liquids, foods, and masticatory forces.
Dental plaque describes the soft white film of organized bacterial colonies (main component),salivary glycoproteins, and inorganic material that readily forms on the surface of teeth.
Note: The strong correlation between the presence of dental plaque and the appearance of
dental caries and periodontal disease has been recognized for many years .
Light curing of composite formulations arose during the late 1960s with the adoption of ultraviolet (UV)
light-polymerized systems. In just a few years, it became obvious that visible light-cured (VLC) composites had many advantages over UV light-cured composites, and practitioners made the shift. Dentistry
has been wed to VLC systems ever since.
VLC systems have totally displaced the UV light systems. Also, VLC systems are much more widely
used than the chemically activated ones (self-cured). An advantage oflight-curing systems as a whole
is that the dentist has complete control over the w'orking time and is not confined to the built-in curing
cycle of the self-cure. This is particularly beneficial when large restorations are placed.
Note: To deal with problems of incomplete curing with VLC due to the thickness of restorations and filler
particles scattering light, manufacturers have developed composite resins that are dual-cured, which
combines self-curing and VLC. Another polymerization method is staged curing, which is a two-staged
cure. However, VLC composites are still the most popular today.
Remember: VLC composites are single-component pastes, and the polymerization process is activated
by an extemal energy source. The alpha-diketone initiator (generally camphor quinone) absorbs energy from a visible (474 nm-blue light) light source. The ketone absorbs energy and reacts with an amine
(added to the system to enhance the effect of the light-sensitive catalyst) to produce free radicals.
1. For large restorations (those that are wider than the diameter of the light tip), cure each
area for the full required time. Do not back off light tip until it lights up entire surface of
restoration.
2. VLC involves light energy in the range of 410 to 500 urn with a peak intensity of about
470 nm.
3. The minimum acceptable level for visible curing light outputs is 300 mW/cm2
4. The tip of the light source should be held within 1 to 2 mm of the surface to cure a light
shade of material to a depth of2.0 to 2.5 mm using a standard exposure time of 40 seconds.
comp
All of the following statements are true concerning posteriQr c()mposite
.
.
restorations EXCEPT one. Which one is the EXCEPTiON? .
posterior composite restorations are frequently indicated in the treatment of occlusal

lesions that allow conservative preparations
posterior composite restorations are contraindicated in a patient with heavy occlusion
(bruxism)
posterior composites are contraindicated in patients with high caries risk

posterior composite restorations may be indicated for the restoration of Class II cavities in premolar teeth where the appearance is very important, the cavity margins
are in the enamel, and the occlusal contacts are on the enamel
posterior composites are contraindicated for cusp replacements unless a dry operating field is maintained
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comp
Which property of filled resins is primarily to blame for thefailure of Class II
composite restorations?
low flexural strength

low compressive strength
low tensile strength
low wear resistance
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OPERATIVE
posterior composites are contraindicated for cusp replacements

unless a dry operating field is maintained
Although the ADA does not endorse composite resins as a substitute for amalgam in posterior teeth,
composite restorations can be excellent if strict guidelines are followed for tooth selection and if the
restorations are done properly. But remember, composite resin restorations are inferior to amalgam in
terms of compressive strength and abrasion resistance (occlusal wear). Also, current composite resins
have no capability to provide an anticariogenic effect as do freshly placed glass ionomer or resin modified glass ionomers, for example.
The most serious limitation of the visible light-cured VLC posterior composite restoration is the polymerization shrinkage, which can cause internal stresses and gap formations at butt-joint interfaces,
which are seen at the gingival floor of Class II and V restorations. Important: Stress from polymerization shrinkage is influenced by restorative technique, modulus of resin elasticity, polymerization rate, and
cavity configuration or "C-factor." The C-factor is the ratio between bonded and unbonded surfaces; an
increase in this ratio results in increased polymerization stress. Three-dimensional cavity preparations
(Class J) have the highest (most unfavorable) C-factor because only"outer unbonded surfaces absorb
stress. To minimize the stress from polymerization shrinkage, efforts have been directed toward improving placement techniques, material and composite formulation, and curing methods. Incremental
curing reduces the C-factor and, therefore, reduces the residual stress of the resulting composite restoration.
Note: The major indication for the use of posterior composites is the demand for esthetics by the dentist and patient. Other criteria are noninvolvement of cusps, minimal occlusal contact, no excessive wear,
and the isthmus must be no wider than one-third of the intercuspal distance.
Remember: Composite is the material of choice if the patient has a documented allergy to mercury.
Important: In the past, posterior composite restorations were contraindicated in a patient with a caries- ,
active mouth. New concepts stress that you should manage the disease (i.e., dental caries) before or at
the same time as you are treating the consequence of the disease (i.e., by placing restorations). Therefore, the current literature does not see a special problem for these restorations in caries-active patients.
They have as bad a prognosis as any other restorative treatment if the disease is not managed simultaneously. Note: However, for the National Boards, it is still a contraindication.
low wear resistance

Ideally, composite resins should be used only to restore minimal cavities in posterior teeth.
Its use should be restricted to those instances which it will not be subjected to excessive
occlusal forces and when teeth are in occlusion, there is cusp-to-cusp contact and not cusp
to restoration.
For Class III preparations using resins, the rule of extension for prevention into embrasures is disregarded for Class III esthetic restorations. This compromise is for esthetic reasons, as well as the unnecessary removal of tooth structure, which will often involve the
incisal edge. If possible, the outline form should place the gingival margin incisally from
the crest of the gingiva.
When placing the composite resin in a Class III preparation, the wooden wedge is placed
to provide some separation of the teeth (for contact), to stabilize the mylar strip, and to
avoid creation of excess gingival flash. Important: Restoring the contact area must be
done properly and diligently.
Remember: For Class III composite preparations, the retentive grooves are placed along
the gingivoaxial and incisoaxialline angles (entirely in dentin). These grooves will provide for mechanical lock in the preparation. Small, rounded retentive areas are preferred,
as contrasted to sharp angles, since it is difficult to insert viscous composite material into
the sharp angles.
Note: Once proper finishing has been completed, a thin layer of unfilled resin can be applied as a glaze (this seals the margins and smoothes the surface). The difficulty in finishing composite resin restorations is due primarily to the softness of the resin matrix and
hardness of the filler particles. The most desirable finished surface for composites is obtained with aluminum oxide disks.
comp
Which composite type is 70% to77% percentfiHed by volume.andhas an
average particle size ranging from 1 to3llm.
microfills
hybrids
microhybrids
packables
flowables
47
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comp
Composite filler particles function to dowhich of the following?
reduce the coefficient of thermal expansion

increase the tensile strength and compressive strength
reduce the polymerization shrinkage
increase the hardness
improve wear resistance
48
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hybrids
The first composite resins that were developed contained large filler particles (10-100 microns in diameter) and became
known as macro fill materials. In the past 20 years, resin-based composites have been improved by reducing particle size, increasing filler quantity, improving adhesion between filler and organic matrix, and using low-molecular-weight monomers
to improve handling and polymerization. By experimenting with particle size, shape, and volume, manufacturers have introduced resin-based composites with differing physical and handling properties. Microfill, hybrid, microhybrid, packable, and
flowable composites now are available to be used for varying clinical situations.
Microfills: are 35% to 50% filled by volume and have an average particle size ranging from 0.04 to 0.1 flm. They have
low modulus of elasticity and high polishability; however, they exhibit low fracture toughness and increased marginal
breakdown.
Hybrids: are 70% to 77% filled by volume and an average particle size ranging from 1 to 3 flm. They do not maintain a high polish but do have improved physical properties when compared with micro fills.
Microhybrids: are 56% to 66% filled by volume and have an average particle size ranging from 0.4 to 0.8 flm.
They have particle sizes small enough to polish to a shine similar to micro fills but large enough to be highly filled, thus
achieving higher strength. The results are resin-based composites with good physical properties, high polishability, and
improved wear resistance.
Packable composites: are 48% to 65% filled by volume and have an average particle size ranging from 0.7 to 20
flm. Their improved handling p,operties are obtained by adding a higher percentage of irregular or porous filler, fibrous
filler, and resin matrix. They are indicated for stress-bearing areas and allow easier establishment of physiological contact points in Class II restorations. Research has shown that the physical properties of packable composites are not superior to conventional hybrids.
Flowable composites: are 44% to 54% filled by volume and have an average particle size ranging from 0.04 to 1
flm. Their decreased viscosity is achieved by reducing the filler volume so they are less rigid, yet they are prone to more
polymerization shrinkage and wear than conventional composites. Flowable composites have been said to improve marginal adaptation of posterior composites by acting as an elastic, stress-absorbing layer of subsequently applied resin-based
composite increments.
'R.--'t-or-.-tiy:-e-M-.7'c-ri-a'-----:-rA-p-p'-ic-at-io-n---------------,
Flowable
PRRs, Small Class V's. linerlbase under posterior composite
Hybrid: ,microhyhr!d.
Anterior restorations, posterior restorations
composite
resin composite.
,,';
Esthetic areas, anterior restorations
'
Class I & II restorations
to1yacid-modified resin cqrnposite
Class III and V restorations, cervical erosion/abrasion, Class I & II

in pediatric patients, sandwich technique for Class II restorations
Glass io"nomer
High caries risk, cervical abrasion lesions, Class V where esthetics

is a concern, atraumatic restorative tx
Hybrid iO,nomer
Class III and V restorations, cervical erosion or abrasion, Class I in

pediatric patients, sandwich technique for Class II, Iinerslbasesl
luting cements, temporary restorations
'
..
'.
reduce the coefficient of thermal expansion

increase the tensile strength and compressive strength
reduce the polymerization shrinkage
increase the hardness
Fillers are placed in dental composites to reduce shrinkage on curing. Physical properties of composite are improved by fillers, however, composite characteristics change based on filler material, surface, size, load, shape, surface modifiers, optical index, filler load, and size distribution.
Composition of composites (filled resins):
Filler particles: the filler particles used are strontium glass, barium glass, quartz, borosilicate glass, ceramic, silica, prepolymerized resin, or the like. The particles are usually combined with 5% to 10% weight of very smallsized (0.04 /lm) particles of colloidal silica. Note: One micron is a critical filler size. Fillers greater than one micron are visible to the human eye. As resin matrix around filler particles wears, the filler becomes prominent and
visible so the composite surface looks rough. Fillers less than one micron do not produce a rough-appearing surface with aging. Fillers greater than one micron are referred to as macro fills, and fillers less than one micron are
referred to as microfills (midi and mini are in between macro and micro). A new classification of filler is the
nanoparticles. The nanoparticles fill between all other particles to further reduce shrinkage. A mixture of different particle sizes is referred to as a hybrid.
Matrix: difunctional monomers either bis-GMA or urethane dimethacrylate (UEDMA). In some cases, a proportion of a lower-molecular-weight monomer, such as TEGDMA, is introduced to lower the viscosity.
Coupling agent: silane which acts as an adhesive between the inert filler and the organic matrix.
*** Recently, ions have been added to the filler to produce desirable physical changes. Lithium and aluminum ions
make the glass easier to crush to generate small particles. Barium, zinc, boron, zirconium, and yttrium ions produce
radiopacity in the filler particle.
I. The normal wear mechanism of the composite resins is best explained by the following events: abrasion of the matrix, followed by exposure of filler particles and subsequent dislodgement of these filler
particles.
2. With any of the restorative resins, cavity varnish or zinc oxide-eugenol should not be used as they
might inhibit polymerization. The use of a cavity varnish might prevent direct contact between the composite and the tooth structure, preventing bonding.
comp
When comparing the physical properties of filled resins to
resins, all
of the following are true EXCEPT one. Which one is the EXCEPTION?
filled resins are harder

unfilled resins have a higher coefficient of thermal expansion
filled resins have a higher compressive strength
unfilled resins have a lower modulus of elasticity
filled resins have a lower tensile strength
49
,OPERATIVE
comp
When restoring a darker shade of composite, keep in mind the following:
UV light is better than visible light

you must keep the light 2 mm away or more
you should cure for longer than normal
darker shades have less chemical bonding
50
OPERATIVE
filled resins have a lower tensile strength

***This is false; filled resins have a higher tensile strength.
The most common classification method for composite resins is based on filler content, filler
particle size, and the method of filler addition. Almost all important properties of composite resins are improved by using higher filler levels. However, as the filler level is increased,
the fluidity decreases.
Highly filled resins typically contain large filler particles but this composition results in a
rough finished surface. Smaller filler particles, are used to produce a resin that has a relatively smooth finished surface.
Resin filler particles are called:
Macrofillers: 10 to 100 microns in diameter
Midifillers: 1 to 10 microns in diameter
Minifillers: 0.1 to 1 microns in diameter
Microfillers: 0.04 to 0.1 micron in diameter. Examples include Dentacolor, Durafill,
Heliomolar R.O., and Silux Plus.
***Hybrid resins .contain a mixture of particles with different diameters, which allows higher
filler levels and still permits good finishing. The principal particle size range from 1 to 3 !lm
Charisma, Herculite XRV, Prodigy, Tetric, TPH (Total Performance Hybrid), and Z100 are
examples.
Note: Hybrid and micro fill resins utilize colloidal silica fillers, which are useful for in-',
creasing the hardness and wear resistance of the base resin material while maintaining high pol- .'
ishability and overall esthetic qualities.
***New resins with nanofillers that range in size from .005 to 0.01 micron have recently been
developed. These particles are so small that very high filler levels can be achieved while still
maintaining workable consistencies. Supreme H-NF and Simile H-NF are examples .
you should cure for longer than normal

Important points to remember when using a visible light-curing unit:
Hold the light as close to the resin as possible - within 2 mrn to be effective.
Place a shield between the light tip and the operator's eyes. Patients who have had recent cataract removal should
have protection also. Note: Studies have shown that the visible light used in polymerization of photo-activated materials can cause retinal damage - always use a shield and eyeglasses for protection.
For deep restorations, you have to cure the composite in increments - if you don't, the deeper areas will not
be cured. Important: No more than 1.5 mm to 2 mm increments should be light cured at one time.
Make sure the bulb in the light is still powerful enough - they have commercially available products to test
the bulb.
With darker resin shades, cure a little longer.
,
I
comp
Of the following, which ones are current monomers for composite

Selectall that apply.
'
bis-GMA
PMMA
UEDMA
TEGDMA
51
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comp
The main ingredient in traditional acrylic resin temporary materials for intraoral fabrication is:
ethyl methacrylate
isobutyl methacrylate
bis-GMA
ethylene imine
methyl methacrylate
52
copyright I) 2013-2014 - Dental Decks
OPERATIVE
bis-GMA
.UEDMA
.TEGDMA
Dental resin composites typically contain a mixture of soft, organic resin matrix (polymer)
and hard, inorganic filler particles (ceramic). Other components are included to improve the
efficacy of the combination and initiate polymerization. The resin matrix consists of monomers, an initiator system, stabilizers, and pigments. The inorganic filler consists of particles
such as glass, quartz, and colloidal silica. The matrix and filler are bonded together with a
coupling agent. The performance of resin composites depends om these basic components.
The recent improvement in these materials has primarily focused on filler technology, but the
resin monomers have remained largely unmodified.
The organic resin matrix is a high-molecular-weight monomer, such as bisphenol A glycidyl
methacrylate (bis-GMA) or urethane dimethacrylate (UEDMA). bis-GMA, which stands for
2,2-bis [4(2-hydroxy-3-methacryloxypropoxy) phenyl]-propane, is an aromatic methacrylate.
Terminal methacrylate groups provide sites for free radical polymerization; it sets to a relatively rigid polymer because it has two benzene rings near its center.
Two disadvantages ofbis-GMA are its questionable color stability and high viscosity; high viscosity is the result of its -OH groups which hydrogen bond; to lower the viscosity, manufacturers add low-molecular-weight (low-viscosity) monomers like triethyleneglycol
dimethacrylate (TEGDMA) and ethylene glycol dimethacrylate (EGDMA); these reduce the
bis-GMA's viscosity, increase cross-linking, and increase hardness. Another monomer frequently used as the matrix for resin composites is UDEMA. This monomer was introduced in
1974 and is a brittle material with low viscosity.
Important: The high filler content and the bis-GMA resin matrix drastically reduce the coefficient of thermal expansion (as compared to the unfilled acrylic resins). The filler also reduces
polymerization shrinkage and increases hardness.
methyl methacrylate
For both inlays and onlays, plastic (acrylic) provisional restorations are fabricated prior to the
final restoration being cemented. Their physical properties enable them to withstand occlusal
forces and the adverse oral environment for short periods. These temporaries must: restore
and maintain proximal contacts, restore and maintain the occlusion, restore and maintain tooth
contours, and the margins should be closed and flush with the tooth.
Methyl methacrylate, ethyl methacrylate, and ethylene imine resins have been employed to
produce provisional restorations. However, methyl methacrylate (MMA) is by far the most
common. It is the liquid monomer that is mixed with the polymer polymethyl methacrylate
(the powder). The monomer partially dissolves the polymer to form a plastic dough.
Note: The monomer is polymerized by the action of an initiator (benzoyl peroxide).
Important: MMA maintains the occlusal and interproximal contact relationships.
Remember: Polymerization should not go to completion in the mouth for fear of overheating the pulp and that the provisional will not be able to be removed from the tooth.
Note: These provisionals are usually cemented in with a ZOE cement.
Classification for provisional restorations:
- Intracoronal Restorations:
ZOE-based and/or ZOE-based temporaries
- Preformed Provisional Shell Crowns:
Po1ycarbonate Crowns
Metal Alloy Crowns
- Custom-Fabricated Provisional Crowns:
MMA-like products (MMAlPMMA, IBMAJPBMA, EMAJPEMA) - self-cure
Epimine-imine products - self-cure
Bis-acryl, bis-methacryl, bis-GMA-like - self-cure, dual cure, VLC
- Resins and Composites
comp
Which restorative material has the lowest thermal conductivity and diffusivity?
amalgam
gold
unfilled resin
filled resin
53
OPERATIVE
comp
Acid etching enamel prior to placement of a composite restoration is required
for all of the following reasons EXCEPT one. Which one is the EXCEPTION?
conserves tooth structure

reduces microleakage
provides micromechanical retention
increases esthetics
54
OPERATIVE
unfilled resin
This characteristic probably offsets, to some degree, the undesirable effects of the relatively high coefficient of thermal expansion, which is 7 to 8 times that of the tooth. Due
to this low thermal conductivity and diffilsivity, the unfilled resin restoration changes temperature quite slowly. Therefore, it takes considerably longer for the unfilled resin restoration to become hot or cold, as compared to metallic restorations, which have a high
thermal conductivity and diffusivity.
The first materials that were used as esthetic materials were based on silicate cements. Due
to solubility problems, the silicate cements were replaced by unfilled acrylic resins. Unfilled acrylic resins contracted excessively during polymerization, permitting subsequent
marginal leakage, and were not strong enough to support occlusal loads. These unfilled
acrylic resins have been replaced by filled resins (also called composite resins). A filled
resin is one in which an inorganic inert filler (usually silica or quartz) has been added to
. the resin matrix.
1. The compressive strength of the unfilled resin is low; the yield strength
and tensile strength are even lower.
2. Unfilled resins are the softest of all restorative materials (low wear resistance - no filler)
3. Compared with amalgam, filled resin, direct gold, and silicates, unfilled
resins show the greatest extent of marginal leakage related to temperature'
change (percolation).
Remember: A low coefficient of thermal conductivity is most characteristic of currently
available cement bases.
increases esthetics
*** This is false; acid etching does not increase the esthetics of the enamel margin. Do
not be confused by the fact that you acid etch the bevel, which itself functions for retention and esthetics.
One of the most effective ways of improving the marginal seal and mechanical bonding
of composite resins to tooth structure is to condition or pretreat the enamel with acid prior
to insertion of the resin. This procedure is referred to as "acid-etch" technique.
Purposes of acid etching:
1. Increases surface energy, which promotes wetting and adhesion.
2. Chemically cleans the tooth structure, which also promotes wetting and adhesion.
3. Creates micropores for micro mechanical retention.
Important: Acid etching paves the way for resin "microtags," which produces a much
improved bond of the resin to the tooth. The effective tag length, as a result of etching
on adult anterior teeth, has been demonstrated to be approximately 7 to 25 11m .
This "acid-etch technique" conserves tooth structure, reduces microleakage, improves
esthetics, and provides micromechanical retention.
1. The aim is to cause maximum enamel dissolution with minimum precipitation of calcium phosphate salts.
2. Studies indicate that acid-etched composite resin restorations have the best
initial seal (microleakage), however, over time, this weakens (amalgam has the
best seal over time).
comp
Enameletching is typically completed with:
i'
37% phosphoric acid

13% phosphoric acid
37% hydrochloric acid
13% hydrochloric acid
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comp
When preparing a Class V composite preparation, you can have _ __
rounded internal line angles because it is
to compress composite
into them than amalgam.
more, easier
less, harder
more, harder
less, easier
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.37% phosphoric acid

Standard acid etching of enamel involves the application of 37% phosphoric acid for 15
seconds with a IS-second rinse and a IS-second drying to roughen the surface of the
enamel. This forms little tags approximately 7 to 25 J..lm in length, providing mechanical retention. When using the acid etch technique, all enamel cavosurface margins should
be chamfered or beveled (this process forms obtuse angles).
Beveling the enamel margins of anterior resin composite preparations is recommended
prior to etching to:
Reduce micro leakage
Improve esthetics: by gradually blending the resin composite into the enamel
Increase bond strength: transversely cut enamel, when etched, provides a stronger
bond to resin composite than etched, longitudinally cut enamel. This occurs because the
end of enamel rods are more completely exposed to the etchant and, therefore, more
effective etching is accomplished and more retentive tags are produced.
Remember: Once you etch the tooth, it cannot be contaminated with saliva. If it is contaminated, you must complete the entire etching procedure again.
1. The depth of enamel dissolution caused by acid etching is approximately 10
to 15 microns.
2. Little correlation exists between resin tag length and enamel/resin bond
strength.
3. Although liquid etchants produce a more uniform etch and a greater number of tags than do gel etchants, no difference in bond strength has been demonstrated between the two.
more, easier
*** When restoring teeth with composite resin, it is much easier to compress the material into rounded line angles.
The outline form of a Class V restoration is not always uniform, as it will vary depending on the location and amount of caries or decalcification-the size and location of the
carious lesion determines the outline form of the cavity preparation. When the carious tissue has been removed and the margins are on reliable enamel or dentin, the outline will
usually be rectangular with the comers round, ovoid, or kidney-shaped, very much resembling the amalgam Class V preparation except that the internal line angles are much
more rounded.
Recent research indicates that preparations with bevels are more resistant to microleakage as compared with those without bevels when an acid-etch technique is used. The
bevel permits the acid to attack the enamel rods at the appropriate angle for maximum effect. The cavosurface margin is beveled wherever it is placed on enamel- this is a major
difference between composite and amalgam preps. When possible, an enamel bevel 0.2
to 0.5 mm wide is advocated as the final stage of preparation. This bevel is etched and provides retention for the restorative material as well as improving the marginal seal and
maintaining the strength of the resin with sufficient bulk. Retentive grooves supplement
the etched enamel retention (these grooves are placed in both incisal and gingival axial
line angles).
Note: Whenever possible, use a composite syringe to place the composite resin in the
restoration -- this will minimize the possibility of trapping air in the final restoration.
comp
Which one of the following IS the. most important event for dentin bonding?
smear layer removal

smear plug removal
peritubular dentin decalcification
intertubular dentin decalcification
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gold
A gold onlay you placed last week fails; Which of the following reasons is most
likely responsible for the failure?
'
you "capped" the functional cusp

you "shoed"the functional cusp
you "capped" the nonfunctional cusp
you "shoed"the nonfunctional cusp
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intertubular dentin decalcification

Dentin bonding systems (DES) consist of3 components:
Etchant: Typical acid conditioners include phosphoric acid, EDTA, maleic acid, and citric acid.
Primer: is designed to penetrate through the remnant smear layer and into the intertubular dentin to fill the
spaces left by dissolved hydroxyapatite crystals. This allows the primer to form an interpenetrating network around
dentin collagen. Note: The bonding primer is based on hydrophilic monomers, such as hydroxyethyl methacrylate (HEMA).
Bonding agent: unfilled resin adhesive is applied. The resin is then cured (light-, self-, or dual-cured). This layer
can now bond to composite or amalgam.
Examples of current dentin bonding system designs:
2-component systems (EP + B)
1-component systems (EPB)
CLEARFIL SE BOND & LINER BOND 2V (Kuraray)
AQ Bond (Sun Medical)
TYRlAN SPE (Bisco)
or Touch & Bond (Parkell)
Adper Prompt L-Pop (3M-ESPE)
Optibond Solo SE Plus (Kerr)
3-component systems (E + P + B)
2-component systems (E + PB)
Scotchbond Multi-Purpose Plus (3M)
Syntac Single -Component (IvoclarNivadent)
Permaquick (Ultradent)
One Coat Bond Self-Etching Bond
(ColtenelWhaledent)
Bond-It (JenericlPentron)
ALL-BOND 2 (BISCO)
Bond-l (JenericlPentron)
Generations of Dentin Bonding Systems (DES):
1. First-Generation DBSs (bonded to smear layer)
2. Second-Generation DBSs (modified/removed smear layer)
3. Third-Generation DBSs (modified/removed smear layer; produced hybrid layer)
4. Fourth-Generation DBSs (optimized for smear layer modification + dentin wetting): three-step etch & rinse
5. Fifth-Generation DBSs (Reduced-Component Bonding Systems): two-step etch & rinse
6. Sixth-Generation DBSs (True One-Component Bonding Systems): subdivided into Type 1 (i.e., two-step; acidified primer and adhesive applied separately) and Type 2 (i.e., one-step; self-etching adhesives are mixed and applied).
7. Seventh-Generation DBSs: adhesives require no mixing and are simply placed in one step.
1. Dentin and enamel bonding strengths are similar for current total-etch products.
2. Most total-etch dentin bonding systems bond better to moist dentin, use Aqua-Prep or Gluma Desensitizer to keep dentin moist.
3. Enamel bonding is fast, strong, and long-lasting; dentin bonding is slower, may be strong, but may
not be long lasting.
you IIshoed" the functional cusp
*** Important: "Shoeing" is never indicated on functional cusps.

Onlay preparations:
Resistance form: two types of cuspal protection:
1. "Capping": refers to the complete coverage of functional cusp with 1.5 rom of gold.
2. "Shoeing": refers to veneering of nonfunctional cusp by means of a slight finishing
bevel.
Note: Except in situations demanding a minimal display of gold (primarily the facial
cusps of maxillary molars and premolars), capping is always preferred over shoeing.
Shoeing
Capping
Onlay preps have:

Improved resistance to fracture due to cuspal coverage
Thickness of gold on occlusal (1.0 mm on nonfunctional cusp and 1.5 mm onfunctional
cusp) resists deformation
Reliance on tapering lingual and buccal walls for retention
Reciprocation of mesial and distal axial walls (near parallel)
External extensions over the cusps add retention if nearly parallel to line of draw
gold
Rapid cooling (by immersion in water) ofa dental casting from th.e high
perature at which it has been shaped is referred to as:
annealing
tempering
quenching
none ofthe above
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gold
Which of the following situations defines an Indication for a Class II gold inlay?
a young patient with high caries rate

a patient with little money to invest in dental work
a patient very concerned about esthetics
a patient with a large lesion, buccal-lingually
a patient with low caries rate but a history of periodontal problems
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quenching
This usually is undertaken to maintain mechanical properties associated with a crystalline

structure or phase distribution that would be lost on slow cooling.
Two advantages gained in quenching:
1. The noble metal alloy is left in an annealed condition for burnishing, polishing, and
similar procedures - it maintains its malleability and ductility.
2. When the water contacts the hot investment, a violent reaction ensues. The investment becomes soft and granular, and the casting is more easily cleaned.
Remember: The set of 3 processes (annealing, hardening and tempering) is collectively

known as "heat treating."
Annealing is the softening of a metal by controlled heating and cooling to make its
manipulation easier. It makes the metal tougher and less brittle.
Tempering is hardening something by heat treatment.
a patient with low caries rate but a history of periodontal problems
Disadvantages and contraindications for a Class II gold inlay:

Expense: gold is 6 to 7 times more expensive than amalgam
Time: at least two visits are necessary
Minimal lesions: best restored with gold foil
Large lesions: if cavity width exceeds one-third the intercuspal width, the tooth
should receive cuspal coverage
In patients with a high caries rate
Young patients
Color: not esthetic
Advantages and indications for a Class II gold inlay:
Tooth contours: where optimum contour and surface finish is desired to maintain
periodontal health
Strength
In patients with a low caries rate
Use against another gold restoration
Biocompatible
Note: A gold inlay is defined as a cast gold restoration that derives its retention from
the internal walls of the cavity preparation.
Remember:
noble metal- metal that is resistant to oxidation; includes gold, platinum, palladium,
and other platinum metals.
nonprecious meta1- relatively inexpensive base metal, such as nickel, chromium, and
cobalt.
precious metal- an expensive metal; includes gold, platinum group metals, and silver.
gold
Gold alloys
.. upon solldificationin the investment. This needs tobe
compensatedfor byan equalamounfof
ofthe mold. -
shrink, expansion
expand, shrinkage
shrink, shrinkage
expand, expansion
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gold
Which of the following finishing margins is essentially a hollow ground bevel,
, creating more bulk of restorative material near the margin and providing a
greater cavosurface angle?
knife edge
beveled shoulder
chamfer
shoulder
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shrink, expansion
Gypsum bonded investments are used with Type I, II, and III gold alloys. Gold alloys
used for cast gold restorations shrink on solidification. Therefore, it is necessary to compensate for the solidification shrinkage of the specific alloy used by expanding the mold
enough to equal the shrinkage.
The dimensional compensation necessary is accomplished by two methods of expansion:
1. Setting expansion: occurs as a result of normal crystal growth but can be enhanced
by allowing the investment to set in the presence of water, producing hygroscopic expansion.
2. Thermal expansion: is achieved through the normal expansion that occurs on
heating the silica (quartz or cristobalite). Note: The amount of expansion depends on
the particular refractory material used (cristobalite produces greater expansion than
does quartz).
Important: Thermal expansion is the principal cause for mold expansion.
Variables that influence expansion:
The older the investment is, the less it will expand
If the water/powder ratio is increased, the expansion is reduced
The longer the spatulation time, the greater the expansion
The longer the time between mixing and immersion in a water bath, the less it will
expand
Note: During solidification of an alloy, the number of grains forming depends on the rate
of cooling and the presence of nucleating agents.
chamfer
A chamfer is essentially a hollow ground bevel. Instead of a flat diagonal cut across the
cavosurface margin, the chamfer is "scooped out," creating more bulk of restorative material near the margin and providing a greater cavosurface angle.
Cavosurface angle configurations that are used when preparing a tooth for a cast gold
restoration:
A bevel is a diagonal cut across the cavosurface margin that is flat in one dimension only and curved in its other dimensions. It involves the external ends of enamel
prisms and follows a continuous curved outline. It can be either a short bevel, which
cuts only the external one-third of the enamel prisms, a full bevel involving the entire thickness of enamel, or a wide bevel involving not only enamel but some dentin,
as well.
A plane is a diagonal cut across the cavosurface margin that is flat in all dimensions. A plane may involve the entire thickness of enamel (which it usually does) or
most of it, but cannot be curved in any direction.
gold
Which of the following allows for proper retention when preparing a tooth
for a disto-occlusal Class II gold inlay?
undercut on mesial
undercut on buccal and lingual walls
occlusal lock (dovetail)
none of the above
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gold
,A patient arrives at your office with their full gold crown in hand.They explain
to you that
dentist delivered it justlast week.You thEm examine the
crown and the preparation. What is the l1lost likely reason the the crown fell
off?
there was very little cement in the crown

the preparation was only 4 mm high
the preparation walls were tapered at about 15
the margins were jagged and undefined
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occlusal lock (dovetail)

When designing a Class II preparation for an inlay, an occlusal lock or dovetail should
be established to prevent proximal dislodgement. Also, the marginal ridges of posterior
teeth that are restored with cast gold should be rounded to help form the occlusal embrasures and be in contact with the cusps of the opposing teeth. Marginal ridges should
be the same height as the adjacent tooth's marginal ridge (or else you can create an interference in retrusive movement).
1. The cement does provide some retention; however, the preparation design
does as well. The cement's main function is for marginal seal, not retention.
2. When removing a Class II inlay, the method of choice is to cut through the
isthmus to remove the occlusal and proximal pieces one at a time.
3. The restoration will not seat ifthere are undercuts. Actually this holds true
for all cast metal restorations. See picture above of a Class II inlay preparation.
the preparation walls were tapered at about 15
Taper provides the optimal friction between the walls and the casting, which is the main retention. The ferrule (or height) of the preparation also provides the friction and, thus, retention, but 4 mm is enough (3 mm is minimal).
Important: For maximum retention of cast gold restorations, the axial walls should be as parallel as possible and as long as possible. Retention is directly proportional to the area of the
axial walls and their parallelism. The axial walls should converge slightly from the gingival
walls to the pulpal wall.
Retention form depends on:
Length of walls (minimum 3 mm): the longer the wall, the greater the amount of draft/draw.
Taper of walls. Important: provides for draw or draft (for the casting to be placed onto
the tooth) but also provides for an appropriate small angle of divergence (2 to 5 degrees per
wall) from the line of draw, which will enhance retention form.
Key point: More parallel = more retention
Circumference
Advantages of cast gold restorations:
They are very strong and able to withstand the forces of mastication
They are ideal for occlusal rehabilitation
They are kind to the gingival tissue
Disadvantages of cast gold restorations:
Esthetics
Cost
Time-consuming
Difficulty of technique
The need to use cement, which is the weakest point in the cast gold restoration
Gold has a high thermal conductivity
gold
The lab calls your office and asksif you wanta particular castingdone in a
base or a noble metal. Which ofthe following responses is appropriate?
base, because the patient has a bad bruxing habit

noble, because the patient has a bad bruxing habit
base, because the patient wants a gold tooth
noble, because the patient wants a gold tooth
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gold
Of the following, which is a correct match between the gold cast alloy component and its effect?
gold -
decreases ductility and malleability
gold -
increases resistance to tarnish and corrosion
copper-hardens the alloy

silver-color modifying
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base, because the patient has a bad bruxing habit

An alloy is a mixture of two or more materials that are mutually soluble in the liquid state.
A pure metal solidifies at a constant temperature, whereas alloys solidify through a range
of temperatures.
Base metal alloys (also called nonprecious metals) are based on active metallic elements
that corrode but develop corrosion resistance via surface oxidation that produces a thin,
tightly adherent film, which inhibits further corrosion. Example: Cobalt-chromium alloys
form a Cr203 oxide film, which passivates the surface. Base metals are less resistant to corrosion. Base metal alloy advantages are principally found only in their strength and low
density.
Types of alloy systems: (classified on the basis of the type of structure that forms as they
solidify)
Solid solution alloys: the metals freeze without segregation of the individual constituents. Note: Are generally used in dentistry because they have a very homogenous
structure and provide maximum strength .
Eutectic alloys: separate into individual grains of the respective constituents. Exhibit complete liquid solubility but limited solid solubility. Example is the silver-copper system.
Remember: Noble metals are very resistant to corrosion and do not oxidize on casting. Noble systems for dental use are based on the noble or precious metal elements gold,
silver, palladium, and platinum.
gold - increases resistance to tarnish an,d corrosion

copper - hardens the alloy
silver - color modifying
*** Gold actually increases ductility and malleability.

Effe,cts.
Various ConstHuehtsoll Gold
Alloy
Major Effect on Gold Casting Alloy
Compound"
Gold (Au)
Increases resistance to tarnish and corrosion; increases ductility and malleability
Copper (Cu)
Increases hardness
Silver (Ag)
Main purpose is to modify the orange color of copper; reduces melting temperature;
increases ductility and malleability
Platinum (Pt)
Raises melting temperature; increases tensile strength; decreases the coefficient of thermal
, , expansion; reduces tarnish and corrosion
Palladium (Pd) Raises melting temperature; increases hardness; acts to absorb hydrogen gas which can
cause porosities in the casting; prevents tarnish and corrosion; has a very strong whitening
effect on gold alloys even when used at a low concentration (i.e., 5 wt%)
Zinc (Zn)
Acts as an oxygen scavenger and prevents oxidation of the other metals during the manufacturing process; increases fluidity and decreases surface tensions, which increases castability
gold
High-goldalloysused for cast restorations are:
greater than 20% gold or other noble metals

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gold
The following statements describe an MOD gold cast onlay preparation.
Which would you have to change to ensure that the onlay will be successful?
the mesial box has an axiopulpalline angle that is longer from facial to lingual than
the axiogingivalline angle
from facial to lingual, the distal axiopulpalline angle is longer than the mesial axiopulpal line angle
the mesial and distal axial walls converge
the distal box has an axiopulpalline angle that is shorter from facial to lingual than
the axiogingivalline angle
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Four Types of High-Gold Alloys:
1. ADA type I: highest gold content, 83% noble metals. Intended for small inlays. Easily burnished due to high ductility.
2. ADA type II: greater than 78% noble metals. Intended for larger inlays and onlays. Can also
be burnished.
3. ADA type III: greater than 75% noble metals. Intended for onlays and crowns. Capable of
being heat-treated.
4. ADA type IV: greater than 75% noble metals. Intended for bridges and removable partial
dentures. Also capable of being heat-treated. Hardest of high-gold alloys .
.
Type
I
II
Hardness
Soft
Yield Sffength
(MPa). Percentage Elongation (%)
"
,','
' " .
18
<140
Medium
III
Hard
20.1:340
IV
Extra-Hard
>340-:-:
>
18
.
,
12
10
Medium-gold alloys are 25% to 75% gold or other noble metals

Low-gold alloys are less than 25% gold or other noble metals
Gold substitute alloys are alloys not containing gold. These alloys are called passive because
they form some type of protective layer (surface oxide film) that offers maximum resistance to
corrosion. Examples include: Palladium-silver alloys and cobalt-chromium alloys.
Remember: The karat of a gold alloy is the number of parts that are pure gold, on the basis of
24 parts as a unit (thus, 24 karat is 100 % gold, while 18 karat is 75% gold). Fineness is measured on the basis of parts of pure gold per 1,000 (1,000 fineness is 100% gold, while 500 fineness
is 50% gold). Pure gold is only used in the foil restoration.
the distal box has an axiopulpalline angle that is shorter from

facial to lingual than the axiogingivalline angle
Remember:
When preparing teeth with short clinical crowns, the facial and lingual walls should
have a minimal gingival-to-occlusal divergence angle for maximum retention.
From facial to lingual, the axiopulpalline angle of an onlay preparation is longer
than the axiogingivalline angle (if it were not, the preparation would be undercut and
the onlay would not seat).
For a cast onlay or inlay, ALL walls must be convergent or there will be an undercut
and the restoration will not be able to be seated.
1. The bevel (0.5 mm width) on the cavosurface margin permits closer adaptation of the gold margin because the thinner margin of gold overlying the bevel
is more ductile and is able to be burnished. The desirable metal angle at the margins of onlays is 40 degrees, except gingivally, where the metal angle should be
30 degrees. Note: You can burnish a 30- to 40-degree gold margin, less than 30
degrees may be too thin and break, greater than 40 degrees may be too thick
and will not burnish.
2. During cementation, the finishing (burnishing) of the margins of a cast gold
restoration should be started as soon as the restoration is well seated into the
preparation.
3. While preparing a tooth to receive an inlay or onlay, a gingival bevel is used
to remove unsupported enamel and to compensate for casting inaccuracies.
Gingival margin trimmers, carbide finishing burs, or fine, tapered diamonds are
used to place this bevel.
4. This gingival margin is always placed gingival to the contact area.
gold
When preparing a ClassVcavity preparation for directfilling gold; you should
ensure that you have all of the following EXCEPT one. Which one is.the
EXCEPT/ON?
rounded internal line and point angles

small retentive undercuts placed in the axio-occlusal and axio-gingivalline angles
mesial and distal walls thatflare and meet the cavosurface at a 90 angle
0
an axial wall that is convex and follows the external contour of the tooth 0.5 mm into
dentin
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gold
The purpose of a sprue former is to create a passage for material to flow into
the investment.
The sprue former is typically attached to a thin portion of the crown.

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rounded internal line and point angles

Class V cavity preparation for direct filling gold:
The outline form is usually either trapezoidal (most popular) or kidney-shaped. The
axial wall is placed .5 rom into dentin (this will make the occlusal wall slightly deeper
than the gingival wall because there is a thicker layer of enamel making up the occlusal wall). The mesial and distal walls are placed at the line angles of the tooth.
*** Remember: For any Class V prep (whether for amalgam, composite, or directfill
ing gold), the outline form is determined by the extension of the carious lesion.
The retention form is attained by sharp internal line and point angles (axio-gingival
and axio-occlusal).
The resistance form is provided by flat mesial and distal walls and a convex axial
wall parallels the external surface of the tooth.
Note: The axial wall is convex in a mesiodistal direction to conserve tooth structure and
minimize pulpal irritation.
Important: The rubber dam is essential to prevent contamination of the gold with saliva. A cervical clamp usually is necessary to retract the gingiva (#212 Ivory clamp). The
hole that is to be punched in the rubber dam for the tooth that is being restored should
be located facial to the normal alignment with the adjacent teeth .

The purpose of the sprue former or sprue pin, as it is usually called, is to provide an
ingate or sprue in the investment through which the molten alloy can reach the mold
after the wax has been eliminated.
The size of the sprue former depends to a considerable extent on the type and size of the
pattern, the type of the casting machine to be used, and the dimensions of the flask or ring
in which the casting is to be made. Generally, however, for the average-size pattern, sprue
formers smaller in diameter than approximately 1.5 rom are contraindicated. If a sprue is
too small, the molten metal freezes completely in this area first, and localized shrinkage
porosity results. The general rule for sprue pin diameter when using a centrifugal type of
casting machine is that the diameter of the sprue pin should be equal to or greater than
the thickest portion of the pattern.
As a general rule, it is desirable to attach the sprue at the point of greatest bulk in the
pattern. There is less chance of distortion on attaching the sprue, and the molten metal is
more apt to remain liquid in this area until the entire mold is filled. The direction of the
sprue former is also important. It should never be attached at a right angle to a broad flat
surface of the mold. The entering hot metal impinges the mold surface at this point to
cause turbulence of the metal, which, in tum, creates a shrinkage void or suck-back porosity. When the same pattern is sprued at an angle of 45 to the proximal wall, a satisfactory casting is obtained.
gold
Dental wax patterns
as possible after fabricatingto minimize
be investedas soon
in the shape caused by:
reduced flow
drying out of the wax
relaxation of internal stress
continued expansion of the wax
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gold
The refractory filler component of gypsum-bonded investments provides
thermal expansion.
The thermal expansion is necessary to compensate for the alloy solidification
shrinkage.

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relaxation of internal stress

The three types of inlay waxes differ in terms of melting point and flow:
1. Type A: hard or low-flow wax that is rarely used except in some indirect techniques
2. Type B: medium-flow wax that is used in some direct techniques.
3. Type C: soft or high-flow wax that is used in indirect techniques for the construction of inlays, onlays, and full crowns.
The essential ingredients of a successful inlay wax are paraffin wax, gum dammar, and carnauba wax with some coloring material. Paraffin wax is generally the main ingredient,
usually in a concentration of 40 to 60%. Gum dammar is added to the paraffin to improve
the smoothness in the molding. It also increases the toughness of the wax. Carnauba
wax is quite hard and tends to decrease the flow of a wax.
Note: However the pattern is prepared, it should be an accurate reproduction of the missing tooth structure. The casting can be no more accurate than the wax pattern. The wax
pattern should be invested as soon as possible after fabrication to minimize changes in
shape caused by relaxation of the internal stresses in the wax .

Main components of gypsum-bonded investments:
1. A refractory filler which is a form of silicon dioxide (SiO],), such as quartz or cristobalite, comprises 60% to 65% of the investment. These two compounds have different
crystal structures and, therefore, have different thermal expansion coefficients.
Key point: This refractory filler regulates and provides the thermal expansion for the
investment.
2. The binder (which is a gypsum matrix of a calcium hemihydrate) comprises 30%
to 35% of the investment. This is the material that hardens after being mixed with the
liquid and, thus, holds the investment together (adds strength). The actual or effective
setting expansion depends on the gypsum content plus the water/powder ratio.
Key point: Using a thinner mix (which contains more water) of a gypsum-bonded investment will decrease the setting expansion, increase the setting time, increase the
porosity of the set material, and ultimately weaken the set material.
3. Modifiers are added to modify various physical properties of the investment. These
modifiers include magnesium oxide, sodium chloride, boric acid, graphite, or potasssium sulfate.
Dental investments serve three important functions:
1. A detailed reproduction of anatomical form.
2. Enough strength to withstand the heat of burnout and the actual casting of the
molten metal.
3. Compensation expansion equal to the alloy solidification shrinkage.
gold
All of the following are .indic:ations Jor a cast gold onlay EXCEPT one.
Which one is.the EXCEPTION?
restoration of large lesions

restoration of ideal occlusion in cases of drifting, hypo- and hyper eruption, etc.
restoration of optimum contour and proximal contact
restoration of brittle teeth (endodontically treated)
restoration of a tooth as an abutment for removable prosthesis, creating ideal guiding
planes, rest seats, and undercuts
restoration of teeth to meet patient preference for gold
restoration of a tooth with minimal ferrule, where a full-coverage crown would not have
enough retention
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:I
gold
On delivery of your first crown, you notice that the margins are open when
you attempt to seat the crown in the. mouth. Which of the following should
you check first?
the occlusal contacts

the proximal contacts
for a void on the crown's interior
for a nodule on the crown's interior
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restoration of a tooth with minimal ferrule, where a full-coverage

crown would not have enough retention
Important: If a tooth is not a candidate for a full-coverage crown, it is not a candidate for an onlay. A
tooth that does not have a minimum of 1.5 mm of ferrule effect will need a core buildup, crown lengthening, or both.
A ferrule effect is defined as the envelopment of the tooth structure by a crown. According to recent studies, 1.5 mm of tooth structure is sufficient to ensure the transmission of the forces of mastication to both
the post and the tooth. A tooth that is fractured at the gumline offers no form of resistance to transversal
forces. The post must take on the entire load, and it is inevitable that cementation fails.
Requirements for a good ferrule effect:
1.5 to 2 mm of buccal and lingual SUbgingival tooth structure
1 mm of tooth thickness after adequate preparation
4 mm of suprabony tooth structure
The main advantage of the onlay is that it can permanently restore and reinforce a tooth by a conservative technique. Although conservation of tooth structure is desirable, such action is offset by a lack
of retention. It has been shown that conservative onlays have inferior retention compared to full crowns.
This is due to the crown's greater axial surface area.
1. Retentive features: parallelism of vertical surface (axial walls) is the primary retentive
feature of an onlay preparation. Sharp point and line angles add to retention.
2. Auxiliary retentive features include a box or a groove. These features may be indicated
where inadequate surface area of vertical walls is present. A box offers a greater increase
in surface area, thus greater retention than a groove, but it is also more costly in terms
oflost tooth structure.
3. The location of the gingival margin in the preparation of proximal surfaces is influenced
by the amount of retention required, the need to extend gingivally to clear the contact
area and convenience form.
the proximal contacts

If a casting fails to completely seat on a prepared tooth, one should first check for residual temporary cement or other debris on the prepared tooth. Once all the temporary cement and other debris are removed, the first step in fitting the casting in the mouth is to
adjust the proximal contact areas.
Very important points:

1. When seating a casting, the initial interferences are usually the proximal contacts.
Complete seating of the restoration can be verified by an x-ray and a sharp explorer
used at the gold tooth margin.
2. When seating cast gold restorations, the occlusion of the restoration should be to
the same degree that teeth contact in that quadrant and on the opposite side (use shim
stock to check occlusion).
3. Initially, if a cast restoration is in hyperocclusion, the patient will complain of cold
sensitivity and pressure in the tooth. If the restoration is not adjusted, the tooth
will become very cold-sensitive, show signs of mobility, and there might be recession
of the facial gingival tissue.
gold
If a lab is getting a high occurrence of surface nodules on the castings they
make, what might you suspect about their in"esting process?
they are vacuum-investing

they are hand-investing
nothing in particular,
and vacuum-investing are the same thing
none of the above
75
OPERATIVE
gold
You are preparing tooth #19 for aMOOB gold ()nlay and tooth #18 for a MOOB
amalgam restoration. Which of the following TWO statements correctly
describe the difference in your preparations ofthe functional cusp?
you will need 2.5 to 3 mm of reduction for gold

you will need 2.5 to 3 mm of reduction for amalgam
you will need 1.5 mm of reduction for gold
you will need 1.5 mm of reduction for amalgam
76
OPERATIVE
they are hand-investing

These defects, or nodules, are caused by the collection of air bubbles during the investing procedure. The best way to help eliminate these defects is to subject the water-investment mixture to a vacuum during the investing procedure to remove the air bubbles.
The porosity ofthe investment is definitely reduced by vacuum-investing, presumably because of the increased density obtained. As a result, the texture of the surface of the casting is somewhat smoother, with better reproduction of fine detail. The compressive
strength of the investment is increased slightly by the vacuum investment (the investment will not fracture as easily).
Not all of the air is removed by the vacuum treatment. The amount removed depends
somewhat on the consistency of the mix. The more viscous the mix, the more air
bubbles remain in the investment. However, a thick mix is usually necessary because of
the desired shrinkage compensation and because of the poor surface texture that is obtained with a thin mix.
you will need 2.5 to 3 mm of reduction for amalgam

you will need 1.5 mm of reduction for gold
Remember:
Working cusps (functional cusps)
Maxillary teeth: lingual
Mandibular teeth: buccal
Non-working cusps (non-supporting)

Maxillary teeth: buccal
Mandibular teeth: lingual
,', Minimal Occlllsal

Cusp
Amalgam
Working
2.5-3.0 mm
Non-working 2.0mm
.,'.
" Cast Gold,
Metal-Ceramic
L5nUn.
1.5-2.0 mm
J_0111lll
1.5-2.0 mm
1. For non-working cusps the minimal reduction for amalgam is 2.0 mm

while forming a flattened surface (this provides resistance form) and, for cast
gold, it is 1.0 mm.
2. For metal-ceramic restorations: facial and lingual reduction - 1.5 mm
3. The difference between tooth preparation for a metal-ceramic restoration
and a porcelain jacket crown is mostly related to the configuration of the finishing line or margin - chamfer or bevel for metal-ceramic restorations and
a butt joint for porcelain jacket crowns.
Important: The most effective means for verifying adequate occlusal clearance is a wax
bite chew-in.
instr/burs
The modified pen grasp is the most common instrument grasp in dentistry;
this is because it allows for the greatest intricacy and delicacy of touch.
77
OPERATIVE
instr/burs
When attempting to remove a hard brittle material,like amalgam, you would
prefer a bur with a:
zero rake angle

positive rake angle
negative rake angle
78
OPERATIVE
With this grasp, the middle finger, index finger, and thumb all rest on the handle close to
the junction of the handle and the shank. The middle finger rests on the shank, and the
thumb and index finger are opposite each other on the handle. (See picture below)
The inverted pen grasp is very seldom used, however, sometimes it is used for cavity
preps utilizing the lingual approach on anterior teeth.
The palm and thumb grasp is the most powerful grasp and is most effectively used on
the maxillary arch. It is similar to the grasp used for holding a knife while paring the skin
from an apple.
The modified palm and thumb grasp allows much of the power of the palm and thumb
grasp but also permits more delicate control. It works best when you can rest the thumb
on the tooth being restored or on the adjacent tooth. It also works best on the maxillary
arch.
negative rake angle

*** Remember: The rake angle = the angle made between the line connecting the edge of the blade to the axis
of the bur and the rake face. This angle may be positive or negative.
Generally speaking, soft materials, such as acrylics, are cut most effectively with positive rake angle burs;
whereas extremely hard and brittle materials (such as amalgam) are best cut with negative rake angle burs.
A rake angle is said to be negative when the rake face is ahead of the radius (from the cutting edge to the axis
ofthe bur). A negative rake angle minimizes fractures of the cutting edge that helps to increase the bur life. Increasing the edge angle reinforces the cutting edge of the bur and reduces the likelihood of the blade to fracture.
Carbide burs used for cutting tooth structure generally have slight negative rake angles and edge angles of
approximately 90. To be most effective, these burs should be rotating rapidly before contacting the tooth.
The clearance angle is also another important factor in blade design. The clearance angle serves to eliminate
friction between the clearance face and the new tooth structure exposed by the cutting edge. The greater the
clearance angle, the less friction.
Reproduced with
permission, from
Sturdevant eM, Rober
son TM, Heymann HO,
and Sturdevant JR.
The Art and Science of
Operative Dentistry,
Third Edition. Mosby,
1995.
Bur blade design. Schematic cross section viewed from shank end of head to
show rake angle, edge angle, and clearance angle.
All of the following factors influence tooth temperature during a cutting procedure:
Diameter and sharpness of the bur
Bur/tooth contact time
Type of coolant used (water is best, air may dehydrate the tooth or cause the tooth to be hypersensitive by drawing odontoblasts into the dentinal tubules)
Amount offorce applied to the bur
instr/burs
The _ _-:-_ _ angle is the angle formed between the ....,-'--:--,-_-,--_face and
the
face.
1 !
edge, rake, clearance

rake, edge, clearance
clearance, rake, edge
79
OPERATIVE
instr/burs
What is the blade width of a cutting instrument with the following formula:
10-85-8-14
10 mm
1,0 mm
0,85 mm
0,80 mm
80
OPERATIVE
edge, rake, clearance

Each bur blade has two sides:
1. The rake face (toward the direction of cutting)
The rake face is the surface (side) of the blade that makes contact with the tooth
surface and faces in the direction of bur rotation.
2. The clearance face
The clearance face is the surface (side) of the blade that faces away from the direction of bur rotation.
Each bur blade has three important angles:
1. The rake angle
The rake angle is the angle made between the line connecting.the edge of the blade
to the axis of the bur and the rake face. This angle may be positive or negative.
2. The edge angle
The edge angle is the angle formed between the rake face and clearance face.
3.The clearance angle
The clearance angle is the angle formed between the clearance face and a tangent
to the path of rotation.
Note: For most effective cutting, a bur should be rotating rapidly before contacting the
tooth.
1.0mm
Cutting instruments have formulas describing the dimensions and angles of the working end:
The first number indicates the width of the blade in tenths of a millimeter - 1.0 mm
(10 x .1) for the example on the front of the card.
The second number indicates the primary cutting edge angle in centigrades - 85 for
the example on the front of the card.
The third number indicates the blade length in millimeters - 8 mm for the example on
the front of the card.
The fourth number indicates the blade angle in centigrades - 14 for the example on the
front of the card.
Three major parts of a hand-cutting instrument:
1. The handle is that part of the instrument held or grasped during activation of the blade.
Types: single-ended or double-ended.
2. The shank serves to connect the blade to the handle. Types: straight or angled (monangle, bi-angle, or triple-angle: meaning one, two or three angles in the shank).
Note: Proper balance of the instrument is accomplished by angling the shank of the instrument so that the cutting edge of the blade is within 2 mm of the long axis of the handle. To
keep the blade within 2 mm of the long axis, the shank of the instrument is angled.
3. The blade is the working end of the instrument and is connected to the handle by the
shank. Blades are of many designs and sizes, depending on the function they are to perform.
*** The nib is not a major part of a hand cutting instrument. It is the working end of a noncutting instrument (i.e., a burnisher; condenser; etc.). The end of the nib, or working surface, is known as the face. Note: It corresponds to the blade of a hand cutting instrument.
instr/burs
Chisels are used primarilyto cut enamet
<
Hatchets are primarily used to cut de6tin.
- both statements are true

- both statements are false
- the first statement is true the second is false
t
- the first statement is false the second is true

t
81
OPERATIVE
instr/burs
Match the type of excavator on the left with the main purpose on the right.
- hoes
sharpening line angles and convenience points for gold foil preps
angle formers
preparing retentive areas on anterior teeth
ordinary hatchet
remove carious dentin and sometimes carve amalgam
-spoons
class III and V direct gold preps
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OPERATIVE
the first statement is true,
second is false
*** Hatchets are also primarily used to cut enamel

q
Chisels may be grouped as:
1. Straight, slightly curved, or bin-angle: primarily used for planing or cleaving enamel. Characterized by a
blade that terminates in a cutting edge formed by a one-sided bevel.
2. Enamel hatchets: are chisel-bladed instruments with the cutting edge in the plane of the handle. They come
paired left and right.
3. Gingival margin trimmers: are similar in design to the enamel hatchet except it has a curved blade and
an angled cutting edge. They are primarily used for beveling gingival margins. Among other uses for these instruments is the rounding or beveling of the axiopulpalline angle of Class II preparations (very important).
Bin-angle
Wedelstaedt
Chisels
Bi-beveled
Mono-beveled
::-.
Hatchets
,I;
"
\;f..
17
23
51 52
5354
There are four subdivisions of excavators:

1. The hoe excavator: has the cutting edge of the blade perpendicular to the axis of
the handle. It is commonly used in Class III and V preps for direct gold.
2. The angle former: has the cutting edge at art angle (other than 90) to the blade.
It is used for sharpening line angles and is especially useful to form convenience
points for gold foil preps.
3. An ordinary hatchet excavator: has the cutting edge of the blade directed in the
same plane of the handle and is bi-beveled. Used primarily on anterior teeth for
preparing retentive areas.
4. A spoon excavator: has a curved blade with a rounded cutting edge. It is used to remove carious dentin and sometimes to carve amalgam.
Note: These can be sharpened with handpiece stones.
instr/burs
You set down the hand
Your assistant hands you a
caries, and then the
of the prep.
..
Ilamalg(lm ontooth#4.
.... ... .
so you cai1 rem9vetlle last bit of
so you can plane
and lingual walls
spoon excavator, enamel hatchet

spoon excavator, straight chisel
gingival margin trimmer, enamel hatchet
gingival margin trimmer, straight chisel
83
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OPERATIVE
instr/burs
To polish a restoration, you will likely use a bur with less cutting blades. This
is because a bur with less cutting blades will cut more efficiently.
84
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OPERATIVE
2013-2014- Dental Decks
spoon excavator, enamel hatchet
*** The enamel hatchet is the only instrument that will allow the dentist to have proper access to
the margins and that will impart the proper cavosurface angle to the margins.
Spoon excavators are used for removing caries and carving amalgam or direct wax patterns. The
blades are slightly curved, and the cutting edges are either circular or claw-like. The circular edge
is known as a discoid, whereas the claw-like blade is termed a cleoid (see picture below). The
shanks may be bin-angled or triple-angled to facilitate accessibility.
:;:;;;:====-1:;
jgj...;;;.
cleoid
The number of bevels that make up the cutting edge can classify hand cutting instruments. For example, enamel hatchets and chisels have single bevels, whereas ordinary hatchets (for example, excavators) have two bevels and are called bi-beveled.
Dental hand cutting instruments are angled to:
Provide better manipulative control
Produce a better distribution of force
Increase efficiency
Establish proper balance when in use
Instruments used to trim restorative materials rather than for cutting tooth structure:
Knives (finishing, amalgam, or gold): used for trimming excess filling material on the facial
and lingual
Files: also used to trim excess filling material, especially at the gingival margins
Discoid-cleoid: used principally for carving occlusal anatomy in unset amalgam restorations

*** Important: The greater the number of cutting blades on a bur results in less efficient cutting but a smoother
surface (polishing burs are of this type). A lesser number of blades on a bur results in more efficient cutting but a
rougher surface. Crosscut fissure burs at high speed or low speed are of this type.
Parts of burs:
1. Shank: the part that fits into handpiece. The three most common types are straight, latch-type angle, and frict.
ion-grip angle.
2. Neck: the intermediate portion of a bur that connects the head to the shank. Its main function is to transmit
rotational and translational forces to the head.
3. Head: the working part of the bur, the cutting edges perform the desired shaping of tooth structure.
Types of burs:
Steel (used mostly for finishing procedures)
Carbide (used for cavity preparation; perform best at high speeds)
Shapes of burs: refers to the contour of the head. The basic head shapes are round, inverted cone, pear, straight fissure, and tapered fissure. Note: Within a given series of burs, the smaller numbers represent small burs; the larger
numbers, large burs.
Recent modifications in bur design:
Reduced use of crosscut burs - noncrosscut burs are now popular
Carbide fissure burs with extended heads
Rounding of the sharp tip comers
The rotational speed of an instrument is measured in revolutions per minute (rpm). There are 3 speed ranges: slow
(below 12, 000 rpm), intermediate (12, 000 to 200, 000 rpm), and high (above 200, 000 rpm) speed. The most useful instruments are rotated at either low or high speed. The crucial factor for some purposes is the surface speed of the instrument - the velocity at which the edges of the cutting instrument pass across the surface being cut. This is
proportional to both the rotational speed and the diameter of the instrument, with large instruments having higher surface speeds at any given rate of rotation.
Diamond abrasive instruments: involve abrasive rather than blade cutting. These instruments are based on small,
angular particles of hard substances held in a matrix of softer material. Diamonds consist of three parts: a metal blank,
the powdered diamond abrasive, and a metallic bonding material that holds the diamond powder onto the blank. The
blank, in many ways, resembles a bur without blades. It has the same essential parts: head, neck, and shank. The clinical performance of diamonds depends on the size, spacing, uniformity, exposure, and bonding of the diamond particles. Diamond particle size is commonly categorized as coarse, medium, fine, and very fine.
misc.
There are several types of bleaching products available for use at home,
which can either be dispensed by a dentist or purchased over.:.the-counter.
Currently, only
home-use:
fray-applied
gels carry the ADA Seal of Acceptance.
30% carbamide peroxide

15% hydrogen peroxide
20% hydrogen peroxide
85
OPERATIVE
misc.
From the following, choose the four zones infour-handed dentistry:
operator zone
assistant zone
transfer zone
patient zone
static zone
86
OPERATIVE
Two methods of bleaching:

1. "In-office": most use a light-activated solution of35% hydrogen peroxide in 4 to 10
minute cycles. This procedure is called "chairs ide bleaching" and may require more
than one office visit. Each visit may take from 30 minutes to 1 hour. Note: Lasers have
been used during tooth whitening procedures to enhance the action of the whitening
agent.
2. "At-home": the active ingredient contained in all of the at-home tooth whiteners
which have earned the ADA's seal, and the compound which has been evaluated in
the vast majority of at-home bleaching studies, is carbamide peroxide at a concentration of 10%. The active ingredient found in most over-the-counter at-home bleaching products is not carbamide peroxide, but instead is hydrogen peroxide.
Note: Bleaching can affect the color of dentin and enamel. Extrinsic stains respond best
to vital beaching. Response is best with yellow stain followed by brown and orange. The
worst response is from gray stains (tetracycline staining).
Other ways to lighten vital teeth:
Direct composites: useful for tetracycline staining
Laboratory-fabricated porcelain veneers: useful when the shape, size, and arrange- !
ment of teeth are esthetically unacceptable
.
Full-coverage crowns (most invasive and costly): may be all-ceramic or porcelain
fused to metal
operator zone
assistant zone
transfer zone
static zone
The operator and the assistant should concentrate on positioning themselves in work circles. The
dentist's work circle should allow easy and unobstructed access to the patient's mouth. The assistant's work circle should include all instruments and supplies needed for the intended operation, also
allowing access to the transfer zone to bring the necessary items to the dentist. When viewed from
above with the patient's head in the 12:00 o'clock position, the right handed dentist will operate in
an area from 8:00 to 11 :00 o'clock. This area is the operator's zone. Nothing should be in this area
that would interfere with the free movement of the dentist. The area from 11 :00 to 2:00 o'clock is
called the static zone. This area is reserved for the mobile cabinet and nitrous oxide apparatus.
The area from 2:00 to 5:00 o'clock is the assistant's zone. Although the assistant will not move as
much as the dentist, nothing should be positioned in this area that would hamper the assistant's
free access to the oral cavity, mobile cabinet, and dental unit. The area form 5:00 to 8:00 o'clock is
the transfer zone. This area is reserved for the transfer of instruments, medicaments, and supplies
to the dentist. Also, the dental unit should be positioned within this arc.
Other considerations for an efficient four-handed dental delivery system:
Concerning the transfer of instruments: the hand instrument to be transferred to the dentist
is held by the assistant between the thumb and the forefinger.
Equipment selection: whatever equipment is used, it should be compatible for the dentist and
assistant. The position of the chairs ide assistant should be higher than the dentist.
Note: Venting the suction exhaust to the building exterior can reduce health hazards to the office
staff from the central suction unit.
misc.
Xerostomia is the most common adverse side effect of medications.
This is attributed to the cholinergic effects of many medications.
both statements are true'

87
OPERATIVE
misc.
When restoring a Class II or Class III lesion, it is important to create properly
shaped embrasures for all of the following reasons EXCEPT one. Which one is
the EXCEPT/ON?
create a spillway for food during mastication

make the teeth self-cleansing
protect the gingival tissue, while also allowing stimulation of it
provide arch stability
88
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OPERATIVE
*** This is attributed to the anticholinergic effects of many medications.

Other etiologic factors for xerostomia include:
Radiation therapy to head and neck
Salivary gland surgery
Autoimmune disorders, such HIV infections, systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's syndrome
Endocrine disorders, such as diabetes and hyperthyroidism
Treatment for xerostomia:
Consider stopping offending medication (at the discretion of the patients physician)
Commercial saliva substitute
Fluoride supplementation
Scrupulous dental care is essential
Anticholinergic drugs (which block receptor sites for acetylcholine) decrease salivary
flow and respiratory secretions during surgery. Examples include: atropine, scopolamine,
methantheline, and propantheline bromide.
Don't forget: Local anesthetics aid in reducing the flow of saliva during operative procedures by reducing sensitivity and anxiety during tooth preparation.
Remember: Cholinergic agents actually increase secretions; a cholinesterase inhibitor
would also increase secretions because it would reduce the metabolism of acetylcholine .
provide arch stability
*** As long as a contact is present, regardless of proper embrasure contour, you will
maintain arch stability
There are four embrasures for every contact area:
1. Buccal (or facial)
2. Lingual (usually larger than the facial)
3. Occlusal (or incisal)
4. Cervical (or gingival)
*** Note: In posterior teeth, the gingival tissue fills this embrasure. Normally it is
"col" shaped when viewed in a faciolingual cross section ..
Functions of embrasures:
1. Make a spillway for food during mastication
2. Make the teeth more self-cleansing
3. Protect the gingival tissue from undue frictional trauma, but at the same time provide the proper degree of stimulation to the tissue.
A contact area is an area in which the mesial and distal surfaces of adjacent teeth in the
same arch make contact. A contact point is a point at which teeth of the opposing arches
meet or touch in occlusion or closure.
The height of contour refers to the thickest portion or point of greatest circumference of
the tooth when viewed from the incisal or occlusal surface. Its functions include forming
the contact area on the mesial and distal surfaces and protecting the gingiva surrounding
the tooth.
misc.
A tooth was restored 3 months ago bya
pfyours.The patient is
complaining of mobility and thermal sensitivity! You take a periapical
ograph. You could see all ()fthe
in that radiggraph to confirm your
.
suspicions, EXCEPT one. Whi.chorie is the EXCEPTION?
hypercementosis
root resorption
periodontal pockets
alteration of the lamina dura
widening of the periodontal ligament space
89
OPERATIVE
misc.
When restoring the embrasures of posterior teeth, the contact should be
formed slightly buccal from.center.
This will create a wider facial embrasure.

90
OPERATIVE
periodontal pockets
*** You should have suspected that the restoration was high, based mainly on the mobility
factor. Occlusal trauma can still cause periodontal pocketing; however, that cannot be
seen on a radiograph.
Some common clinical signs of trauma from occlusion include:
Increased tooth mobility is the most common clinical sign
Thermal sensitivity (cold): presumably, this sensitivity is due to venous hyperemia of
the tooth
Attrition of the enamel
Recession of the facial gingival tissue
Remember: Whenever a restoration is done, the occlusion has to be right. The degree of
contact on the restoration should be to the same degree that teeth contact in that quadrant
and on the opposite site.
Note: The radiograph of choice for evaluating root surfaces, supporting bone, and the
periodontal ligament is the periapical film .
*** This will create a wider lingual embrasure and a narrow facial embrasure.
The primary purpose of the proximal contact relationships between adjacent teeth in the
dental arches is twofold. This relationship serves both to stabilize the dental arches by the
combined support of the individual teeth and to prevent the impingement of food material on interseptal tissues between the teeth
The proximal contact area functions to:
1. Support neighboring teeth (stabilizes the dental arch)
2. Prevent food particles from entering the interproximal areas
3. Protect the periodontium
4. Form embrasures
The loss of proximal contact between teeth may result in periodontal disease, malocclusion, food impaction, or drifting of teeth.
Remember: When viewed from the facial, all premolars have their contacts at the junction of the occlusal and middle third. From this same view, molars have a proximal
contact located in the middle third. From the occlusal view, all posterior teeth have contacts that are located slightly buccal of the middle third (mesial and distal). This creates
a wide lingual and a narrow facial embrasure.
misc.
Which of the f()lIowing would NOT necessarily indicate the need for root canal
treatment or extraction of a carious tooth?
lingering pain over 15 seconds

negative electric pulp test
frank apical radiolucency
percussion sensitivity
91
copyright CO 2013-2014 - Dental Decks
OPERATIVE
misc.
On the first day in your solo private practice, you have a pulp exposure. Which
of the following are favorable factors in avoiding root canal treatment?
it is a mechanical exposure of 1 mm
the tooth had never been symptomatic
the pulp tissue appears pink
the hemorrhage is severe
it is a pinpoint carious exposure
92
copyright CO 2013-2014 - Dental Decks
OPERATIVE
percussion sensitivity
*** A tooth with percussion sensitivity could need caries control with a sedative temporary filling. It could also need occlusal adjustment (which can cause reversible pulpitis as
well).
Pulpal necrosis is the death of the pulp. A tooth affected with a necrotic pulp may have
no painful symptoms. It may appear discolored. The EPT (electric pulp tester) will be of
value because there will be no response at any current level. The tooth sometimes responds to heat but will not respond to cold. Treatment is root canal or extraction.
Note: Symptomatic apical periodontitis is characterized by pain, which is commonly
triggered by chewing or percussion. Symptomatic apical periodontitis alone is not indicative of an irreversible puJpitis. It indicates that the apical tissues are irritated, which
may be associated with an otherwise vital pulp with a potentially reversible pulpitis. In the
absence of acute pain, a negative EPT test, or a frank apical radiolucency, a carious tooth
with sensitivity to percussion may respond to caries control (temporary filling). If it doesn't respond to a sedative filling, root canal is indicated.
o
:
Pulpal ])iagl1osis
Treatment
Cold Response
00
"
00":0'
00
Normalpulp
Not delayed or very short linger NOlleneecleg,o
pulpitis
,0,
0:':
0'
0'
Lingers less than 10-15 seconds
Lingers longer than 15 seconds

Symptomatie
Irreversible pulpitls
o:
No response
Pulp
:
o'
RCT or extraCtion
'"
00
"
RCT or extraction
it is a mechanical exposure of 1 mm
the tooth had never been symptomatic
the pulp tissue appears pink
Direct pulp capping involves the prompt application of a setting calcium hydroxide cement to a
"pinpoint" (less than 1 mm in diameter), well-isolated traumatic pulpal exposure. This procedure
may be expected, in most instances, to stimulate the formation of a reparative "dentin bridge" over
the exposure site and to preserve the underlying pUlpal tissue in a healthy condition.
Favorable factors for direct pulp capping include: the visual evidence of un inflamed (pink) pulp
tissue, the absence of copious hemorrhage through the exposure, no previous symptoms of pulpitis, a small noncarious exposure (a mechanical pulp exposure), and a clean cavity uncontaminated
with saliva.
The following adverse responses may occur following direct pulp capping procedures:
Physical or microbial insult to the pulp may result in persistent inflammatory changes, which
may culminate in partial or complete pulpal necrosis.
Regulation of the mineralization processes involved in dentin bridge formation may become deranged, resulting in extensive calcification and obliteration of the pulp canal space by mineralized tissue.
Very rarely, the differentiation of odontoclasts may be induced with the development of internal resorptive lesions.
1. Direct pulp capping is especially successful in immature teeth.
2.The failure of this direct pulp capping procedure would be indicated by symptoms of
pulpitis at any time or the lack of a vital response after several weeks or months.
3. Direct pulp capping should not be attempted on teeth with a history of pain, sensitivity
to percussion, or periapical radiolucencies (root canal therapy may be indicated).
4. Direct pulp capping is generally not performed on primary teeth.
misc.
iln
The ideal amount of time from placing

indirect pulp cap until reopening
the tooth to remove the remaining.decay is:
.7- 10 days
.2 - 3 weeks
1 month
3 - 4 months
.1 year
never, unless the tooth becomes symptomatic there is no need for further treatment
93
copyrightc> 20132014 Dental Decks
OPERATIVE
misc.
A patient walks into.your office for anemergencyvisit. He asks the receptionist for a cold glass of water and seems to betilting his head sideways as to
hold the water on one side of his mouth. Immediately, you suspect which reason for his visit?
pulp necrosis
reversible pulpitis
symptomatic irreversible pulpitis
asymptomatic apical periodontitis
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copyright c> 20132014 Dental Decks
OPERATIVE
3 - 4 months
Two types of pulp capping procedures:

1. Indirect pulp cap: a calcium hydroxide base is placed on a thin layer of question
able dentin remaining over the pulp. It is performed when a carious exposure is anticipated. After a 3- to 4- month waiting period, the tooth is reopened and the remaining
decay is removed. During the waiting period, it is hoped that there will be secondar
dentin formation, allowing complete removal of the decay without pulp exposure.
Classic example: A radiograph of a first molar shows gross decay that may involve
a hom of the dental pulp. The ideal treatment would be to do an indirect pulp cap and
place a sedative filling (JRM). If tooth remains asymptomatic, in 3 -t04 months you
can reenter the tooth and remove all decay with subsequent placement of a permanent
filling. Note: If this patient had pain in the tooth (aggravated by heat and tender to
percussion), and excavation of the carious lesion revealed exposure of the pulp hom
without evidence of vital tissue, the emergency treatment pending eventual root
canal therapy is to place a small cotton pellet dampened with eugenol over the exposure and seal the cavity with a temporary material (IRM).
Rationale for indirect pulp capping - there are three dentinal layers in a carious lesion:
1. A necrotic, soft, brown dentin outer layer, teeming with bacteria.
2. A firmer, discolored dentin layer with fewer bacteria.
3. A hard, discolored dentin deep layer with a minimal amount of bacterial invasion.
2. Direct pulp cap: a calcium hydroxide base is placed directly on a pulpal exposure.

Symptomatic irreversible pulpitis is a clinical diagnosis based on subjective and objective
findings indicating that the inflamed pulp is incapable of healing. Additional descriptors include lingering thermal pain, spontaneous pain, and referred pain. In the early stages, it may
appear as just a sensitive tooth. As the condition continues, the pain may be described as a
gnawing or dull throbbing. The treatment accepted by most clinicians is pulp removal (root
canal therapy). Note: The tooth is usually percussion-positive.
At first, the pain is initiated and sustained only by the stimulus (this is reversible pulpitis).
Later, as the pUlpal swelling spreads from the initial area of damage or irritation to the rest of
the pulpal tissue in the chamber, the pain initiated by the stimulus becomes more prolonged
(this is symptomatic irreversible pulpitis). If enough pulpal tissue becomes damaged, the pain
may initiate or persist without any stimulus at all. At the same time, the degenerative inflammation of the pulp may reach down the entire length of the root or roots and begin to cause
the apical PDL to become inflamed (symptomatic apical periodontitis). Now the patient may
have not only a throbbing toothache but also pressure sensitivity (to the pressure of chewing
or percussion). This stage marks a later point in the pulpal degenerative timeline when the
tooth is the "hottest" and usually the most difficult to get numb.
Important: Sometimes it is hard to distinguish between reversible and irreversible pulpitis,
in which case caries control (the placement ofa temporary filling) is a conservative approach
toward making the final diagnosis. If a tooth responds well to this temporary filling, then the
need for root canal therapy at this time is ruled out.
Remember: Reversible pulpitis is a clinical diagnosis based upon subjective and objective
findings indicating that the inflammation should resolve and the pulp should return to normal.
Once the causative agent (i.e., bacteria or a restoration in hyperocc!usion) is removed or adjusted, the pulp will most likely return to normal.
misc.
A cold test reveals a lingering pain.Y9uask the. patient to raise her hCinduntii
the pain subsides. The patiEmt raises her hand for about8
What does
this data suggest?
pulp necrosis
reversible pulpitis
symptomatic apical periodontitis
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OPERATIVE
pins
What was previously an MOD amalgam in #20 now shows that the entire lingual portion of.the t()oth hasfractured off. You believe that the tooth is restorable with a pin-retained amalgam .restoration/core. How many pins will
you likely use and why?
one, because you are missing the lingual cusp only

two, because you are missing both the mesio- and disto-lingualline angles
three, because you are missing the mesial, distal, and lingual walls
96
-OPERATIVE
reversible pulpitis
Reversible pulpitis and may be caused by physical, chemical, or bacterial insult. Following restoration placement, teeth often become hyperemic and are sensitive to cold for
a few days. The pain is not spontaneous and does not last longer than approximately 10
seconds after the stimulus is removed. It is this fact, its short duration and low intensity,
that distinguishes it from the pain of symptomatic irreversible pulpitis. Remember: Teeth
that are diagnosed as having a reversible pulpitis respond on a lower level of current on
the EPT (electric pulp tester) than a normal tooth.
Treatment: If possible, the source (e.g., high restoration) should be removed. If indicated, a sedative restoration can be useful. If due to deep caries, an indirect pulp cap
should be used only in permanent teeth and when pulp pathology is believed to be reversible (e.g., no periapical pathology, no lingering spontaneous pain that might be worse
overnight, and stimulated pain ofshort duration only).
Important: Reversible pulpitis caused by bacterial insult is a limited inflammation of
the pulp. The tooth can recover if the caries is eliminated by timely operative treatment.
When the pulp becomes severely inflamed, as indicated by a thermal stimulus producing pain that lasts long after the stimulus is removed (longer than 15 seconds), this suggests "symptomatic irreversible pulpitis." The pulp is unlikely to recover after removing
the caries.
Remember: The most effective way to reduce injury to the pulp during tooth preparation
is to use adequate irrigation to avoid heating of the dentin.
two, because you are missing both the mesio- and disto-Iingualline angles
*** The rule of thumb is one pin per missing line angle.
The largest pin that can safely be placed should be selected in any situation. The optimal placement is at the line angles or comers of the tooth, where the tooth/root mass is
greatest and the risks of perforation into the pulp or furcation are minimal.
Advantages:
More conservative and less time involved than castings
Enhances retention form (adds walls) and is an economical alternative to castings
Disadvantages:
Can cause dentin crazing
Microleakage can occur at pin channel
Pins weaken amalgam alloy
Placement can result in pulpal exposure, perforation, and fracture of the tooth
Types of Pins:
Cemented
Friction-lock
Self-threading
pins
The most retentive style
because ttleyare
cemented into pinholes that are smaller than the pin itself.
..
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pins
Regarding the use of pins, choose the statements that are true.
use one pin per missing axial line angle, cusp, or marginal ridge, up to a maximum offour
use large-diameter pins whenever possible
use the minimum number of pins compatible with adequate retention (pins weaken amalgam)
pins should extend 2 mm into dentin and restorative material
keep at least 2 mm of dentin between the pin and the DEJ
pins should be placed away from furcation areas and parallel to the external tooth surface
coating of pins with adhesion promoters such as PANAVIA and 4-META materials improves
fracture resistance of composite and amalgam cores
pins are bent to make them parallel or to increase their retentiveness
OPERATIVE
98
*** Although the pinhole is smaller than the self-threaded pin, it is NOT cemented.
Self-threaded pin systems (for example, TMS, Whaledent) use holes sized just under the screw
diameter. The elasticity (resiliency) of the dentin functions to retain the screwed pin. This system comes with a self-limiting drill of optimal 2 mm depth and self-shearing pins that guard
against overtightening. This type of pin system is the most frequently used of the three types
of pins.
The TMS (Thread-Mate System) system has four sizes of pins (regular, minim, minikin and
minuta). They are available in titanium or stainless steel plated with gold.
Cemented pins are serrated stainless steel pins that are cemented into pinholes that are larger
than the diameter of the pin.
Drill Size
Regular
Minn:n
0.027"
>
'.
Minikin
Minuta '.
l'hi Diameter
"
0.021"
0:024'; ..... ,....
0.017"
0.019"
0.0135"
Friction-locked pins are tapped into pinholes that are smaller than the diameter of the pin..
They are retained by the elasticity of the dentin.
Note: The increased strength of the latest dentin/enamel bonding agents, coupled with the revived use of retentive slots, pot-holes, grooves, and channels, has led to a reduction in the use
of pins. Examples of dental adhesives include: AMALGAMBOND Plus, ALL-BOND 2,
DenTASTIC, and Easybond. These systems allow adhesion to preconditioned substrate with
the added benefits of retention and sealing of the restoration and a stronger total cohesive mass
to support all remaining cuspal segments of the tooth.
use one pin per missing axial line angle, cusp, or marginal ridge, up to a
maximum offour
use large-diameter pins whenever possible
use the minimum number of pins compatible with adequate retention
(pins weaken amalgam)
pins should extend 2 mm into dentin and restorative material

pins should be placed away from furcation areas and parallel to the
external tooth surface
coating of pins with adhesion promoters such as PANAVIA and 4-META
materials improves fracture resistance of composite and amalgam cores
*** Pins are not to be bent to make them parallel or to increase their retentiveness. Occasionally, bending a pin may be necessary to allow for condensation of amalgam occlusogingivally. When pins require
bending, a bending tool must be used. A hand instrument (e.g., an amalgam condenser or spoon excavator) should not be used. Note: There should be at least 0.5 to 1.0 mm of dentin between the pin and
the DEJ.
The main advantage of pins is to improve the retention oflarge restorations. Unfortunately, pin retention techniques are not without disadvantages. Pins are known to weaken the restorative material into
which they intrude. If placed by force, they can create stresses that cause crazing of the tooth structure.
They may provide an additional deep path for microleakage. If placed in close proximity to the pulp, they
may aggravate an existing pulp problem or create one. The use of pins may be contraindicated in young
teeth with very large pulps and in teeth with reversible pulp pathology, which might be aggravated by
instrumentation. Placement is always influenced by the limitations of access and vision.
Remember: Cusps to be restored with dental amalgam should be reduced by 2 mm while forming a flat
surface (perpendicular to the occlusalforces).
Note: After restoring a tooth, make sure you check the occlusion very carefully. If a restoration is left
in supraocclusion, the patient will return complainirig of discomfort when biting, usually with no other
symptoms.
pins
When preparing a pin channel, you perforate into the vitalpulp chamber.
What best describes your next
explain to the patient the need for root canal treatment

allow bleeding to stop, dry with paper point, place calcium hydroxide
allow bleeding to stop, dry with paper point, place pin to depth of 1 mm as to not
enter the pulp chamber
allow bleeding to stop, dry with paper point, place pin elsewhere, and restore with
amalgam
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OPERATIVE
rdam
The two most frequently quoted disadvantages of using the rubber dam are:
time consumption
patient objection
cost
staff allergies to material
100
OPERATIVE
allow bleeding to stop, dry with paper point, place calcium hydroxide
Remember: If, when attempting to drill a pinhole the drill enters a vital pulp chamber,
the proper treatment is to allow the bleeding to stop, dry with a sterile paper point, and
place calcium hydroxide in the hole. Proceed with a better location for a pinhole. If a pin
channel perforates the external surface of the tooth and all factors are favorable, a pin can
be placed provided there is no extension beyond the surface of the tooth.
Ideally, pins should be placed 1 to 1.5 rom inside the cavosurface margin and at least 0.5
mm inside the dentinoenameljunction (DEJ), if present. Placement of the pin channel at
least 0.5 mm away from the DEI helps prevent crazing or complete fracture of the remaining enamel. Note: The optimal depth of the pinhole into the dentin is 2 mm.
The rule ofthumb: Pins should be 2 mm into dentin, 2 mm within amalgam, and 1 mm
from the DEI (to be safe) with no bends in the pins. Important: The twist drill used to
prepare the pin channels must be angled so that it remains in dentin only. The channel
should be prepared parallel to the external surface of the tooth.
When pins are placed nearer the occlusal surface, as in cuspal coverage areas, the pins
should project only minimally into the restorative material (2 mm for amalgam). Long
pins near an area of occlusal loading will significantly weaken the amalgam; additionally, the purpose of the pin in cuspal coverage areas is to bind the cusp to the restoration, .
and to resist lateral displacement with occlusal function.
Note: Maximal interpin distance results in lower levels of stress in dentin.
time consumption
patient objection
*** However, if you become proficient in placing the rubber dam and explain to patients
the advantages of using it, these claims will be eliminated.
Advantages of using the rubber dam:
Dry, clean field
Access and visibility
Improved properties of dental materials
Protection of the patient and the operator
Operating efficiency
The following conditions may preclude the use of the rubber dam:
Severely tilted teeth
Some third molars
Teeth that are not erupted sufficiently
Some respiratory problems, such as asthma or severe colds, in which breathing
through the nose is difficult
Remember: The use of a rubber dam is the standard of care when performing endodontics.
rdam
The rubber dam can still be used effectively even if teeth are crowded and
overlapped because the hole punch pattern does not always have to be followed.
101
OPERATIVE
rdam
The Young rubber dam frame is used more than the Wo()dbury version,
because it provides less softtissue retraction.
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In this case, you can punch the holes closer or in a similar pattern to the teeth, allowing
for the elimination of wrinkles and avoid having papillae protruding through.
Five functions of rubber dam isolation:
Retracts soft tissue, such as lips, cheeks, and tongue
Provides for clean, dry field
Protects the patient by eliminating the possibility of swallowing debris or instruments. Protects the dentIst somewhat by isolating him/her from possible infectious
conditions in the patient's mouth.
Provides for maximum physical properties of materials. For example: The rubber
dam provides a dry field, which is essential for placement of amalgam restorations
as well as cements. Remember, the cements that are placed under dry conditions
have maximum strength. Also, a dry field prevents delayed expansion of amalgam.
Saves time - rubber dam saves time because the operator can work more efficiently in a clean, dry field where visibility is not impaired.
Important: For or a rubber dam clamp to be stable, all four points of the jaws of the
clamp must contact the tooth gingival to the height of contour. They should not extend
beyond the line angles to prevent impingement of the interdental papilla and possible
interference with placement of a wedge.
I.A frequent cause of interdental papillae protruding from beneath the rubber
dam is holes that were punched too close together.
2. Wrinkling of the rubber dam between isolated teeth is the result of holes that
were punched too far apart.
*** It is true that the Young rubber dam frame provides less soft tissue retraction than the
Woodbury. However, that is not why it is used - it is simply more convenient.
Important points about using the rubber dam:
Apply lubricant to the lips and comers ofthe patient's mouth.
Plot the hole on the rubber dam. Always isolate a minimum of three teeth. Punch
the appropriate size hole for a particular tooth. For a tooth bearing a clamp, the
hole should be one size larger than those without a clamp.
An appropriate clamp is selected that will fit the most distal tooth to be isolated. The
dam may either be stretched over the clamp with the clamp in place on the tooth, or
the clamp may be carried with the dam and placed on the tooth in one step.
Once the dam is placed, it is secured with either a Woodbury or Young holder
(frame).
The rubber dam is inverted into the gingival sulcus using floss and/or a blast of air and
an instrument such as a plastic instrument - this will prevent seepage of saliva.
Removal of the rubber dam - very important: Removal is the reverse of application,
except all ligatures (interdental septum of dam) must be cut and removed before the
dam is removed.
5/fl
Put the following steps in order for proper sealant placement.
apply acid etch

place the low viscosity sealant material
apply bonding agent
wash acid etch away
use rubber prophy cup with pumice
103
OPERATIVE
5/fl
The light cured sealants require UV light.
The light cured sealant types are shown to be clinically better than chemical
cured sealants.

104
OPERATIVE
use rubber prophy cup with pumice

apply acid etch
wash acid etch away
apply bonding agent
place the low viscosity sealant material
Important: Sealants need micro mechanical retention. The surfaces should be cleaned with a prophylaxis blUsh or lUbber cup and pumice with water. When the teeth are effectively isolated from saliva
contamination, the surfaces are dried and acid-etched by the application of a 30% to 50% phosphoric
acid solution for 1 minute. The solution should be gently agitated during the application. This is then
washed away and dried, leaving a frosty-appearing (dull and chalky) etched surface.
Miscellaneous information concerning sealants:
1. The placement of sealants is a highly effective means of preventing pit and fissure caries. It is safe.
It is clliTently undelUsed in both private and public dental health care delivery systems.
2. The substantial reductions in dental decay that have occurred in the young population of the United
States are due, for the most part, to the use of systemic and topical fluorides. The control of smooth
surface caries that is provided by fluorides is of critical importance to the additiOJ:lal effectiveness of
sealants.
3. The properties of sealants are closer to those of unfilled direct resins than to those of filled resins
(composites).
4. Sealants are weak compared to filled resins (composites). The strength of a sealant is sacrificed
into make it flow into the pits and fissures (the viscosity needs to be low enough to flow into the
pits andfissures).
5. The most likely result of inadvertently sealing a small carious lesion in the occlusal surface of a
tooth is that the caries would be arrested.
6. Research indicates that pit and fissure sealants are retained best on maxillary and mandibular bicuspids. However, the first molars (max. and mand.) benefit the most from sealants.
7. If a topical fluoride is to be used in conjunction with a pit and fissure sealant, the fluoride must be
applied either before the conditioner (acid etchant) or after the sealant.

Remember: Light cured materials are all cured by visible light nowadays, not UV. Also, both light
cured and chemical cured sealants have indistinguishable results.
Pit and fissure sealants were first developed in the 1970s and 1980s, and their effectiveness in preventing caries has now been well established. Two predominant types of pit and fissure sealant materials are available: resin-based sealants and glass ionomer cements.
Available resin-based sealant materials can be polymerized by autopolymerization, photopolymerization using visible ligh, or a combination of the two processes.
Glass ionomer cements are available in two forms, both of which contain fluoride: conventional
and resin-modified. Glass ionomer cements, which do not require acid etching of the tooth surface,
generally are easier to place than are resin-based sealants. They also are not as moisture-sensitive
as their resin-based counterparts. Glass ionomer materials, which were developed for their ability
to release fluoride, can bond directly with enamel. It is hypothesized that release of fluoride from
this material may contribute to caries prevention. However, the clinical effect of fluoride release
from glass ionomer cement is not well established.
1. The success of a sealant is highly dependent on obtaining and maintaining an intimate
adaptation of the sealant to the tooth surface and thereby, hopefully, sealing it.
2. Research has demonstrated that caries protection is 100% in pits and fissures that
remain completely sealed.
3. Resin-based sealants are the first choice of material for dental sealants.
4. Glass ionomer cement may be used as an interim preventive agent when there are indications for placement of a resin-based sealant but concerns about moisture control
may compromise such placement.
5.Placement of pit and fissure sealants significantly reduces the percentage ofnoncavitated carious lesions that progress in children, adolescents, and young adults for as long
as 5 years after sealant placement, compared with unsealed teeth.
s/fl
Fluoride reduces the rate of enamel solubility.
This increases the hardness ofenam'e!l.

105
OPERATIVE
s/fl
The average cost for a community to fluoridate its water is estimated to range
from approximately $0.50 a yearper personin large communities to approximately$3.00 a year per person in small
For. most cities, every
$1 invested in water fluoridation saves _ _ in dental treatment costs.
$10
$25
$38
$58
106
OPERATIVE
*** Fluoride does not make the enamel harder but reduces its rate of solubility.
Fluorides exert their antic aries effect by three different mechanisms:
1. The presence of fluoride ions greatly enhances the precipitation into tooth structure
of fluorapatite from calcium and phosphate ions present in saliva. This insoluble precipitate replaces the soluble salts containing manganese and carbonate, which were lost
due to bacterial-mediated demineralization. This exchange process results in the enamel
becoming more acid resistant.
2. Incipient, noncavitated, carious lesions are remineralized by the same process.
3. Fluoride has antimicrobial activity. In low concentrations, fluoride ion inhibits the
enzymatic production of glucosyltransferase. Glucosyltransferase prevents glucose
from forming extracellular polysaccharides, and this reduces bacterial adhesion and
slows ecological succession. Intracellular polysaccharide formation is also inhibited,
preventing storage of carbohydrates by limiting microbial metabolism between the
host's meals. Thus, the duration of caries attack is limited to periods during and immediately after eating.
1. The concentration of fluoride in the body fluids is regulated by an equilibrium relationship between bone and urinary excretion.
2. Fluoride ion is easily exchanged for hydroxyl ion in the lattice structure of
enamel because the fluoride ion is slightly smaller than the hydroxyl ion, and
it has a greater affinity for the hydroxyapatite crystal than does the hydroxyl ion.
$38
In relation to teeth, fluoride is characterized by the following:

Its concentration increases in the external layer of enamel throughout life
Its concentration increases during topical application but decreases for a few days
after treatment
Fluoride uptake is greater in enamel than in dentin or cementum
Increasing the fluoride content in the external layers of the tooth increases the resistance of the enamel to demineralization
Remember: The optimal concentration of fluoride in community drinking water depends
on the average air temperature and the average water consumption. For temperate climates, it is 1 ppm, and for warmer and colder climates, the amount can be adjusted from
0.7 to 1.2 ppm, respectively.
1. In communities without fluoridated water supplies, the most cost-effective
method of delivering fluoride to 6- to 12-year-old children is through school
water fluoridation (as opposed to fluoride tablets, brushing with ajluoride
gel, or rinsing with jluoride mouth rinse).
2. The most effective means of increasing the fluoride content in the external
layers of teeth is the daily application of 1.23 % acidulated phosphate fluoride
in fitted trays for 4 minutes. Obviously, this is not realistic since we do not
routinely do "daily" applications.
sIft
All persons should know whether the fluoride concentration in thei.r primary
source of drinking water is below optimal (
), optimal
(
), or above optimal
.).
!j
less than 0.5 ppm, 0.5-1.0 ppm, greater than 1.0 ppm
107
OPERATIVE
I'I
sIft
Studies have established that root sensitivity is due, in part, to open dentinal
tubules at the root surface.
The hydrodynamic theory is the proposed mechanism for this sensitivity.

108
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The optimal fluoride levels for public water supplies is about 1 part per million (PPM).
At 0.1 PPM and below, the preventive effect is lost, and the caries rate is higher for such
populations lacking sufficient fluoride exposure.
This knowledge is the basis for all individual and professional decisions regarding use of
other fluoride modalities (e.g., fluoride toothpaste for children under 2 years ofage, mouth
rinse, or supplements). It is recommended that parents and caregivers of children, especially children aged less than 6 years, know the fluoride concentration in their child's
drinking water. For example, in nonfluoridated areas where the natural fluoride concentration is below optimal, fluoride supplements might be considered, whereas in areas
where the natural fluoride concentration is more than 2 ppm, children should use alternative sources of drinking water.
Fluoride is obtained in two forms: topical and systemic. Topical fluorides are found in
many types of toothpaste, mouth rinses, and special gels or pastes applied in the dental office.
Systemic fluorides are those that are ingested. They include fluoridated water and dietary
fluoride supplements in the form of tablets, drops, or lozenges. Systemic fluorides are integrated into children's teeth as their tooth structures form.
The greatest reduction in tooth decay is achieved when fluoride is available both topically and systemically. Water fluoridation provides both types of contact.

The most accepted theory to explain the unusual sensitivity and response of exposed
root surfaces to various stimuli is the hydrodynamic theory. This theory postulates that
the pain results from indirect innervation caused by dentinal fluid movement in the
tubules, which stimulates mechanoreceptors near the predentin.
The rationale of desensitization procedures is not fully understood. Some techniques may
depend on denaturation of the superficial ends of Tomes fibers or of nerve endings in
dentin. Other procedures are designed to deposit an insoluble substance on the ends of the
fibers or nerves to act as a barrier to stimuli. Still others are designed to stimulate secondary dentin formation, thus insulating the pulp from external stimuli.
Numerous forms of treatment have been used to provide relief, such as topical fluoride,
fluoride rinses, oxalate solutions, dentin bonding agents, sealants, iontophoresis, and desensitizing toothpastes. All of these methods have met with varying degrees of success,
and none has been totally effective (although dentin bonding agents provide the best rate
ofsuccess). When these conservative methods fail to provide relief, restorative treatment
is indicated.
Note: The application of sodium fluoride has been recommended as an effective treatment for root sensitivity based on the precipitation of calcium fluoride crystals in the open
dentinal tubules.
s/fl
Which of the following types and concentrations of fluoride should be recommended for home'-care custom tray use by a patient with head and neck
cancer?
1.23% acidulated phosphate fluoride and 1% neutral sodium fluoride

0.4% stannous fluoride and 1.23% acidulated phosphate fluoride
0.4% stannous fluoride and 1% neutral sodium fluoride
1.23% acidulated phosphate fluoride, 0.4% stannous fluoride, and 1% neutral sodium
fluoride
109
II
OPERATIVE
s/fl
Match the following fluoride application options with their respective key
point.
acidulated phosphate fluoride (APF)
causes the most severe staining
stannous fluoride (SNF2)
most common over-the-counter fluoride
sodium fluoride (NaF)
most common in-office fluoride
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OPERATIVE
0.4% stannous fluoride and 1% neutral sodium fluoride

The gel contains either 1.0% sodium fluoride or 0.4% stannous fluoride. For maximum benefit, the gel must be in direct contact with the teeth. Fluorides are recommended
to protect these patients from postirradiation caries.
Remember two important points:
1. The fluoride found in commercial toothpastes is not adequate for people who have
undergone treatment with head and neck radiation.
2. These patients must continue to use the fluoride gel as directed for the rest of their
lives to protect their teeth from rampant decay.
Instructions for patient: The trays containing the fluoride are placed over the teeth for
a prescribed time (usually 10 minutes), and he/she may not eat or drink for at least 30
minutes. Usually this is done at night after toothbrushing and just before going to bed.
The daily use of fluoride gel in custom trays at home is indicated in the following situations:
Rampant enamel or root caries in any age group
Xerostomia
Head and neck radiation therapy
For use on abutment teeth under an overdenture
Hypersensitive root surfaces
Important: Fluorapatite is the most stable reaction product of a topical application of
fluoride.
acidulated phosphate fluoride (APF) - most common in-office fluoride

stannous fluoride (SNF2 ) - causes the most severe staining
sodium fluoride (NaF) - most common over-the-counter fluoride
Important:
1. Acidulated phosphate fluoride (APF) is the most commonly applied in-office fluoride treatment.
2 . The combination of 1.23% sodium fluoride and 1 M orthophosphoric acid results in
acidulated phosphate fluoride. It is very stable in solution.
3. The most common recommended over-the-counter fluoride is 0.05% sodium fluoride.
4. Stannous fluoride (8% F) has a very bitter, metallic taste, may burn the mucosa, and
has a short shelf life.
5. The tin ion in stannous fluoride may be responsible for staining the teeth, but it may
be beneficial for arresting root caries.
s/fl
Acidulated phosphate
has a 1<;>"" pH ..
Because of this, it is contraindkated on
and

111
OPERATIVE
s/fl
A young child gets into the bathroom cabhlet and ends up eating a full tube
of toothpaste. The mom calls you first.
telling her to call poison COI1trol, you will ask all of the following questions EXCEPT one. Which one is the
EXCEPTION?
how much does the child weigh?

what kind of toothpaste was it?
how old is the child?
did the child get into any other dental products (i.e., mouthwash)?
112
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Important:
The pH of APF is approximately 3.5 (acidic)
The pH of NaF is approximately 9.2 (basic)
The pH of SnF2 is approximately 2.1 to 2.3 (acidic)
Important: APF solutions and stannous fluoride (SNF:JJ should not be used on patients with
porcelain, glass ionomer, and composite restorations. They have been shown to remove the
glaze fl:om the surface of these restorations. Neutral sodium fluoride (NaF) is best to use if
these restorations are present. Also, APF should be avoided on implant patients, it may corrode the surface of titanium implants.
When painting fluoride on, it is very important to isolate the teeth with cotton rolls. When
using fluoride trays, cotton rolls may be placed in the premolar areas to increase patient comfort and help keep the fluoride in place. Patients are asked not to brush, rinse, eat, or drink 30
minutes after a fluoride treatment so that the fluoride is left undisturbed and is able to continue
reacting with the hydroxyapatite for some time after the initial application. Fluoride treatments should be applied for 4 minutes, although there are now some I-minute products that
are being marketed.
how old is the child?
*** As with any toxin, the toxicity of fluoride is based on weight, not age.
Fluoride, administered in large doses, can be fatal and should be kept with all other medications - out of the reach of children. This includes fluoridated toothpaste, gels, and
mouth rinse. The generally accepted toxic amount of fluoride that needs to be consumed
at one time is 5 mg/kg of body weight. This means that a child who weighs 25 lbs would
need to consume the equivalent of 56 1-mg tablets of fluoride, not a difficult task to accomplish for most 2-year-olds.
Important: An 8.2-ounce tube of toothpaste contains 232 mg of fluoride or 28 mg per
ounce.
Note: The most common forms of fluoride found in toothpastes are sodium fluoride and
sodium monofluorophosphate. Amine fluoride and stannous fluoride are less common.
s/fl
Sealants cap be effective when placedover
caries is cau'sed by anaerobic micro()rganisms.
carious lesions because

.
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terms
Which of the following is least associated with the shorHerm strength of a
material?
creep
modulus of elasticity
resilience
brittleness
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*** Sealants can be effective when placed over incipient carious lesions because caries is caused
by aerobic microorganisms.
Studies have carefully demonstrated that once an incipient carious lesion is sealed, the caries is
stopped for most intents and purposes. Since caries is caused by aerobic microorganisms, once
sealed over with a sealant an anaerobic environment is created in which the microorganisms become
static or die. There is no further action because there is no metabolite to reach the organisms,
there is no oxygen for them to exist in their environment, thereby they die.
1. Sealants act as a physical barrier in preventing bacteria from accumulating in the
!Note . pits and fissures of the teeth.
2. Care should be taken not to mix the sealant resin too vigorously prior to placement
or to overmanipulate the sealant resin on placement. Either of these errors could incorporate air into the sealant resin, resulting in a void in the surface of the sealant.
3. As long as a sealant remains intact, decay will not develop underneath it.
4. The following factors may influence which teeth are candidates for sealants: the
presence of interproximal decay, patient age, and how caries-prone the patient is.
5. Sealants should be placed right after the tooth has fully erupted, before the decay
process has had a chance to begin. For permanent molar placement, this would usually
be around age 6 and 12, give or take 6 months.
6. Although sealants are most commonly placed on permanent molars, they may be
placed on deciduous teeth in the following instances: the presence of deep pits and fissures, a very caries-prone mouth, and a tooth that is not likely to be exfoliated any time
soon.
7. The most common reason for sealant failure is salivary contamination, usually due
to inadequate isolation.
creep
*** Creep (strain relaxation) - deformations over time in response to a constant stress.
The key term in the question is "short-term."
Materials that are relatively weak or relatively close to their melting temperature are more
susceptible to creep. Dental wax deforms (creeps) under its own weight over short
periods. Traditional dental amalgam restorations are involved in intraoral creep.
Brittleness is generally considered to be the opposite of toughness. A brittle material is
apt to fracture at or near its proportional limit. A brittle material has a high compressive
strength but a low tensile strength (e.g., amalgam). Note: This is why amalgam preparations do not have beveled margins (they need butt joints).
The modulus of elasticity is a measure of the stiffness or rigidity of a material (it is the
ratio of stress to the strain below the elastic limit). Important: The higher the modulus
of elasticity, the stiffer, or more rigid, the material and the less strain it exhibits for a given
stress.
Resilience is the energy that a material can absorb before the onset of any plastic deformation.
Remember: Toughness is the property of being difficult to break. It is affected by the
yield strength, percent elongation, and the modulus of elasticity.
terms
Plastic deformationtakes place Pr.ior toelastic deformation.
The distinction between these two. is terrh.ed the
limit:i

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terms
In general, ductility ___---:.,--_-'-_in temperature, whereas malleability
-,.--____'---,---"- in temperature.
increases with increase, decreases with increase

decreases with increase, increases with increase
none of the above
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*** Elastic deformation takes place prior to plastic deformation. The distinction between
these two is termed the "elastic limit."
The elastic limit is the greatest stress to which a material can be subjected, such that it will
return to its original dimensions when the forces are released. Up to the elastic limit only
elastic deformation is involved, but beyond that, there is a combination of elastic and plastic deformation, with the plastic portion increasing and the elastic portion decreasing up
to the breaking point.
An example would be if a small tensile stress is induced in a wire, the resulting strain
might be such that the wire will return to its original length when the load is removed. If
the load is increased progressively in small increments and then released after each addition of stress, a stress value finally will be found at which the wire does not return to its
original length lifter the load is removed. In such a case, the wire is said to have been
stressed beyond its elastic limit.
The "proportional limit" is the greatest stress that may be produced in a material such
that the stress is directly proportional to the strain. A material that has a high proportional
limit compared to one with a lower proportional limit also has more resistance to permanent deformation.
Although the two terms, elastic limit imd proportional limit, are defined differently,
their magnitudes are so nearly the same that, for all practical purposes the terms can often
be used interchangeably.
Note: The yield strength represents a stress slightly higher than the proportional limit.
Yield strength is "strength measured at the stress at which a small amount of plastic strain
occur." Also called the yield point.
decreases with increase, increases with increase

Ductility is the ability of a metal to easily be worked into desired shapes (for example, the
ability to form a wire from a meta!). These materials undergo extensive plastic deformation prior to fracture (in tension). Ductility depends on plasticity and tensile strength.
Note: Ductility is usually expressed in terms of the percent elongation; the higher the
value, the more ductile the alloy.
A related term is malleability, which describes a metal being able to be hammered (compression) into a thin sheet without rupture. It also depends on plasticity, but is not as dependent on tensile strength as is ductility.
Gold is the most ductile and malleable metal, and silver is second. Of the metals of interest to the dentist, platinum ranks third in ductility and copper ranks third in malleability.
Note: Percent elongation is the total amount that the object stretches (i.e., the total
strain), which is the sum of the elastic deformation and the plastic deformation.
terms
An enamel bonding agent that bonds enamel to composite is termed a
"c.ohesive joint'li this is because there are three materials involved.
"
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terms
Match the following mechanical properties of loading terms with their.
correct pictures.
shear
flexion
torsion
compression
diametral compression/tension
tension
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*** An enamel bonding agent that bonds enamel to composite is termed an "adhesive
joint"; this is because there are two unlike materials being bonded together.
Adhesion is a process of solid and/or liquid interaction of one material (adhesive or
adherent) with another (adherend) at a single interface. Most instances of dental adhesion are also called dental bonding. A pit and fissure sealant bonded to etched enamel
is a case of dental adhesion.
An adhesive j oint is the result of interactions of a layer of intermediate material (adhesive or adherent) with two surfaces (adherends) producing two adhesive interfaces.
Examples include orthodontic bracket bonding resin, enamel bonding system for a composite resin, and a bonded porcelain veneer.
There are two principal types of adhesion:
1. Physical forces: called van der Waals forces
2. Chemical forces: called chemisorption
Adhesive potential can be predicted by measuring the spreading or wetting of the adhesive over the surface of the substrate. This is done by determining the contact angle of the
drop of adhesive as it spreads out. The smaller the angle, the greater the wetting and,
thus, the potential for adhesion.
compression
tension
shear
torsion
Qt
flexion
diametral compression/tension
*** Strain is the actual change in shape or deformation that accompanies any stress.
terms
Secondary dentin is formed in response to
wear.
operative procedures, or
The dentin formed in response is formed by !;econdary odontoblasts.

both statements are false .
the first statement is true! the second is false
the first statement is false! the second is true
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OPERATIVE
II
terms
When preparing for an amalgam, an operator should allow for proper retention form. This is because hilproper preparations can cause fracture of amalgam restorations.
the statement is correct! but the reason is not
the statement is not correct! but the reason is correct
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OPERATIVE
*** Tertiary dentin is formed in response to caries, operative procedures, or wear. Secondary odontoblasts secrete tertiary (reparative) dentin.
Throughout life, the dentin will respond to environmental changes (normal wear, caries,
operative procedures, etc.). These changes initiate the deposition of tertiary dentin,
which is fonned by replacement odontoblasts (termed secondary odontoblasts). This
reparative dentin will be limited to the site of irritation. The composition of reparative
and secondary dentin is basically the same (reparative dentin is more irregular), and
they differ only in location of deposition.
If the environmental insult is strong enough, it will kill the odontoblast and its tubular
process, leaving the tubule empty. If there is a collection of empty tubules, they are referred to as "dead tracts." In time, these tubules (dead tracts) will calcify. The term used
to describe the tubules that become calcified is "sclerotic dentin."
1. Primary dentin is the dentin forming the initial shape of the tooth. It is deposited before completion of the apical foramen.
2. Secondary dentin is dentin that is formed after completion of the apical
foramen. It is formed at a slower rate than primary dentin as functional stresses
are placed on a tooth. Secondary dentin is a regular and somewhat uniform layer
of dentin around the pulp cavity.
3. The junction between primary and secondary dentin is characterized by a
sharp change in the direction of dentinal tubules.
*** Resistance form is involved in fracture, not retention form.

Retention form is that form the cavity takes to resist dislodgement or displacement of the restoration. For example, the buccal and lingual walls of a Class I amalgam preparation converge occlusally; thus preventing dislodgement of the amalgam. For Class II restorations, this resistance to
dislodgement is provided by the occlusal dovetail and retention grooves in the proximo axial line
angles.
Resistance form is that form the cavity walls take to resist the forces of mastication. Resistance
fonn prevents fracture of the restoration and the tooth.
Examples: Severely undermined cusps should be reduced so as to prevent fracture. The axiopulpalline angle in Class II amalgam preparation is rounded or beveled so as to reduce concentration of stresses and thus prevent fracture of the brittle amalgam. Also, proper angulation of
cavity walls (converging) and pulpal and gingival walls that are perpendicular to occlusal forces
(flat walls at right angles to the long axis of the tooth) help achieve resistance form.
Important: The most common cause of fracture at the isthmus of a Class II amalgam restoration
is inadequate depth at the isthmus area (must be adequate depth to obtain resistance form). Most
detrimental to the strength of a posterior tooth in a cavity preparation is an increase in faciolingual
width.
Remember: G.V. Black is known as the father of modem dentistry. He is known for his principles
of tooth preparations, in which he outlines the proper methods to prepare teeth for fillings. The
phrase, "extension for prevention" is still famous in the dental community today and represents
Black's idea that dentists should follow preventive measures to aid patients from developing tooth
decay. Further, he organized a classification system with 5 categories for different patterns oftooth
decay which is still in use today. Since that time, only one more category (Class VI) has been added
to his classification system. Note: Class VI cavities are on the incisal edges of anterior teeth or on
the occlusal cusp heights of posterior teeth.
terms
The outline form of acavity preparation is defhled as:
"that form the cavity takes to resist the forces of mastication"

"that form the cavity takes to resist dislodgement or displacement of the restoration"
"the shape or form of the cavity on the surface of the tooth"
"the shape or form of the preparation after carious dentin has been excavated"
"the shape or form the preparation assumes after the retention form has been
completed"
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OPERATIVE
terms
A patient returns to your office only 24 hours after you cemented her new
gold crown on tooth #19. She claims to feel asharp electrical sensation in both
her upper and lower jaw on the left side. When you explain to her what might
be happening, you call it:
electromagnetic pulse
alternating current corrosion
electrolyte explosion
galvanic shock
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OPERATIVE
lithe shape or form of the cavity on the surface of the tooth ll
Two important points should be remembered in obtaining the outline form:

1. In general, the margins should be placed in areas of lessened caries susceptibility.
This principle is called "extension for prevention" (phrased by G. V. Black).
*** TODAY-modification of principle: extension determined by extent of DECAY
and RESTORATIVE material.
2. In general, all undermined enamel (which is enamel not supported by sound dentin)
should be removed.
*** The above two points are influenced by:

The lateral spread of decay at the DEJ
The type of restorative material to be used
The tooth and its relative position in the arch
Important: Extension (for prevention) can be restricted in patients with very low caries
susceptibility.
Remember: If, when establishing the ideal outline form, caries remains on any of the.
walls of preparation, the next step is tei extend the outline form before excavating any
caries.
galvanic shock
Galvanic shock is the brief but sharp electrical sensation one can receive when two dissimilar metals come into contact in the mouth.
An example of this phenomenon: An amalgam restoration is placed on the occlusal surface of a lower tooth directly opposing a gold inlay in an upper tooth. Because both
restorations are wet with saliva, an electric couple exists, with a difference in potential between the dissimilar restorations. When the two fillings are brought into contact, the potential is short-circuited through the two alloys. The result is sharp pain. Such postoperative pain usually occurs immediately after insertion of a new restoration and,
generally, it gradually subsides and disappears in a few days.
Note: The amount of electricity involved in galvanic shock can range up to 1.0 microamperes and 500 millivolts.
terms
Match the dental material on the left with the appropriate Coefficient of
Thermal Expansion (ppm/cx 10) onthe right.
unfilled resins
14.4
composite resins
11.4
amalgam
81 - 92
direct gold
22- 28
tooth
28 - 35
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terms
Which cavities can involve any teeth, ante.rior or posterior?
class I
class II
class III
class IV
class V
class VI
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OPERATIVE
-------,
Coefficient of Thermal Expansion
(ppm/c x 10)
11.4
14.4
22-28
28-35
81-92
The coefficient of thermal expansion is a measure of the tendency of a material to
change in shape when it is subjected to temperature changes (jor example, when eating
or drinking hot or cold items). A possible break in the marginal seal of any restoration becomes imminent when there is a marked difference in the coefficient of expansion between the tooth and the restorative material. The closer the coefficient is to the tooth, the
better (direct gold is best). If the coefficient of thermal expansion is referenced to a single dimension, it is called the "linear coefficient of thermal expansion" (LCTE). The LCTE
is expressed in units of ppmtC.
One of the consequences of thermal expansion and contraction differences between a
restorative material and adjacent tooth structure is percolation, which is defined as the
cyclic ingress and egress of fluids at the restoration margins. The possibility of recurrent decay at the margins increases with increased percolation.
class I
class V
class VI
Cavity classification: standardized methods of recording the need for restoration exist to facilitate communication among clinicians, researchers, and dental educators. The most commonly accepted means of classifying cavities is by the names of the surfaces involved. Cavity
type is classified further based on the type of treatment and anatomical area involved. This classification, developed by Dr. G. V. Black in 1908, is designated by Roman numerals as Class
I, Class II, Class III, Class IV, Class V, and Class VI (this is the only category that has been
added to his original classification system). Note: It is important to remember that the classification relates to location and not size of the cavity.
Class I cavities: involve the pits and fissures, while all other classifications involve smooth
surfaces of the teeth.
Class II cavities: involve the proximal surfaces and occlusal surfaces of premolars and
molars.
Class III cavities: involve the proximal surfaces of incisors and canines that do not involve
the incisal angle.
Class IV cavities: are located on the proximal surface of incisors and canines and do involve the incisal angle.
Class V cavities: are on the facial or lingual surface of all teeth and do not involve a pit
or fissure.
Class VI cavities: are on the incisal edges of anterior teeth or on the occlusal cusp heights
of posterior teeth.
Remember: The best method for definitive detection of incipient carious lesions on the interproximal surfaces of posterior teeth (distal surface of canines through molars) is by bitewing radiographs.

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amalgam

copyright C> 20132014 Dental Decks

neither the statement nor the reason is correct

(1.0 - 1.5 mm is acceptable but not ideal)

Close adaptation to cavity walls

Coefficient oftherinal expansion similar to tooth structure, Very good

High edge strerigth "

High abrasion resistance

Permanently restores M-D

Irisohibility in oral fluids

Ease of manipulation and placement

there is no such thing as a mercury allergy; plus, there is no mercury in amalgam

occlusal isthmus width

occlusal isthmus width

Form a reverse bevel at the axial

both statements are true

both statements are true

both statements are true

the first statement is false, the second is true

gingival margin will be less deeper

insufficient trituration and condensation

insufficient trituration and condensation

both statements are true

both statements are true

should result in a long bevel

mandibular first bicuspid

should remove unsupported enamel which may fracture

mandibular first bicuspid

it reduces marginal discrepancy

permits easy separation of the retainer from the

it reduces marginal discrepancy

the outline form is determined primarily by the

a decrease in particle size will decrease compressive

*** The opposite is true.

both statements are true

the statement is not correct, but the reason is correct

thus: Amalgam restorations require a 90 cavosurface margin

Outer planes carried into cleans able

both statements are true

Tin (Sn) 25-27%

Copper (Cu) 6% or less:

- Provides better clinical performance: less marginal breakdown

creep is a process that happens over time

creep is a process that happens over time

the statement is correct, but the reason is not

final application thickness

final application thickness

both statements are true

both statements are true

the statement is correct, but the reason is not

cause the setting time of the mix to be prolonged.

stronger final set

stronger final set

both statements are true

*** Only glass ionomer is used as a cement

agent) and a permanent restorative material. Glass

the first statement is false, the second is true

chemical reaction of acids and bases

the statement is correct, but the reason is not