LIST OF CONTENTS PART (1) 1. Fundamentals of cavity preparation.7 1.1 Introduction. 7 1.2 Objective of cavity preparation. 7 1.

3 Definition of cav ity preparation. 7 1.4 Principle 1.4.1 1.4.2 1.4.3 of cavity preparation and lin ing. 7 Principle of tooth preparation. 7 Cavity preparation terminology and abbr eviation. 8 Preparation of lining. 8 1.5 Cavity classification, location, and description. 10 1.5.1 Cavity classifica tion. 10 1.5.2 Cavity location, and description. 14 1.6 Procedure in cavity prep aration. 17 1.6.1 Cavity preparation walls. 17 1.6.2 Cavity preparation floor. 1 7 1.6.3 Cavity preparation angles. 18 1.6.4 Cavity preparation point angles. 19 2. Moisture control and tooth isolation. 20 2.1 Mouth Rinsing: 20 2.1.1 Performing a mouth rinse. 21 2.2 Oral Evacuation Met hod: 22 2.2.1 Saliva Ejector. 22 2.2.2 High-Volume Oral Evacuator. 22 2.2.3 Posi tioning the High-Volume Evacuator during a procedure. 26 2.3 2.3.1 2.3.2 2.3.3 2 .3.4 2.4 Isolation techniques: 27 Cotton Rolls. 27 Cotton Rolls Placement. 28 Re lated Aids. 29 Placement and removal of cotton rolls. 30 Rubber dam isolation. 3 1

2.4.1 Dental dam equipment. 32 2.4.2 Preparation of dental dam application. 35 2 .4.3 Preparation, placement, and removal of dental dam. 37 3. Caries Excavation and Temporary Restoration. 42 3.1 Access cavity and caries excavation. 42 3.1.1 The establishment of outline f orm. 42 3.1.2 The establishment of resistance form. 43 3.1.3 The establishment o f retention form. 44 3.1.4 Convenience form. 44 3.1.5 The treatment of residual caries. 44 3.1.6 Finishing of enamel walls and cavo-surface margins. 45 3.1.7 Th e toilet of the cavity or cleaning of cavity. 45 3.2 Temporary Restoration. 46 3 .2.1 Introduction. 46 3.2.2 Note on principles of caries excavation. 46 3.2.3 Te mporary restoration with Zinc Oxide and Eugenol. 3.2.4 Temporary restoration wit h GIC (Fuji VII). 49 3.2.5 Temporary restoration with Zinc Phosphate. 50 3.2.6 T emporary restoration with Gutta-Percha. 51 3.2.7 Mounting the teeth. 51 4. 4.1 4 .2 4.3 5. 5.1 5.2 6. 6.1 6.2 6.3 6.4 7. 7.1 7.2 7.3 7.4 7.5 7.6 7.7 PART 2 LIST OF CONTENTS 165 Preventive Resin Restoration. 54 Fissure Sealant. 54 Pit restora tion with composite. 57 Pit restoration with GIC (Ketac Molar). 47 59 Acid-Etch Techniques and Abrasion Cavity Restoration. 61 Acid-etch Technique. 61 Abrasion Cavity Restoration. 62 Amalgam Restoration. 63 Amalgam restoration mat erials. 63 Class I amalgam restoration. 65 Class II small and medium amalgam res toration. Class V amalgam restoration. 122 Composite Restoration. 125 Composite Restoration Materials. 128 Class III composite restoration. 129 Practical class for class III composite restoration. 142 Tooth preparation for class III in clin ical procedures. 143 Class IV composite restoration. 144 Practical class for cla ss IV composite restoration. 154 Class V composite restoration. 255 97

1. Introduction to Operative Techniques. 168 Classification of techniques and storative strategies. Tooth preparation. 172 Direct Techniques. 175 Semidirect T echniques. 185 Indirect Techniques. 194 New technologies for tooth colored resto rations. 208 Luting procedure. 216 Finishing and polishing procedure. 221 2. Instrumentation and Operators position. 225 Hand instruments. 225 Rotary instr ument. 240 Position of operator. 246

3. Dental Caries. 251 What is caries? 251 The carious proce sion. 256 Dental plaque. 256 Epidemiology of dental caries. 256 Modifying the ca rious process. 257 The first visible sign of caries in an enamel surface. 258 Th e microbiology of dentine caries. 259 Active and arrested lesions in dentine. 26 0 Root caries. 261 Secondary or recurrent caries. 262 Residual caries. 263 Why i s dentine caries brown? 264 Prevention of caries by plaque control. 264 Diet and caries. 268 Fluoride supplementation. 269 Saliva and caries. 171 The operative management of caries. 277

4. Sharpening of Hand Instrument. 283 Stationary sharpening stones. 283 Mecha al sharpeners. 283 Handpiece sharpening stones. 284 Sharpening of hand instrumen t. 284 Principles of sharpening. 285 Mechanical sharpening techniques. 285 Stati onary stone sharpening techniques. 285 Sharpness test. 287 5. Dental Physiology. 287 Structure of the head and neck. 287 Major muscles of astication and facial expression. 289 Blood supply to the face and mouth. 296 Ly mph nodes. 298 Nerve supply to the mouth. 299 Structures of face and oral cavity . 303 The teeth. 309

6. High Speed Technique. 310 Development of rotary equipment. 310 Rotary spee ange. 313 Laser equipments. 313 Other equipment. 315 Rotary cutting instruments. 316 Diamond abrasive instruments. 321 Cutting recommendations. 322 Hazards with cutting instruments. 322 1. FUNDAMENTALS OF CAVITY PREPARATION. 1.1 Introduction: Cavity preparation is t he mechanical alternation of defective, injured or diseased tooth in order to be st receive a restorative material that will reestablish a healthy state for the tooth including esthetic correction when indicated, along with normal from and f unction. Teeth needs for restoration are variety of reasons as follow: To restor e the integrity of the tooth surface. To restore the function of the tooth. To r estore the appearance of the tooth. To remove the diseased tissue from the tooth . 1.2 Objectives of cavity preparation: The objectives of general cavity prepara tion are:

 To remove diseased tissue as necessary and at the same time provides the protect ion to the pulp. To locate the margins of the restoration as conservative as pos sible. To ensure the cavity form, it should be under the force of mastication of the tooth or the restoration or booth will not fracture and restoration should not be displaced. To allow the restorative material and functional placement. 1. 3 Definition of cavity preparation: Cavity preparation is the mechanical alterna tion of a tooth to receive a restorative material, which will return the tooth t o proper anatomical form, function, and esthetics. The procedure of the preparin g the tooth is the removal of the defective or friable tooth structure. Any rema ining infected or friable tooth structure may result of further carious progress ion, sensitivity or pain or fracture of the tooth and / restoration. 1.4 Princip le of cavity preparation and lining: 1.4.1 Principles of tooth preparation. Gain access to caries. Remove all caries (Minimal caries removal 1-1.5 mm) Cut away all significantly unsupported enamel. Extended margins so that they are accessib le for instrumentation and cleaning. Why restore? To restore function. To preven t further spread of an active lesion, this is not amenable to preventive measure s. To prevent pulp vitality. To restore aesthetics. 1.4.2 Cavity preparation ter minology and abbreviation. Simple cavity: Preparation involving one surface of t he tooth. Compound cavity: Preparation involving two surfaces of the tooth. Comp lex cavity: Preparation involving three or more surfaces of the tooth. For recor d and communication, the description of a cavity preparation is abbreviated by u sing the first latter, capitalized, of each tooth surface involved. Examples are (1) An occlusal cavity is an O. (2) A preparation involving the mesial and occl usal surfaces is a MO. (3) A preparation involving the distal and occlusal surfa ces is a DO. (4) A preparation involving the mesial, occlusal and distal surface s is a MOD. Abbreviations for simple, compound, and complex cavities: MOD: :Mesi o-occlusal-distal DO: :Disto-occlsal MO: :Mesio-occlusal MI: :Mesio-incisal DI: :Disto-incisal LI: :Linguo-incisal DL: :Disto-lingual MODBL: :Mesio-occluso-dist o-bucco-lingual I=incisal, M=Mesial, D=Distal, B=Buccal, O=Occlusal 1.4.3 Prepar ation of Lining.

Although the placement of cavity liners and base is not a step in cavity prepara tion, it is a step in adapting the preparation for receiving the final restorati ve material. The used of air-water spray coolant in high-speed rotary instrument also protects the pulp as it dissipates the heat generated during cavity prepar ation. The use of lining/liner or base in cavity preparation becomes essential w hen the cavities finish deep in the dentine or when the cavities lie close to th e pulp. In a deep or extensive cavity, usually lining material was placed first. Lining may serve one or more of the following purposes; Protective lining/Pulp protection Therapeutic lining Structural lining a lining b Fig-1.1 (a) and (b) P rotective or Therapeutic Fig-1.2 Structural lining Protective lining/Pulp protection To protect dentine a nd pulp in metallic and in non-metallic restoration. The lining materials are; 1 . Zinc Oxide and Eugenol Cement 2. Fortified Zinc Oxide Cement 3. Calcium Hydrox ide Cement 4. Zinc Phosphate Cement Therapeutic lining To apply medicament such as chlorobutanol, carbolized resin, silver nitrate, and etc. The medicament may be applied directly to the dentine and covered with zinc oxide eugenol. Recommen ded materials are Fuji lining LC. Ledermix cement, Dycal (CaOH2), Zinc oxide eug enol cement. Can be placed the thickness 0.5 mm or less. Structural lining The s tructural function of a lining is usually combined with its protective function. Recommended materials are Zinc oxide eugenol cement, kalzinol cement, Fiji IX, Fuji II, and Fiji II LC. Can be placed the thickness 2mm or more. 1.5 Cavity classification, location, and description: 1.5.1 Cavity classificatio n. G.V Black developed five standard cavity classifications and sixth class was added later. Class I: :Class I caries are developmental cavities in the pit and fissure of teeth (following Fig-1.3) They are located in: : The occlusal surface of the posterior teeth (premolar and molar) The buccal or lingual pit of molar The lingual pit near the cingulum of the maxillary incisors.

Class I cavity: The Fig-1.3 Shown the class I caries, (A).Occlusal surface of pr emolar and molar, (B).Buccal surface of Molar, (C ).Lingual surface of Maxillary incisors. Restoration with amalgam is recommended and some extents are countera cted by adhesive materials as composite and glass ionomers cement. (c) Fig 1.3 C lass I cavity Class II cavity: Class II caries are on the proximal (mesial or di stal ) surface of the posterior teeth (premolars and molars) The following Fig-1 .4(1) shown on the proximal surfaces of (A) premolar and molar, (B) placed prior to an MO or MOD restoration on the surface of premolar and molar The bottom par t of the following figure is Class III cavity. 1 2 Fig-1.4 (1) Class II and (2) Class III caries. Class III cavity: Class III caries are on the interproximal surface (mesial or d istal) of the anterior teeth (canines, lateral incisors and central incisors. Th e above Figure Fig-1.4(2) shown the class III cavity (M and D on the interproxim al surface of central incisor and lateral incisor Fig-1.4 (2). Class IV Cavity: Class IV caries are on the interproximal surface (mesial or distal) of anterior teeth include the incisal edge. The Fig-1.5 showing class IV cavity. Fig-1.5 Class IV cavity Class V cavity: Class V: Caries affecting on the cervica l surfaces. The Fig 1.6 showing the class V cavity. Fig-1.6A The class V cavity.

Class VI cavity: Class VI: Cavity affecting by abrasion on facial surface of the teeth. The Fig-1.6 B shown the class VI cavity. Fig-1. 6B Class VI cavity. Root service caries. As gingival recession The fig-1. 7 shown root service cavity. Fig-1.7 Root service cavity. 1.5.2 Location and description. Class I: Decay is d iagnosed in the pits and fissures (Fig-1.8) of the occlusal surfaces of molars a nd premolars, buccal or lingual pits of molars, and lingual pits of maxillary in cisors. Because most of this type of decay is confined to a small area, the dent ist will choose to restore these surfaces with composite (tooth-colored) resins. Fig-1.8 Decay in the pit and fissure of occlucal surface of molar and premolar. Class II: Decay is diagnosed in the proximal (mesial or distal) (Fig-1.9) surfac es of premolars and molars. Because this surface area is harder to detect visual ly, a radiograph is used to detect the decay. The design of the restoration will most commonly include the occlusal surface and may possibly involve more than t wo surfaces. The type of dental materials used to restore this classification is either silver amalgam (chosen for its strength) or newer composite (tooth-color ed) resins designed for posterior teeth (chosen for esthetic appeal). If the too th has extensive decay, the dentist may choose to crown the tooth with a gold or porcelain inlay, only, or crown. Fig-1.9 Decay in mesial or distal surface of premolars and molars. Class III: De cay is diagnosed in the proximal (mesial or distal) (Fig-1.10) surfaces of incis ors and canines. This decay is similar to that of class II, except it involves a nterior teeth. It is easier for the dentist to access these surfaces with less t ooth structure affected. The type of dental material used to restore this classi fication is composite (tooth-colored) resins (for esthetic appearance).

Fig-1.10 Decay in the proximal (mesial or distal) surfaces of incisors and canin es. Class IV: Decay is diagnosed in the proximal (mesial or distal) (Fig-1.11) s urfaces of incisors and canines. The difference between class IV and class III d ecay is that class IV involves the incisal edge or angle of the tooth. The type of dental material used to restore this classification is composite (toothcolore d) resins (for esthetic appearance). If the tooth has extensive decay, the denti st may choose to crown the tooth with a porcelain crown. tooth. Fig-1.11 Decay in mesial or distal and incisal edge or angle of the Class V: Decay is diagnosed in the gingival third of facial or lingual (Fig-1.12 ) surfaces of any tooth. This is also referred to as a smooth surface decay. The type of dental material used to restore this classification depends on which te eth are affected. If the decay occurs in posterior teeth, the dentist may choose silver amalgam; if anterior teeth are involved, composite (tooth-colored) resin will most likely be used. Fig-1.12 Decay in the gingival third of facial or lingual surfaces. Class VI: Decay is diagnosed on the incisal edge of anterior teeth and the cusp tips of posterior teeth (Fig-1.13). Class VI decay is caused by abrasion (wear) and defects. The dental material is chosen based on which teeth are involved. Fi g-1.13 Decay on the incisal edge of anterior teeth and the cusp tips of the post erior teeth. 1.6 Procedures of cavity preparation: 1.6.1 Cavity preparation wall s. Surfaces of the wall were prepared by operator internal boundaries of the cav ity. The surrounding walls of the cavity take the name of the surface of the too th towards which they are placed; Internal wall: An internal wall is a prepared cavity surface, which does not extend to external tooth surface. Axial wall: An internal wall is parallel with the long axis of the tooth and adjacent or neares t pulp chamber or pulp canals. Pulpal wall: An internal wall is both perpendicul ar to the long axis of the tooth and coronal to the pulp. External wall: An exte rnal wall is a prepared cavity surface, which extends to the external surface of the tooth. Mesial wall: An external wall towards the mesial surface of the cavi ty. Distal wall: An external wall towards the distal surface of the cavity.

 Occlusal wall: An external wall towards the occlusal surface of the cavity. 1.6.2 Cavity preparation floor. Floors (or seat) term used which refers to the b ottom or wall representing the deepest penetration in a cavity preparation (Fig1.14). They are reasonably flat and perpendicular to the occlusal forces that ar e directed occluso-gingivally. Examples are: The pulpal wall, which can also be known as pulpal floor. The gingival wall, which also known as gingival floor (as in Class II or Class V). Such floors provide a stabilizing seat for the restora tion, thus distributing the stresses evenly in the tooth. Fig-1.14 Cavity preparation floor. 1.6.3 Cavity preparation angles. Line angle t erm given to a line formed by the junction of two walls or a wall and a floor (F ig-1.15), named by combining the names of the two walls, e.g. Mesio-buccal line angle: Disto-buccal line angle, Axio-pulpal line angle. Internal line angle: A l ine angle which apex point, into the tooth (faciopulpal). External angle: A line angle which apex point, away from the tooth (e.g., axio-pulpal) Fig-1.15 Cavity preparation line angle (occlusal view) 1.6.4 Cavity preparation point angles. Point angle: Term given to a point where the three surfaces or thr ee line angles (Fig-1.16) are meeting. It was named by combining the names of th e three walls, e.g. Mesio-biccal-pulpal point angle, Disto-lingual-pulpal line a ngle. Cavosurface angle: Term given to the angle of tooth structure formed by th e junction of a prepared cavity wall and the external surface of the tooth. Whil st the principles have been systematically set out in a specific number of steps and stages. There is a certain degree of overlapping, and principles affecting stage frequently have a bearing on another. Additionally, some steps may be over looked depending upon the clinical situation. Pulp protection is needed in the c ase where cavity preparation finishes deep into the dentin or lie close to the p ulp. We should aim to provide the best form, which will protect the tooth while achieving maximum durability of the restoration. Fig-1.16 Cavity preparation point angle

Fig-1.17 Cavity preparation line angles, point angles and carvo-surface margin ( upper mesial view, lower occlusal view) Caries) must be removed. 2. MOISTURE CONTROL AND ISOLATION During the dental procedure, one of the most r esponsibilities is to maintain the clinical field. The tooth, surrounding tissue , and the oral cavity can be come a catch all for water, saliva, blood and tooth f ragments. The type of procedure you are assisting in and the access to the area will be dictate the type of isolation method chosen. 2.1 Mouth Rinsing: The two basic types of rinsing procedures used in dentistry are limited-area rin sing and complete mouth rinsing. Limited-area rinsing is performed frequently be cause the debris can be accumulated during the preparation o tooth. This must be quickly without delay in the procedure. The completed mouth rinse is performed at the completion of dental procedure. 2.1. 1 Performing a Mouth Rinse Fig-2.1 Performing a mouth rinse. Equipment and supplies HVE tip Saliva ejector Air-water syringe 1. 2. 3. Procedure steps 1. Decide which oral evacuation system would be best for the rin sing procedure. 2. Grasp the air-water syringe in your left hand and the HVE or saliva ejector in your right hand. Limited-Mouth Rinse 1. Turn on the suction, a nd position the tip toward the site for a limited-area rinse. 2. Spray the combi nation of air and water onto the site to be rinsed. Purpose: The combination of the air and water provides more force to clean the area thoroughly. 3. Suction a ll fluid and debris from the area, being sure to remove all fluids. 4. Dry the a rea by pressing the air button only. Full-Mouth Rinse 1. Have the patient turn t oward you. Purpose: Turning the head allows the water to pool on one side, makin g it easier for you to suction. 2. Turn on the HVE or saliva ejector, and positi on it in the vestibule of the patients left side. Note: Position the tip carefull y so that it does not come into contact with soft tissue. 3. With HEV or saliva ejector tip positioned, direct the air-water syringe from the patient maxillary r ight across to the left side, spraying all surfaces.

4. Continue down to the mandibular arch, following the same sequence from right to left. Purpose: This pattern of rinsing forces the debris to the posterior mou th, where the suction tip is positioned for easier removal of fluids and debris. 2.2 Oral Evacuation Method: 2.2.1 Saliva Ejector This instrument used to remove small amount of saliva or water from a patients mouth. It is small straw like tu be has flexible to conform to many areas in the mouth (Fig-2.2). Fig-2.2 Saliva ejector. 2.2.2 High-Volume Oral Evacuation The high-volume oral evacuator (HVE) is stronger source of moisture control, com monly used during dental procedure. Maintain the mouth free from saliva, blood, water, and debris. Retract the tongue or cheek away from the procedure site. Red uce the bacterial aerosol caused by the high-speed handpiece. Oral Evacuation Ca ution: Improper or careless use of the HVE could cause soft tissue to be acciden tally sucked into the tip, and tissue damage could result. Keeping the tip at an a ngle to the soft tissue helps prevent this from happening. If the soft tissue is accidentally sucked into the tip, rotate the angle of the tip to break the suctio n or quickly turn the vacuum control off to release the tissue. HVE Tips: The mo st commonly used HVE tips are made of a semi hard plastic that is sterilized aft er a single use. Tips are also available in stainless steel, which also must be sterilized before reuse (Fig-2.3). Fig-2.3 HVE tips. HVE tips are available with either straight or with a slight a ngle in the middle. All types have two beveled working ends (beveled meaning sla nted.) The bevel is slanted downward for use in the anterior portion of the mout h. For use in the posterior portion of the mouth, the bevel is slanted upward. W hen placing the HVE tip into the handle of the suction unit, the tip is pushed i nto place through a plastic protective barrier, which will cover the HVE handle. If the incorrect end of the tip has been placed in the suction, do not turn it around; it is now contaminated and must be replaced with a new tip. Holding the Oral Evacuator: The oral evacuator may be held in two ways: either the thumb-tonose grasp or pen grasp (Fig-2.4). Either method provides control of the tip, wh ich is necessary for patient comfort and safety. Many assistants alternate betwe en positions, depending on the resistance of the tissue to retract and the area being treated. Fig-2.4 Method of holding the oral evacuator tip: Top; thumb-to-nose grasp, and Bottom; pen grasp.

When assisting a right-handed dentist, hold the evacuator in the right hand. Whe n assisting a left-handed dentist, hold the evacuator in the left hand. The othe r hand is then free to use the air-water syringe or transfer instruments to the dentist as needed. To be most efficient in HVE placement, you should position th e HVE tip in the mouth first, and then the dentist can position the hand piece a nd mouth mirror (Fig-2.5). Fig-2.5 A The HVE tip is placed on the lingual surface and slightly distal to th e tooth being prepared. On the mandibular it is also used to retract the tongue (Placement of HEV tip on maxillary and mandibular right side). the on surface. Fig-2.5 B The HVE tip is placed on the opposite surface of tooth being prepared; for example, if the dentist is working the facial surface, the HVE tip is posit ioned on the lingual (Placement of HEV tip on maxillary and mandibular anterior side). Fig-2.5 C The HVE tip is placed on the buccal being cheek. side). surface and sl ightly distal to the tooth prepared, also helping to retract the (Placement of H EV tip on maxillary and mandibular left 2.2.3 Positioning the High-Volume Evacuator During a procedure 1. 2. 3. Equipmen t and Supplies Sterile HVE tip Plastic barrier cover for HVE handle and hose Cot ton rolls. Procedure Steps. 1. Place the HVE tip in the holder by pushing the end of the ti p into the holder through the plastic barrier. Purpose: Leaves the opposite end exposed and ready for use. 2. If necessary, use the HEV tip or a mouth mirror to gently retract the cheek or tongue. 3. For a mandibular site, place a cotton ro ll under suction tip. Purpose: Provides patient comfort, aid in stabilizing tip placement, and prevent injury to the tissue. 4. Place the bevel of the HEV tip a s close as possible to the tooth being

prepared. Purpose: Suction will draw the water into the tip immediately after it leave the tooth being prepared. 5. Position the bevel of the HEV tip parallel t o the buccal or lingual surface of the tooth being prepared. 6. Place the upper edge of the HEV tip so that it extends slightly beyond the occlusal surface. Pur pose: Suction will catch the water spray from the hand piece as it leaves the to oth being prepared. Fig-2.6 Posterior Placement. Placement. Fig-2.7 Anterior 2.3 Isolation techniques: 2.3.1 Cotton Rolls During tooth preparation, water is expressed from the high sp eed hand piece to cool the tooth and remove debris. However, when placing a comp osite or amalgam restoration or when cementing a cast restoration a clean, dry e nvironment is necessary. One method of ensuring dry conditions is the use of cot ton rolls. When a dental dam is not an option, cotton roll isolation is used as an alternative method to control moisture in the operative area. (Isolation, as used here, means to keep the area separated and dry.) Cotton rolls are available in a variety of sizes and are flexible so they can be bent to fit an available space. Some cotton rolls have a light coating on the surface to make them slight ly stiff. A softer type of cotton roll is not coated, but is wrapped with a cott on thread. There are advantages and disadvantages to using cotton rolls: Advanta ges Can be placed quickly and securely Are simple to use No additional equipment is needed for placement. 1. 2. 3. Disadvantages 1. Do not prevent contamination of the area by the patient tongue. 2. Do not prevent debris from dropping into the mouth or throat. 3. If removed, dry cotton rolls may adhere to the oral mucosa, which can injury the tissue. 4. Must be replaced if they get wet before the procedure is completed. 2.3.2 Cotto n Roll Placement When part of the maxillary arch is isolated, cotton rolls are p laced on the cheek side of the teeth in the mucobuccal fold. This fold holds the cotton rolls securely in place. (The mucobuccal fold is the area where the mast icatory mucosa covering the alveolar ridge turns upward and becomes the lining m ucosa of the cheek) (Fig-2.8) A B Fig-2.8 A and B , Cotton roll placement for th e maxillary

arch. Because of movements of the tongue and the tendency of saliva to pool in the flo or of the mouth, cotton roll isolation is more difficult to achieve in the mandi bular arch. Cotton rolls are placed in both the mucobuccal fold and on the lingu al side of the arch (Fig-2.9). A B Fig-2.9 A and B, Cotton roll placement for ma ndibular arch. When the anterior portion of the mandible is isolated, cotton rolls and a saliva ejector can be used. To isolate the posterior portion, two cotton rolls and a s aliva ejector may be used (Fig-2.10). Depending on the location, cotton rolls ar e placed and removed with either cotton pliers or gloved fingers. If the cotton rolls become saturated. Fig-2.10 cotton roll placement for anterior. 2.3.3 Related Aids Dry Angle: Some dentist will use a triangle-shaped absorbent pad to help isolate posterior areas in both the maxillary and mandibular arches. The pad is placed on the buccal mucosa over Stensens duct (Fig-2.11). (This duct from the parotid gland is located opposite the maxillary second molar.) These p ads block the flow of saliva and protect the tissue in this area. Follow the man ufacturers directions for placement and if necessary replace pad if they become s oaked before the procedure is completed. To remove, use water from the air-water syringe to thoroughly wet the pad before separating it from the tissue. Fig-2.11 Application of a dry angle. 2.3.4 Placement and removal of Cotton Rolls 1. 2. 3. Equipment and Supplies Basic setup Cotton rolls Air-water syringe Maxillary placement 1. Have the patient turn toward you with their chin raised. Purpose: Provide better visualization and easier placement of cotton roll. 2. Us ing the cotton pliers, pick up a cotton roll so that it is positioned evenly wit h the beaks of the pliers. 3. Transfer the cotton roll to the mouth, and positio n it securely in the mucobuccal fold closet to the working field. Note: Once you place the cotton roll with the pliers, you may want to use your gloved finger o r handle end of the cotton pliers to push the cotton roll further into the mucob uccal fold. 4. This placement can be used for any location on the maxillary arch .

Cotton rolls placement for maxillary. Mandibular placement 1. Have the patient t urn toward you with the chin lowered. Purpose: Provides better visualization and ease in the placement of the cotton roll. 2. Using the cotton pliers, pick up a cotton roll so that it is positioned even with the beaks of the pliers. 3. Tran sfer the cotton roll to the mouth, and position it securely in the mucobuccal fo ld closet to the working field. 4. Carry the second cotton roll to the mouth, an d position it in the floor of the mouth between the working field and the tongue . Note: Have the patient lift the tongue during the placement and then relax to help secure the cotton roll in position. 5. If you are placing cotton rolls for the mandibular anterior region, bend the cotton roll before placement for better fit. 6. If using saliva ejector for the procedure, place it after the cotton ro ll is in position in the lingual vestibule. Cotton rolls placement for mandibula r. Cotton roll removal 1. At the completion of a procedure, remove the cotton ro ll before the full mouth rinse. If the cotton roll is dry, moisture it with wate r from air-water syringe. Purpose: Dry cotton rolls will adhere to the oral muco sa lining and tissue may damage when a dry cotton roll is pulled away from the a rea. 2. Using cotton pliers, retrieve the contaminated cotton roll from the site . 3. If appropriate for the procedure, perform a limited rinse. 2.4 Rubber dam i solation: The dental dam is a thin latex barrier used to isolate a specific tooth or sever al teeth during treatment (Fig-2.12). These teeth are referred to as being isola ted. The dental dam is applied after the local anesthetic has been administrated and while the dentist is waiting for it take effect. Before the application of the dental dam, the isolated teeth should be clean and free of plaque or debris. If not removed, the plaque or debris could be dislodged and injure the gingival tissue. When indicated, tooth brushing or selective coronal polishing is perfor med before dam placement. Before placing the dental dam, review the patients medi cal history for any indications of latex sensitivity. If this is a problem, the dentist must be consulted before the application is continued. Fig-2.12 Dental d am. 2.4.1 Dental Dam Equipment The specialized equipment used for rapid and effi cient placement of dental dam is shown in Figure-2.13 and described in table 2.1 . Indications for use of dental dam a. It serves as an important infection contr ol protective barrier. b. It safeguards the patients mouth against contact with d ebris, acid-etch materials and other materials during treatment.

c. It protects the tooth from accidentally inhaling or swallowing debris, such a s small fragments of a tooth or scraps of restorative material. d. It protects t he tooth from the contamination of saliva or debris if pulpal exposure accidenta lly occurs. e. It protects the remainder of oral cavity from exposure to infecti ous material when an infected tooth is opened during endodontic treatment. f. It provides the moisture control that is essential for the placement of restorativ e materials. g. It improves access during treatment by retracting the lips, tong ue, and gingival. h. It provides better visibility because of the contrast of co lor of the dam and the tooth. i. It increases dental team efficiency, discourage s patient conversation, and may reduce time required for some treatment. Fig-2.13 Dental dam setup for application. Table-2.1 Dental dam and equipment. T ype of Equipment Description of Equipment Dam Material Material comes in latex or latex-free material. Size is 6 x 6 0r 5 x 5. Comes in a wide range of colors. There are three gauges of thickness (thin, medium, and heavy). Dental dam frame It is a U shaped frame made of either plastic or metal stretches the material away from the face and being worked on. Dental dam napkin A cotton absorbent sheet placed between the dental dam and patient. Lubricant A water-soluble material that can be placed on the underside of the dam around the punched area for easier placement between tight contacts. Dental dam punch A hole punch device used to create the holes in the dam that expose the teeth to be isolated. The sizes used for specific teeth are: No.1 Mandibular incisors No .2 Maxillary incisors No.3 Premolars and canines No.4 Molars and bridge abutment s No.5 Anchor tooth with the clamp

Dental dam stamp Stamp designed in the shape of dental arch that imprints teeth on the dental dam to be punched. Dental dam forceps A forceps that is used in the placement and removal of the dental dam clamp. Den tal dam clamps A crown-shape piece of metal that anchors the dental dam material on a tooth. Th ere are many designs of clamps that fit the contour of each tooth in the mouth. For safety purposes, it is important to always ligate to bow portion of a clamp with floss before placing in the mouth. This will prevent the clamp from being a ccidentally swallowed. 2.4.2 Preparation of the Dental Dam Application Each application of dam is prepl anned to accommodate the dentists preferences, the tooth and teeth involved, and the procedure to be preformed. Several important factors must be included in pla nning for holes to be punched in the dental dam. i. The arch, its shape, and any irregularities, such as missing teeth or a fixed prosthesis ii. The number of t eeth to be isolated iii. Identification of the anchor tooth and location of the key punch hole iv. The size and spacing of the other holes to be punched; (the a nchor tooth holds the dental dam clamp, and the keypunch hole covers the anchor tooth). Maxillary Arch Applications In preparation for maxillary application, th e dam material is stamped or marked. This mark automatically designates the marg in of dam for these holes. If the patient has a mustache or very thick upper lip , it is necessary to allow extra space for the anterior teeth area. Mandibular A rch Applications. In preparation for mandibular application, the dam is stamped or marked. Because of the small size of the mandibular anterior teeth, the holes are punched closer together than those for posterior teeth. Curve of the Arch I t is necessary to make the adjustments to accommodate an extremely narrow or wid e arch. Failure to do this will increase the difficulty when inverting the edges of the punched holes of the dam. Bunching the stretching on the lingual aspect of the dental dam occur if the curve of the arch is punched too narrow or too wi de. Folds and stretching of the dam on the facial aspect occur if the arch is pu nched too

curved or too narrow. Malaligned Teeth If a tooth or teeth are misaligned within the dental arch, special consideration of their position is taken before the de ntal dam is punched. (Malaligned and malposed mean that the individual tooth is not in its normal position within the dental arch.) If a tooth is lingually posi tioned, the hole punch size remains the same, but the hole is placed about 1 mm lingually from the normal arch alignment. If the tooth is facially positioned, t he hole punch size remains the same, but the hole is placed about 1 mm facially from the normal arch alignment. Teeth to be Isolated Single-tooth isolation is u sed commonly for endodontic treatment and for selective restorative procedures, such as Class V restorations. Some dentists choose to isolate only the tooth to be treated. Others prefer to have two teeth isolated so that the second tooth ac ts as an anchor tooth to hold the clamp. During treatment in the posterior area, this provides more stability and better visibility. For multiple-tooth isolatio n, in which optimum stability is needed, it is desirable to have the quadrant is olated having this many teeth isolated counteracts the pull on the dam that is c reated by the curvature of the teeth in the arch. When anterior maxillary teeth are to be treated, maximum stability is achieved by isolating the six anterior t eeth (canine to canine). Key Punch Hole The anchor tooth holds the dental dam cl amp. The key punch hole is punched in the dental dam to cover the anchor tooth. A larger, number 5-size hole is necessary for the key punch because it must also accommodate the clamp. Hole Size and Spacing The size of each hole selected on the dental dam punch must be appropriate for the tooth to be isolated. A correct ly sized hole allows the dam to slip easily over the tooth and fit sungly in the cervical area. This is important to prevent leakage around the dam. In general, the holes are spaced from 3.0 to 3.5 mm between the edges, not the centers, of the holes. This allows adequate spacing between the holes to create a septum tha t slips between the teeth without tearing or injuring the gingival. The septum i s the portion of the dental dam between the holes of the punched dam. During app lication, this portion of the dam is passed between the contacts (Septum is sing ular, septa is plural). Ethical Implications In the application of the dental da m, you may be asked to place this by yourself. If this is the cave, verify that this is a legal function in your state for dental assistants and that you have h ad special training in the application process. 2.4.3 Preparation, Placement, an d Removal of Dental Dam. Equipment and supplies 1. Basic setup 2. Precut 6-by-6inch dental dam 3. Dental dam stamp and inkpad or template and pen 4. Dental dam punch 5. Dental dam clamp or clamps with ligature attached 6. Dental dam clamp forceps 7. Young frame 8. Dental dam napkin 9. Dental tape or waxed floss 10. Co tton rolls 11. Lubricant for patients lips 12. Lubricant for dam 13. Black spoon 14. Crown and bridge scissors

Fig-2.13 The basic setup for dental application. Patient preparation 1. Check th e patients record for contraindications and to identify the area to be isolated. Inform the patient of the need to place a dental dam, and explain the steps invo lved. 2. Assist the dentist in the administration of local anesthetic. The opera tor will determine which teeth are to be isolated and note whether there are any malposed teeth to be accommodated. 3. Apply lubricating ointment to the patients lip with a cotton roll or cotton tip applicator. Note: The patients comfort is o f concern throughout the placement and removal of the dental dam. 4. Use the mou th mirror and explorer to examine the site where the dam is to be placed. It sho uld be free of plaque and debris. Purpose: If the dam is placed in an area with plaque and debris, the dam could push the plaque and debris into the sulcus and irritate the gingival tissue. Note: If debris or plaque is present, selective to oth brushing or coronal polishing is performed on these teeth before the applica tion of the dental dam. 5.Floss all contacts involved in the placement of the de ntal dam. Purpose: Any tight contacts may tear the dam. Punching the dental dam 1. Use a template or stamp to mark on the dam the teeth to be isolated. 2. Corre ctly punch the marked dam according to the teeth to be isolated. Be sure to use the correct size of punch hole for the specific tooth. 3. If the teeth have tigh t contacts, lightly lubricated the holes on the tooth surface (under surface) of the dam. Purpose: This eases placement of dental dam over the contact area of t he teeth. Placing the clamp and frame 1. Select the correct size of clamp. 2. Se cure the clamp by tying a ligature of dental tap on the bow of the clamp. 3. Pla ce the beaks of the rubber dam forceps into the hole of the clamp. Grasp the han dles of the rubber dam forceps, and squeeze to open the clamp. Turn upward, and allow the locking bar to side down to keep the forceps open for placement. 4. Pl ace yourself in the operators position, and adjust your patient for easier access . 5. Retrieve the rubber dam forceps. Positions the lingual jaw of the clamp fir st, then the facial jaw during placement, keep an index finger on the clamp to p revent the clamp from coming off before it has been stabilized on the tooth. 6. Check the clamp for fit.

Fig-2.15 Lingual placement. finger on clamp Fig-2 16 Keep an index Fig-2.17 Position the frame over the dam. dam. Fig-2.18 Use the floss and pushing the 7 Transfer the dental dam to the side; stretch the punched hole for the anchor t ooth over the clamp. 8 Using cotton pliers, retrieve the ligature and pull it th rough so that it is exposed and easy to grasp if necessary. 9 Position the frame over the dam and slightly pull the dam, allowing it to hook onto the projection s of the frame. Purpose: Ensures a smooth and stable fit. 10 Fit the last of the dam over the last tooth to be exposed at the opposite end of the anchor tooth. Purpose: This stabilizes the dam and aids in locating the remaining punch holes for the teeth to be isolated. 11 Using the index fingers of both hands, stretch the dam on the lingual and facial surfaces of the teeth so that the dam slides t hrough each contact area. 12 With a piece of dental tape or waxed floss, floss t hrough the contacts, pushing the dam below the proximal contacts of each tooth t o be isolated. Note: Slide the floss through the contact rather than pulling it back through the contact. This will keep the dam in place. 13 If the contacts ar e extremely tight, use floss or a wedge placed into the interproximal area to se parate the teeth slightly. 14 A ligature is placed to stabilize the dam at the o pposite end of the anchor tooth. 4. Inverting the dental dam 1. Invert, or reverse, the dam by gently stretching it near the cervix of the tooth. a. Purpose: Inverting the dam creates a seal to prevent the leakage of saliva. 2. Apply air from the air-water syringe to the t ooth being inverted to help in turning the dam material under. a. Purpose: When the tooth surface is dry, the margin of the stretched dam usually inverts into t he gingival sulcus as the dam is released. 3. A black spoon or burnisher can be used to invert the edges of the dam. 4. When all punched holes are properly inve rted, the dental dam application is complete. 5. If necessary for patient comfor t, a saliva ejector may be placed under the dam. This is positioned on the floor of the patients mouth on the side opposite the area being treated. 6. If the pat ient is uncomfortable and has trouble breathing only through the nose, cut a sma ll hole in the palatal area of the dam by pinching a piece of dam with cotton pl iers and cutting a small hole near the palatal area. Fig-2.19 Inverting the dam. 5. Removing the dental dam 1. If a ligature was used to stabilize the dam, remo ve it first. If a saliva ejector was used, remove it.

2. Slide your finger under the dam parallel to the arch and pull outward so that you are stretching the holes away from the isolated teeth. Working from posteri or to anterior, use the crown and bridge scissors to cut from hole, creating one long cut. 3. When all septa are cut, the dam is pulled lingually to free the ru bber from the interproximal space. 4. Using the dental dam forceps, position the beaks into the holes of the clamp, and open the clamp squeezing the handle. Gen tly slide the clamp from the tooth. 5. Remove both the dam and the frame at one time. 6. Use a tissue or the napkin to wide the patients mouth lips, and chin fre e of moisture. 7. Inspect the dam to ensure that the entire pattern of the torn septa of the dental dam has been removed. 8. If a fragment of the dental is miss ing, use dental floss to check the corresponding interproximal area of the oral cavity. Purpose: Fragment of the dental dam left under the free gingival can cau se gingival irritation. Fig-2.20 Removing the clamp. Fig-2.21 Remove the clamp gently. Fig-2.22 Remove the dam and frame at one time 3. CARIES EXCAVATION AND TEMPORARY RESTORATION. 3.1 Access cavity and caries exc avation. 3.1.1 The establishment access cavity and outline form. In based primar ily on the location and extent of the carious lesions, tooth fracture, or erosio n. In carious lesion, the rough outline form is established after penetration in to carious dentine and removal of enamel overlying the carious dentine. The fina l outline is not established until carious dentine and its overlying enamel have been removed. The initial cutting can be achieved by using either flat fissure tungsten carbide or a small round diamond bur. The above caries should be remove d either by using slow speed stainless steel round bur or spoon excavators (hand instruments). Caries at dentinoenamel junction (DEJ) and soft, infected dentine (active caries) must be removed. With the used of plastic (frasaco) teeth in th e laboratory, access is gained by preparing an initial depth of 0.2 to 0.8 mm be low the dentinoenamel junction. Cavity margins are placed in the positions where they will occupy the final preparation.

Fig-3.1 Access cavity and outline form. Fig-3.2 Depth of cavity preparation and pulpal relation. 3.1.2 The establishment of resistance form. Defined as the design of the internal form of the cavity pr eparation or walls that will enable both the restoration and the tooth, to withs tand the masticatory forces without fracture. The fundamental principles involve d in obtaining resistance form are as follow: Enamel walls are supported by soun d dentine. Utilize the proximal box shape with a relatively flat floor. Junction of the proximal box walls should be rounded off to avoid sharp line angle. Prox imal axial wall is at the right angles to the pulpal and gingival floor. Rounded and internal line angle to reduce stress concentration. Cavo-surface line angle s are kept away from areas of stress such as inclination and tips of cusps. The axiopulpal line angle should be rounded off to allow reasonable thickness of mat erial in this area. Provide enough thickness of restorative material to resist f racture under load (1.5 mm to 2.0 mm occlusogingivally). Restrict the extension of external wall to allow strong cusp and ridge to remain with dentine support. Cusp capping weak cusps in extensive cavity preparations. 3.1.3. The establishment of retention form. Defined as that shape of the prepare d cavity that resists displacement or removal of the restoration from tipping or lifting forces. Since retention needs are related to the restorative material u sed, the principles of retention form varies depending on the used restorative m aterials. For amalgam restoration , in class I and class II cavity preparations, the materials is retained in the tooth by developing external cavity wall which converge occlusally. For composite resin restoration, in class III and class IV cavity preparation, the external walls diverge outwardly to provide strong enam el margins. In some cases, retentive coves, grooves, locks or dovetails are inco rporated to increase the retention of these restorative materials to the tooth s tructure. Composite restorations are retained in the tooth by a physical bond, w hich develops between the material and acid-etched tooth structure. Glass Ionome r Cement (GIC) restorations are retained in the tooth by chemical bond which dev elops between the material and conditioned tooth structure. 3.1.4. Convenience f orm. Defined as the shape or form of the cavity which allows adequate observatio n, accessibility and ease of operation during preparation and restoration of the tooth.

 Widening access to permit space for bur and instruments (instruments for tooth c utting, instruments for carrying restorative materials and instruments for placi ng and condensing the restorative materials) upon placement of restorative mater ial. Convenience form which involves the removal of sound, strong tooth structur e should be limited and which is necessary. 3.1.5 The treatment of residual caries. Removal of remaining carious dentine, ap plies primarily to the caries in the deepest part (pulpally) of the preparation. Other caries have been removed when the outline form was established. It may al so include (where applicable), the elimination of any defective restoration left in the tooth after initial cavity preparation and to consider as follow: Remain ing deep caries is carefully removed with a slow speed stainless steel round bur (if possible, under water spray) or a sharp excavator. Pay particular attention to the lateral spread of caries at the DEJ; ensure to clean DEJ first before at tempting deeper caries. 3.1.6 Finishing of enamel walls and cavo-surface margins. This is ensuring the c avo-surface margin are smooth and continuous to facilitate finishing of restorat ion margins. The objectives of finishing the cavosurface margins and walls are: To provide a mechanically strong interface between tooth and restoration. To obt ain the best possible marginal seal at the tooth / restoration interface. To obt ain an optimal angle of the materials at the tooth / restoration interface. To a llow for a smooth marginal junction. To define where the restorative materials s hould end. Should remove any sharp edges or margin, which could be a stress conc entration area or point and might break or fracture. Factors to be considered ar e: Enamel walls must follow the direction of the enamel rod. For restoration not utilizing bonding (e.g.: using amalgam), any unsupported weak or fragile enamel must be removed. For bonded restorations (e.g. using composite resin, GIC, comp omer or resinmodified GIC), enamel that is not supported by dentin and is not ex posed to significant occlusal loading is frequently allowed to remain in place a nd is reinforced by bonding to its internal surface. 3.1.7 The toilet of the cav ity or cleaning of cavity. Final procedures in cavity preparation included as fo llow: Washing all debris from the cavity (tooth chips, saliva, blood etc) using air-water spray. Ensure that the cavity is not wet, lightly dry the cavity using air spray

(be careful not to dessicate exposed dentin). Inspect cavity carefully for any t races of remaining debris, caries, fragile enamel, and deminearlized tooth struc ture. Advice to the patient: In the clinic, every patient should be explained ab out the treatment given and must given an advice post-operatively. For example i s to advise patient not to eat hard food at new amalgam restoration site due to a risk of break because amalgam is not fully set within 24 hours. Others include the oral hygiene care. 3.2 Temporary restoration. 3.2.1 Introduction. Operative dentistry among others involves restoration of car ious teeth. In this module will learn the technique of removing caries while mai ntaining the health and integrity of the pulp. The objectives of this simulation study are: Detect carious lesions on extracted teeth. Use the correct instrumen ts to gain access and remove carious dentine at the DEJ (periphery of cavity) as well as over the pulp. Identify carious dentine, which needs to be removed (inf ected dentine) and those, which can be left behind (affected dentine). List the temporary restorative materials, which is available in the dental faculty. Corre ctly mix and apply the temporary restorative material into the cavity. 3.2.2 Not e on principles of caries excavation. Remove caries at the peripheral first befo re doing the central part. Remaining dentine at the periphery of the cavity must be clear of stains and hard dentine. All decayed, stained and softened dentine must be removed peripherally for a distance of about 1 to 1.5 mm from the amelodentinal junction (ADJ) (Fig3.1). Removal of central caries this must be done ca refully to avoid exposing the pulp estrogenically. Although can leave hard and s tained dentine in the central part of the cavity (overlying the pulp). F ig-3.1 Caries excavation. In any carious cavity, beneath the active caries there is a layer of possibly st ained and definitely decalcified dentine. This is healthy and should not be remo ved. If remove all stained dentine, will be remove the healthy layer above the p ulp and will expose the pulp. 3.2.3 Restoration with Zinc Oxide and Eugenol.

Simple zinc oxide and eugenol, mixed to firm putty consistency, or the same ceme nt containing an accelerator such as zinc acetate, are equally useful in this ro le. Zinc oxide and eugenol is frequently said to be obtunded, and the cement mix ed with clove oil even more so. Certainly, it is non-irritant to freshly cut den tine, but it frequently leaves a cavity highly sensitive except when it has rema ined for some months. There are occasions when the deepest layer overlying the p ulp can be left in a position when the remainder is removed. This deep layer may then be used as a lining or sublining to the permanent restoration. There are 2 exercises should be complete; ESERCISES TASK TEETH Exercise 1 Caries excavation and temporary restoration using Zinc Oxide Eugenol ( Kalzinol). Natu ral teeth / Frasaco teeth: 1 molar (upper or lower), carious and cavitated not i nvoling the proximal surfaces. Exercise 2 Caries excavation and temporary restor ation using Rein Modified Glass Ionomer cement (Fuji VII) Natural teeth / frasoc o teeth: 1 molar (upper or lower), carious and cavitated not involving the proxi mal surfaces. The equipment and materials needed are as listed below: No. Stage Equipment / Ma terial 1 Access TC High speed bur 010 / 012 2 Caries free

Slow speed round bur (size 014 -023) 3 Lining Calcium hydroxide (Dycal). Glass I onomer Cement (Vitrebond) 4 Temporary Restoration (Cement) Zinc Oxide Eugenol (K alzinol) Glass Ionomer Cement (Fuji VII) 5 Cement mixing Glass slab Spatula 6 Pl acement of restorative material Plastic Instrument 7 Others Gauze Gain access th e cavity by removing some overlying unsupported enamel with high-speed bur. Remo ve all the caries along the DEJ using a large slow speed round bur. Remove soft and leathery carious dentine from the pulpal floor using a spoon excavator. Rest ore the cavity using Zinc Oxide Eugenol (Kalzinol). Ensure that the restoration is homogenous with the tooth. Fig-3.2 Access cavity with Remove the caries High speed bur. Low speed round bur. Fig-3.3 Fig-3.4 Placement of temporary restorative material into the class II prepared m olar. 3.2.4 Restoration with GIC (Fuji VII). Gain access, remove all caries from DEJ and soft and leathery dentine from the pulpal floor, after that wash and dr y.

 Apply dentine conditioner for 15 seconds, wash and dry. Mix Fuji for 10 seconds. Apply Fuji into the cavity and shape the restoration. Light cure the restoratio n for 15 seconds Check the restoration; ensure that it conforms to the anatomy. Fig-3.5 Apply conditioner. capsule. Fig-3.6 Fuji VII Fig-3.7 Fuji capsule mixer. the cavity Fig-3.8 Placed the Fuji into Fig-3.9 Shape the restoration. 3.2.5 Restoration with Zinc Phosphate Cement. Zin c phosphate cement may also be used as a temporary filling. Small wisps of cotto n wool lightly impregnated with clove oil or eugenol may be placed over the pulp and into the deeper undercuts to reduce the possibility of irritation. This cem ent may be used as a thick creamy mix or as a thick mix of putty consistency. If a thick creamy mix is used, a blunt-ended probe is the most suitable instrument for teasing the cement, a small portion at a time, into the appropriate part of the cavity. With cement of putty consistency, a discrete portion of cement is c arried to position on a small round-ended plastic instrument is suitable. When i n position, the cement should be tamped firmly against the cavity surface and co nformed to the correct shape with plastic instruments moistened with alcohol. Fig-3.10 Mixing zinc phosphate cement with stainless Steel spatula on thick glas s slab. 3.2.6 Restoration with Gutta-percha. Temporary gutta-percha can be used for shor t periods in simple cavities affecting one surface, or in compound cavities well enclosed and not exposed to excessive bite. It is unreliable as a cavity seal, but if the surface of the mass is made tacky by immersion in chloroform before i nsertion, it is probable that closer adaptation to cavity walls can be achieved. This particular is easy to remove but often leaves the dentine of the cavity hy persensitive, to reduce it by applying carbolated resin to the cavity before ins ertion of gutta-percha. Although the wide range of usefulness temporary cement m aterial is zinc oxide and eugenol. 3.3 Mounting the teeth. Some of the exercises that will involve using natural teeth which mounted on

plaster blocks. In this exercise, how to mount the teeth in the blue Perspex tra y. First mix the plaster with water thickly and pour into the Perspex tray, then the tooth mounted onto the plaster in the middle of tray. Please note this moun ted teeth can use for the exercise (1) caries excavation and temporary restorati on and (2) class V restoration. Mount the teeth list below. They are listed acco rding to the order of exercise in this simulation clinic. If you do not have all the teeth now, you may mount them in stages, i.e. mount the teeth that you will be using first. You must mount at least six teeth for each exercise; the teeth which going to use, should be mounted in the middle. 3.3.1. The teeth need for m ounting. NO. TEETH CRITERIA EXERCISE 1 2 Molars (upper/lower) Large occlusal car ies, preferably not involving the proximal surfaces. Caries excavation and tempo rary restoration. Mount on plaster block for table to exercise. 2 2 Canines or premolars (upper/lower) Sound or with abrasion cavity on the bucc al surface. Class V restoration. Mount on plaster block for table to exercise. E nsure that at least 5 mm of root surface is exposed. 3 2 Incisors (upper/lower) Small or medium size caries on the proximal surface. Class III restoration COMPETENCY TEST Must be an upper incisor tooth 4 1 Incisors (upper/lower) Sound or with proximal caries involving an incisal angle/edge.

Class IV restoration. 5 1 molar (upper/lower) Sound or stained fissure. Fissure sealant. 6 1 molar (upper/lower) Caries localized in a pit, other fissur es sound. Preventive Resin Restoration. 7 2 premolar and/or molar (upper/lower) Small cari es on proximal surface (< 1/3 width of tooth). Class II composite resin restorat ion. ______________ COMPETENCY TEST 8 1 molar (upper/lower) Caries (medium/large) on occlusal surface. Class 1 amalgam restoration. 9 1 premolar or molar (upper/lower) Medium or large caries on the proximal surface (> 1/3 width of the tooth). Large Class II amalg am restoration. 10 1 molar (upper/lower) Large caries involving 1 or more cups. Pinned and bonded amalgam. 4. PREVENTIVE RESIN RESTORATION. 4.1 Fissure sealant Sealant restoration was born, for the use of pit and fissure sealants. Dental se alant is highly effective in preventive dental caries in the pit and fissure

areas of the teeth. 100% caries protection by properly placed and retained the d ental sealants on the tooth surface. The technique restore the carious area and seals the rest of the fissures. The restoration is indicated where a cavity is p resent (either a microcavity in the enamel or in a cavity with dentine at its ba se). The lesion will usually be visible on a bite viewing radiograph as an area of radiolucency in the dentine. Fissure sealant is also can be placed on molar d uring development, to prevent decay. Fig-4.1 Placed Fissure Sealant Application for dental sealants. The technique fo r applying fissure sealant on a molar tooth, which should not have carious. The equipments and materials are as Fig-4.1. Fig-4.2 Materials and equipments for dental sealants. Applying fissure sealant o n a molar tooth: Apply rubber dam. Clean the tooth using prophylaxis paste and b rush, wash and dry. Acid etch for 15 seconds, wash and dry. Placed fissure seala nt-just enough to flow within fissures and grooves. Light cure for 10 seconds. C heck occlusion. Fig-4.3 Place the etching on cleaned molar tooth. Fig-4.4 Light curing for 10 sec. Fig-4.5 Checking Occlusion

Fig-4.6 Completed of fissure sealant on permanent molar. 4.2 .1 Pit restorations with Composite resin. Cavity preparation: o o o o o cure. o o Isolated with rubber dam. A small round bur is used to remove caries and access cavity. If the cavity much larger, place the lining and then place etching. GIC place as second liner. The cavity is fil led with an increment of posterior composite and light Place final increment of composite and light cure. Completed restoration. Fig-4.7A Composite Resin materials set. Fig-4.8 Occlusal cavity in molar. Fig-4.9 Access Cavity. Fig-4.10 Lining is placed. is placed. Fig-4.11 GIC Fig-4.12 Placed Composite and Light-cure composite. Fig-4.13 Place final Fig-4.14 Completed restoration. After 5 years. Fig-4.15

After 14 years. Fig-4.16 After 9 years Fig-4.17 4.2.2 Pit restoration GIC Light-Cure. Glass ionomer cement (Fig-4.17) is one of the newer cement systems. The GIC (ketac molar) is type one system of GIC lightcure, which also can be used for pit and fissure sealant (Fig-4.18 to Fig-4.23). Fig-4.17A Various brand name of GIC. Fig-4.19 B Ketac Molar GIC material including liquid, powder and conditioner. Fig-4.18 conditioner. Remove the caries and rinse. Fig-4.19 Apply the Fig-4.20 Dry the cavity. Mixing the GIC Fig-4.21 Fig-4.22 Place the GIC Fig-4.23 Complete restoration. 5. ACID-ETCH TECHNIQUE AND ABRATION 5.1 Acid-etch technique. CAVITY RESTORATION. Equipment and supplies: Basic setup, cotton rolls /dental dam for isolation, app licator (cotton pellets for liquid etching and syringe tip for gel), etching mat erial, high-velocity evacuator, air-water syringe and timer(Fig-5.1).

Procedure: 4. The prepared tooth must be isolated with rubber dam or cotton roll s 5. The surface of the tooth must clean and free from any debris, plaque or cal culus. 6. After clean, dry surface carefully. 7. The etching material is place o nly where it is needed (Fig-5.2). 8. The tooth structure is etched from 15 to 30 seconds. 9. After etching, the surface is thoroughly rinsed and dried for 15 to 30 seconds. 10. An etched surface has a frosty-white appearance. Fig-5.1 Basic set for etching technique. Fig-5. 2 5.2 Place the Etching gel on the molar tooth. Abrasion cavity restoration. Defects occurring at the cervical areas of the teeth may be due to the effects o f caries, abrasion from toothbrush and tooth paste, erosion and a fraction. In t his exercise, will simulate an abrasion cavity on a natural tooth and restore it using GIC. Restoration of abrasion cavity with Fuji II : Prepare a cervical abr asion cavity on the buccal surface a canine or premolar tooth (using pear bur). This step will only be done if using a sound natural tooth. Choose a suitable ce rvical matrix, bend it to shape. Pumice the tooth surface, wash and dry. Apply c onditioner for 15 seconds, wash and dry. Place the GIC (Fuji II) material into t he cavity, cover with the cervical matrix, remove any excess material and wait u ntil the material is set. Remove the matrix. Apply the bonding agent on the rest oration and light cure. Final restoration, polishing (only if necessary) should be done 24 hours after placement. Fig-5.3 Abrasion cavity 3mm height and width. Fig-5.4 Band with matrix. Fig-5.5 Pumice the tooth surface. conditioner. Fig-5.6 Applying the Fig-5.7 Remove the matrix. Place the Fuji II. Fig-5.8 Fig-5.9 Place the bonding and light cure. Fig-5.10 Complete

restoration. 6. AMALGAM RESTORATION. 6.1 Amalgam Restoration Materials. After the cavity has been prepared and the liners and base has been placed, the tooth is ready to be restored. One of the most common restorative materials is dental amalgam., which has been used for many years, dental amalgam is an effective, long lasting, and comparatively inexpensive restorative materials. Amalgam is a combination of an alloy with mercury. An alloy is a combination of two or more metals. Fig-6.1 Mercury Spill Kit. Amalgam Capsules Fig-6.2 Example of Fig-6.3 Kerr amalgamators. amalgamator. Fig-6.4 Placing capsule in the Fig-6.5 Activating the amalgam timer. amalgam carrier. Fig-6.6 Loading an Fig-6.7 Placing amalgam scrapes materials. in a sealed container. Fig-6.8 Amalgam bonding Fig-6.9 Matrix Band. (U/left, L/right). Fig-6.10 A (U/right, L/ left), B 6.2 Class I amalgam restoration 6.2.1 Armamentarium. 6.2.1.A Tray setup. Mouth m irror Explorer

 Tweezers Periodontal probe Hatchet Gingival marginal trimmer.

6.2.1. B Cavity preparation Contra-angle slow speed hand piece. Burs- stainless steel (SS), tungsten carbide (TC), diamond burs. 6.2.1.C Condensation and curvin g Amalgam carrier Amalgam condenser Carver Ball burnisher 6.2.1.D Fin polishing Multifluted SS finishing burs- variety of shapes Finishing stones- var iety of shapes Bristle brush Rubber cup Cotton roll Dappen dishes Flour of pumic e Whiting 6.2.2 Class I cavity The occlusal carious lesion begin in the area of pit and fi ssure where bacterial plaque is free to attack the inaccessible and poorly fused enamel ridges. Access to the lesion can be initially opening into the dentine t hrough the most affected portion of the tooth. Cavity preparation is extended to all defective pit and fissures and into those areas that seems subject to futur e breakdown. 6.2,2.1 Outline form Caries should be eliminated and rough outline of the cavity prepared. Margins should be placed on sound tooth structure. Conse rve ridges involved in occlusal contacts whenever possible. Include all defectiv e pit and fissures. 6.2.2.2 Resistance form Create flat pulpal floor (perpendicu lar to the long axis of the tooth). Prepare wall that create 90 degree cavo-surf ace margins of enamel Prepare wall that create 90-degree cavo-surface margins of amalgam. Round all internal line angles. Preserve adequate bulk of the mesial a nd distal marginal ridges. Provide sufficient depth of pulpal floor occlusogingi vally (1.5-2.0 mm) to resist fracture. 6.2,2.3 Retention form Should create wall s that are parallel to each other or converge occlusally. 6.2.2.4 Convenience fo rm The cavity should be of sufficient width to include the defect but otherwise as narrow as the available smallest plugger to allow sufficient condensation of amalgam. 6.2.2.5 Removal of remaining carious dentine Removal of remaining cario us dentine applies primarily to the caries in the

deepest part (pulpally) of the preparation. It may also include (where applicabl e), the elimination of any defective restoration left in the tooth after initial cavity preparation. For exercise on frasaco teeth, this step is obviously unnec essary and cavity preparation depth is confined to 1.5 2.0 mm. 6.2.2.6 Finishing of enamel walls. Remove all unsupported enamel rods. Unnecessary step in frasac o teeth except to remove any unsupported plastic at cavo-surface margin. Smooth the cavosurface margins so that amalgam can be adequately carved and finished. 6 .2.2.7 Features of the prepared cavities. The outline for the cavity wall is pla ced halfway from the center of the defective pit, fissures and grooves (Fig-6.11 ). A bucco-lingual width of 1.5 mm through the central groove and 1 mm in other extensions should place the wall in sound enamel and dentine (Fig-6.11). The pul pal depth is measured 1.5 mm from the central fissure, desirably about 0.2 mm in to dentine (Fig-6.12). AB outline. D Fig-6.11D Cavity outlines Cavity measuremen ts. The pulpal floor is flat and parallel to the occlusal plane of the tooth. Th e depth of the prepared external walls is 1.5-2mm, depending on the cuspal incli nes. The prepared external walls (mesial, distal, lingual and buccal) are parall el to each other and perpendicular to the pulpal floor (Fig-6.13A). However, in some cases, the walls are prepared with a slight occlusal divergent (Fig6.13B). Fig-6. 12 C Fig-6.11 A Initial caries, B Instrumentation , C Final Occlusal walls. Fig-6.13A External walls. Fig-6.13 B In the case where extension of the preparation ( to include fissure or caries ), becomes closer into the mesial and / or distal marginal ridges, the preparation require slight tilting of the bur distally ( not more than 10 degrees ). This c reates a slight occlusal divergent to prevent undermining the dentine support of the marginal ridge. This principle is applicable when there is a limited distan ce between the proximal surface extensions to the marginal ridges. For premolar teeth, the distance should not be less than 1.6mm (figure-6.14). for molars, the minimal distance is 2 mm. direction of mesial and distal walls is influenced by remaining thickness of marginal ridges as measured from mesial or distal ridge. Mesial and

distal wall should converge occlusally when distance from a to b is greater than 1.6 mm (left). If the distance is 1.6 mm or less, the walls must diverge occlus ally to conserve ridge supporting dentine (right). Fig-6.14 The direction of mesial and distal walls thickness. The cavity should b e of sufficient width to include the defect but as narrow as possible, realizing that it must be wide enough to permit instrumentation such as insertion and con densing of amalgam. Occlusal outline covers all the primary grooves and is locat ed in the middle 1/3 of the occlusal surface (Fig-6.15). Fig-6.15 Primary grooves outline. The mesial and distal margins should be parall el with the corresponding marginal ridges (Fig-6.16). Fig-6.16 Mesial and distal margins parallel to marginal and oblique ridge. 6.2.3 Preparation cavity class I. Pencil was used to defective grooves on the occlusa l surface of the tooth. (Fig-6.17, Fig-6.18). Place a jet 330 tungsten carbide b ur, flat fissure diamond or a small round bur (size 1 or 2) in the hand piece ( jet 330 bur; present in both high and slow speed, SS round bur; in slow speed, f issure diamond; present both in high and slow speed). A B C Fig-6.17 A Pencil de fective groove, B TC Jet 330, C Example of TC burs (Jet 330,245) groove. Fig-6.18 Pencil the defective Position the bur in the central fossa at right angle / perpendicular to the occl usal surface (Fig-6.19, Fig-6.20). Enter the central pit with the bur and cut to just below the dentinoenamel

junction approximately 1.5 mm (fig-6.21). Fig-6.19 Bur position Fig-6.21 Cut bel ow serface. dentinoenamel junction. Fig-6.20 Perpendicular to occlusal Apply light intermittent pressure to avoid burning the tooth. Remove the debris from the operating area with a gentle stream of air. Move the bur along the fiss ures and grooves to obliterate the penciled defects maintaining the depth specif ied (2 mm) and keeping the bur perpendicular to the occlusal surface. Maintain u niform depth of the pulpal floor. Remove the enamel just short of the desired ou tline form. Using bur in slow-speed hand piece, smooth the pulpal floor as well as preparing the facial and lingual walls to achieve parallelism (Fig-6.22). All preparation walls must be parallel or 90 degree to the pulpal floor (Fig-6.23), except in the case where there is a limited distance between the proximal surfa ces extensions to the marginal ridges as previously explained in 6.2.2.7. Elimin ate any sharp corners of the cavosurface outline (Fig-6.24) with the bur and rem ove any debris. Fig-6.22 Achieve cavity wall. Eliminate corner 6.2.4 Placement of lining or base . Fig-23 Pulpal floor. Fig-6.26 The use of lining / liner or base in cavity preparation becomes essential when t he cavities finish deep in the dentine or when the cavities lie close to the pul p. Otherwise, placement of the lining or bases may be indicating as follow (Fig6.25,26 and 27). Fig-6.25 Lining. Fig-6.26 Varnish Fig-6.27 Liner and Base. 6.2.5 Restoration of cavity. 6.2.5. A Trituration The process includes the combining or mixing of liquid mercury with dry amalgam ally power. This process is carried out using amalgamators or amalgam triturator s. The objectives are; 1. To coat each particle of alloy with mercury. 2. To beg in the reaction that will produce a solid mass. The required amount of amalgam i s triturated with a 1:1 ratio of alloy and mercury in an amalgamator. For tritur ation time, please follow the manufacturers instruction. After the triturating is completed, empty the contents of the capsule onto the glass dish and begin the condensation immediately.

 Nowadays, use of encapsulated amalgam alloy ready for trituration is recommended ( a weight, standardized amount of amalgam power and mercury sealed in a capsul e). The encapsulated products provide more consistent mixes of amalgam and are s afer for use in the dental office. 6.2.5.B Condensation Condensation is the proc esses of compressing and directing the dental amalgam into the tooth preparation with amalgam condensing instruments (condensers or pluggers) until the preparat ion is completely filled and then, overfilled with a dense of amalgam. Proper co ndensation of amalgam promote; 1. Better adaptation of the amalgam to the walls of the preparation. 2. Elimination of voids due to compaction of the materials. 3. Reduction in the amount of residual mercury in the restoration. 4. Greater re storation strength. Voids and increased residual mercury have been associated wi th weakened amalgam product thus reduce the strength of the restorations. Adequa te condensation techniques requires a significant amount of force to be applied to the condenser; 1. The force should be about 2-5 kg when using admixture amalg am. 2. For special amalgam, the force is considerably less, because heavy forces tend to push the spherical particles to the side and punch through the amalgam ma ss. 3. The size of the condenser end determines the amount of force to be exerte d to the amalgam mass: the larger the end, the less force per unit area is appli ed. 4. Therefore, larger condenser must exert more force on the condenser to del iver adequate condensation pressure. 5. Amalgam should be condensed both vertica lly and horizontally or laterally (towards the walls of the preparation) (Fig-6. 28). Fig-6.28 Lateral and occlusogingival force to Properly condense amalgam. When am algam is condensed, mercury is brought to the surface creating a mercury-rich am algam on the surface. To reduce the amount of mercury left in the restoration (r esidual mercury), the preparation is overfilled, and the mercury excess is carve d off. The lower the residual mercury left in the restoration, the higher its st rength. Condensation procedure. This condensation procedure must be completed wi thin three to four minutes from the start of trituration. If the amalgam is not used within this time, the remaining mix should be discarded and a new mix prepa red. Fill the smallest end of the amalgam carrier with the triturated amalgam. H olding the carrier like a pen, pick up the amalgam by pushing the carrier into i t (Fig-6.29). Inject one-half of the amalgam in the carrier into the prepared ca vity (Fig6.30). Use the smaller end of the no.1 small round condenser to pack th e amalgam

into the cavity (Fig-6.31). Start condensation in the central pit area, directin g the condenser at right angle to the pulpal floor while exerting firm force on the amalgam to pack it onto the floor and into the line angle. In condensing ama lgam, always be sure to use a condenser that fit the cavity and to exert firm pr essure on the amalgam. The condenser must be able to reach the pulpal floor in a ll parts of the cavity (Fig-6.31 to Fig-6.33). Fig-6.29 Picking up the amalgam. Fig-6.31 Condensing 1. 2. 3. 4. Fig-6.32 Incorrect condenser. Fig-6.30 Inject am algam. Fig-6.33 Correct condenser Firm condensation pressure is necessary in order to; Remove excess mercury from the mix, Push the alloy particles together to mark a dense filling. Adapt the am algam to all part of the cavity. Remove voids in the amalgam. Remove the mercury-rich ding and condensing small illed and all portions of malgam and use the larger densed the excess amalgam , the surface of residual nsing excess. surface from the amalgam with the condenser. Continue ad increment of amalgam until the cavity preparation is f the amalgam are thoroughly condensed. Add additional a end of the round condenser to overfill the cavity. Con beyond the margins and the final contour. In this case mercury will be carved away (Fig-6.34). Fig-6.34 Conde

6.2.5.C Burnishing. After it is condensed with amalgam condenser, amalgam should be further condensed with a large burnisher, such as an ovoid (football) burnis her. This called precarving burnishing. This should take place immediately after c ompletion of condensation. Apart from aiding condensation, burnishing is the fir st step in shaping the occlusal surface of the restoration. Procedure of burnish ing. 1. Using the ball furnisher with firm hand pressure, burnish the amalgam fr om the central sulcus to the margins. 2. This burnishing will draw the excess me rcury into the over packed amalgam, which will be removed during carving procedu re ( Fig-6.35 and Fig-6.36). 3. After carving is completed, the margins may be b urnished again with light hand pressure to remove any roughness or flash remaini ng, thus ensuring a better marginal integrity (Fig-6.37). Fig-6.35 Burnishing. Fig-6.36 Remove excess Fig-6.37 Remove

roughness. Mercury. 6.2.5.D Carving Should begin immediately after condensation and precaving burnis hing. May be carved with any bladed dental instrument that has sharp edge. Most commonly used instruments are cleoid-discoid carver, Hollenbach or H carver (som e may find spoon excavator useful for amalgam carving). Most amalgam carving is perfomed using pulling strokes. Pushing strokes can be advantageous in developin g occlusal anatomy (grooves). Small class I and class II should be carved with e namel surface as a guide. The carver should rest on the enamel adjacent to the p reparation and be pulled in a direction parallel to the margins of the preparati on. When a stroke perpendicular to the margin of preparation is needed, carver s hould be pulled from enamel to amalgam. Procedure Amalgam carving 1. Remove the bulk of the over packed mercury rich amalgam with the large carver (Fig-6.38). 2 . Carve from distal to mesial, resting a portion of the blade on the adjacent to oth structure (Fig-6.39) to lessen the chances of removing too much amalgam ( Fi g-6.40). 3. Remove the excess amalgam shaving from the occlusal surface with a g enetic stream of air. 4. Develop the occlusal anatomy of the restoration with a carver. Carve along the margins, resting the side of blade on the inclines of th e cusps (Fig-6.41). 5. Keep the point of the carver centered between the margins of the restoration and use short, light strokes to carve the amalgam. 6. This w ill reestablish the desired contours and grooves and will avoid thin and weak ma rgins (Fig-6.42) 7. Examine the carving with a carver and remove any thin layer or flash of amalgam that extends out over the enamel surface. 8. The amalgam mus t be carved back to the cavity margins to prevent subsequent fracture at the mar gins. 9. Lightly wipe the occlusal surface with a cotton roll to remove any part icles of amalgam. Fig-6.38 Remove excess Fig-6.39 Carving guide Fig-6.40 Carving Fig-6.42 Carver Fig-6.41 Develop occlusal anatomy centered 6.2.5.E Checking occlusion Occlusion is checked when the carving appear to be correct. This is accomplished with an articulating paper that marks the contact when the maxillary and mandib ular teeth are brought together. A piece of articulating paper is placed over th e restoration and the patient is instructed to close his / her mouth very lightl y to check if the occlusion is correct.

 Remember to advise the patient not to bite too hard because of the danger of fra cturing the restoration, which is weak at this stage. Amalgam that has not been carved adequately will have high spot present on its surface, which should then be removed by additional carving. It is important to check the occlusion before th e amalgam becomes hard as the adjustment of occlusion with hand instrument becom es difficult once the amalgam has set. The process of light closure with articul ating paper is repeated, and additional carving is accomplished until the teeth can be closed to prerestoration occlusion. 6.2.5.F Finishing and polishing Finis hing of an amalgam restoration includes evaluating the restoration for problems and correcting those, to ensure margins are even and contours and occlusion are correct as well as smoothing the restoration. Polishing is defined as smoothing the surface to a point of high gloss or luster. Allow at least 24 hours for the amalgam process to be completed before polishing the restoration. Begin any nece ssary finishing procedure by marking the occlusion with articulating paper and e valuate the margin with an explorer. If the occlusion in to be improved, white o r green stone can be used to correct the discrepancy. The area may be further sm ooth using light pressure with a suitably shaped finishing bur (Fig-6.47). The b ur should be held perpendicular to the margin to guide the bur and prevent UN ne cessary amalgam removal (Fig-6.43). Then, margin is re-checked with the explorer (Fig-6.44). Fig-6.43 Eliminate discrepancies. Fig-6.44 Check with explorer. If the grooves or fossa is not adequately defined, a small round bur may be used to define the grooves. Polishing procedure is initiated by using a course, rubb er abrasives point at low speed and air-water spray to produce a smooth, satiny appearance of an amalgam surface. It is crucial to use rubber point at slow spee d as the points disintegrate and can elevate the restoration / tooth temperature if used in high speed. If amalgam surface does not exhibit smooth, satiny appea rance after polishing, the surface is probably still rough. Then, resurfacing wi th a finishing bur should be repeated. When the surface of the amalgam is modera tely polished with no scratches present, a high polish can be imparted to the re storation with a series of mediumand fine grit abrasive points. As an alternativ e to rubber abrasive point, final polishing can be accomplished using a brush wi th flour of pumice and finally, with the rubber cup. Fig-6.45 Brush Polish. Fina l Polish. Fig-6.46 Fig-6.47A Multifluted finishing burs (Stainless

steel). Use for smoothing the surface and enhancing the anatomy and marginal Ada ptation of amalgam/restorative materials. Fig-6.47 B Outline form of various cla ss I preparation. 6.2.6 Practical cavity class I. 1. 2. 3. 36 Buccal pit, 36 Occlusal ( Entire fis sure involved) 25 Occlusal (Central fissure only) 17 Occlusal (Oblique ridge pre served) 6.2.7 Class I cavity with lingual/palatal extension.

6.2.7A. Armamentarium 1. 2. 3. 4. 5. 6. 1. 2. 1. 2. 3. 4. 1. 2. 3. 4. 1. 2. 3. 4 . 5. 6. 7. Tray setup: Mouth mirror Explorer Tweezers Periodontal probe hatchet Gingival Marginal Trimmer Cavity preparation: contra-angle slow speed hand piece burs; stainless steel(SS), Tungsten carbide (TC), and diamond burs Matricing: T offlemire matrix retainer universal matrix band wooden wedges scissors plastic i nstrument Condensation and carving: amalgam carrier amalgam condenser / plugger amalgam carver burnisher Finishing: multiflute SS finishing burs; variety of sha pes finishing stones- variety of shapes bristle brush rubber cup cotton roll dap pen dish flour of pumice 6.2.7B Preparation of class I with palatal extension The occlusal preparation fo llows the principles for a class I cavity preparation. The margins are halfway f rom the center of the defective grooves (Fig-6.48). The occlusal portion of the occluso-lingual preparation has minial width to preserve adjacent tooth structur e. However, when the disto-lingual cusp is small, the occlusal portion of the oc cluso-lingual preparation is cut more at the expense of the oblique ridge. This will avoid weakening the disco-lingual cusp (Fig-6.49). The lingual portion of t he occluso-lingual preparation is a box, which has a flat gingival floor / set, with the mesial and distal wall parallel with one another (Fig-50). Fig-6.48 Cav ity margins fig-

6.49 Cavity Shape. (A) parallel wall. The extremities of the occlusal grooves an d the portion of the wall adjacent to the marginal ridges are prepared at 95 deg ree to the pulpal floor. This result in a slight flare in this area (Fig-51) or the axial wall diverges occlusally. This principle is indicated only when the di stance between the mesial and / or distal axial walls of the preparation to the marginal ridge or to the buccal and /or lingual tooth surface is 1.6 mm or less for premolar and 2.00 mm for molar teeth. If the distance are more than 1.6 mm f or premolar and more than 2.00 mm for molar teeth (to the marginal ridge or to t he buccal and / or lingual tooth surface and no extension is necessary to includ e a pit or fissure caries), the mesial and / or distal axial walls are prepared to converge occlusally. This principle has been previously described for better understanding. The pulpal floor of both preparations is flat in dentin. The axia l wall of the occluso-lingual preparation is flat, in dentin, and at a slight ob tuse angle to the pulpal floor (Fig-6.52). Fig-6.51 Occlusal view Fig-6.52 Axial wall view (B) Fig-6.50 (A) Box shape lingual , (B) Flat seat and 6.2.7C Measurement of prepared cavity Fig-6.53 Occlusal view Measurements Fig-6. 54 Cavity depth Fig-6.55 6.2.7 D Procedure of cavity preparation Pencil the defective grooves on the occl usal and lingual surface of the tooth as illustrated (Fig-6.56). Enter the penci led occlusal lesion with the bur in the high or slow-speed hand piece. Position the bur perpendicular to the occlusal surface and with light and intermittent pr essure; penetrate to depth of approximately 1.5 mm. this will establish the leve l of the pulpal floor (Fig-6.57). Remove the debris from the operating area to i ncrease visibility. Maintaining the depth specified and holding the bur perpendi cular to the pulpal floor, move the bur along the grooves to obliterate the penc iled defects. Create and maintain a flat pulpal floor (Fig-6.58). Fig-6.56 Penci l the groove. Cavity depth. Fig-6.57

Fig-6.58 Flat pulpal floor. Direction of cut Fig-6.59 Enter the occlusal portion of the penciled occlusal-lingual lesion with the bur to establish the depth of the pulpal floor (again 1.5 mm). then move the bur fac ially to prepare the distal pit area of the preparation. This cut should be slig htly more at the expense of the oblique ridge to avoid weakening the small disto -lingual cusp. Move the bur lingually at the proper depth along the occlusal gro ove until the bur has cut through the lingual surface (Fig-6.59). Position the b ur parallel to the lingual surface at the lingual groove and begin preparing the lingual step with the side of the bur (Fig-6.60). This will produce a cut that is deeper toward the occlusal (2.0 mm) than at the gingival (1.5 mm), resulting in an axial wall entirely based in dentin. Extend the lingual box gingival to th e termination of the lingual groove. Do not make the cavity wider than the width of the bur or extend the pulpal floor deeper than previously indicated. Finish the occlusal portion of the occluso-lingual preparation with the bur, flaring on ly the distal extremity of the groove and the portion of the wall adjacent to th e marginal ridge if the distance is 1.6 mm or less (Fig-6.61,62). Otherwise, the axial walls are prepared at least parallel to the pulpal floor or slightly conv erge occlusally. Fig-6.60 Bur position portion finished Fig-6.61 Occlusal view. Fig-6.62 Occlusal Position the bur perpendicular to the lingual surface and with the end of the bu r flatten the axial wall, while using the side of the bur to prepare parallel me sial and distal wall (fig-6.63). Use the end of the bur to flatten and finish th e gingival wall. The gingival wall must meet the tooth surface at a 90-degree an gle. A flat gingival seat at the lingual extension is desirable for resistance f orm. The retention form of the lingual extension is accomplished by cutting rete ntion grooves or locks with the side of the bur. Grooves are placed in dentin in both mesio-axial and disto-axial line angles. Grooves are placed in dentin in b oth mesio-axial and disto-axial line angles. Grooves taper occlusally and termin ate at the level of the pulpal floor (Fig-6.63). Finish the mesial and distal wa ll of the lingual step with the enamel hatchet, using a planning-scarping action (Fig-6.64) Fig-6.62 Flatten axial wall Fig-6.63 Retention grooves. Fig-6.64 Finish with enamel hatchet.

6.2.7 E Matricing Preparations with missing wall such as in the case of occlusopalatal/lingual and Class II require the use of a matrix to confine the restorat ive material during placement. The purpose of the matrix is to: Substitute for m issing walls so that adequate condensation forces can be applied Allow re-establ ishment of contact with the adjacent tooth Restrict extrusion of the amalgam and formation of an overhang at the interproximal margin Provide adequate physiolog ic contour for the proximal surface of the restoration Impart an acceptable surf ace texture to the proximal surface, particularly the contact area that cannot b e carved and burnished. The most commonly used matrix in the United States is To fflemire system. Others Type of matrix systems available are Squiveland, Auto-ma trix and Palodent Matrix (held in place by Biting ring). A. Tofflemire matrix Tw o type : straight and contrangle ( Fig-6.65) Fig-6.65 Shows the two types of Tof flemire matrix. 1. 2. 3. 4. 5. 6. Consist of 6 main components: (Fig-6.66, 67, 68, 69). Locking nut Adjusting nut Retaining screw Vise Head Matrix band (which goes into the vise and head). Fig-6.66 Parts of a retainer. Fig-6.67 Parts of the Toffiemire retainer. Fig-6.68 Occlusal and gingival edge of the band. holder B. Matrix band placement Fig-6.69 Vise slot of matrix Turn the locking nut on the matrix retainer counterclockwise to free the retaini ng screw from the slot on the vise (Fig-6.66) Position the Tofflemire retainer w ith the head up and the slot in the vise and the head facing you (Fig-6.67). For m a loop with the matrix band and line up the end of the band. The edge

of the band, which is toward the gingival, forms a smaller circumference than th e occlusal side (Fig-6.68) With the occlusal edge of the band facing the slot, i nsert the band into the vise so that the band ends are adjust visible at the end of the vise slot (Fig6.69). The loop of the band may extend from the head of To fflemire retainer in one of three directions (1) straight, (2) left, (3) right ( Fig-6.70). Fig-6.70 The loop of the band extension. With the retainer head up an d the slot facing you, thread the band into the head and out through the right s lot for application on a maxillary right tooth and mandibular left. For applicat ion on a maxillary left tooth and mandibular right, thread the band through the left slot. Turn the locking nut clockwise to secure the band in the retainer (Fi g6.71A, B). Place the band on the tooth, with the retainer on the facial side (F ig6.72). (A) (B) Fig-6.71 (A) Mandibular left, (B) Maxillary right. Fig-6.72 Placement of bend on the tooth Fig-6.73 The slot in the head of matrix directed to gingival Fig-6.74 The slot in the head of matrix directed to occlusal. The band must be a ssembled with the slot in the head directed gingivally, not occlusally (Fig-73). Make sure that the band covers the gingival margin of the cavity preparation. T urn the adjusting nut on the retainer clockwise until the band fit snugly. To av oid injury to the gingival and the periodontal fibers do not over seat the band. 6.2.8 F Restoration of palatal extended class I cavity. A. TRIRURATION Prepare as describe in previous section 5.2.5 A in class I amalgam restoration.

B. CONDENSATION Follow procedure described in previous section 5.2.5 B for condensation on the o cclusal surface. Inject a small increment of amalgam into the lingual step porti on of the occluso-lingual cavity and use the small end of the condenser to pack the amalgam into the lingual step. Direct the condenser gingivally and laterally while exerting firm force on the amalgam to thoroughly condense it along the me sial, distal, and gingival margins. Continue to add and condense small increment s of amalgam until the amalgam is condensed along the entire length of the mesia l and distal margins of the lingual step. Add and condense small increments of a malgam to fill the occlusal portion of the cavity. Use the small end of the roun d condenser to pack the amalgam into this area (Fig-6.74). Use the larger end of the condenser to over pack the cavity with additional amalgam. Lateral condensa tion of amalgam toward all walls will improve adaptation (left) and overfill sho uld be condensed with a large condenser (right) (Fig-6.75). Fig-74 Use small condenser. condenser. Fig-6.75 Use large C. D. BURNISHING Follow the same procedures as described in the previous section 5.2.5 C. CARVING Remove the excess amalgam inside the matrix strip with an explorer. This will le ssen the chances if fracturing the amalgam when the strip is removed (Fig6.76). Fig-6.76 Remove excess amalgam. Turn the locking nut the matrix retainer counter clockwise to release the matrix band from the retainer. Remove the retainer in a n occlusal direction (Fig6.77). Remove the matrix band from the tooth (Fig-6.78) . Remove the bulk of the over packed and burnished mercury- rich amalgam from bo th restoration with the caver. Carve along the margins, resting a portion of the blade on the adjacent tooth structure (Fig-6.79). Fig-6.77 removal of retainer.

Fig-6.78 Remove matrix band. along margins. Fig-6.79 Carve Remove the amalgam shaving from the tooth with a gentle stream of air. Develop t he anatomy of the occluso-lingual restoration with a carver. Keep the point the carver more toward the distal to reestablish the desired groove (Fig-6.78, 79). Develop the anatomy of the occlusal restoration with a carver. Carve along the m argins, resting the side of the blade on the inclines of the cusps. Maintain the point of the carver centered between the margins the reestablish the desired co ntours and grooves. Remove any thin layer of amalgam that extends out over the e namel surface. Lightly wipe the occlusal and lingual surface with a cotton roll to remove any particles of amalgam. 6.81 Develop anatomy. E. Fig-6.80 Position carver. FigCHECKING THE OCCLUSION Follow the same procedures as described in previous section 5.2.5 E. Examine the restoration for high spots. Reduce any high spot with additional carving. F. FINISHING AND POLISHING Follow the same procedures as described in previous sect ion 5.2.5 F.

6.2.9 Practical class I cavity with lingual/palatal extension. 6.2.9A Class I wi th palatal extension on 17 6.3 Class II small and medium amalgam restoration. 6.3.1 Armamentarium Basic tra y setup 1. 2. 3. 4. Mouth mirror Explorer Tweezers Periodontal probe Cavity preparation 1. 2. 3. 4. Contra-angle slow speed hand piece Burs Enamel ha tchet Gingival marginal trimmers

Matricing 1. Tofflemire matrix retainer 2. Universal matrix band 3. Wedge and wo od Condensation and carving 1. Amalgam carrier 2. Condenser 3. Carvers Finishing and polishing 1. 2. 3. 4. 5. 6. 7. 8. 9. Finishing burs Green and white stone F ine and extra-fine cuttlefish disks Rubber point Rubber cup Bristle brush Dappen dishes Flour of pumice Proximal strip 6.3.2 Preparstion of class II cavity on lower molar (MO). This preparation combi nes the features of an occlusal cavity and the proximal box. The occlusal margin s of the preparation starts from the center of the defective grooves, fissures a nd pits. The walls are parallel to one another and are perpendicular to the pulp al floor as noted in (Fig-6.82 ). However, in some cases, the walls are prepared with a slightocclusal divergent or flare (Fig-6.83). In some cases where extens ion of the preparation (to include fissure or caries), becomes closer into the m esial and/or distal marginal ridges, the preparation require slight tilting of t he bur distally (not more than 10 degrees).This creates a slight occlusal diverg ent to prevent undermining the dentin support of the marginal ridge. This princi ple is applicable when there is limited distance between the proximal surfaces e xtensions to the marginal ridge as previously described in features of the prepar ed cavities. The occlusal view shows that the facial and lingual walls of the pro ximal box are extended into their respective embrasures only enough to be free o f contact with the adjacent tooth. These walls diverge slightly to meet the tang ent to the mesial surface at a 90 degrees angle (Fig-6.84). The mesial view show s that the lingual wall of the proximal box is parallel or to the long axis of t he tooth. The facial walls approximately parallel or to the facial surface (Fig6.85). The gingival wall is flat and perpendicular to the long axis of the tooth . The pupal floor is flat in dentin, and parallel to the occlusal plane of the t ooth (Fig-6.86). The axial wall is parallel to the long axis and curves slightly to follow the facio-lingual curvature tooth. This wall is in dentine (Fig-6.87) . The axio-pulpal line angle is beveled. Any unsupported enamel is removed

from the gingivo-cavosurface (Fig-6.87, 88). There are retentive grooves in the lingo-axial and facio-axial line angles. These grooves in the dentine only and f ollow the facio-lingual curvature of the axial wall (Fig-6.89). view Fig-6.82 Outline form Fig-6.83 Occlusal view. Fig-6.84 Ficial and lingual wall Fig-6.85 Mesial Fig-6.86 Gingival and pulpal floor position. position. Fig-6.87 Axial wall Fig-6.88 Beveled angle. retentive grooves. Measurements of Class II cavity (in m m) Fig-6.89 Linguo-axial & fasio-axial Fig-6.90 Occlusal view Fig-6.91 Mesial view Fig-6.92 Cross-sectional view 6.3.3 Some examples of common class II cavity feat ures and molars. Fig-6.93 Slot on M & D 6.95 MOD Fig-6.96 DO preparation distowi th distal pit -palatal extension. Fig-6.94 in maxillary premolars MO & DO FigFig-6.97 MO distal pit Fig-6.98 MO with with marginal ridge. Fig-6.99 DO with mesiocclusal fissure. 6.3.4Procedure of cavity preparation Fig-6.100 MOD preparation.

 Pencil the defective grooves on the occlusal surface of the tooth (Fig-6 101 ). With articulating paper, record the occlusal contact of the opposing tooth. Modi fy the outline form so that the margins of the preparation do not lie on a conta ct area. Enter the pit nearest the involved proximal surface with a no.245 bur t ilted as illustrated. Proximal, the long axis of the bur and the long axis of th e tooth crown should remain parallel during the cutting procedures. Ass the bur approaches the distal pit, the proper depth (one-half to twothirds the length of the cutting portion of the bur),which just exposes the dentin, should be establ ished (approximately 1.5 mm) (Fig-6.102 ). Fig-6-101 Pencil defective grooves position. Fig-102 Burs Remove the debris from the operating area with a gentle stream of air. Move the no.245 bur distally along the depth specified and keeping the bur perpendicular to the occlusal surface. Extend the cut toward the mesial to obliterate the penc iled defects. As you approach the marginal ridge, direct the cut toward the cent er of the contact area. Do not break through the mesial marginal ridge at this t ime (Fig6.103 ). Use the bur in a hand piece as a guide for determining the occl usogingival depth of the preparation. With the bur stationary, hold it verticall y next to the mesio-facial surface of the tooth so that the tip of the bur is 0. 5 mm below the contact area. This is where the gingival wall will be. Note how m uch of the bur must penetrate the tooth to reach the desired level of the gingiv al wall (Fig-6.104 ). Fig-6.103 Marginal ridge Fig-6.104 Occlusogingival depth. With the no.245 bur, start the end of the bur cutting along the exposed proximal dentinoenamel junction, two third at the expense of the dentin and onethird at the expense of the enamel. Need to ensure that the burs long axis is approximatel y parallel to the long axis of the tooth crown, but tilted slightly to the dista l. With the pressure directed gingivally and slightly towards the mesial to keep the against the proximal enamel, pendulate the bur facially and lingually along the dentinoenamel junction. Because the dentin is softer and cuts easier than t he enamel, the bur should be held against the harder enamel to guide and create an axial wall that follows the outside contour of the proximal surface. The mesi o-distal width of the completed proximal ditch cut should be onethird in enamel and two-thirds in dentine. When the proximal ditch cut is all in dentine, the ax ial wall often is too deep. Because the proximal enamel becomes less thick from occlusal to the gingival, the end of the bur will come closer to the external to oth surface as the cutting moves gingivally. The proximal ditch cutting is diver ged gingivally so that the facio-lingual dimension at the gingival will be great er that at the occlusal (Fig-6.105, 106, 107). Do not remove all of the proximal enamel but leave a thin shell of enamel in

this area to protect the adjacent tooth from contact with the bur. Break out the thin remaining proximal enamel with the enamel hatchet, using it as lever to fr acture the enamel. Finish the facial, lingual, and gingival wall of the proximal box with the enamel hatchet using a planning-scraping action (Fig-6.108, 109). seat position. Fig-6.105 Proximal depth. Fig-6.106 Gingival the wall. Fig-6.107 Occlusal convergence. Fig-6.108 Finishing Fig-6.109 Finishing with planning-scraping action. With the gingival margin trim mer, from a slight bevel at the axio-pulpal line angle (Fig- 6.110). With the sa me instrument, sweep across the gingivo-cavosurface to remove unsupported enamel rods and cause a slight rounding of the facio-gingival and linguo-gingival line angle (Fig-6.111, 112). Fig-6.110 Bevel axio-pulpal line angle carvosurface margin. Fig-6.111 Bevel gingivo With the no.169L (TC) or tapered diamond bur in the slow-speed hand piece, cut a retentive groove in the lingual axial line angle (Fig-6.113). Begin at the ling o gingivo axial point angle and used only the tip of the bur drawing it occlusal ly (in the dentin only). The groove should be about 0.5 mm deep at gingival and gradually fade towards the occlusal (Fig-6.114). Avoid placing the groove entire ly at the axial dentinal wall. Remember that the curvature of the axial wall. In addition, beyond the height of the pulpal floor. Use the same method described in the in the fascio-axial line angel. the expense of either the lingual or groove must follow the facio-lingual the groove must not extend occlusally previous step to cut a retentive groove Fig-6.112 Line angle rounded. Fig-6.113 Groove placement.

Fig-6.114 After groove placement. 6.3.5A Figures of class II on second premolar (MO) Fig-6.115 Visualization of pr oximal preparation. Proximal box. Fig-6.116 Fig-6.117 Mesial wall fractured off using hand instrument. Fig-6.118 Undermined proximal enamel removed using hatchet. Fig-6.119 Beveling a xiopulpal line angle. Fig-6.120 A.Bevel enamel portion of gingival wall using gi ngival marginal trimmer, B&C. Round off linguogingival and buccogingival corners by rotational sweep with gingival marginal trimmer. 6.3.5B Figures of class II on first premolar (MO) Fig-6.121 A. Two surface preparation, B.Occlusal view, C. Proximal view. Fig-6.212 Compare the difference between 34&34 in size of pulp c hambers, lingual cusps direction of pulpal walls. 6.3.5C Figures of class II on second premolar (MOD). Fig-6.213 MOD preparation of second premolar. Fig-6.124 MOD cavity of first prem olar. 6.3.5D Figures of class II cavity preparation on maxillary first molars.

Fig-6.125A. MOD Caries of first molar. molar. Fig-6.125B M&D restoration on Fig-6.126 A.Conventional MO preparation, B. MO preparation extended to distal pi t, C. MOL preparation distal pit and oblique ridge, D. MO with buccal fissure ex tension. 6.3.5E Figure of class II cavity on mandibular fist molar. Fig-6.127A. MOD preparation on MOD amalgam mandibular first molar. restoration o n mandibular molar. Fig-127C. MOD cavity with lining. molar replaced one lingual cusp. 6.3.6 Matricing Fig-6.127B. Fig-127D. MOD restoration on Thread the band into the retainer head. Then turn the locking nut clockwise to s ecure the band in the retainer. Position the retainer head is facing you. Form a loop with matrix band and line up the end of the band. Rest the band on a paper pad and with a ball burnisher contours the proximal area of the band about 1 mm from the edges. Place the band on the tooth; make sure that the band covers the gingival margin of the cavity preparation. The band must be wide enough gingivo -occlusally to provide a wall along the entire length of the proximal box. Ideal ly it should extend about I mm above the adjacent marginal ridge, but not higher . If necessary, trim the band with a scissors to obtain correct dimensions. Turn the adjusting nut on the retainer clockwise until the band fits snugly (Fig-6.1 28). Fig-6.128 A Placed the matrix band. Fig-6.128B Placed the strip, band and wedge. Fig-6.128C Band placement. To avoid injury force the matrix band Shape the wedge Insert the wedge from with a tweezer. to the gingival and the periodontal fiber s, take care not to too for gingivally. with carver to fit it to the mesial ging ival embrasure form. the lingual into the mesial embrasure as far as it will go

 Recontour the band with the ball burnisher to establish close contact between th e band and the adjacent tooth. A cavity base is placed as stated in class I if i ndicated. Fig-6.129 Shown the correct placement of matrix band. 6.3.7 Restoratio n on class II cavity. 6.3.7A Trituration. Prepare a previously described for cla ss I. 6.3.7B Condensation. Fill the carrier with the triturated amalgam. Inject one half of the amalgam in the proximal box. Use a small end of the founded diam ond shaped condenser to pack the amalgam into the proximal box. Direct the conde nser gingivally and laterally while exerting firm pressure on the amalgam to tho roughly condense it along the facial, lingual and gingival margins and into the retentive grooves. Remove the mercury rich amalgam with the large end of the con denser. Continue to add and condense increments of amalgam until the amalgam is condensed along the entire length of the facial and lingual margins of the proxi mal box. Add and condense small increments of amalgam to fill the occlusal porti on of the cavity. Use the small end of round condenser to pack the amalgam into the area. (Fig-6.130). Add additional amalgam and use the large end of round con denser to over pack the cavity, condensing the excess amalgam well beyond the ma rgins and final desired contour. Fig-6.130 Amalgam condensation. 6.3.7C Burnishing. Burnish all accessible occlusal margins. 6.3.7D Carving. With an explorer, remove the excess amalgam inside the occlusal opening of the matrix band. Roughly carved the restorations which will lessen th e chances of fracturing the amalgam when the strip is removed and to reduce the level of the marginal ridge area to that of the adjacent tooth (Fig-6.131). Remo ve the wedge with a tweezers. Then turn the locking nut on the matrix retainer c ounterclockwise to release the band. Remove the retainer from the band in an occ lusal direction. Carefully withdraw the matrix band first from the opposite prox imal surface.

 Do not lift the band directly toward the occlusal because this will tend to frac ture or dislodge the unset amalgam. Remove the excess amalgam at the gingival ma rgin and shape the gingival embrasure with the interproximal carver, using the r emaining tooth structure as a guide. Insert the carver first from the facial and then from the lingual and curve along the entire length of the gingival margin, take care not to flatten this area. Use a carver to remove the excess amalgam f rom the facial and lingual proximal margins and to contour the facial, lingual, and occlusal embrasures. Carve along the margins in an occlusal direction restin g the blade on the adjacent tooth structure (Fig-6.132). Remove the excess amalg am from the occlusal surface with the discoid-cleoid carver. Carve along the mar gins from distal to mesial. Begin developing the occlusal anatomy with the carve r, guiding the tip of the carver to establish the occlusal contours and grooves over the marginal ridge (Fig-6.133). Examine the restoration to make sure that n o amalgam extends over the tooth surface beyond the cavity margins (Fig-6.134). Lightly wipe the occlusal surface with cotton to remove any particles of amalgam . Fig-6.131 Remove excess amalgam. Fig-6.132 Contour facial, lingual and occlusal embrasures. Fig-6.133 Develop occlusal anatomy. Fig-6.134 Examine restoration. 6.3.7E Checking Occlusion. Examine the restoratio n for any high contact or high spot using articulating paper by closing the uppe r and lower jaw lightly on each other. Reduce any high spots with additional car ving with amalgam carver. The process of light closure with articulating paper i s repeated, and additional carving is accomplished until the teeth can be closed to prerestoration occlusion. 6.3.7F Finishing and Polishing Allow at least 24 h our for the amalgam to harden thoroughly before polishing the restoration. Smoot h the facial and lingual margins and round the marginal ridge with the fine and extra-disks .If the margins were carved smoothly, the fine disk need not be used . Using a slow speed and light, intermittent pressure move the disk gingivoocclu sally along the margins and up onto the occlusal surface. A few revolutions with the disk should make the margins smooth (Fig-6.135). Proximal strips can also b e used to contour the proximal surface of the restoration.

 Avoid damaging the proximal contact of the proximal contact of the restoration and injuring the proximal gingival. Check the proximal margins with the explorer. The re should be no catch of the explorer tin when passed in either direction across the margins. Fig-6.135 A Finishing with fine disc. Fig-6.135B Abrasive-coated d iscs (Polishing discs). Fig-6.135 C Mandrel (snap-on or screw-on). Fig-6.135D Finishing instruments. PRACTICAL CLASS Cavity Class II with Amalgam Restoration. 6.3.3 6.3.3 6.3.3 6.3. 3 B DO on 46 C MOD on 35 D MO on 16 (preserve distal pit) E DO on 26 (preserve m esial pit)

6.3.2. Class II amalgam in clinical procedure. the tooth is The tooth is prepare d with dental handpieces and assorted burs. Once prepared, it is restored with d ental amalgam. Equipment and supplies (Fig-6.136 to Fig-6.138). Basic setup: mouth mirror, expl orer, cotton pliers. Air-water syringe tip, HVE tip, and saliva ejector. Cotton rolls, gauze sponges, pellets, cotton tip applicators, and floss. Topical and lo cal anesthetic setup. Rubber dam setup. High- and low-hanpieces. Assortment of d ental burs Spoon excavator Hand cutting instruments (hatches, chisels, hoes, and gingival margin trimmers). Paper pad, cement spatula, and placement instrument. Matrix retainer, matrix bands, and wedges. Locking pliers or hemostat. Amalgam capsules. Amalgam well. Amalgam carrier and condensers. Amalgamator. Carving ins truments. Articulating paper and forceps. Fig-6.136 Amalgam procedure tray placed Setup armamentarium. retainer. Fig-6.137 (A) Matrix band and wedge ( B ) Matrix band Fig-6.138 Lining material. Procedure Steps. Greet and prepare the patient for th e procedure. Review the medical history. Prepare for the administration of the t opical and local anesthetic. Placed the rubber dam (Fig-6.139 to Fig-6.141). Pre pared the cavity. Placed the lining. Placed the matrix band with retainer. Prepa red the amalgam capsules then placed the amalgam into the cavity and condensed t he amalgam. Carving and burnishing the amalgam. After finishing the curving of t he anatomy in the restoration, removed the matrix carefully. Remove the rubber d am carefully. Used the articulating paper and the check occlusion.

 The restoration is wiped off with a wet cotton roll and to remove any blue mark left by articulating paper. Rinse the patients mouth thoroughly to clean any debr is from the mouth. The patient is cautioned not to chew on restoration for a few hours and dismissed. Fig-6.139 Cavity being prepared by dentist. use. Fig-6.140 Loaded carrier, ready for Fig-6.141 placing the articulating paper. 6.3 Class II complex amalgam restorati on. Fig-6.143 MO Complex. Fig-6.145 Complex MOD. Fig-6.142 Complex (large) Cavity Fig-6.144 Complex MO Fig-6.126 The complex cavity restored with amalgam restoration which protects th e entire occlusal surface. Fig-6.147 The complex (large) cavity, length 5.5 mm, deep 2.5 mm Note: The cavity preparation, restoration of class II compound/compl ex large cavities should be follows as described as in preparation of class II a malgam restoration. 6.4 Class V amalgam restoration. Class V carious cavities occur as a result of stagnation on the surface close to the gingival margin, more commonly on the buccal than on the lingual aspect. Th e cavity may frequently extend below the free gingival margin and if recession h as occurred the carious area which may extend into the cementum and dentine if t he root. The restoration of the class V cavities resembles in many ways that of class I, however some significant interesting differences. it is worthy of note that cavities in premolar and molar teeth, the use of reversed mirror head is a considerable help. This simple variation of the normal mouth mirror often gives better retraction of the cheek, reflection of light on the cavity, and a reflect ed view of the working field, with considerably greater case of manipulation. Fi g-6.148 Eighteen years old amalgam restoration on anterior mandibular teeth. Fig-6.149 Numerous stained class V caries lesions. Fig- 6. 150 A moderately deep , V-shaped cervical notch in a maxillary canine.

6.4.1 Cavity preparation The outline form of this type of cavity usual conforms to the general shape shown in Fig-6. The cavity preparation may be started in ei ther one of two ways. Removal of carious tissue may be performed with an excavat or or with a round bur No.4 or 5, in a straight handpiece in preference to a con tra-angle, where access permits. The bur should be used with light, circular, st roking movement. The completed cavity should be of uniform depth between 1.5 and 2 mm. The principles applying to the lining of this cavity are in all respects the same as in the case of the class I cavity. The contour of the floor is estab lished in the same way. Enamel margins should be surveyed and smoothed with the enamel finishing bur, whilst at the same time establishing the 90-degree cavo-su rface angle. The use of high-speed instruments in this type preparation is littl e difference in general technique. A fissure bur may be used from the outset thr ough to the completion of preparation and the effective water spray provides a c lear field. Lightness of touch and ease of control assist in avoidance of the gu m margin. Fig-6.151 Outline form of may be used class V cavity on premolar amalg am restoration. Fig-6.152 A hand instrument as a matrix for class V Fig-6.153 Class V restoration on dam to canine and premolar need to re restore. moister Fig-6.155 Cavity preparation custom matrix, stabilized with wedges to su pport amalgam placement. 6.4.2 Insertion of amalgam Fig-6.154 Place the rubber control the bleeding and Fig-6.156 A The cavity toilet completed and dry field obtained, the insertion of amalgam fol lows the same pattern as that described for class I cavities. Amalgam insertion starts in the normal manner when the cavity is two-thirds filled the matrix band is placed and condensation proceeds through the aperture previously made ,packi ng toward the cavity margin. A smooth, highly polished filling is perhaps of gre ater importance in the class V restoration. Care in curving to eliminate irregul arities after condensation. Polishing proceeds as previously described and a rub ber cup is used in place of the cup-shape brush and then completed final restora tion.

Fig-6.157 Complete Amalgam Insertion amalgam. Fig-6. 158 Final Restoration with 7. COMPOSITE RESTORATION. Composite restoration known as tooth colored restorati on. There is nothing more gratifying than the sight of an intact young anterior dentition in an adolescent or preadolescent patient, particularly the healthy, n atural gingival-enamel relationship that is characteristically observed in young dentitions. Tooth-colored restorative materials have increasingly been used to replace missing tooth structure and modify tooth color and contour, thus enhanci ng facial esthetics. The search for an ideal esthetic material for conservative restoration has resulted in improvements in materials and techniques, particular ly in recent years. Synthetic resins and the acid etch technique represent major advances. Adhesive materials that have strong bond to enamel and dentin further simplify restorative techniques. Cavity preparation technique for class III, cl ass IV, class V, which is to be restored with direct tooth colored restorative m aterials, is covered this chapter. CLASS III CAVITY: The cavity is a box formed by the incisal, facial, gingival, and axial walls (Fig-7.1). Every attempt is ma de to maintain contact with the adjacent tooth with natural tooth structure (Fig -7.2). Extension of the outline form is minimal. Retentive grooves in the incisa l and gingival dentinal walls are optional (Fig-7.5). Positioning matrix band fo r class III cavity (Fig-7.6). Various size and form of class III cavities (Fig-7 .3, 7.4 and 7.7 to 7.10). Fig-7.1 Cavity shape. Maintain contact. Fig-7.3 (A) Po int of entry to class III preparation with Cavity in mandibylar canine , (B) Sma ll retention. Preparation with cervical and mesial retention. Fig-7.2 Fig-7.4 Larger lingual lock Fig-7.5 Cavity outline. Matrix band in position for class III. Fig-7.7 Larger cl ass III cavity. cavity, a. from gual, b. from mesial aspects. Fig-7.6 Fig-7.8 Outline form of class III lin

cavity. Fig-7.9 Use of modified lingual lock as retention in large class III Fig-7.10 a, The persistence of stain at the amelo-dentinal junction. B, The appe arance of stain at labio-cervical margin, deep to enamel. Composite Restoration Materials Fig-7.11 Composite materials. Shade guide. Fig-7 .12 Articulating Fig-7.11 A Composites, Bonding, Etching, paper, and Dappen dishes. materials. Fig-7.11B Some brand of composite Fig-7.11 E The instruments, materials, and equipment for composite restoration. Class III composite restoration. 7.2.1. Tooth preparation for class III cavity. 7.2.1.1ARMAMENTTARIUM 1. Mouth mirror BASIC TRAY SETUP 2. Explorer 3. Tweezers 4 . Periodontal probe CAVITY PREPARATION 1. Contra-angle slow-speed hand piece 2. Burs 3. Enamel hatch et MATRICING 1. Mylar strip 2. Transparent wedges MIXING AND PLACEMENT

1. 2. 3. 4. 5. 6. Mixing pad Acid etch Unfilled resin /Bonding Composite resin Disposable mixing s patula Plastic instrument FINISHING 1. Two sided finishing strips 2. Twelve fluted carbide bur 7.2.1.2Cavi ty preparation Pencil the lingual outline form on the tooth (Fig-7.13). The cont act area is not to be included in the final outline of the preparation. Enter th e lingual portion of the tooth near the center of the penciled area with the rou nd bur in high-speed hand piece (Fig-7.14). Hold the bur perpendicular to the li ngual surface and move the hand piece gingivally and incisally to cut a trough. Do not remove all of the proximal enamel but leave a thin shell of enamel in thi s area. Fig-7.13 pencil the outline Entry point With the bur in the slow-speed h and piece, smooth the axial wall and further develop the box form (Fig-7.15). Av oid overextending the preparation facially and incisally. It is better to leave an enamel contact with the adjacent tooth when possible. Break out the remaining proximal enamel with the enamel hatchet, using it as a lever to fracture the th in enamel (Fig-7.16). Use the enamel hatchet to smooth the incisal and gingival wall. Plane the wall by carefully thrusting the instrument facially. Maintain fi rm control of the instrument to avoid fracturing of the facial wall. Fig-7.14 Fig-7.15 Develop box form 7.16Break proximal enamel Fig Smooth the facial and axial wall with the hatchet. Rest the side of the blade ag ainst the axial wall and, with the end of the cutting edge, scrape the facial wa ll first incisally and then gingivally (Fig-7.17 ). Clinically, when acids etch technique is being used; a 45-degree bevel along the cavosurface margin of the e namel is created. This bevel: 1. Increase the tooth surface area for acid etchin g. 2. Provides an area for unfilled resin tag penetration. Clinical results of t his additional step are: 1. Increased retention of the restoration. 2. Minimized abrupt visual change from the restorative material to the

remaining enamel surface. 3. Decreased marginal leakage. With the round bur in t he conventional speed hand piece, cut a retentive groove at the expense of the d entine in the incisal dentinal wall (Fig-7.18). The incisal groove should finish in the dentine only. Avoid undermining the enamel at the incisal corner. Using the method described previously, create a retentive groove in the gingivo-axial line angle (Fig-7.19). The gingival groove may be slightly larger than the incis al due to the greater bulk of the dentin in this area. Fig-7.17 Smoothen wall Fig-7.18 Retentive groove placement. 7.19 After placement 7.2.1.3 Features of cl ass III cavity involving labial and palatal surface. FigFig-7.20 Class III caries on lateral incisor of mesial aspect Fig-7.21 Class III caries on central incisor of mesial aspect. 7.2.1.4 Cleaning the tooth Using a rubber cup I slow-speed hand piece, clean the enamel surface with slurry of flou r of pumice and water mixed in a dappen dish. Clinically, this has the effect of removing bacterial plaque and salivary contaminants, and cutting debris and sta in from the prepared cavosurface bevel and adjacent enamel. This procedure provi des a clean surface that is more receptive to acid etching .Do not use paste-con taining fluoride, as this will diminish the effect of acid etching. Do not use p aste-containing fluoride, as this will diminish the effect of acid etching. Rins e the tooth with a water spray to remove the pumice. Carefully dry the tooth wit h a gentle steam of air (do not over dry/ desiccate the dentin). 7.2.1 5 Lining / base application Prior to acid etching, moderate and deeply exposed to protect the pulp tissue from: 1. The etching solution 2. The chemical irritation of the composite resin. When a great amount of tooth structure has been lost due to ca ries or fracture, a base should be used underneath the restoration, Otherwise, l ining the exposed dentin should be sufficient in protecting the pulp. Materials for use as lining or base for tooth colored restoration has been described in pul p protection. If the cavity is very deep and very close to the pulp ( that requir es indirect pulp capping) or small, pin-point pulp exposure occur while doing ca vity dentin must be covered

preparation ( that requires treatment with direct pulp capping), then, calcium h ydroxide lining (e.g.; dycal ) need to applied on the tooth surface overlying th e pulp. Dispense a drop each of the catalyst and base pastes of the calcium hydr oxide material on a paper-mixing pad (Fig-7.22). Using the mixing instrument pro vide with the material, mix the catalyst and base together. Touch the tip of the mixing instrument to the paste and carry a small amount to the dentine to be co vered. Touching the instrument to the dentine will transfer the calcium hydroxid e to it. Apply to form a thin, uniform layer and allow the material to set. Alwa ys remember that calcium hydroxide lining is placed overlying the pulp / close t o the pulp, placement of a base above the calcium hydroxide layer is needed (usi ng either conventional GIC such as Fuji IX or RM-GIC such as Fuji II LC ) before restoring the cavity with composite resin. This is to protect the calcium hydro xide layer from fracture as they become rigid after set. Inspect the preparation to ensure dentine overlying the pulp has been covered with the calcium hydroxid e. If not, repeat the previous mixing steps. Lining / base should not extend bey ond the DEJ onto enamel, as it will inhibit acid etching and subsequent bonding. Excess lining / base is removed with an explorer or spoon excavator. Fig-7.22 A Dycal, Mixing pad, gauge, dycal applicator. Fig-7.22B Mixing dycal. dycal applicator Fig-7.22C Mixed dycal with 7.2.1 6 Acid-etch technique Dispense two to three drops of phosphoric acid solut ion (35 % to 37 % depending on manufacturers formulation Fig-7.23) into a plastic well or dappen dish. Use a small brush or applicator, paint the enamel with the acid gently for 20 to 30 seconds (follow the manufacturers instruction). Then, r eturn the brush to the dispensed acid, and paint the enamel again with fresh etc hant. Be certain to coat the prepared enamel bevel as well as 4 to 5 mm of intac t adjacent surface enamel. Following the acid application, rinse the tooth thoro ughly from all aspects with a water spray for 30 seconds. With the air spray, dr y the tooth carefully from all aspects to remove all moisture. The presence of a ny moisture on the enamel will interfere with the successful bonding of the resi n. The etched enamel surface should exhibit a chalky white appearance (can be re fer previously described etching technique).

Fig-7.23 Etching materials 7.2.1.7 Placement of unfilled resin / bonding Apply one drop of the unfilled resin into a plastic well (is also known to as in termediary resin, bonding agent and enamel bond). Mix the two drops together wit h a fresh applicator brush, and paint the unfilled resin over the etched enamel and protected dentine. Be sure to paint the unfilled resin beyond the fracture l ine over the etched enamel surface (Fig-7.24). The resin ensures wetting of and penetration into the etched enamel surface. This enhances retention and sealing of the composite resin. The unfilled resin is then light cured for 10 seconds (F ig-7.25). . Fig-7.24 Applying the bonding. Fig-7-25 light curing. 7.2.1.8 Matricing Place a 1 -inch Mylar strip interproximally and secure it against the gingivo-cav osurface with an appropriate wedge (Fig-7.26). If necessary, contour the matrix with a warmed large, round burnisher or contouring plier. Test the final positio n of the strip by practicing your direction of pull, which will be used in the f ollowing procedure ( Fig-7.27 and 7.28). The surface quality left by the mylar s trip matrix cannot be surpassed by any finishing or polishing procedure. Check fit. Fig-7.26 Strip placement. Fig-7.27 Fig-7.28 The final position. Fig-7.8 A Mesial cavity filled with composite, the matrix strip held in position during setting. 7.2.1.9 Composite resin placement Using a plastic instrument, insert the composi te resin into the preparation taking care to avoid creating pockets of air or vo ids in the restoration. The resin should be introduced into the cavity increment ally, with each layer less than 2 mm in thickness. This is to ensure good depth of curve and to reduce the polymerization shrinkage of the composite resin. Avoi d incorporating air voids into the matrix or preparation by slowly folding small amounts of the material into the most remote parts of the preparation (Fig-7.29 ). Pack the composite resin using plastic instruments. It is desirable to use Te flon plastic instrument as compared to metallic plastic instrument because

Teflon cause less scratching to the composite resin surface during packing or in sertion. Slightly overfill the preparation (Fig-7.30). Pull the mylar strip to c reate a contour to the restoration that will require the least amount of finishi ng and polishing while ensuring good adaptation of the material to the cavity pr eparation (Fig-7.31). Remember that any further contouring or finishing will onl y decrease the surface quality. Fig-7.29 Material insertion. Slightly overfills. Fig-7.31 Fig-7.31 Pull the strip to create contour. 7.2.1.10 Finishing and polishing With the fine carbide or tapered diamond bur in the high-speed hand piece, remov e any gross marginal excess of material that resists flicking off with the explo rer (Fig-7.32, 33). Some of the burs that can be used are diamond bur L10 for co ntouring the labial surface and pear shape or F40 bur contouring the palatal sur face and cingulum area. White stone (tapered and round shape) can also be used t o further contour the labial and palatal surface of the restorations. The proxim al surface can be contoured using an inter proximal finishing strip that has two abrasive surfaces (fig-7.34). Fig-7.32 lingual view Remove marginal excess. Fig-7.33 Fig-7.34 finishing with strip. Pass the strip through the contact from the incisal aspect. With a labio-lingual motion, contour the proximal aspect of the restoration in order to minimize fla sh and create a physiologic gingival embrasure. Dry the restoration with a gentl e stream of air. Carefully check for defects such as voids, marginal defects, an d excess material. Clinically, additional composite can be added to the restorat ion, as needed providing the rubber dam has maintained moisture control. The fin al polish of the restoration is accomplished using snap-on-polishing discs (Ex, Soflex) in a slow speed hand piece. Starting with the medium, and progressing to the fine and extra-fine grit, gently polishes all aspects of the composite rest oration. Figure 7.35 shows some of the instruments for composite resin polishing . A B Fig-7.35 A (A) Polishing strips, (B) finishing diamond

burs. Fig-7.25 B Finishing diamond burs for composites (for remove composite excess. Fig-7.35 C Polishing strips and polishing discs for composites. Fig-7.35 D Sof-Lex dicks and the snap-on mandrel and Moore-Flex Dicks. Fig-7.35 E Brasseler polishing cup and points and Min-identoflex polishing cup a nd point with snap-on mandrel .

7.3 PRACTICAL CLASS FOR CLASS III COMPOSITE RESTORATION. 1. Class III restoratio n on tooth 12 (mesial). 2. Class III restoration on tooth 33 (distal). 7.4 Tooth preparation for class III in clinical procedure. The tooth is prepared with dental handpieces and assorted burs. Once the tooth is prepared, it is res tored with composite. Equipment and supplies (Fig-7.36 to Fig-7.37). Basic setup : Mouth mirror, explorer, cotton pliers. Air-water syringe tip, HVE tip, and sal iva ejector. Cotton rolls, gauze sponges, cotton pellets, cotton tip applicators , and dental floss. Topical and local anesthetic setup. Rubber dam setup. Highand low-handpieces. Assortment dental burs (including diamond and cutting burs). Spoon excavators. Hand cutting instruments (biangle chisel and wedelstaedt chis el). Base and liner with maxing materials and placement instruments. Etching and applicator, if necessary (usually come with composite system). Primer ((usually come with composite system). Composite materials including a shade guide. Compo site placement instrument (plastic instrument). Curing light with protective shi eld. Celluloid matrix strip and wedges. Locking pliers or hemostat. Finishing bu rs or diamonds #12 scalpels. Abrasive strips. Polishing discs. Lubricant Articul ating paper and forceps. Procedure Steps. The patient is seated and prepared for the procedure. Confirm the procedure and review the medical history. Rinse the patient mouth and apply the topical anesthetic and give LA. The shade is determi ned for the composite materials. Place the rubber dam. Prepare the cavity. Place d the base or liner.

 Place the acid-etch for 15 second according to manufacture direction. Place the matrix strip and plastic wedge. Place the bonding material and light cure (10 se c) according to manufacturer direction. Place the composite into the cavity and light cure (20-30 sec) according to manufacturer direction, if the material is s elf-cure mixed and place the cavity wait for a few minutes to set. Remove the ma trix strip and wedge. Use the low-speed handpiece with finishing burs, diamond, and abrasive discs to finish the restoration. Removed the rubber dam carefully. Check the occlusion with the articulating paper, if any high mark removes it. Th e patient mouth is rinsed and the patient is given postoperative instructions. Fig-7.36 Composite tray setup. metal clip. Fig-7.37 Celluloid matrix strip with 7.8 Class IV composite restoration. 7.8.1 ARMAMENTARIUM 7.8.2 CLASS IV CAVITY Th e cavity is represented by an axial wall that is the line of fracture (Fig-7.38) . For this procedure, contact with the adjacent tooth is broken. Clinically, how ever, contact with the adjacent tooth may be maintained in order to conserve too th structure. Extension of the outline form beyond the fracture site is minimize d unless weakened or unsupported tooth structure is present. The fracture involv es a triangular- shaped area of dentin surrounded by enamel that is beveled at a 45 degree angle, about 1 mm wide. No undercut or pin is necessary for mechanica l retention as the composite restoration is retained by acid etching the enamel. Fig-7.38 Class IV line of FEATURES OF THE RESTORATION the fracture. 7.8.2.1 The restoration restores all missing tooth structure including incisal edge, int erproximal contact, and contours (Fig-7 .39 ). It extends 1 to 2 mm beyond the c avosurface bevel. The restoration terminates on an area of enamel that has been previously etched and painted with unfilled resin/bonding. Fig-7.39 Extent of restoration. (A= extent of prepared cavity, B= extent of comp osite resin, C= extent of enamel) unfilled resin, D= extent of etched

7.5.2.2 MESIO-INCISAL EDGE FRACTURE STIMULATION 1. In order to stimulate a defec t requiring a class IV composite resin restoration, a mesio-incisal fracture is created on maxillary central incisor. 2. The simulated fracture should involve a triangular-shaped area of enamel that is just into dentine. 3. The size of simu lated fracture, depending upon the tooth selected, may increase in order to allo w exposure of dentine on the fractures surface for purpose of this procedure. Cl inically, however the preparation of dentine should be minimized. 4. Pencil the fracture line on the labial and lingual surface on the tooth selected. 5. The ar ea of tooth structure to be removed and should extend approximately 3 mm gingiva lly and 3 mm distally from the original mesio-incisal corner. 6. The fracture li ne should extend gingivally to contact area, so that the restoration restores th e contact as well as the missing mesio-incisal corner. 7. Using a tapered diamon d bur in the high-speed hand piece, remove the mesioincisal corner of the tooth as described above. 8. a class IV composite resin restoration is retained mainly via acid etched enamel. 9. Therefore, establishment of retention with mechanica l undercuts and threaded pins is not necessary in a small and moderate-size cavi ty. 10. With a diamond bur or carbide-finishing bur, create 45-degree bevel 1 mm wide along the entire cavosurface margin (Fig-7.40). 11. The bevel is located e ntirely in enamel and should not extend into dentine. Its purpose is to; a. Incr ease the tooth structure area for acid etching. b. Provide a suitable area for u nfilled resin tag penetration. c. Remove unsupported enamel. 12. Clinically, the bevel has the effect of; a. Increasing the retention of the restoration. b. Dec reasing the marginal leakage. c. Minimizing an abrupt visual change from the res torative material to the remaining enamel surface. Fig-7.40 Bevel cavosurface ma rgin. r 7.5.2.3 CLEANING THE TOOTH 1. Using a rubber cup in slow-speed hand piec e, clean the enamel surface with slurry of flour of pumice and water mixed in a dappen dish. Clinically, this has the effect of removing bacterial plaque and sa livary contaminants, and cutting debris and stain from the prepared cavosurface bevel and adjacent enamel. 2. This procedure provides a clean surface that is mo re receptive to acid etching ( Fig-7.41). 3. Do not use paste-containing fluorid e, as this will diminish the effect of acid etching. 4. Rinse the tooth with a w ater spray to remove the pumice. 5. Carefully dry the tooth with a gentle steam of air (do not over dry / desiccate the dentin).

Fig-7.41 Clean the enamel. 7.5.2.4 LINING / BASE APPLICATION 1. Prior to acid etching, moderate and deeply exposed dentine must be covered to protect the pulp tissue from; a. The etching solution b. The chemical irritatio n of the composite resin. 2. When a great amount of tooth structure has been los t due to caries or fracture, a base should be used underneath the restoration. O therwise, lining the exposed dentine should be sufficient in protecting the pulp . 3. Materials for use as lining or base for tooth colored restoration has been described in Pulp Protection. 4. if the cavity is very deep and very close to the pulp (that requires indirect pulp capping) or small, pin-point pulp exposure occ ur while doing cavity preparation (that requires treatment with direct pulp capp ing), then ,calcium hydroxide lining (e.g. Dycal) need to applied on the tooth s urface overlying the pulp. 5. dispense a drop each of the catalyst and base past es of the calcium hydroxide material onto a paper-mixing pad (Fig-7.42) Fig-7.42 Mixing calcium hydroxide 6. Using the mixing instrument provided with t he material, mix the catalyst and base together. 7. Touch the tip of the mixing instrument to the paste and carry a small amount to the dentine to be covered. 8 . Touching the instrument to the dentine will transfer the calcium hydroxide to it. 9. Apply to form a thin, uniform layer and allow the material to set. 10. Al ways remember that when calcium hydroxide lining is placed overlying the pulp / close to the pulp, placement of a base above the calcium hydroxide layer is need ed (using either conventional GIC such as Fuji IX or RM-GIC such as Fuji II LC) before restoring the cavity with composite resin. This is to protect the calcium hydroxide layer from fracture as they become rigid after set. 11. Inspect the p reparation to ensure dentine overlying the pulp has been covered with the calciu m hydroxide. If not, repeat the previous mixing steps. 12. Lining / base should not extend beyond the DEJ onto enamel, as it will inhibit acid etching and subse quent bonding. 13. Excess lining / base is removed with an explorer or spoon exc avator. 7.5.2.5 ACID-ETCH TECHNIQUE 1. Dispense two to three drops of phosphoric acid solution (35% to 37% depending on manufacturers formulation) into a plastic well or dappen dish. 2. Using a sma ll brush or applicator, paint the enamel with the acid gently for 20-30 seconds (follow the manufacturers instruction). 3. Then, return the brush to the dispense d acid, in order to wet the enamel with fresh etchant (Fig-7.43). 4. Be certain to coat the prepared enamel bevel as well as 4 to 5 mm of intact adjacent surfac e enamel.

5. Following the acid application, rinse the tooth thoroughly from all aspects w ith a water spray for 30 seconds (Fig-7.44). 6. With the air spray, dry the toot h carefully from all aspects to remove all moisture. The presence of any moistur e on the enamel will interfere with the successful bonding of the resin. The etc hed enamel surface should exhibit a chalky white appearance. Fig-7.43 Etching wi th water. 7.5.2.6 MATRICING Fig-7.44 Rinse 1. Place a 1 inch length of mylar matrix strip interproximally between the prepa red tooth and the adjacent tooth. The matrix strip should extend gingival to the cavosurface bevel interproximally. 2. Place a transparent wedge from the labial to secure the gingival portion of the matrix strip against to tooth being resto red (Fig-7.45). 3. Evaluate the position of the matrix strip and its ability to: Minimize the gingival extent of the composite. Simulate the contour of the ulti mate restoration. Extend beyond the incisal edge in order to encompass the mesio -incisal edge being restored. 4. Clinically, a celluloid crown from is often use d as an alternate from of matricing. 5. The crown from must be contoured to the approximate shape of the final restoration. It serves to delineate both the inte rproximal, palatal, and labial contours. 6. Test the final position of the Mylar matrix by practicing young direction of pull, which will be used in the followi ng procedure. Fig-7.45 Matrix strip placement. 7.5.2.7 PLACEMENT OF UNFILLED RES IN / BONDING Applying one drop of the unfilled resin into a plastic well (is als o known to as intermediary resin, bonding agent and enamel bond). Mix the two dr ops together with a fresh applicator brush (fig-7.46) and paint the unfilled res in over the etched enamel and protected dentine. Be sure to paint the unfilled r esin beyond the fracture line over the etched enamel surface (Fig-7.47). The res in ensures wetting of and penetration into the etched enamel surface. This enhan ces retention and sealing of the composite resin. The unfilled resin is then lig ht cured for 10 seconds. Fig-7.46 Mix bonding agent. on etched surface. 7.5.2.8 COMPOSITE MATERIALS Fig-7.47 Paint Composite resin restorations can be done with micro filled, marco filled, or hyb rid materials. The micro filled materials should be used to restore incisal frac tures only when the maxillomandibular relationship is normal and when the

remaining natural teeth can serve as the primary support for centric, protrusive , and protrusive lateral functions. When the occlusion is heavy and the incisal composite restoration is expected to bear most of the occlusal load, macrofilled or hybrid type of composite material are specifically indicated because of thei r greater fracture resistance in stress-bearing situations The best materials fo r restoration of incisal fracture are as follows: 1. Highly polishable hybrids: Prisma APH; Herculite XRV; Z-100. 2. Heavy filled micro filled composite materia ls: Heliomolar, Helio Progress. 3. Semipolishable hybrids: Silux plus, durafil V S. 4. Some brand of composite materials set (Fig-7.48). ( A) ( B) Fig-7.48 Composite resin materials set. 7.5.2.9 COMPOSITE RESIN PLACEMENT Using a plastic instrument, insert the composite resin into the preparation taki ng care to avoid creating pockets of air or voids in the restoration. The resin should be introduced into the cavity incrementally, with each layer less than 2 mm in thickness. This is to ensure good depth of cure and to reduce the polymeri zation shrinkage of the composite resin. Remember to stabilize the matrix strip across the palatal aspect of the cavity preparation with finger pressure during insertion of material. Once the cavity has been filled, the matrix must be drawn across the preparation in order to simulate the ultimate contours of the restor ation. Light cure the composite on the labial and lingual surface for 40 seconds each. Held the matrix firmly onto the tooth surface for a few minutes while the composite is being cured or polymerized. Proper positioning of the strip will m inimize the amount of finishing while ensuring good adaptation of the material t o the cavity preparation. Repeat the previous steps until the cavity is slightly overfilled with the composite resin. When using a chemical cure composite resin , place an equal proportion of base and catalyst pastes of the composite resin o n the paper pad. Mix the paste thoroughly for 30 seconds with a plastic mixing s patula. Condense the freshly mixed composite resin into the disposable tip of a composite injection syringe. Seal the tip with a plug provided and place the tip into the syringe. Complete the loading of the syringe quickly so as not to encr oach on the working time of composite resin. The mix can then be injected into t he preparation (Fig-7.49, 7.50). Fig-7.49 Material placement. Positioning the st rip. 7.5.2.10CONTOURING, FINISHING, AND POLISHING Remove the transparent wedge a nd the Mylar strip. If gross marginal excess of material present, begin shaping the contours of the ultimate restoration using a diamond bur in the high-speed h and piece (Fig7.51). Fig-7.50

Some of the burs that can be used are diamond bur L10 for contouring the labial surface and pear shape or F40 bur for contouring the palatal surface and cingulu m area. The composite resin should extend beyond the limits of the cavosurface b evel for purposes of esthetics, sealing and retention. Sand paper disks in a slo w-speed hand piece may be used on the labial and incisal aspects to further cont our the restoration (Fig-7.52). White stone (tapered and round shape) can also b e used to further contour the labial and palatal surface of the restorations. Th e proximal surface can be contoured using an interproximal finishing strip that has two abrasive surfaces (Fig-7.53). Pass the strip through the contact from th e incisal aspect. With a labio-lingual motion, contour the mesial aspect of the restoration in order to minimize flash and create a physiologic gingival embrasu re (Fig-7.54). Dry the restoration with a gentle stream of air. Carefully check for defects such as voids, marginal defects, and excess material. Clinically, ad ditional composite can be added to the restoration, as needed providing the rubb er dam has maintained moisture control. The final polish of the restoration is a ccomplished using snap-on-polishing discs (Ex. Soflex) in a slow speed hand piec e. Starting with the medium, and progressing to the fine and extra-fine grit, ge ntly polishes all aspects of the composite restoration. Clinically, the rubber d am may be removed at the completion of finishing so that the restoration first c an be checked in centric occlusion and protrusive guidance and then polished add itionally. Fig-7.51 Remove excess Fig-7.52 Contour labial. Fig-7.53 Contour lingual. proximal surface. Fig-7.54 Contour 7.6 Practical Class Class IV Composite resin on 11 (MI) Class IV Composite resin on 12 (DI)

7.7 Class V composite restoration. 7.7.1 ARMAMENTARIUM Basic tray setup: 1. 2. 3. 4. Mouth mirror Explorer Tweezers . Periodontal probe. Cavity preparation: 1. 2. Contra angle slow speed hand piec e Burs. Mixing and placement: 1. 2. 3. 4. 5. Mixing pad. Mixing spatula. Glass i onomer. Cavity conditioner. Plastic instrument (Teflon- type) instrument. Finish ing: 1. 2. 3. Diamond finishing bur White stone points Snap on soflex discs poin ts. 7.7.2 CLASS V CAVITY Class V cavity preparation, by definition, are located in t he gingival one third of the facial and lingual tooth surfaces. Because of the e sthetic consideration, composite resin or GIC (Fig-7.55A) used for the restorati on of class V lesions. In certain circumstances, GIC and composite (Fig-7.55B) r esin restoration are used together in the same cavity (using different layers of material), to obtain good adhesive of GIC to dentine and achieve greater aesthe tic and strength of composite resin. This type of technique and restoration is k nown as sandwich technique and sandwich restoration. (A) (B) Fig-7.55 (A) GIC Light cure, (B) Composite self sure.

7.7.2.1 OUTLINE FORM The outline form of the cavity stops at the extent of the d efect or caries, and removal of tooth structure can be kept to a minimum. Howeve r, unsupported enamel should not be left in area subject to high load. For the r estoration of the cervical abrasion lesions, for which glass ionomer cement is o ften used, the outline from of the defect is used as cavity outline from but som etime the coronal (enamel) margin is altered (Fig-7.56 to 7.59). The cavity marg in should ideally be placed above the gingival margin to gain better moisture co ntrol. Fig-7.56 Class V cavity. with two pin holes Fig-7.57 Large class V cavity Fig-7.58 Class V cavity in premolar. Fig-7.59 Cavity outline. 7.7.2.2 RETENTION FORM A particular retention from does not need to be consciously provided, in fact, i f one is too much of a box form, air bubbles will be trapped in the corners. In order to increase adhesiveness with the cement, a fresh dentine surface is expos ed as much as possible and any carious dentine is removed. 7.7.2.3 PREPARATION FOR CONVENTIONAL CLASS V CAVITY The conventional class V for composite is indicated for portion of a carious les ion entirely or partially on the buccal / labial or lingual root surface of the tooth. The preparation will be limited only to removal of any defects and conser ving as much tooth as possible. The features of the preparation include a 90-deg ree cavosurface angle, uniform depth of the axial line angle and sometimes, the retentive groove. Enter the tooth using a tapered TC or similar shaped diamond b ur at a 45degree angle to the tooth surface by tilting the hand piece distally. As the cutting progress distally, maintain the burs long axis perpendicular to th e external tooth surface during preparation of the outline form. This should res ult in 90-degree cavosurface margins. The depth of the cavity (axial wall depth) is about 0.75 mm. this depth will provide adequate external wall width for: Str ength of preparation wall

Strength of composite Placement of retentive groove, if necessary. The axial wal l should follow the original contour of the root surface i.e. convex outward mes iodistally and sometimes occlusogingivally. Final tooth preparation consists of the following steps: 1. Removing remaining infected dentine on the axial wall or old restoration (if applicable). 2. 2.Lining, if necessary 3. Sometimes, may ne ed to prepare retentive groove. However, retention groove is considered unnecess ary when axial depth into dentine is only 0.2 mm and the periphery of tooth of t he tooth preparation is still in enamel. No .1/4 round bur is used to prepare th e groove, along the full length of gingivoaxial and incisoaxial (occlusoaxial) l ine angles. These grooves are about 0.25 mm in depth into the external walls. Be veling of the enamel margin is sometimes done and is indicated in the case of : 1. The replacement of an existing, defective class V restoration, which not prev iously beveled. 2. For a large, new caries lesion. The advantages of the beveled preparation are: 1. Increase retention due to the greater surface area of etche d enamel. 2. Decrease micro leakage due to the enhanced bond between the composi te and the tooth. 3. Decrease the need for groove retention (therefore, less rem oval of tooth structure). A.CLEANING AND CAVITY CONDITIONER The cavity preparation is rinsed with water an d lightly air-dried. Condition the cavity to cleanse the preparation, which remo ves the smear layer and makes the adhesion of the cement to the dentine surface more reliable. B.PLACEMENT RESTORATION. It is necessary to remove excessive mois ture from tooth structure. Mixed glass ionomer cement as soon as possible in ord er to obtain the best bond. The restorative glass ionomer cement is placed in th e cavity using a syringe or a special instrument for pacing and contouring GIC. A cervical matrix can also be used to contour the restoration along the margins while the restoration is setting. The basic anatomy is finished while the cement is in the fluid state. C.CONTOURING. If fluidity disappears while the anatomy i s being carved, do not try to create any more anatomy, keep your hands off. Atte mpts to change the contour after fluidity disappears causes stippling or bumps o n the surface. If there is a lack of material, another mix is made quickly and a n additional layer added.

D. FINISHING. The finishing should be done at least one day after the placement of the restoration to allow surface hardness to occur. One technique is to conto ur the basic anatomy using a diamond point for finishing, and then to finish the surface with snap on discs or something similar. Abrasive strip is used to cont our the proximal surfaces. Because the GIC is now stable in water, white stone p oints and silicone points can be used with adequate irrigation to contour the re storation. Finishing with polishing pastes, brushes, and rubber cups should be a voided because the heat produced may cause craze lines. 7.7.2.4. FEATURES OF CAVITY CLASS V ON CANINE TOOTH. (A) (B) Fig-7.60 (A) Class V preparation with composite, (B) Step by step preparation. Fig-7.61Class V caries and outline form. 45-degree. Fig-7.62 Bur held at preparation. Fig-7.63 Completed large, beveled conventional class V 7.7 Practical class. Class V GIC on 25 (B) Class V Composite on 11 (B) Class V GIC o n 33 (B)

EVALUATION CRITERIA EVALUATION CRITERIA GRADE Excellent A student is able to com plete the task without any assistance and direct guidance from the supervisors a nd has excellent knowledge about the procedures. 4 Good A student need a minimal amount of help to complete the task and is able to show evidence of understandi ng of the concept / procedure. 3 Satisfactory A student need to be repetitively guided to complete the task and need further explanation about the given concept / procedure. 2 Poor There has been irretrievable damage to the tooth structure and the student lacks the knowledge of the given concept / procedure. The superv isor has to complete the stage of treatment for the student. 1 Assessment sheet for hands skill exercises (1) EXTERNAL OUTLINE FORM(inc bevel) Exercise Marks Signature Marks Signature Exercise1 Shape 1 Exercise 2 Shape 2 Ex ercise 3 Shape 3 Exercise 4 Shape 4 (2) REPEAT INTERNAL FORM (Parallel walls / undercut, internal line angle) Marks Signature M arks Signature REPEAT Exercise Exercise1 Shape 1 Exercise 2

Shape 2 Exercise 3 Shape 3 Exercise 4 Shape 4 (3) FINISH ( SMOOTHNESS) Exercise Marks Signature Exercise1 Shape 1 Exercise 2 Shape 2 Exercise 3 Shape 3 Exercise 4 Shape 4 REPEAT Marks Signature

1. Introduction to Operative Techniques. 168 Classification of techniques and storative strategies. 168 Tooth preparation. 172 Direct Techniques. 175 Semi dir ect Techniques. 185 Indirect Techniques. 194 New technologies for tooth colored restorations. 185 Luting procedure. 216 Finishing and polishing procedure. 221 2. Instrumentation and Operators position. 225 Hand instruments. 225 Rotary instr ument. 240 Position of operator. 246 3. Dental Caries. 251

 What is caries? 251 The carious process and the carious lesion. 256 Dental plaqu e. 256 Epidemiology of dental caries. 256 Modifying the carious process. 257 The first visible sign of caries in an enamel surface. 258 The microbiology of dent ine caries. 259 Active and arrested lesions in dentine. 260 Root caries. 261 Sec ondary or recurrent caries. 262 Residual caries. 263 Why is dentine caries brown ? 264 Prevention of caries by plaque control. 264 Diet and caries. 268 Fluoride supplementation. 269 Saliva and caries. 271 The operative management of caries. 277

4. Sharpening of Hand Instrument. 283 Stationary sharpening stones. 283 Mecha al sharpeners. 283 Handpiece sharpening stones. 284 Sharpening of hand instrumen t. 284 Principles of sharpening. 285 Mechanical sharpening techniques. 285 Stati onary stone sharpening techniques. 285 Sharpness test. 287 5. Dental Physiology. 287 Structure of the head and neck. 287 Major muscles of astication and facial expression. 295 Blood supply to the face and mouth. 296 Ly mph nodes. 298 Nerve supply to the mouth. 299 Structures of face and oral cavity . 303 The teeth. 309

6. High Speed Technique. 310 Development of rotary equipment. 310 Rotary spee ange. 313 Laser equipment. 313 Other equipment. 315 Rotary cutting instruments. 316 Other abrasive instruments. 321 Cutting recommendations. 322 Hazards with cu tting instruments. 322

1. Introduction to the Operating Technique. Operative dentistry is the art and s cience of the diagnosis, treatment, and prognosis of defects of teeth that do no t require full coverage restorations for correction. Such treatment should resul t in the restoration of proper tooth form, function, and aesthetics, while maint aining the physiologic integrity of the teeth in harmonious relationship with th e adjacent hard and soft tissues, all of which should enhance the general health and welfare of the patient. Although operative dentistry once was considered th e entirety of the clinical practice of dentistry, today many of the areas previo usly included under operative dentistry have become specialty areas. As informat ion increased and the need for other complex treatments was recognized, areas su ch as endodontics, prosthodontics, and orthodontics became dental specialties. O perative dentistry is still recognized, however, as the foundation of dentistry and the base from which most other aspects of dentistry evolved. There are three main operative technique, such as direct techniques, semi direct techniques, an d indirect techniques. Classification of techniques and restorative strategies Esthetic restorative technique for teeth can be categorized into three groups; t he direct techniques consist only of intraoral procedures requiring a single app ointment, the semi direct techniques include intraoral as well as extraoral step s to produce luted chairside restorations, and as opposed to the indirect techni ques, which require several appointments and the collaboration of dental laborat ory. Fig-1.1 Three main restorative techniques. Fig-1.2 A Direct technique. Fig-1.2C Prepared Cavity. Fig-1.3 A Semidirect Techn ique Fig-1.3C Luted model. Fig-1.4A Indirect Technique Fig-1.2B Preoperative tooth. Fig-1.2D Postoperative tooth Fig-1.3B Preoperative tooth. Fig-1.3D Postoperative tooth. Fig-1.4B Preoperative tooth.

Fig-1.4C Model with Inlay/Onlay Fig-1.4D Postoperative tooth. Fig-1.5 Due to particular anatomy, premolars require special attention in case o f large amalgam replacements. Modification of the conventional preparation for a luted restoration. Fig-1.6 For small restorations with thick restorative techniques are indicated. For thin gingival enamel (less than 1 mm in a luted restoration (semidirected or Fig-1.7 A Preoperative View. Fig-1.8Composite inlays, PFM crowns. Fig-1.8A Preo perative View. Fig-1.8C Restorated with PFC. Tooth preparation gingival enamel, direct large preparation with thickness and height), indirect) is indicated. Fig-1.7 B View of working model. Fig-1.7C Postoperative View. Fig-1.8 B Preopera tive radiograph. Fig-1.8D Postoperative radiograph. Optimal adhesion can be obtained by micromechanical retention to enamel rods, ac id etched perpendicularly to their long axes. The bevelling of enamel margin is therefore a prerequisite for any direct adhesive technique, which can never full y compensate for composite resin polymerization shrinkage. This basic concept re mains valid for new restorative techniques (Fig-1.9). A B C Fig-1.9 ( A )Typical example of an adhesive preparation with thick enamel margins bevelled, ( B ) SE M view of the transitional line between the bottom of the cavity and the bevel, ( C ) At a higher magnification, it appears that prisms are exposed mainly perpe ndicular to their long axes on the bevel, which provides a more efficient bond t o acid-etched enamel. Tooth preparation for direct techniques A distinction shou ld be made between the treatment of decayed but unrestored teeth and the replace ment of existing restorations; Preparation for preventive restorations; for supe rficial fissure caries, decayed tissue may be removed by selective ameloplasty. This is the most conservative approach for limited decay on posterior teeth (fig -1.10A). For direct adhesive fillings, the conventional geometry of Black caviti es is not optimal. Lutz and co-workers described the adhesive preparation as con sisting of a conservative round or ovid proximal box and occlusal extensions, in cluding bevelling of enamel margins (Fig-1.10B).

Fig-1.10 Different preparation designs for direct techniques. (A) Preventive pre paration (B) More deeply preparation. All sound structures are maintained so tha t the general cavity design is ovid with some area of unsupported enamel. (C) Bu ccolingual preparation (D) For replacement of existing metallic restorations, th e modification of the cavity design in preparation for an adhesive technique req uires the bevelling of all margins. This is the bevelled conventional preparatio n. Tooth preparation for semi- or indirect technique. Semidirect and indirect (l uted) restorations require tapered cavities, usually with butt margins. Internal undercuts should be filling with a base material to avoid destructive preparati ons. Here also, rounded internal and external lines are preferred (Fig-1.11). Th is design improves more accurate ceramic inlays / onlays (Fig-1.12). Fig-1.11 Different preparation designs for luted adhesive restorations. ( A) Sev ere carious lesions preparation, (B ) Preparation for replacement of large exist ing restorations. Fig-1.12A Ceramic overlays model. restorations. A A B Fig-1.12 B fitting B Fig-1.13A Ceramic inlays preparation, B. After 15 years. Fig-1.14 A Overlay ma rgin on molars, B. Finishing design Fig-1.14 C Full crown preparation. taper Fig-1.16A Occlusal contacts. Fig-1.15 Semidirect intraoral more and width. Fig-1.16 B Minimal thickness Fig-1.16C Minimum width, proximal contact. Direct Techniques There are many direct filling techniques, including simple one, like the bulk rest oration, and more sophisticated one, like three-sited light-curing technique.

Direct techniques are generally indicated for preventive, small to medium size r estoration (Fig-1.17). The choice of filling method is based on the size and vol ume of the preparation. Fig-1.17 A Preventive restoration Fig-1.17 B Small Class I and Class II restoration Fig-1.17C Medium Class I and Class II restoration Preventive restoration: a sing le application of composite and subsequent polymerization may be performed (bulk technique) (Fig-1.18 to Fig-1.20) Fig-1.18 The bulk technique is indicated only when the cavity volume is minimal. Fig-1.19 A Initial carious lesions involving the occlusal grooves of posterior m ade. mandibular teeth and distal surface of the tooth. Fig-1.19C Restored in the simplest manner, with a bulk of composite. Fig-1.19 B Very conservative preparation were Fig-1.19 A Superficial proximal carious lesion Fig-1.20B Prepared the cavity. composite technique. Fig-1.20 C Restored with with a bulk Small class I and class II restoration: for such preparation, a multilayer techn ique is advocated and conventional horizontal layering should be carried out (Fi g-1.21 to Fig-1.22). For class II cavities, this technique is based on the use o f conventional metallic matrix, which improves polymerization by light reflectio n (Fig-1.23). Tunnel restorations (Fig-1.24) are appropriate only for very super ficial lesions in which decayed tissues can be completely removed without

excessive weakening of the occlusal ridge. An adhesive restoration will bond to all cavity walls, including the tunnel, currently appears to be the best restora tion option. Fig-1.21Horizontal layering is to be applied in narrow but deeper cavities to co mpensate for composite resin. Fig-1.22A Preoperative view of prepared cavity. a failed composite restoration. Fig-1.22 C Filled with horizontal composite increm ents. Fig-1.23 A Preoperative view of decayed first upper molar. Fig-1.22 B The Fig-1.22D Completed restoration Fig-1.23B Prepared Cavity. Fig-1.23 C Placed a clear plastic fixed wedge. matrix band. Fig-1.23 D Metal band was with a wooden cavity filled. Fig-1.23 E Placed the bonding and Light-cure glass ionomer. Fig-1.23 F Remaining volume was Fig-1.23G Filled last increment. characterization give the restoration more natu ral appearance. Fig-1.23H Internal was applied to a Fig-1.23 I Final view of restoration. Fig-1.24 A Preoperative radiograph amalgam of amalgam restoration. canal. Fig-1.24 B Removed old filling and prepared Fig-1.24 C The neighbouring tooth was properly protected. Fig-1.24 D Placed the etching, bonding,

Fig-1.24 E Filling with occlusal restoration. cavity with composite. Fig-1.24 F Completed Medium class I and Class II restoration: since horizontal layering can theoretic ally not fully compensate for polymerization shrinkage, medium size class II cav ities should be restored using better performing techniques. In this situation, as far as direct techniques are concerned, the three-sited light-curing techniqu es should be provide optimal proximal adaptation and seal (Fig-1.25). The ration ale of this technique is first to place a traditional glass-ionomer base to redu ce the area to be filled with composite and then used an original multilayer met hod (Fig-1.26). Fig-1.25 The three sited light-curing technique. Fig-1.26 A Preoperative amalgam filled lower first molar. Fig-1.26C The placed placed. Fig-1.26D The second com posite layer and then third composite layer was placed. Fig-1.26B A cavity is co mpleted. clear matrix and translucent reflecting wedge was and the first composite layer was anatomy Fig-1.26 E Placed Composite Fig-1.26 F The occlusal shape is given to the occlusal part. last increcement. Fig-1.26G Postoperative view. The quality of contact point may be improved by us ing special instrument, such as the contact pro, designed to push the matrix eff iciently against the neighbouring tooth (Fig-1.27). The use of polymerization ti ps (fig-1.28) or ceramic inserts (Fig-1.29) has been proposed as an alternative technique for controlling polymerization shrinkage. Occlusally, when the cavity walls are weakened, the composite may be applied in oblique layers to be cured t hrough the cusps (Fig-1.30 to Fig-1.31). A more natural appearance may be achiev ed through appropriate composite layering and by the application of intense colo urings resins, on the restoration either surface or, preferably, under the last composite layer (Fig-1.32). A functional anatomy can also be obtained with speci fic modeling instruments (Fig-1.33). This final touch greatly facilitates occlus al adjustments and save

precious chair side operating time. Fig-1.27 A Clear plastic matrix tooth Fig-1.27B Matricing the Fig-1.27 C place the wedge A Fig-1.27C Completed restoration B C Fig-1.28 Polymerization tip placed on light-cure top and curing. A B C Fig-1 .29 A Ceramic Inlay, B Placed inlay, C completed procedure. A B Fig-1.30 For medium class I cavities, horizontal layering is not ideal becau se of the tension that will be exerted on opposing walls (A),In this situation, marginal quality benefits from the use of an oblique incremental technique (B) ( vectors of polymerization are indicated by arrows). Fig-1.31 A Old filling to be replaced. Fig-1.31C Placing Composite. Fig-1.31E Co lored liquid resin. Fig-1.31B Prepared Cavity. Fig-1.31D Placing Composite. Fig-1.31 F Restore anatomy occlusal Fig-1.31 H Completed restoration. Fig-1.31 G Brushing the tooth. Fig-1.32 Composite layer. Semidirect Techniques Fig-1.33 specific modeling instruments When cavity dimensions or extension toward the cementoenamel junction contraindi cates a direct filling method number of teeth are concerned at the same time sem idirect techniques are best indicated (Fig-1.34). The semidirect approach is pro viding the patient with luted restorations without the cost of indirect labmade inlays or onlays (Fig-1.35 to 1.36). Actually, as already stated, adequate proxi mal contours and contacts of direct class II restoration may be particularly dif ficult to achieve (Fig-1.37), to improve the quality of large class I and II res torations, can be performed chairside with intra-, and extraoral steps, during a single appointment. The composite or ceramic restorations fabricated are to be luted exclusively with an adhesive technique. Intraoral Composite Inlays The inl ay is made by placing one or two composite increments inside the insulated and c offered cavity (Fig-1.38). After in-mouth polymerization, the

inlay can be removed, showing that the cavity has been properly tapered and is f ree of any undercut. For MOD or complex cavities, should be use another semitech nique (Fig-1.39). Actually, the microretentions created by coarse diamonds may b e sufficient to lock the restoration inside the cavity (Fig-1.40). The technique should be applied mainly to one- and two-surface restorations. There should be sufficient preparation taper. The general design should be even. The preparation walls should be smooth. A proper insulation medium should be used. Fig-1.34 General indications for semidirect techniques. Fig-1.35 A Preoperative Radio-graph showing carious lesions. Fig-1.35B Decayed Tooth. Fig-1.35 C Restoration done. Fig-1.36 A large carried tooth. Fig-1.36B Restoration completed. Fig-1.36 C After 1 year Postoperative Radiograph. Fig-1.37 The absence of distop roximal contact is evident after completion of the composite restoration on the second premolar. This demonstrates a common problem encountered with direct fill ing methods, especially when plastic matrices are used. Fig-1.38A Severely decayed tooth. Fig-1.38B Prepared cavity. Fig-1.38C Coffered and insulated. Fig-1.38D Built-up restoration Fig-1.38E completed anatomical shape. postcuring. Fig-1.38F Inlay is taken out for Fig-1.38 G Cemented Inlay. Fig-1.38 H Completed Inlay Fig-1.39 General design of preparations for intraoral

semidirect techniques. Fig-1.40A Decayed molar tooth. Fig-1.40B Cavity is insulated. Fig-1.40 C Filled with composite. Extraoral Composite Inlays / Onlays Fig-1.40 C Eliminated filling. The interesting feature of this approach (Fig-1.41) is the extemporaneous fabric ation of the inlay / onlay over a model, extraorally. The use of a simple algina te or, ideally, of a condensation silicone for making the impression is highly r ecommended (Fig-1.42). Compared to semidirect intraoral restorations, those made extraorally exhibit generally enhanced esthetic potential and anatomy, thanks t o application of better performing and sophisticated layering (Fig-1.43). CAD / CAM (computer Aid Design / Computer Aid Manufacturer) restoration require very s pecific procedures. Before cementation, the semidirect composite restorations ar e preferably subjected to a photothermic treatment (postcuring process) in a spe cial oven (Fig1.44). This procedure allows the optimal resin conversion rate to be reached in a few minutes, ensuring dimensional stability (Fig-1.45). For both intra- and extraoral techniques, occlusion is preferably checked before postcur ing and adhesive cementation (Fig-1.46). Actually, if necessary, occlusal anatom y and proximal contacts may be adjusted and reshaped extraorally. For economic r easons, indications for extraoral composite restorations may sometimes extend to more complex cases, provided the practitioners skill and experience make it sens ible (Fig-1.47). Fig-1.41 Special attention should be paid to preparation finishing. Microretenti ons created by coarse diamond burs (A) may be sufficient to impede the removal o f intraorally made inlays, despite the use of a separating medium (B). Fig-1.42A Prepared Cavity. Preoperative View. Fig-1.42B shade is placed. Fig-1.42C Model is separated. Fig-1.42D Dentin Fig-1.42E Enamel, incisal layers are subsequently deposited. Fig-1.42G Precement ation inlays. Fig-1.42 F Completed restoration on the working models. Fig-1.42H Cementing.

Fig-1.42I Postoperative anatomy view. Fig-43A Special silicon die on working model. Fig-1.43B Restoration shapes is completed. Fig-1.43C Finalizes the restoration. Fig-1.45 Photothermal treatment Fig-1.47 Tr y-in of inlay to control accuracy. model. Fig-1.48B Decayed teeth. Fig-1.44 Composite inlays. Fig-1.46 Postcuring process Fig-1.48A Preoperative radiograph. Fig-1.48C Working view. Fig-1.48D Finished restoration. Fig-1.48E after 2 years Indirect Techniques Serial class II cavities or full coronal coverages cannot be properly restored u sing the techniques already reviewed, composite and ceramic indirect methods are best indicated for such cases (Fig-1.49). The choice between ceramic and compos ite as restorative materials has become increasingly complicated since composite materials have improved in their physicomechanical properties, wear resistance, and esthetic potential (Fig-1.50). For serial class II restorations without cus p coverage, indirect composite inlays seen preferable (Fig-1.51). There are seve ral comparison parameters of clinical importance in evaluating both materials (T able-1). Table-1 Comparison parameters of ceramics and composites. Evaluation parameters Ceramics Composites Convenience of clinical procedures Practicability of laborat ory procedures Repair potentiality and feasibility of In-mouth corrections Esthe tics: short term long term Polishability + + +++ +++

+/-++ +++ ++ +++ ++ ++ Wear resistance of the restorative material of nists Elasticity module, brittleness Coefficient of thermal expansion of bonding procedures Chemical stability Biocompatibity +++ ++/+ +++ + ++ +++ ++ + ++ + ++ Clinical follow-up Cost + + + (+ + + ) = ideal; atisfactory; ( + ) = acceptable; ( - ) = unsatisfactory.

the antago Efficiency + + +++ ++ (+ + ) = s

Fig-1.49 General indications for indirect techniques. These techniques are advoc ated for the treatment of serial inlays, onlays, and single or multiple overlays . A B Fig-1.50 The esthetics potential of modern composite resin is incontestable. As shown on this working model, composite inlays now exhibit an appearance simi lar to those made of ceramic (A). View after two years restoration of clinical s ervice was demonstrate the satisfactory behaviour of composite for indirect tech nique (B). AB CD of Fig-1.51 Preoperative views of a full mouth to be restored b ecause failed amalgam fillings and new interprocemal carious lesions (A-

B). The completed composite inlays (C-D), but lower premolars were restored usin g a direct method. The use of ceramic can also be advised (Fig-1.52).bonded cera mic restoration exhibit more fractures (Fig-1.53) than composite restorations. T he ceramic inlay is less apt to absorb functional strains and supposedly transmi ts more mechanical stresses to the adhesive interface than do the softer composi te restorations (Fig-1.54). For large serial class II restorations including cus p coverage, the use of ceramic indirect inlays/onlays is favoured (Fig-1.55). in the particular case of total occlusal coverage in vital teeth with a short clin ical crown, indirect ceramic restorations are also indicated (Fig-1.56). When en ough supporting enamel remains, the bonded-to-tooth overlay is the last conserva tive approach before the conventional prosthetic solution (Fig-1.57). A C Fig-1. 52 Ceramics are still considered appropriate for fabricating serial inlays, as i ndicated here for the replacement of failed amalgam filling (A). However, the so fter and smoother materials, such as a low-fusing ceramics, were preferred in th is particular configuration (B). Completed LFC inlays in mouth (C). B Fig-1.53 Typical example of a fractured inlay made with conventional fired ceram ic. This frequent event drove researchers to develop stronger materials and cons ider more seriously the use of composite resin. Fig-1.54 A theroretical concept that suspects the high rigidity of ceramics of h aving a negative influence on the marginal adaptation of intracoronal restoratio ns. Actually, they seem less likely than composites to absorb functional stresse s that are transmitted to the adhesive interfacesly than composites to absorb fu nctional stresses that are transmitted to the adhesive interfaces. A B D C E Fig-1.55 For very large restorations, such as serial onlays and overlays, the me chanical resistance of the restorative material is a primary consideration. To r ebuild the posterior teeth (A), a high-strength material (In-Ceram; Vita) was us ed for fabricate crowns and bonded-to-tooth overlays (B-C), Postoperative view o f the restored posterior teeth (D-E).

A C B D Fig-1.56 The restoration of a single tooth with a bonded ceramic overlay is a co nservative option for extended decay (A) that would normally require a prostheti c solution. Tooth preparation shown that enough enamel is present on margins to provide ideal conditions for a fully bonded restoration (B). The ceramic overlay is presented on the working model (C). Final clinical view (D). Fig-1.57 Compar ison of a traditional and an adhesive prosthetic restoration. The advantage of t he adhesive option regarding tissue conservation is evident. Base lining for indirect restoration: to prevent restoration fractures, some wea k materials, such as calcium hydroxide cement, zinc-phosphate cements, and possi bly even traditional type III glass ionomers, are contraindicated as a base or l ining (Fig-1.58). The first choice materials for use as a base under indirect re storations are the compomers or restorative composites (Fig-1.59). Fig-1.58 Deformation of the restoration over insufficiently resistant bases shou ld not be discounted as a possible cause of ceramic fracture. Considering the de ntin as a reference for elastic behaviour and resistance to compression, only co mpomers and composite restorative materials should be used. E = elasticity modul e. A C B D Fig-1.59 In this clinical example, after removal of the old amalgam filling and decayed tissue, the cavity does not provide the necessary confuration for a lute d restoration (A-B). A mechanically resistant base of compomer (C) was placed to make an indirect ceramic restoration possible (D). Provisionalization: Provisionalization is necessary first to protect the pulpode ntinal complex from any bacterial, mechanical, and thermal aggression. Subsequen tly, it will stabilize relations with proximal and antagonist teeth, as well as maintain an acceptable function (Fig-1.60). the use of soft light-curing resins such as Fermit (Vivadent) is particularly simple and appears to be clinically an acceptable provisionalization technique for a short duration, although no cemen t is used ( Fig-1.61 to Fig-1.62). Because there is a high probability of margin al leakage with these materials, their in-mouth stay should be restricted to a f ew days, preferably in lined cavities. For other cases, the classic method, whic h makes use of a self-curing acrylic material for fabricating cemented temporari es

has to be applied (Fig-1.63). Therefore, the eugenol-free temporary cements do n ot provide a definitive advantage regarding contamination of cavity surfaces. Th e bacteriostatic property of eugenol stays beneficial, provided a total-etch wil l later be applied (Fig-1.64). Fig-1.60 Interim restorations are mandatory for b iologic and mechanical protection of the pulpodentinal complex. They also assume a functional role, especially for restorations that include cusp coverage. Fig-1.61 Soft light-cured material interim restorations, without cementation, is particularly convenient for short-term provisionalization. Fig-1.62 can also be they patients, Light-cured temporaries for used for serial cavities, are considered comfortable by and they are easily removed. Fig-1.63A Cavity with acrylic resin. disks. Fig-1.63C Ready inlay Fig-1.64A ZnO eugenol temporary cement. Fig-1.63B Shaped with bur or Fig-1.63D Completed restoration. Fig-1.64B View postoperative. Fabrication methods: For Composite Resins: Modern composite lab kits generally i nclude the same materials as those designed for chairside use mainly light-cured small particle hybrids (Fig-1.65). For Ceramics: Dental ceramics for use in adh esive dentistry can be processed in several ways; firing pressing casting machin ing There are some parameters to consider when selecting a ceramic system. In re lation to objectives of each case, one has to choose from the following ceramic systems (Fig-1.66 to 1.70). A B C D E Fig-1.65 Specific procedures for the fabrication of an indirect composite rest oration. The first step consists of placing a dye spacer on the bottom of the pr eparation (A). Colour dentin masse is used as the first layer (B). Subsequent in crements of enamel(C) and translucent incisal (D) masses are added. Completed re storation on working model (E).

A C B D E Fig-1.66 Specific procedures for the fabrication of a low-fusing ceramic resto ration (LFC). The initial step involves preparing a base of conventional porcela in over a refractory dye (A). The fired base is viewed on its refractory dye (B) and after transfer to the working model (C). Then build-up the low-fusing ceram ic directly on the working model, without having to integrate the refractory dye inside the working model (D). Final view of the restoration made of two constit uents; the base of conventional porcelain covered by the LFC material (E). A C D B E F Fig-1.67 Specific procedures for the fabrication of a restoration with the s lipcasting technique. The first step involves the application of the spinell. su spension over a special refractory material (A) after the first firing; the base is removed from the dye and reshaped (B). The second firing consists of impregn ating the base with colored glass (C) the bases inner and outer surfaces are view ed after the removal of glass excesses (D-E). The base is then transferred to th e working model for veneering with conventional reinforced porcelain. View of th e completed restorations showing the in-ceram crown and in / onlay materials, us ed to restore the premolars and molars (F). A C D B E Fig-1.68 Specific procedures for the fabrication of conventionally fired ceram ic inlays. View of the master model with dye spacers (A). The hard stone dyes ha ve to be replicated and transferred onto the working model so that the ceramic i s builtup with the required anatomic and functional references (B). The two porc elain inlays are shown at the completion of stratification and modelling (C). Du ring a last firing, their surfaces are characterized and glazed (D). The restora tions are ultimately transferred to the master model for final adjustments (E). A B C D Fig-1.69 Specific procedures for the fabrication of a restoration using the cast ceramic technique. The first step consists of modelling the future rest oration with wax and preparing it for casting (A). View of the casted restoratio n; in the glass state, they appear totally transparent (B). The restorations are then subjected to a thermal ceramization process. This demonstration onlay is v iewed after it has been adjusted and reseated on its original dye (C). Completed restoration after the last firing of superficial stains (D). A C D B

E F Fig-1.70 Specific procedures for the fabrication of a restoration with the press ed ceramic technique. The initial steps are very similar those of the dicor cast glass technique; the restorations are first modeled in wax (A) and mounted on a spruce before investment and pressing (B) pressed inlay as they appear after inv estment removal (C). The restorations must then be prepared and adjusted to fit the original master model (D). They appear translucent but monochromatic; they r equire esthetic characterization, carried out during the last firing of intensiv e ceramic surface stains (E) completed restorations (F). Machined restoration: The most widespread system is the CELAY pantograph. Recent ly, a fully-automated pantograph was also developed. These devices are used to r eplicate a resin master restoration in ceramic through the simultaneous action o f the sensor (manually or automatically controlled) on all prototype surfaces an d of diamond burs and discs in the ceramic block. Initially advocated for chairs ide application, the Celay milling machine now seems to be more popular for lab use. Although the idea of applying pan-tography to dentistry was attractive, the clear advantage of semidirect composite restorations regarding practicability a nd efficiency considerably limits the future of this technique. CAD/CAM is also applicable to lab work, but their use still very limited. New technologies for t ooth colour restoration 1. CAD/CAM System The growing application of computer-aided design (CAD) and com puter-aided manufacture (CAM) in the automobile and aerospace industries since t he 1970s is a good example of a profitable synergy between the evolution of new technologies and production needs. The main goal was certainly not to question t he ability of dental technicians to produce accurate, functional, and natural-lo oking indirect restorations. A logical objective of pioneers in CAD/CAM systems was to simplify, make more profitable, and standardize the production of dental restorations. 2. Objectives and Potentials of CAD/CAM System to eliminate tradit ional impression methods to design, for example, with the aid of a computer, the future restoration in accordance with the preparation, the function, and the na tural anatomy to produce the restoration chair side to machine the restoration ( ie,by rotating device, sono- or electro-erosion, laser, etc.) to improve restora tion qualities: mechanical resistance, marginal fit, surface quality, and esthet ics. (1) Full integrated CAD/CAM devices (CEREC and CEREC11, Siemens), for a cha irside restorative approach, and (2) systems that consist of several modules wit h, at least, distinctive CAD and CAM stations. These two basic modules may theor etically operate through different schemes: CAD and CAM stations are located in the dental office and operate successively, following impression taking, for a c hairside elaboration of the restoration. The impression (optical or other)is tak en in the dental office, where the CAD operation is carried out. Date are transm itted to a central CAM station for restoration manufacturing.

 The impression (optical or other) is taken in the dental office; collected infor mation is then transmitted to a central station, where CAD and CAM modules opera te. 3. CEREC and CEREC 2 The basic philosophy of the CEREC unit was to associate an optical impression method with a computer-driven fabrication module in a sin gle mobile workstation. The system development included computer-aided 3-D imagi ng designing and numerically controlled machining of the restoration. In vitro t ests demonstrated that durable and satisfactory margin adaptation was achieved w ith the first CEREC computer-machined ceramic inlays (Mormann et al, 1984). CERE C computer restorations have also been tested in vivo for 5 to 9 years and, thus , have demonstrated their clinical validity (Schmalz et al, 1994; Walther et al, 1994). CEREC restoration includes several distinct and original steps; Optical impression Powdering of the preparation Computer-aided design of the restoration Computer-driven milling of the restoration In-mouth development and refinement of occlusal anatomy. A. The optical impression Only preparations that meet certa in design criteria can be measured; inlay and onlay preparations meet this deman d because all parts of interest are clearly visible by the scan head when orient ed along the future line of insertion (Fig1.70). Fig-1.70 The CEREC system uses a miniaturized camera to take optical impressions of the preparations. The camer a is viewed in action. B. Powdering The differences in reflection and absorption of the incident light between cusps and steep walls due to the cavity geometry and dissimilar optical properties of dental tissues requires the entire field of view to be coated with a thin opaqu e layer. The projection of titanium dioxide over the prepared tooth produces a u niform scattering of light, which is appropriate for the optical impression (Fig 1.71). Fig-1.71 The cavity preparation, covered with special opaque powder, is r eady for impression taking. C. Data acquisition and imaging Before we can measure our object in 3-D, we have to make sure that the scan head is properly positioned to its target. Currently a search mode precedes the impr ession. During the search mode, the scan head functions like a conventional vide o camera, producing a live image on the monitor. The search mode is initiated by activating the foot switch; release triggers the 3-D capture (Fig-1.72). some p oint or lines have to be identified and drawn by the operator as a starting poin t for the computer 3-D synthesis of the restoration (Fig-1.73). Fig-1.72 Trigger ed image of the Fig-1.73 Visualization of the

cavity outline Preparation, as viewed on the and the machCEREC 1 monitor screen. screen, bottom surface profile lines can be seen. D. Milling of the Restoration as identified by the operator ine. On the left part of the and occlusal For computer inlays, overlays, and veneers, industrially preformed ceramic block s are being used (Vita CEREC blocks; Vitazahnfabrik; Dicor-CEREC blocks; DENTSPL Y international) (Fig-1.74) which is almost frees from pores and do not require high glazing (Bieniek and Marx, 1994). The CEREC 1 used a single diamond-coated disk for the ceramic machining. It appeared that the majority of the restoration s could be accommodated with this simple device. The milling head was initially driven by a pressurized water jet, which simultaneously cooled and cleaned the c utting disk (Fig-1.75). An electrically driven device later replaced this first version of the CEREC 1 milling system. Milling of the restoration in the ceramic blank results from three basic movements of the computer-driven machining modul e (Fig-1.76). In CERCE 2, the CAM module was implemented with a second form-mill ing tool, which provides six milling axes instead of three. Fig-1.74 Milling mod ule. Fig-1.75 CEREC milling unit. Fig-1.76 Three axis milling. E. Finishing and polishing of CEREC Restorations When they are applied to the specific CEREC industrial ceramics, such in-mouth f inishing procedures generate a restoration surface quality compatible with occlu sion toward antagonist natural teeth (Fig-1.77). Fig-1.77 Completed CEREC restor ation. F. Indications for CEREC Restorations The CEREC restoration lies perfectly within the indication area of the semidirec t techniques. This includes a direct restorative approach and do not justify lab oratory procedures. This corresponds in particular to large but isolated lesions (Fig-1.78). The development of occlusion in the very dense machinable ceramics proved to be too time-consuming for obtaining acceptable anatomy (Fig1.79 to Fig -1.80). Regarding the colour, it can only be said that CEREC restorations are to oth colored (Fig-1.81 to Fig-1.83). Actually, the precision and balance of the r esulting occlusal function is far less predictable than that obtained with conve ntional laboratory procedures (Fig-1.84). Fig-1.78 Preparation is too extensive for a direct restorative technique. The even design of the cavity is suitable fo r a semidirect CAD/CAM application.

Fig-1.79 Immediate try-in of the the Restoration, produced by the and CEREC 1mac hine. refinement. Fig-1.81 For this case, an attempt was made to improve the est hetic outcome by fifing effort, and ceramic stains in the restoration Occlusal f issures. Fig-1.83 The same restoration, manaAfter some weeks of function. indire ct s are highly recommended. Fig-1.80 Representative aspect of restoration after recontouring occlusal Fig-1. 82 Cemented restoration in the mouth, producing CEREC restorations of high quali ty require extensive training, extended chairside time. Fig-1.84 Serial restorations can be ged with the CEREC system but restoration 4. Other CAD/CAM Dental Methods There are now several systems that can be used t o produce CAD/CAM restorations. These devices are aimed at fabricating full crow ns, copings, or bridge framework out several materials, such as composite resins , ceramics, or metals. In general, however, these systems were not developed for the particular configuration of intracoronal or partial restorations. Different concepts were applied to the 3-D recording of the preparation than to the gener ation of the final piece. The complexity of the overall device may vary greatly depending on the system considered. Currently, apart from the CEREC and Duret sy stems, other available CAD/cam systems involve a 3-D preparation recording on a stone cast, although originally, it was expected to alleviate the needs of conve ntional impression procedures. Several different methods were employed to record spatial coordinates of the prepared teeth; Laser holography (Duret, 1988) Laser scanners (Uchiyama, 1991; Miasaki et al, 1995) (Microdenta system; CAP system; Nissan CAD/CAM system) Stereo photographs (Rekow, 1988) Mechanical digitizer (St rupowsky, 1994; Hegenbarth, 1995) (Precident DCS system; Procera system) The com mon characteristic of all these systems is the computer processing of acquired d ata for 3-D object reconstruction. The way external contours and anatomy are ela borated may differ, depending on the structure to be manufactured. For complete restorations, functional anatomy may be developed by using a library of preregis tered natural tooth forms, to be integrated within neighbouring structures and a dapted to recorded interocclusal relations. 5. Future of CAD/CAM in Dentistry

It is obvious that only a part of the initial objectives, such as those describe d at the beginning of this chapter, can be fulfilled by used of the aforementati oned technologies. Currently, the CEREC is the only system that gives the dentis t an integrated production means of manufacturing porcelain restorations without the need for a dental laboratory. However, as already mentioned, the indication s of the technique remain limited by its concept and the procedures involved. To achieve natural esthetics and anatomy with CEREC restorations is still challeng ing and lacks reliability. A certain number of obstacles to the further developm ent of these technologies, relating to practical, economical, and philosophic co nsiderations, may be foreseen; CAD/CAM application in industry, dentistry requir es the fabrication of unique pieces. An ideal system should integrate some impor tant steps and functions (such as impression taking, intrinsic color elaboration , surface taking, intrinsic color elaboration, surface finishing, and polishing) . CAD/CAM and some other high-technology systems to face restrictions in their u se and to play only a minor role in dentistry, for at least the next decade. 6. Other Technology Celay The Celay is a well-known hand-operated system. First, a pro-inlay is produced in the patients mouth or on a model. The pro-inlay, made of wax or composite resin, is fixed on the scanning side of the machine. Ceramic i nlays, onlays, coping, and even three-unit bridge substructures can be fabricate d. CERAMATIC The CERAMATIC is an integrated automatic copy-milling unit for allceramic and aluminium oxide materials. The system concept is similar to the Cela y, and it uses CEREC Vita blocks (MKll ceramic). Sono-erosion The sono-erosion i s high-resistance ceramics machine. Sonicsys micro This preparation technique is not limited to extremely small direct restoration. Every proximal preparation, for both direct and indirect restorations, metal or metal-free, can be finished effectively with SONICSYS instruments (Fig-1.85 to Fig-1.89). Fig-1.85 Microprep set. Fig-1.86 Preparation with Lens from SONICSYS the small instrument. Fig-1.87 Restoration after completion of Finishing. Fig-1.88 Preparation cavity. instruments (size 3 is shown). Sonicsys approx Fig-1.89 Mesial & distal proximal Preparation

A special set of six instruments, three sizes for mesial and distal are offered for finishing the margins and standardizing small to medium size class II caviti es (Fig-1.89 and Fig-1.90). Proximal inlays respond to these instruments (Fig-1. 91). This system is directly place the inlay into the tooth, no try-in required, both proximal surfaces in an MOD cavity could be restored in a single step. Fig -1.90 SEM view prep: with SONICSYS approx instruments. Fig-1.91 Computer-aided d esign SONICSYS proximal inlay. of a Luting procedures While traditional gold inlays and onlays are retained principa lly by means of micromechanical retention and friction provided by the cement, s emidirect and indirect esthetic restorations are maintained by micromechanical o r chemical adhesion between the adhesive cement, dental tissues, and restorative material. This makes the luting procedures a clinical step of the whole treatme nt. 1. Cleaning of cavity surface If interim restorations were placed, the compl ete removal of temporary cement is the first step. This is performed with hand i nstruments and pumice brushed over the cavity surfaces, or with an air-powder ab rasive device, which proved the most effective final cleansing methods. 2. Resto ration try-in Thickness of the cementing space: it is recognized that thin resin cement layers, the polymerization shrinkage is mainly directed uniaxially. The marginal fit of semidirect and indirect restoration (composite or ceramic) shoul d lie within 100 microns; internal gaps may be greater up to 300 microns because of the use of dye spacers and adjusting procedures, therefore should provide be tter adaptation, and seal (Fig-1.192). Fig-1.192 The particular configuration of thin cementing spaces where the ratio high. Compensatory movements: it is probable that perfectly fitting units will l ock inside the cavity during insertion and impede any compensatory movements, su ch as restoration descent and flexion of remaining wall (Fig-1.193). Fig-1.193 T he typical compensatory movements that can occur during more spaces. the cementa tion of adhesive restorations, such phenomena are likely to take place with larg e cementing of bonded surface (BS) to free or unbonded surface (FS) is extremely Adhesion potential: Because of insufficient adhesion potential for light cure GI C, only compomers and composite resin should be considered for luting procedure. Wear of the luting cement: Luting composite undergoes more wear than the

restorative composites and that gap (Fig-1.194). Therefore, it least occlusally. Fig-1.194 The ar attained; occlusal surfaces.

occlusal wear is proportional to the interfacial seems important to reduce the cementing gap, at wear pattern of composite luting cements with we The cement rapidly undergoes vertical

unit approximately half of the cementing space width is from this point, materia ls loss should be reduced to a minimum. Practical and clinical considerations: It appears that precise restorations are preferable because they will reduce polymerization stresses within the internal gap, limit wear of the cement, and facilitate the removal of cement excesses, pr oviding restoration margins (Fig-1.195). A B C cementation. service. Fig-1.195 ( A) Try-in of composite inlay. (B) Just after (C) After two years view of clinica l 3. Material selection The flow and removal of cement from the cementing gap is p roblematic in proximal areas. In this respect, high-viscosity materials permit t he cement excesses to be cut rather than wiped off, which generally spreads the luting composite and contaminates larger surfaces. Sufficient working time is cr itical to placing the restoration in its correct position and eliminating cement overflow before chemical curing Fig-1.196). Fig-1.196 A Immediate post-luting r adiograph ceramic inlay. 4. Surface treatments The luting of semidirect or indir ect restorations implies a double bond; one between the luting composite and the tooth, the other between the luting composite and the ceramic or composite rest oration. Tooth substrate Bonding to ceramics Bonding to composite 5. Clinical ap plication The cement is preferably placed or injected inside the cavity to facil itate manipulation of the restoration (Fig-1.197). Insertion of the restoration has to follow immediately, as polymerization activation will speed up at mouth t emperature. Clinically, the technique of two-phase insertion (partial insertionr emoval of main cement excesses-composite insertion) is tricky and, of course, co ntraindicated when using fast-curing dual cement. radiograph of ceramic inlay. F ig-1.196B Post operative of

AB C D E G I J F H K Fig-1.197 (A) Lab made Composite restoration was inserted, (B) Checked adaptat ion, (C) The cavity is etched, (D) Adhesive is applied, (E) The luting cement is placed or injected into the cavity, (F) proximal excesses are removed with a pr obe, (G) Flossing interdental areas, (H) Excesses cement wipe off with a probe, (I) Finally, levelled with a brush, (J) Glycerine gel is applied, (K) Before lig ht cure. 6. Polymerization of luting composite The composite polymerization of l uting composite by means of single light activation can be obtained only under a thin layer of translucent and clear restorative materials (less than 1.5 to 2.0 mm, depending on its translucency and shade). The use of dual-cure materials is more validated for luting of adhesive restoration. Therefore, powerful light-cu ring is mandated. It is also strongly recommended that each restoration surface be exposed to the curing light for at least one minute. Finishing and polishing procedure The function, adaptation, anatomy, and esthetics of the restorations a re determined during the restorative procedures. The objectives of finishing and polishing are 1. Level the occlusal and proximal margins so that the restoratio n is in perfect continuity with the dental tissues. 2. Smooth the irregular surf aces or preserve those already finished. 3. Correct any existing marginal defect s. These objectives have the restoration quality, which preserved or improved du ring the last restorative steps (Fig-1.198). A B C Fig-1.198 (A) Preoperative view, (B) Completed direct composite restoration, ( C ) Postoperative view. 1. Polymerization of the composite top layer

The hardening of the resin surface is known to be affected by the presence of ox ygen, during the final light curing to obtain complete resin polymerization. Thi s procedure seems beneficial to both direct and luted restoration (Fig-1.199). F ig-1.199 The final light curing is done with the restoration isolated from oxyge n by a glycerine gel to achieve a hardening of the composite top layer. 2. Resto ration reshaping and recontouring The accessibility and relief of the margins ha ve to be taken into consideration as they will determine which kind of instrumen tation is best indicated (Fig-1.200). The use of an EVA-type reciprocating handp iece with diamond tips (Fig-1.201) is considered only for removing bulk overhang s, which should only occur in exceptional cases. A C D B surface perfect and F Fig-1.200 Accessible margins with flexible disks (A & B), Gingival margins are finished and polished with strips ( C ), For occlusal, irregular, surface margi ns used superfine diamond burs (D & E), Completed restoration. Fig-1.201 EVA-typ e handpiece with fine diamond-coated tip for removal of gross restorative materi al excess. 3. Polishing To obtain a perfectly smooth composite surface may often be difficu lt and results only in an ephemeral gloss, which disappears rapidly after wear a nd degradation of the surface takes place. Composite Materials: Flexible discs a ppear to be reliable polishing instruments for most of the materials. They shoul d be considered as the basic system for flat and accessible surface. For irregul ar surfaces and margins, fine diamond burs, multifluted carbide burs, silicone p oints, and polishing pastes can be utilized. However, no general consensus regar ding the optimal polishing instrumentation for these areas (Fig-1.202). a final polishing with pastes and brushes seems profitable only for particular areas suc h as occlusal grooves or during extraoral and laboratory procedures. Gingival ma rgins are still finished in a traditional manner with aluminous or glass metal s trips. Fig-1.202 A variety of finishing and polishing rotary instruments. Ceramics: Pore-free ceramics, such as low-fusing ceramics or mechinable ceramics , can be quite easily polished to a clinically satisfactory gloss with flexible discs, fine diamond burs, silicone points containing aluminium oxide or silicon carbide, and

special diamond or aluminium oxide polishing pastes (Fig-1.203) for other kinds of ceramics, finishing procedures should be reduced to occlusal adjustments beca use these materials are more difficult to repolish in the mouth. Fig-1.203 Special rubber points and soft wheels containing fine abrasive particl es proved to be efficient in the finishing and polishing of ceramics. 4. Sealing the restoration margins and surface The rebonding of the restoration margins with low-viscosity resin was therefore recommended as a serviceable fini shing procedure (Fig-1.204). The longterm clinical significance of this operatio n is, unknown. The sealing of composite surface with a low-viscosity resin may a lso reduce restoration wear by penetrating porosities and microcracks. A B Fig-1 .204 Preoperative View (A), Apply the liquid resin to penetrate all surface micr odefects. 2. Instrumentation and Operators position. Hand instruments Black also organized the naming and numbering of hand instrument such as cutting instrument s and non-cutting instruments. Cutting instruments, which he called excavators, were to be used in shaping the tooth preparation. Metals: For many years, carbon steel was the primary material used in hand instruments for operative dentistry because carbon steels were harder and maintained sharpness better than stainles s steels. Stainless steels are now the preferred materials for hand instruments, because all instruments must be sterilized with steam or dry heat between patie nts and because the properties of stainless steels have improved. Cutting Instrum ents: Before rotating instruments were available, dentists could cut well-shaped cavity preparations using sharp hand instruments alone. The advent of the dental handpiece in 1871, first attached to a foot-operated engine, allowed increased speed of tooth preparation. Most tooth preparation today with rotary instruments but hand cutting instruments are still important for finishing many tooth prepa ration. Design: Hand cutting instruments are composed of three parts: handle (or shaft), shank, and blade (Fig-2.1). The primary cutting edge of a cutting instr ument is at the end of the blade (called the working end), but the sides of the blade are usually bevelled and also may be used for cutting tooth structure (Fig -2.2). Blade of instrument is normally short and use with minimal force (Fig-2.3 ). A variety of handles configurations are available (Fig-2.4). Fig-2.1 Componen ts of hand instrument. Fig-2.2 The design of blade bevels. Fig-2.3 The design of shank.

Fig-2.4 Various type of handles. Nomenclature: The terminology organized by black in the early part of the last c entury is still used today with minor modifications. Most names Black assigned t o cutting instruments were based on the appearance of the instrument, such as ha tchet, hoe, spoon, and chisel. Instruments classified by the number of angles in the shank (Fig-2.5). Fig-2.5 Instruments classified by the number of angle in the shank, a. straight, b. monangle, c. binangle, d. triple angle, e. quadrangle. Hatchet: In a hatchet (also called an enamel hatched), the blade and cutting edg e are on a plane with the long axis of the handle; the shank has one or more ang les (Fig-2.6 and Fig-2.7).The face of the blade of the hatchet will be directed either to the left or the right in relation to the handle, and the instrument is usually supplied in a double-ended form. There are left-cutting and right-cutti ng ends of double-ended hatchet. Fig-2.6A( a)Binangle hatchet, (b)binangle spoon . A double end hatchet or spoon would have a left-cutting end and a right cuttin g end. Fig-2.6B End view of binangle hatchets paired, a right-cutting, b left-cu tting. A double-end binangle hatchet has left cutting and right-cutting end. Fig-2.7 Monangle hatchets (left cutting). Chisel: A chisel has a blade that is e ither aligned with the handle, slightly angled (Fig-2.8A), or curved (Fig-2.8C) from the long axis of the handle, with the working and at a right angle to the h andle. Fig-2.8A Straight chisel. Fig-2.8 B Chisels;(a) binangle, (b) monangle, ( c) wedelstaedt, (d) straight. The blade for a, c, and d are slightly rotated to visualize the face, as well as the side bevel. Hoe. A hoe has a cutting edge tha t is as a right angle to the handle, like that

of a chisel. However, its blade has greater angle from the long axis of the hand le than does that of the chisel; its shank also has one or more angle (fig-2.9). Fig-2.9 Design of Hoe,(a) monangle,(b) binangle. The blade of A hoe has an angl e from long axis of the handle of greater than 12.5 centigrades. Spoon: the blad e of a spoon is curved, and the cutting edge at the end of the blade is in the f orm of a semicircle (Fig-2.10). The shank of some spoons holds a small circular, or disk-shaped, blade at its end and the cutting edge extends around the disk e xcept for its junction with the shank, these are called discoid spoons (Fig-2.10 ). Fig-2.10 Spoon or excavators Gingival margin trimmer: A gingival margin trimmer is similar to an enamel hatchet, except that the blade is curved and bevel for t he cutting edge at the end of the blade is on the outside of the curve and its f ace is inside of the curve (Fig-2.11). Double-bevelled or bi-bevelled cutting ed ges are also available (Fig2.12). Fig-2.11 Gingival marginal trimmer. Fig-2.12 C utting edge bi-bevelled Numeric formulas: Black developed a system of assigning numeric formulas to inst ruments (Fig-2.13, 14). For designating the degrees of angulation, centigrades a re used (Fig-2.15).There are available Three-number formula (Fig-2.13, 2.14) and Four-number formula (Fig-2.16) Fig-2.13 Three number Formula of blade Four numb er formula Fig-2.15 Centigrade centigrades scale, divide into 100. Fig-2.16 Indi cation to 16 Fig-2.14 Fig-2.16B Centigrade scales inset to show angulation indicator of 7.0 centigrade s for the blade angle and 95.0 centigrades for cutting edge angle of this gingiv al margin trimmer (four number formula). Noncutting Instruments: Non-cutting instr uments are similar in appearance to cutting instruments; except that the blade u sed for tooth preparation is replaced with a part has a totally different use. A malgam carrier: Amalgam is placed into the preparation with an amalgam carrier, which has a hollow cylinder that is filled amalgam (Fig-2.17). Fig-2.17 Amalgam Carriers. Condensers: Condensers are used to compress amalgam or to push resin c omposite or glass-ionomer materials into all area of the preparation (Fig-2.18).

Fig-2.18 Various types of Condensers. Carvers: Cavers are used to shape amalgam, resin composite, and other tooth colored materials after they have been placed in tooth preparation (Fig-2.19, Fig2.20, Fig-2.21). Fig-2.19 Cleoid-discoid carv er: a cleoid end, b discoid end. Fig-2.20 Cleoid (top) and discoid (bottom) ends of the cleoid-discoid carver. Fig-2.21 Various types of carvers. Burnishers: Burnishers are used for several f unctions, to make shiny or lustrous, especially by rubbing to polish and to rub (a material) with a tool for compacting or smoothing or for turning an edge (Fig -2.22). Fig-2.22 Various types of Burnishers. Plastic instruments: Plastic instr uments (or plastic filling instruments) were used to carry and shape tooth color ed restoration. It is useful for placing the cement materials and composite mate rial into the prepared cavity (Fig-2.23). Fig-2.23 Plastic instruments, made of stainless steel, is useful for placing a rubber dam, placing and shaping resin c omposite and other tooth-colored restorative materials, and packing gingival ret raction cord into the sulcus around a crown or abutment preparation before an im pression is made. Cement spatulas: A variety of materials in operative dentistry requires mixing, some on a glass slab, and others on a paper pad. Several spatu las are available with various size and thickness (Fig-2.24). Fig-2.24 Various sizes and shapes of cement spatulas. Mirrors: For every procedu re performed in the mouth, needed mouth mirror for clear version and to retract the soft tissue (tongue, cheeks, or lip) (fig-2.25). Fig-2.25 Various types of m outh mirrors.

Explorers: Explorers are pointed instruments, which are used to feel tooth surfa ces for irregularities and to determine the hardness of exposed dentin (Fig2.26) . Fig-2.26 Various sizes and shapes of dental explorers. Periodontal probes: Per iodontal probes are designed to detect and measure the depth of periodontal pock ets. In operative dentistry, they are also used to determine dimensions of instr uments and various features of preparations or restorations (Fig-2.27) Fig-2.27 Various types of periodontal probes. Forceps: Forceps of various kinds are usefu l in operative dentistry. Cotton forceps are used for picking up small items, su ch as cotton pellets, and carrying them into the mouth (Fig-2.28). Other forceps useful in operative dentistry include haemostatic forceps (Fig-2.29) and articu lating paper forceps Fig-2.30). Fig-2.28 Cotton forceps; (a) College (no.17), (b ) Meriam (no-18) Fig-2.29 Hemostats: (a) Halstead mosquito straight 6-inches, (b ) mosquito curved 5-inches. Fig-2.30 Articulating paper forceps. Instrument Gras ps: Usually one-handed grasps are used, but occasionally two-handed instrumentat ion is needed to make refinement of a preparation more precise (fig2.31). Fig-2. 31 Two handed instrumentation. Pen grasp; the most frequently used instruments g rasps in operative dentistry (Fig-2.32,33,34). Fig-2.32 Pen-grasp. (downward) mo tion Fig-2.34 Pen-grasp is used more in posterior teeth. Palm or palm-grasp; in this grasp, the thumb serves as a brace (Fig-2.35). Side to side, rotating or th rusting movements of the instrument by the wrist and fingers are controlled by t humb, which is firmly in contact with the teeth (Fig-2.36). Instrument Motions 1 . chopping Fig-2.33 Pen-grasp used in chopping

2. 3. 4. 5. 6. pulling pushing rotating scraping thrusting Fig-2.35 Palm-thumb grasp. Fig-2.36 The palm-thumb grasp is used frequently when a hand cutting procedure. Rotary instruments Handpieces: In dentistry two basic types of handpieces are used, the straight ha ndpiece (Fig-2.37) and the contra-angle handpiece (Fig-2.38). In the straight ha ndpiece, the long axis of bur is the same as the long axis of the handpiece. The straight handpiece is used more frequently for laboratory work but is occasiona lly useful in clinically. There are two types of contra-angle handpiece, slow sp eed, and high-speed handpieces. Low-speed range is 500 to 15,000 rpm, some are a ble to slow to 200 rpm, and others are achieving to 35,000 rpm. High-speed handp ieces have a free-running speed range greater than 160,000 rpm, and some handpie ces attain free-running speeds up to 500,000 rpm. In the United States, most den tists are accustomed to air-turbine high-speed handpieces. The speed of these ha ndpieces during tooth preparation is 180,000 rpm and lower, depending on the app lication pressure and the power of the handpiece. For air-turbine handpiece, spe eds during tooth preparation are significantly less than their free-running spee ds. Fig-2.37 Straight handpiece Fig-2.38 Contra angle handpiece. Burs: Hand-rotated dental instruments have been used since early 1700s, the foot engine was used in 1871, and electric engine was used in 1872. High-speed was u sed in 1947. Burs have three major parts, the head, the neck, and the shank (fig -2.39, 2.40). The bur in Fig-2.41 has a negative rake angle. The basic shapes of tooth preparation burs used in operative dentistry are shown in Fig-2.42. The h ead of some trimming and finishing burs are shown in table 2-1.and table-2.2. Fi g-2.39 Round burs for both handpieces. Fig-2.40 Burs; head, neck, and shank Fig-2.41 Typical bur head. Fig-2.42A Basic Bur head shapes Fig-2.42B Recommended burs kit.

Thable-2.1 Shapes and diameters of regular carbide burs used for tooth preparati on (US designation). Table-2.2 Shapes and diameters of some of the available 12-bladed carbide finish ing bur used for smooth cut in tooth preparation and finishing restorations (US designations) . Air abrasion technology: In the 1940s, an instrument called the Airdent (SS Whit e) was introduced as a means of cavity preparation, and then it was reintroduced in 1980s. A large number of air-abrasion units are being used for opening fissu re, for some cavity preparation (Fig-2.43). A B Fig-2.43A Air-abrasion handpiece , B Cavity class I preparation. Magnifiers: the quality, and the serviceability and longevity of dental restoration is dependent on the ability of the operator to see what he or she is doing. Magnification devices are helpful in restorative procedure. Among the finest magnifiers are the telescopes (Fig-2.44,45). A C B Fig-2.44 Binocular telescopes (A,B,C). A C B Fig-2.45 Binocular lopes (A,B,C). Position of operator The position of dental team is shown in Fig-2.46). Criteria for proper positioni ng of the seated operator (Fig-2.47). 1. The operator is seated in an unstrained position with back straight, feet flat on the floor, and thighs angled so that the knees are slightly lower than hip level. 2. The operator should position elb ows close to sides, and shoulders should be relaxed. 3. The oral cavity should b e positioned at the operators elbow height. 4. The operators head should be positi oned facing forward with eyes focused downward. Fig-2.46 The operators position themselves correctly for procedure.

Fig-2.47 Proper positioning for a seated operator. 5. The table 2.3 and Fig-2.48 shown zones for a right-handed and a left-handed operator. 6. An instrument is r etrieved from the tray setup using the thumb, index, and middle finger of the le ft hand (Fig-2.49) 7. The used instrument is retrieved at the end of the handle, or opposite end of the working end, using the last two fingers of the left hand (Fig-2.50). 8. The new instrument is transferred in the transfer zone and posit ioned firmly into the operators grasps (Fig-2.51). Thable-2.3 Operating Zones Zones Description Static zone Operators zone Assistants zone Transfer zone Directly behind the patient. A dental unit and a mobile cabi net can be positioned here. To the side of the patient. The dentist is seated an d moves in this area. To the opposite side of the patient from the operator. Dir ectly over the patients chest. This is the area where the instruments and dental materials are exchanged. Special caution must be taken not to transfer anything over the patients face Fig-2.48( A )Operating position for a right handed dentist, left zones. Fig-2. 4 8(B) Right zones for left handed dentist. Fig-2. 49Retrieving an instrument from the tray setup. Fig-2.50 The used instrum ent is retrieved from the operator. Fig-2.51 The new instrument is positioned in the operators grasp. 9. Operators gra sp in receiving an instrument depends on type of instruments (Fig-2.52). 10. Beg inning a procedure, transferring the mouth mirror and explorer (Fig2.53).

11. Transferring the hinged instrument and cotton pliers (Fig-2.54,55). All dent al instruments and materials are generally delivered to operator near the patien ts chin. Fig-2.52 Basic instrument grasps used and By operator, A pen, B Palm, C Palm-thumb Fig-2.53 Transferring the mirror explorer. Fig-2.55 Transferring a hi nged Fig-2.54 Transferring cotton pliers. instrument. 3. Dental Caries. What is caries? Dental caries is a process that may take place on any tooth surface in the oral cavity where a microbial biofilm (dental plaque) is allowed to develop over a pe riod of time. Although there are some 300 bacterial species in dental plaque. Pl aque formation is a natural, physiological process, which is an example of a bio film, a community of micro-organism attached to the tooth surface. The bacteria in the biofilm are always metabolically active, causing minute fluctuations in p H. These may cause a net loss of mineral from the tooth when the pH is dropping. This is call demineralization. Alternatively, there may be a net gain of minera l when the pH is increasing. This is call remineralization. The cumulative resul t of deand remineralization process may be a net loss of mineral and a carious l esion can be seen. Alternatively, the changes may be so slight that a carious le sion never becomes apparent (Fig-3.1) Levine (1977) established the chemical rel ationship of enamel plaque and the factor which determined the movement of miner al from saliva/plaque to enamel and vice-vesra, which he termed as the ionic see saw mechanism (Fig-3.2). Fig-3.1 Upper (with plaque), lower (removed plaque). F ig-3.2 Levines ionic see saw theory of dental caries. There are also can be seen figure of various type of caries. The classifications of dental caries are as fo llow; 1. Pit and fissure: 2. Smooth surfaces 3. Enamel caries 4. Root caries (Ge riatric caries) 5. Primary caries 6. Secondary or recurrent caries

7. 8. 9. 10. 11. 12. Residual caries Active carious lesion Inactive or arrested carious lesion Rampan t caries. Early childhood caries (adolescent caries) Bottle caries or nursing ca ries. A B Fig-3.3 Caries in the pit, fissure, and smooth surfaces (A), caries on the smooth surface (Buccal surface) as see in the radiograph. Fig-3.4 Root cari es. Fig-3.5 Progress of caries in the fissure, and pit, smooth surface. Fig-3.6 Secondary caries on the on the margin of amalgam colour restoration restoration. Fig-3.7 Secondary caries on on the margin of tooth (can be arrested by plaque control alone) groups as follow; fissure caries (type I), Smooth surface caries caries occurring at the age when the gingival These dental caries also can be three A. According to morphology (anatomy) of teeth: Pit and occurring on anatomical p it and fissure of all the teeth. (type II), occurring on smooth surface of the t eeth. Root cemento-enamel junction or cementum. This occurs in older recession, it is also known as geriatric caries. Fig-3.8 Fissure caries on occlusal. C-II. Fig-3.9Smooth surface caries Fig-3.10 Caries on the root surface. B. According to severity and progress of le sion: Incipient caries appears as a white opaque region on any tooth surface. A white lesion or incipient lesion can undergo remineralization thereby reversing the process. Rampant caries, involving at lest two teeth and two surfaces. Arres ted caries may become arrest, if there is a change in oral environment, it appea rs as a dark brown pigmentation with smooth surface, and it will be on occlusal as well as interproximal surfaces. Recurrent caries occurs at interface of tooth and restorative material because of many factors such as defective cavity prepa ration, microleakage, and combination of these. Radiation caries, one of the com plications of radiotherapy of oral cancer lesions is xerostomia, which leads to an early development of widespread caries. ABC Fig-3.11 Arrested caries (A) Seco nd molar, (B) First molar, (C) second molar.

Fig-3.12 Rampant caries in a 19 years old man, teeth look clean. Fig-3.13 Rampant caries, teeth not clean. to obvious (poor oral hygiene) plaque deposits. Fif-3.14 teeth discoloured Fig-3.15 Radiation caries. This patient has been irradiated in the region of the salivary glands for the treatment of a malignant tumour. Heavy plaque deposite are obvious over the lesions. C. According to age pattern: Nursing bottle caries, in early infancy period, bot tle-fed babies develop caries usually on maxillary incisors. The prolonged breas tfeeding especially at night can also result in such caries. Adolescent caries, acute caries attack is usually seen at 4-8 yrs of age. Caries attack after this period is usually characterized as adolescent caries. Geriatric caries occurs in older adults around age of 50 or so is referred to as geriatric caries. Usually caries of cementum falls under this category. Fig-3.16 Nursing bottle caries (rampant). childhood caries. A teeth. B Fig-3.17Early C Fig-3.18 Arrested (geriatric) caries can be seen on the gingival margin of The carious process and the carious lesion The word caries is used to denote both the carious process and the carious lesio n, which forms as a result of that process. The carious process occurs in the bi ofilm at the tooth or cavity surface and the carious lesion that form on the too th tissue; the interactions of the biofilm with dental tissues result in the les ion in the tooth. The metabolic activity in the biofilm cannot be seen, but the lesion, which is its reflection or consequence, can be seen. Thus the dentist is working on a reflection, and there is a danger that the dentist might forget th at the action in the biofilm. Carious lesions can form on any tooth surface, thu s they can form on enamel, cementum, or dentine. Dental plaque Dental plaque is an adherent deposit of bacteria and their products, which forms on all tooth surfaces and is the cause of caries. The plaque is a biofilm- a co mmunity of microorganisms attached to a surface (Fig-3.13,Fig-3.14,Fig-3.15, and

Fig-3.19). The organisms are organized into three-dimensional structure enclosed in a matrix of extracellular material derived from the cells themselves and the ir environment. Dental plaque formation can be described in sequential stages; 1 . Formation of pellicle: an a cellular, proteinaceous film, derived from saliva, which forms on a naked tooth surface. 2. Within 0 4 hours, single bacterial cel l colonize the pellicle, a large proportion of these are streptococci (S. sangui s, S. oralis, S mitis). There are also Acintomyces species and Gram-negative bac teria. Only about 2% of the initial streptococci are mutans streptococci, and th is is of interest because these organisms are particularly associated with the i nitiation of the carious process. 3. Over the next 4 24 hours, the attached bact eria grow, leading to the formation of distinct microcolonies. 4. In 1-14 days, the Streptococcus- dominated plaque changes to a plaque dominated by Actinomyces . Thus, the population shifts; this is called microbial succession. The bacteria l species become more diverse and microcolonies continue to grow. 5. In 2 weeks, the plaque is mature but there are considerable site-to-site variations in its composition. Each site can be considered as unique and these local variation may explain why lesion progress in some sites but not other in the same mouth. Epid emiology of dental caries Epidemiology is the study of health and disease states in population rather than individuals. The epidemiologist defines the frequency and severity of health pr oblems in relation to such factors as age, sex, geography, race, economic status , nutrition, and diet. Epidemiological surveys are importance to politicians bec ause they should indicate areas of need where public money may be spent appropri ately. 1. measuring caries activity: in the case of dental caries, the measureme nts of disease are used as follow, the number of decayed teeth with untreated ca rious lesions (D) the number of teeth which have been extracted and are therefor e missing (M) the number of filled teeth (F). The measurement is known as DMF in dex . 2. practical problems with DMF and def indices: there are some potential p roblems in the use of these indices. In young children missing deciduous teeth m ay have been last as a result of natural exfoliation, and these must be differen tiated from teeth lost due to caries. Permanent teeth are lost for reasons other than caries, such as trauma, extraction for orthodontic purpose and periodontal disease, or to facilitate the construction of dentures. For this reason missing teeth may be omitted from the indices and only decayed and filled surface inclu ded. 3. the relevance of diagnostic thresholds: the recording of caries in epide miological surveys is usually carried out at the caries into dentine level of di agnosis, enamel lesions are not recorded, which mean that epidemiological survey s inevitably underestimate the caries problem. 4. Caries prevalence: dental cari es is the main cause of tooth loss in people of all ages. The regular use of flu oridated toothpastes, perfectly twice a day is single factor for caries prevalen ce. 5. the position in the UK: National surveys of dental , carried out in UK ev ery 10 years, show the most dramatic improvement in young adults but in elderly people have particular problem because; oral hygiene may be poor if people are n ot able to brush or forget to do so salivary flow may be reduced by medications diet may change, with more sugar consumed.

Fig-3.19 Old people (Poor Oral Hygiene) of residential home. Modifying the cario us process Caries is a multifactorial disease. The cause is pH fluctuations in the bacteria l plaque, but these in turn may be influenced by such factors oral hygiene, diet , fluoride, and salivary flow. Also important such as social class, income, educ ation, knowledge, attitudes and behaviour. The basis of preventive, nonoperative treatment is modification of one or more of the factors involved in the carious process. Since the process usually takes months or years to destroy the tooth, time is on the patients side. The dentist can help the patient modify the carious process in a number of ways: 1. 2. 3. 4. Oral hygiene instruction. Dietary advi ce Appropriate use of fluoride Operative treatments. Fig-3.20 A diagrammatic representation of the carious process as an alternating process of destruction and repair. Sound enamel or dentine will become carious i n time if plaque bacteria are given the substrate they need to produce acid. How ever, progression of lesions can be arrested by improving plaque control, modify ing diet, and using fluoride appropriately. The first visible sign of caries in an enamel surface The earliest visible sign of enamel caries is the white spot lesion; to see the white spot lesion, the plaque overlying it must be removed with a brush the toot h thoroughly dried with a three-in-one syringe (Fig-3.21), this can be done occl usally (Fig-3.24) as well as buccally (Fig-3.25) or lingually. Fig-3.21 White spot cover with plaque. Fig-3.22 A red dye used to stain. Fig-3.2 3 Plaque removed with toothbrush Fig-3.24 White spot on FS of MT. surfaces The m icrobiology of dentine caries Fig-3.25White spot on the buccal The first wave of bacteria infecting the dentine is primarily acidogenic. Since demineralization precedes bacteria penetration, the acid presumably diffuses ahe ad of the organisms. The pH of carious dentine can be low, and members of the de ntine bacterial community in active lesions tend to be acidogenic. Infected dent ine has higher proportions of Gram-positive bacteria, thus lactobacilli predomin ate, with fewer mutans streptococci.

 Active and arrested lesions in dentine The rate of progress of caries in dentine is highly variable and under suitable environment conditions, the carious process can be arrested (Fig-3.26) and the l esion may even partly regress. The caries of dentine (Fig-3.27 and Fig-3.28) doe s not automatically progress. Before the enamel surface is cavitated these lesio ns can be arrested by preventive treatment. It is a dentists responsibility to ex plain to patient how they may arrest the disease in their mouth. Once the biofil m is sitting on the dentine, demineralization can spread laterally along the ena mel-dentine junction, undermining sound enamel (Fig-3.29). Fig-3.26 Arrested lesion on the buccal aspect of the lower first molar. A small amalgam restoration is also present. These lesions are likely to have formed yea rs earlier at the gingival margin B Fig-3.27 A sharp probe has been jammed into the white spot lesion on the buccal aspect of this extracted molar, (A) shows th e lesion before probing and (B) shows the lesion with probe which damaging. On t he occlusal surface, the enamel lesion has formed on the wall of the fissure and the lesion at the enamel-dentine junction is much under than the lesion at the enamel surface. Fig-3.28 A hemisected occlusal lesion where there is a cavity in the tooth down to the dentine. At this stage, the lesion spreads laterally alon g the enamel dentine junction. Notice the shape of the cavity; it is wider at th e base than at the top. This will prevent the patient cleaning plaque out of the hole. Fig-3.29 Diagram of histological changes after cavitation. Note that demi neralization of enamel precedes bacterial penetration.TZ (translucent zone), DEM IN (demineralization). Root caries Root surfaces become exposed, these surfaces are susceptible to root caries and also appear more vulnerable than enamel to me chanical wear and chemical damage (Fig-3.30, Fig-3.31). Exposed root surface occ ur following gingival recession, which is usually associated with periodontal di sease, and so it is hardly surprising that root caries is more commonly seen in older people. If the biofilm is regularly disturbed with a toothbrush and a fluo ride containing toothpaste, the root surface will not develop a clinically detec table lesion. Despite the presence of these bacteria, active, soft root carious lesions can be converted into arrested lesion (Fig-3.32), which is minimally inf ected. Placing a restoration does not confer immunity on the tooth, and secondar y or recurrent caries may occur in the tooth tissue adjacent to the filling mate rial secondary caries is the same as primary caries but located at the margin of a restoration (Fig-3.33) Fig-3. 30Root caries on (M), Fig-3.31 Caries on (B) cl ose to gingival margin. A Fig-3.32 Arrested lesion. Fig-3.33 Secondary caries at the margin

Tooth brushing only can arrest it. Secondary or recurrent caries of tooth coloured restoration. Secondary or recurrent caries is primary caries next to a filling caused by the biofilm at the tooth surface or the surface of any cavity. Thus, it is most ofte n localized gingivally where plaque is most likely to stagnate (Fig-3.33, Fig-3. 34, Fig-3.35, Fig-3.36). It can be arrested by regular disturbance of biofilm wi th fluoride-containing dentifrice. This emphasizes the point that the best way o f managing caries is by preventing lesion progression and not by filling holes i n teeth, even the very best operative dentistry is a poor substitute for unblemi shed enamel and dentine, and operative dentistry must be seen as making good a f ailure to prevent disease from progressing in the first place. Operative dentist ry also enables the patient to resume effective plaque control by filling the ho le where plaque may stagnate. Fig-3.34 Caries on the margin of white colour rest oration A B C Fig-3.36 Secondary lesions (A,B, C) on the margin of previous rest oration. Residual caries Fig-3.35 Caries on the margin of amalgam restoration. When preparing a carious tooth to receive a restoration, the dentist removes sof t, infected dentine. This is a part of carious lesion, but not all of it. Demine ralization of dentine precedes bacterial infection and beyond the demineralised area is the region of tubular sclerosis. The parts of the carious lesion that re main after cavity preparation are called residua caries. The nature of this tiss ue will depend on where the dentist has decided to stop removing tissue. A B Fig -3.37 This amalgam restoration has ditched margins and the enamel around the fil ling is stained. The amalgam has been dissected out of the cavity. The dentine b eneath is stained brown and in places has a dry and crumbly texture. This is res idual caries that the dentist left when the tooth was originally restored. Why i s dentine caries brown? The possibilities seem to be; 1. The colour is comes exogenous stain absorbed fr om the mouth (e.g. from tea, coffee, red wine). 2. The colour comes from pigment -producing bacteria. 3. The colour is the product of a chemical reaction called the Maillard reaction. A brown colour is produced when protein breaks down in th e presence of sugar (think of cutting up an apple and leaving it). Prevention of caries by plaque control The carious process is the metabolic activity in the plaque (biofilm). Plaque is the cause of caries, and a tooth, which is completely free of plaque, will not decay. People are not able to completely remove plaque themselves even with supe rvision. Increased sugar intake, decreased salivary flow speed up the carious

process, and the fluoride tends to decrease the rate of mineral loss. Brushing t wice daily with fluoride toothpaste has been advocated by the profession for man y years. Patient should always be asked whether, and how often, they brush their teeth and what toothpaste they used. Moat toothpaste contains fluoride, but not all, and it is important to check this. The most simple and effective way to co ntrol the development and progression of caries at the individual level is to br ush away plaque with fluoride toothpaste. Professional personal cleaned the teet h at regular intervals. White spot lesion can be developed in the enamel in 23 w eeks. The prevention of caries by mechanical removal of plaque (Fig-3.38 to Fig3.45), and a chemical agent for plaque control ( the most effective is 2 % of ch loehexidine mouth). Fig-3.38 A disposable mouth mirror allows the patient to see plaque on lingual a nd interproximal area. AB Fig-3.39 A powered toothbrush with a small, circular head that performs rotat ing movements (A). The bass method of tooth brushing. Note the angulations of th e bristle against the tooth surface and the direction of the vibratory motion (B ). Fig-3.40 Cleaning a partly erupted tooth with a toothbrush, bring the brush in a t right angles to the arch. Fig-41 The use of dental tape for interproximal clea ning of upper teeth, and floss holders and super floss. Note how the controlling fingers are close together and the tape is wrapped around the surface of the to oth being cleaned. Fig-3.42 The use of dental tape for interproximal cleaning of the lower teeth. Two index fingers are used to control the floss. bridge. Fig-3.43 The use of super floss to remove plaque under a brush (B). Fig-3.44 The use of an interdental brush. AB Fig-3.45 Interdental brush in vario us sizes (A). The use of a single-tufted for cleaning the lingual surface of a l ower molar Diet and caries

Dietary advice has an important role in the management of the carious process, i n conjunction with oral hygiene and use of fluoride. Sugar is the most important dietary item in caries aetiology. Sugar is metabolized to acid by plaque microo granism. Fermentable carbohydrate and cariogenic plaque need to be present on a tooth surface for acid to produce when bacteria degrade sugars. The acid is prod uced by bacteria metabolism of the carbohydrate substrate. The process is well i llustrated in Fig-3.19. This figure illustrates that that the resting pH attaine d can vary with the tooth surface under rest. Thus, plaque within active occlusa l carious cavities has lower resting pH value than plaque on inactive occlusal c arious lesions or sound surface. Both frequency and amount of sugar are associat ed with dental caries. It is more practical to advice limiting frequency of inta ke in sugar. Classification of sugars for dental health purposes: Sugars integra ted into the cellular structure of food (e.g. in fruit) are called intrinsic suga rs. Sugars present in free form (e.g. table sugar) or add to food (e.g. sweets, b iscuits) and called extrinsic sugar. These may be more readily available for metab olism by the oral bacteria and are therefore potentially more cariogenic. Milk c ontains lactose but is not generally regarded as cariogenic. Cheese and yoghurts , without added sugars, may be considered safe for teeth. Thus, the most damagin g sugars for dental health are non-milk extrinsic sugars (NMES). Recommended and c urrent level of sugar intake: The recommended intake of non-milk extrinsic sugar s is a maximum of 60 g/gay, which is about 10 % of daily energy intake. In young people aged (4-18) years, intake of NMES was 85 g/day for boys and 69 g/day for girls. The main sources of these sugars were soft drinks and confectionery. Sta rch, Fruit, and Fruit sugars: Raw starch (e.g. raw vegetable) is low cariogenici ty. Cooked and highly refined starch (e.g. crisps) can cause decay, and combinat ion of cooked starch and sucrose (e.g. cakes, biscuits, sugared breakfast cereal ) can be highly cariogenic. Currently dietary advice recommended at least five p ortions of fruits and vegetables per day. Fruit contains sugars (fructose, sucro se, and glucose) but fresh fruit appear to be of low cariogenicity. Although the fruit juice, juicing process releases the sugars from the hole fruit, and these drinks are potentially cariogenic. Dry fruit also cariogenic, and the drying pr ocess releases some of the intrinsic sugars. General advice: It is impossible to cut sugar completely but can be reduce the total amount of sugar intake, and re strict sugar intake mainly in meal times. Sugary foods or drinks between meals a re harmful, fruit, peanuts, or cheese may be acceptable, although peanuts should not be given to children under 5 years, as a real risk of death due to inhalati on of a single nut. The bedtime snack or drink is important for plaque pH may re main low during sleeping at night. Nutrational recommendations for good health; 1. Enjoy your food 2. Eat a variety of different foods 3. Eat the right amount t o be a healthy weight 4. Eat plenty of foods rich in starch and fibre 5. Eat ple nty of fruit and vegetables 6. Dont eat too many foods that contain a lot of fat 7. Dont have sugary foods and drinks too often 8. If you drink alcohol, drink sen sibly Foods and drinks with low potential for dental caries. 1. Bread (sandwiche s, toast, crumpets, and pitta bread). 2. Pasta, rice, starchy staple foods

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Cheese Fibrous foods (e.g. raw vegetables) Low sugar breakfast cereals (e.g. shr edded wheat) Fresh fruit (whole and not juices) Peanuts (not for children under 5 years) Sugar-free chewing gum Sugar-free confectionery Water Milk Sugar-free d rinks Tea and coffee (unsweetened) Protective foods: The consumption of some foods after sugar has been shown to ra ise plaque pH. Cheese is useful in this respect, and can be recommended as the l ast course of a metal or as a safe snack. Chewing gums containing xylitol have a lso been shown to raise salivary pH after a sugar snack. Fluoride supplementatio n It was possible to reduce caries by supplying optimal level of fluoride. In 1930 , the research of UK and US showed excessive fluoride in the drinking water, rel ated to a low prevalence of dental caries. There is a great deal of scope to aff ect the fluoride concentration of enamel since it can be deposited in three stag es of enamel development. Low concentrations, reflecting the low levels of fluor ide in tissue fluids, are incorporated in the apatite crystals during their form ation. After calcification is complete, but before eruption, more fluoride is ta ken up by the surface enamel which is in contact with tissue fluids. Finally, af ter eruption and throughout the life, the enamel continues to take up fluoride f rom its external environment. Enamel from newly erupted teeth also takes up more fluoride than mature enamel. Caries is chemical dissolution of the dental hard tissues by the acid produced when bacteria degrade sugars. Under the normal cond ition, oral fluids are supersaturated with both hydroxyapatite and fluorapatite. However, as pH is lowered in the plaque fluids below the critical pH of 5.5, pl aque fluids becomes undersaturated with hydroxyapatite and a carious lesion form s. The first sign of excessive intake of fluoride during the tooth eruption, the tooth with fluorosed or mottled enamel. When fluorosis is mild, enamel merely l oses its lustre and, when dried, opaque white flecks or patches can be seen (Fig -3.46).Mild fluorosis (Fig-3.47) shows in a child where the water is fluoridated . Fluoride occurs naturally in water supplies, at low concentration. In USA, art ificially added fluoride in water supplies. The effect water fluoridation on den tal caries show a reduction in caries in both deciduous and permanent dentations of about 50 %. Water fluoridation is the most cost-effective public health meas ure to control dental caries. The materials, fluoride supplements are as follow; 1. Fluoride in drinking water 2. Salt fluoridation 3. Fluoride in toothpaste 4. Fluoride mouthwashes 5. Fluoride varnish A anterior striations and B C Fig-3.46 Mild fluorosis. Note white flecks on upper teeth (A). Moderate fluorosis. Note white yellow-brown discolouration on central incisors (B). Severe fluorosis. Not e loss of enamel.

Fig-3.47 This patient shows mild fluorosis and spent his childhood in Birmingham , UK, where the water is artificially fluoridated. There is cloudy, diffuse mott ling in the incisal third of the teeth, blending with the surrounding enamel, ce rvically, horizontal white lines can be seen. Saliva and caries Saliva is very important in countering pH drops, and this is one reason why peop le with dry mouths are a high risk of active caries. Saliva is a complex oral fl uid consisting of a mixture of secretions from the major salivary glands and the minor glands of the oral mucosa. Ninety percent of saliva is produced by the th ree pairs of major glands; parotid, submandibular, and sublingual. The rest of i t is produced by thousands of minor salivary glands distributed throughout the m outh and throat. Most of the saliva is produced at meal times as a response to s timulation due to tasting and chewing. For the rest of the day, saliva flow is l ow, the constant slow flow of saliva, which moistens, and helps to protect the t eeth, tongue, and mucous membranes of the mouth and oropharynx. The flow rate pe aks during the afternoon and virtually stops during sleep. Saliva aids swallowin g and digestion. The causes of reduced salivary flow are radiotherapy, drugs, di sease, and age. Saliva can influence the carious process in several ways. 1. The flow of saliva can reduce plaque accumulation on the tooth surface and increase the carbohydrate clearance from oral cavity. 2. The diffusion into plaque of sa livary components such as calcium, phosphate, hydroxyl, and fluoride ions can re duce the solubility of enamel and promote remineralization of early carious lesi ons. 3. Saliva proteins could increase the thickness of acquired pellicle and so help to retard the movement of calcium and phosphate ions out of enamel. The pH of saliva shows great variation as compared to the pH of blood. The pH at which any particular saliva ceases to be saturated with calcium and phosphate is refe rred to as the critical pH. The typical pattern of caries development is shown i n Figure-3.48. Fig-3.48 A typical patterns of carious attack in a patient with x erostomia, in this case caused by radiotherapy in the region of the salivary gla nds. The cusp tips and incisal edges are typically attacked because dentine is o ften exposed by tooth wear in this area. Dentine is more susceptible to caries t han enamel. CARIES CONTROL STRATEGIES The patient should see the dentist at leas t every 3 months. Plaque control needs to be excellent, and professional plaque control should be considered. Until salivary flow returns to normal limits, the risk of caries is high. Therefore, stimulated flow rates should be measured ever y 3-4 months to help to establish the level of caries risk. Rigid dietary contro l is impractical. However, each time the patient is seen, the opportunity should be taken to reinforce the importance of avoiding sweet drinks and snacks. The b edtime sweet drink is particularly dangerous. Taste sensation is lost during rad iotherapy but when it returns, 2-4 months later, there often is a sudden craving for sweet foods and drinks. Patients should also be discouraged from attempts t o stimulate salivary flow by sucking sweets. Instead, chewing a sugar-free gum c ontaining xylitol will be safer and more effective. The use of a saliva substitu te until salivary flow returns will also be helpful.

Patients should use a sodium fluoride (0.05 % NaF) mouthrinse daily for several years to help arrest any initial carious lesions. It will also help to alleviate sensitivity from pre-existing areas of exposed dentine which have lost the prot ective action of saliva. A low-alcohol or water-based product with a mild taste should be chosen. Fig-3.49 Custom-made flexible, vacuum-moulded trays for self-a pplication of chlorhexidine or fluoride gel. The patient in custom-made applicat or trays should apply a 1% chlorhexidine gel (Corsodyl) for 5 minutes every nigh t for 14 days. This is repeated every 3-4 months until salivary flow returns to normal. Such treatment has been shown to keep the level of mutans streptococci i n control for at last 3 months. Compliance with this regime can be checked befor e and after treatments by use of proprietary kits to measure levels of mutans st reptococci. Any possible chlorhexidine staining can be removed when these patien ts are seen at their regular recall visits. It is important to note that chlorhe xidine is inactivated by sodium lauryl sulphate, the detergent present in most t oothpaste. Patients should therefore be instructed to rinse toothpaste out thoro ughly before any application of chlorhexidine. Any patient with dry mouth should avoid smoking, alcohol, and caffeine-based drinks since any of these can exacer bated the problem. Caries diagnosis Diagnosis is identifying a disease from its signs and symptoms. Carious lesions may be diagnosed at any level of the carious process. For convenience, the levels are graded D (decay) follow by the number. The higher number is the more advanced the lesion. D1 are clinically detectable enamel lesions which intact surfaces D2 are clinically detectable cavities limi ted to enamel D3 are clinically detectable lesions in dentine D4 are lesions int o the pulp. The diagnosis of caries requires good lighting and dry, clean teeth. If deposits of calculus or plaque are present, the mouth should be cleaned befo re attempting accurate diagnosis. Remember to brush plaque out of the fissures b ecause it is easy to miss a white spot lesion at the entrance to a fissure unles s the surface is clean (Fig-3.50). Good bitewing radiographs (Fig-3.51) are also essential in diagnosis. Diagnosis the caries shown in (Fig-3.53 to Fig-3.59). a b Fig-3.50 This fissure looks both clean and caries free (a). The plaque has be en brushed away and the surface has been dried. The lesion is now visible as whi te areas at the entrance to the fissure (b). a b Fig-3.51 A biteweing radiograph showing occlusal caries in the first molar. Clinically there was no obvious cav ity although the enamel was discoloured (a, and b). A B Fig-3.52 Root surface ca ries in an area of plaque stagnation close to the gingival margin (A). Arrested root caries in a plaque free area, coronal to the gingival margin (B).

BC Fig-3.53White and brown spot lesions on the occlusal surface of a molar (A). A microcavity, looking like a slightly enlarge, brown fissure on a first molar ( B). The soft demineralised dentine has now been removed from the tooth (C). A A B C Fig-3.54 Caries on occlusal surface (A). Prepared cavity (B). The machine in use with the tip on the occlusal surface of a premolar. The surface should be clean and dry. A B Fig-3.55 A bitewing radiograph showing caries in enamel and dental on the mo lar mesial (A) and distal (B) aspect of the upper first molar. Fig-3.56 A mirror view of the palatal aspect of the upper anterior teeth. Lesions are visible mes ially and distally on the upper right central incisor. A B C D Fig-3.57 Separator is placed between the canine and first premolar (A). Sepa ration achieved 48 hours later (B). Taking an elastomer impression of the contac t area (C). Elastomer impression of the contact area showing no cavitation on th e distal aspect of the canine, a restoration is not needed. Fig-3.58 Ditched ama lgam restorations. AB Fig-3.59 A large amalgam restoration (A). An orthodontists nightmare. The brackets have been removed from the teeth and multiple white spot lesions have formed because oral hygiene was poor and many sugary snacks and dr inks were consumed. The operative management of caries. Practicing dentist spend a major part of their time, and derive of their income, from repairing the ravages of dental caries. The under graduate may come to bel ieve that the operative dentistry is the treatment of carious process, now denta l school teach cariology together with operative dentistry so that student can a ppreciate that the carious process can be modified by preventive treatment. Thus , treatment of carious process involves both preventive and operative treatment. The preventive treatments demand the full cooperation of the patient and the op erative treatment that dentist needed to place restoration for high-risk patient s. The most important reason for placing a restoration is to aid plaque control. If the patient is unable to clean plaque out of a hole in a tooth, the carious

process is almost bound to progress. The reasons for recommendating restorative treatments are; The tooth is sensitive to hot, cold and sweet. Dentine is good b ut when a tooth is cavitated, some of this insulation is lost. Sensitivity is le ss likely in chronic lesions where tubular sclerosis and tertiary dentine have r educed dentine permeability. The pulp is endangered Previous attempts to arrest the lesion, but failed and there is evidence the lesion is progressing (this usu ally requires an observation period of months or years ) Function is impaired Dr ifting is likely to occur through loss of a contact point. For aesthetic reasons . The cosmetic improvement can be very satisfying and the dentist will enjoy res toring teeth, smiles, function and dental health (Fig3.60), cavities on free smo oth surface (fig-3.62), (fig-3.63). Fig-3.60 A Before operative restoration. Fig -3.60 B After operative restoration. Fig-3.61 Cavities on free smooth surfaces. Fig-3.62 Secondary cavity on the margin of the filling. 1. Fissure Sealant procedure Isolation Cleaning the teeth Etching Washing Drying the etched enamel Mixing the resin Sealant application Checking the occlusion R ecall and reassessment A B C Fig-3.63(A) a wingless clamp in position on an upper molar. Floss has been att ached to the holes of the clamp so that the dentist can retrieve it should the c lamp fracture across the bow. (B) The floss is now threaded through the punched and lubricated hole in the rubber dam. (C) The dentist now slides the rubber ove r the bow of the clamp, one side and then the other side. The dental nurse gentl y pulls on the floss as the rubber is placed. A B C Fig-3.64 (A) a winged rubber dam clamp engaged in the hole in the rubber. (B) Clam

and rubber are being placed on the tooth simultaneously. The dental nurse gently retract the rubber so that the dentist can see the tooth clearly. flat plastic instrument is used to disengage the rubber from the wings of amp. Fig-3.65 A rubber dam separated from the face by a soft paper towel. er may be trimmed to avoid contact with the nose of the patient. A B

should (C) A the cl A rubb

C Fig-3.66 (A) Application of the etchant gel to the occlusal surface of a lower second molar. (B) The dried etched area appears matt and white. (C) The complet ed fissure sealant. Note it has been applied within the etched area to ensure ma rginal seal. Fig-3.67 Part of the sealant has been lost and it should be repaire d. 2. Stepwise excavation Stepwise excavation is a technique where only part of the soft dentine caries is removed at the first visit during the active phase of caries progression. 3. Caries removal This section is going to be contentious! The current operative tradition is: Remove necrotic carious dentine and infected tissue with an excavator or slowly rotating round bur until hard dentine is rea ched. Now remove sufficient tooth structure to obtain a cavity suitable for the filling material of choice. Protect the pulpo-dential complex from further damag e by placing a restoration that seals the cavity. It appears important to preven t penetration of microorganisms. Research seems to show that it is this bacteria l ingress that potentially damages the pulp, rather than any toxological effect of the dental material. However, this concept does not really fit with present k nowledge of the carious process which occurs in the biofilm. It is the interacti on of this biofilm with the dental tissues that results in the carious lesion. I n the meantime, the author would suggest the following approach in the clinic; W hen removing caries make the enamel-dentine junction hard but do not worry about stain unless there is an appearance problem. e.g. in an anterior tooth. Stainin g is irrelevant to bacterial recovery. Excavate demineralised dentine over the p ulpal surface to the level of firm dentine provided there is no likelihood of pu lpal exposure Deep lesions, in symptomless vital teeth, should be gently excavat ed; soft demineralised dentine may remain where its removal might expose the pul p. A permanent restoration is placed. Do not re-enter Where it is not possible t o remove soft, infected dentine (perhaps the

patient is anxious or not cooperative), seal in the infacted dentine, in a syspt omless, vital tooth, this should have a high success rate. 4. Active disease wit h temporary dressing. When a patient presents with multiple carious lesions, a combined preventive and operative approach will be required. This approach must include a creful histor y and examination, diagnosis of the cause of disease, extraction of teeth which are obviously unsavable, institution of preventive measures, and stabilization o f large, active lesions. All lesions where pulpal involvement looks likely on a radiograph should be treated in the following way. The tooth should initially be tested to determine whether the pulp is vital. If it is, a local anaesthetic is given and access gained to the carious dentine, and demineralised tissue remove d as described in the previous section. A glass ionomer cement temporary dressin g is placed. Where caries has resulted in frank exposure of a vital pulp, remova l of the pulp is often advisable to prevent pain. Eventually such teeth require root canal therapy it they are to be saved, but initially the pulp cavity may be dressed with a mild antiseptic on cotton wool and the tooth restored with a gla ss ionomer cement as a temporary filling. Where inadequate anaesthesia or insuff icient time preclude complete removal of the coronal and radicular pulp, a vital exposure can be dressed with a corticosteroid antibiotic preparation before pla cing a temporary filling. These products are unrivalled in their ability to supp ress the inflammatory process and hence the pain of pulpitis, but root canal the rapy is the eventual treatment of choice if the tooth is to be saved. Where gros sly carious teeth are found to be non-vital, but the teeth are restorable, the p ulp cavity may be dressed with a mild antiseptic on cotton wool and the tooth re stored temporary. If, however, the patient has symptoms of acute apical infectio n, thorough debridement of the root canal system is required before placement of a mild antiseptic dressing I the coronal pulp chamber and temporary restoration of the tooth. 4. Sharpening of Hand Instrument. Selecting the proper cutting, instrument with dull cutting edges cause more pain, prolong operating time, more difficult to co ntrol, and reduce quality and precision in tooth preparation. Stationary sharpen ing stones The most useful sharpening equipment consists of a block or stick of abrasion ma terial called a stone. Stationary stones are often called oilstones because of the common practice of applying a coating of oil to them as an aid to the sharpenin g process. Stationary stones are available in coarse, medium, or fine grit. Only fine grit stone is suitable for final sharpening of dental instrument to be use d for tooth preparation. Coarse and medium grit may be used for initial sharpeni ng of a badly damage instruments. Coarse stones cut more rapidly, but produce a rougher surface. Sharpening stones are made from any of several natural or synth etic materials. Four types of materials are in common use for sharpening stones. 1. Arkansas stone; It was naturally occur mineral containing microcrystalline q uartz, white or grey in color, and hard enough to sharpening steel but carbide i nstruments. 2. Silicon carbide; It is the most commonly used for grinding wheels and

sandpapers and for sharpening stone, it is hard enough to cut steel but not hard enough to sharpen the carbide instruments, it is normally in dark color, often black or greenish black. 3. Aluminum oxide; Coarse and medium grit stones are ge nerally brownish in color. Fine grit stones usually in white color and have supe rior properties. 4. Diamond; It is hardest and most effective for cutting and sh aping hard materials. It is only material capable of sharpening carbide and stee l instrument. Mechanical sharpeners As high-speed rotary cutting instruments have been improved and their use has in creased, the use of hand cutting instruments and the need for resharpening has d ecreased. As a result, some dental office personnel do not do enough hand sharpe ning to remain confident of their proficiency. Under such circumstances, the use of a powered mechanical sharpener is beneficial. The Rx Honing Machine (Rx Honi ng Machine Corp Mishawaka IN) is an example of a mechanical sharpener (Fig- 4.1) . This instrument moves a hone in a reciprocation motion at a slow speed, while the instrument is held at the appropriate angulation and supported by a rest. Th is is much easier than having to hole the instrument at the proper angulation wh ile moving it relative to the hone. Interchangeable aluminum oxide hones of diff erent shapes and coarseness are available to accommodate the various instrument sizes, shapes, and degrees of dullness. Restoration of the cutting edge is accom plished more easily and in less time than by other sharpening methods. This type of sharpener is also very versatile and, with available accessories, can fill a lmost all instrument sharpening needs. A B Fig-4.1A Type of mechanical sharpener , B Sharpening enamel hatchet. Fig-4.1 An example of a mechanical sharpener. Han dpiece sharpening stones Mounted Sic and aluminum oxide stones for use with straight and angle handpieces are available in various size and shapes (see section on other abrasive instrum ents). Those intended for use in straight handpieces, particularly the cylindric al instruments with straight-sided silhouettes, are more useful for sharpening h and instruments than are the smaller points intended for intraoral use in the an gle handpieces. Because of their curved periphery, it is difficult to produce a flat surface using any of these instruments. These stones also may produce incon sistent results because of the speed variables and the usual lack of a rest or g uide for the instrument. Satisfactory results can be obtained, however, with min imal practice, especially on instruments with curved blades. Principles of sharp ening The choice of equipment used for sharpening is up to the dentist. In the use of any equipment, several basic principles of sharpening should be followed: 1. Sha rpen instruments only after they have been cleaned and sterilized. 2. Establish the proper bevel angle (usually 45 degrees) and the desired angle of the cutting edge to the blade before placing the instrument against the stone, and maintain these angles while sharpening. 3. Use a light stroke or pressure against the st one to minimize frictional heat. 4. Use a rest or guide whenever possible.

5. Remove as little metal from the blade as possible. 6. Lightly hone the unbeve led side of the blade after sharpening, to remove the fine bur that may be creat ed. 7. After sharpening, resterilize the instrument along with other items on th e instrument tray setup. 8. Keep the sharpening stones clean and free of metal c uttings. Mechanical sharpening techniques When chisels, hatchets, hose, angle formers, or gingival margin trimmers are sha rpened on a reciprocating honing machine (i.e., sharpener), the blade is placed against the steady rest, and the proper angle of the cutting edge of the blade i s established before starting the motor. Light pressure of the instrument agains t the reciprocating hone is maintained with a firm grasp on the instrument. A tr ace of metal debris on the face of a flat hone along the length of the cutting e dge is an indication that the entire cutting edge is contacting the hone (see Fi g.-1.B). Stationery stone sharpening techniques The stationary sharpening stone should be at least 2 inches wide and 5 inches lo ng because a smaller stone is impractical. It also should be of medium grit for hand cutting instruments. Before the stone is used, a thin film of light oil sho uld be placed on the working surface. In addition to establishing the proper 45degree angle of the bevel and the cutting edge to the stone, several fundamental rules apply to using the stationary stone: 1. Lay the stone on a flat surface, and do not tilt the stone while sharpening. 2. Grasp the instrument firmly, usua lly with a modified pen grasp, so that it does not rotate or change angles while being sharpened. 3. To ensure stability during the sharpening strokes, use the ring and little finger as a rest, and guide along a flat surface or along the st one. This prevents rolling or dipping of the instrument, which results in a dist orted and uneven bevel. 4. Use a light stroke to prevent the creation of heat an d the scratching of the stone. 5. Use different areas of the stones surface while sharpening because this helps prevent the formation of grooves on the stone tha t impair efficiency and accuracy of the sharpening procedure. 6. When the sharpe ning chisels, hatchets, or hoe on the stationary stone, grasp the instrument a m odified pen grasp, place the blade perpendicular to the stone and tilt the instr ument to establish the correct bevel (Fig-4.2). 7. It may be expedient to use a palm-and-thumb grasp when sharpening a trimmer with a 95- or 100-centigrade cutt ing edge angle (Fig-4.3). 8. The blade is tilted to form small acute angle with the surface of the stone, and the stroke is straight along the stone and toward the edge of the blade only (Fig-4.4). 9. the stone may be placed on flat surface or held in the hand (Fig-4.5), and a small cylindrical stone is pass back and f orth over the surface. Fig-4.2 Sharpening the instrument holds by Instrument hol ds by modified Palm-grasp. Pen grasp. Fig-4.3 Sharpening the Fig-4.4 Sharpening amalgam or gold knife. Fig-4.6 Used a small cylindrical stone

Fig-4.5 Sharpening a small spoon excavator. Sharpness test Sharpness of an instrument can be tested by lightly resting the cutting edge on a hard plastic surface. If the cutting edge digs in during an attempt to slide t he instrument forward over the surface, the instrument is sharp. If it slides, t he instrument is dull. Only very light pressure is exerted in testing for sharpn ess. The principles and techniques discussed provide sufficient background for t he operator to use proper methods in sharpening other instruments not discussed. It cannot be overemphasized that sharp instruments are necessary for optimal op erating procedures. It also has been found prudent to have multiple tray setups so that a substitute instrument is available if necessary, or substitute sterile instruments should be available so that other sterile tray setups are not disru pted by the borrowing of instruments. 5. Dental Physiology. it is important for the dental study of anatomy ( the study of the structure of the human body) and physiology ( how the human body functions). This chapter als o introduces the basic terms and definition of dental physiology. Structure of t he head and neck As a dental study, the knowledge and understanding of the structures of the head and neck will be useful for most of the dental treatment procedure. There are t wo type of bone; a. Compact bone: also known as cortical bone is hard, dense, an d very strong. The outer layer of bones is needed for strength, so that the oute r layer of the mandible is made of a compact bone. b. Cancellous bone: also know n as spongy bone is lighter in weight and not strong as compact bone. It is foun d in the interior of bone, and the inner layer of the maxillary bone is made of cancellous bone. The periosteum is the specialized connective tissue covering of all bones in the body. The cranium bone was protected the brain, which is the b one of skull (Fig-5.1 to Fig-5.7). Fig-5.1 Frontal view of the skull. Fig-5.2 Lateral view of the skull. Fig-5.3 Base of skull. Fig-5.4 Midsagittal view of the skull.

Fig-5.5 Bones and landmarks of the hard palate. mandible. Fig-5.6 Topical view of the Fig-5.7 View of mandible. A, from the front. B, from behind and above. C, from t he left and front. D, internal view from left. c. The paranasal sinuses; are spa ces that contain air within the bones of the skull. Their functions include prov iding mucus, making the bone of the skull lighter, and helping to produce sound (Fig-5.8). These sinuses are named for the bones in which they are located (Tabl e-5.1). Fig-5. 8 The paranasal sinuses. Table-5.1 The paranasal sinuses and it function. Name of sinuses Locati on Significant of sinuses Maxillary sinuses Frontal sinuses Ethmoid sinuses Sphenoid sinuses In the maxillary bones, they are the largest sinuses. In the frontal bone, within the forehead, just above the eyes. In the ethmoid bo ne, irregularity shaped air cells separated from the orbital

(eye) cavity by a very thin layer of bone. In the sphenoid bone close to the opt ic nerves. Infection in any of the sinuses may causes pain in the maxillary teet h. The symptoms of sinusitis (inflamed sinuses) are headache, foul-smelling disc harge, fever, and weakness. Infection in one sinus can travel through the nasal cavity to the other sinuses, leading to serious complications for the patient. An infection in these sinuses may damage vision and / or the brain. d. A joint ( TMJ) is the junction between two or more bones. The temporomandibular joint (TMJ ) is located on each side of the head where the temporal bone and the mandible j oin (Figure-5.9). This joint makes it possible for the lower jaw to move so that we can speak and chew. A patient may have a disorder with one or both of their TMJs. The dental professional must have an understanding of the anatomy of the T MJ, the normal movements of the joint, and any possible disorders of the joint ( Figure-5.10). Fig-5.9 Lateral view of the skull showing the and the temporomandi bular joint. Fig-5.10 Palpation of the patient during movements of both temporom andibular joints. e. The capsular ligament is a dense fibrous capsule that surro unds the TMJ. It is attached to the neck of the condyle and to the nearby surfac es of the temporal bone. The ligaments of the TMJ attach the mandible to the cra nium (Figure-5.11). A B mandible Fig-5. 11Lateral view of the joint capsule of the temporomandobular joint And it s lateral ligament. f. The articular space is the area between the capsular ligament and the surface of the glenoid fossa and the condyle. The articular disk, also known as the men iscus, is a cushion of dense connective tissue that divides the articular space into fluid-filled upper and lower compartments. The structure of these compartme nts and the presence of the fluid make the smooth movement of the joint possible . g. The TMJs are constructed for specialized hinge-and-glide movement, which al low the mouth to open and close (Figure-5.12). Hinge action is the first phase

in opening the mouth. During this movement, the body of the mandible drop downwa rd and backward. Gliding action is the second phase in opening the mouth. This p hase consists of a gliding movement by the condyle and articular disk forward an d downward along the articular eminence. This movement occurs during the forward movement (protrusion) of the mandible. The backward movement is called retrusio n. Fig-5.12 Hinge and gliding actions of the temporomandibular joint. Major muscles of mastication and facial expression The muscles of mastication are responsible for closing the jaws, bringing the lower jaw forward and backward, and shifting the lower jaw side to side. The muscles of mastication work with the TMJ to acc omplish these movements (table-5.2) and Fig-5.13. Table-5.2 The muscles of masti cation and facial expression. Muscle Buccinator External (lateral) pterygoid Int ernal (medical) pterygoid Masseter Mentalis Orbicularis oris Temporal Zygomatic major Compresses the cheeks and holds food in contact with the teeth. Depresses, protrudes, and moves the mandible from side to side. Close and aids in sideways movement. Raise Raise Close Raise Draws the and and the the mandible, close the jaws, and occludes the teeth. wrinkles the skin of the chin and pushes up the l ower lip. puckers the lips, aids in chewing by pushing the food against the teet h. mandible, close the jaw, and occludes the teeth. angles of the mouth upward a nd backward, as in laughing. Function Fig-5.13 Muscle of the soft plate. Blood supply to the face and mouth Arteries c arry oxygenated blood away from the heart to all parts of the body with a pulsin g motion. Veins carry blood back to the heart. The major arteries and veins of t he face and mouth are shown in Figure-5.14 and Table-5.3. Fig-5.14 A Major arter ies and veins of the face and oral cavity. Fig-5.14B Facial Arteries

Fig-5.14 C Facial veins. Table-5.3 Major arteries of the face and mouth. Structu re Blood supply Muscles of facial expression Maxilla Maxillary teeth Mandible Mandibular teeth T ongue Muscles of mastication Branches and small arteries from maxillary, facial, and ophthalmic arteries Anterior, middle, and posterior alveolar arteries Anter ior, middle, and posterior alveolar arteries Inferior alveolar arteries Inferior alveolar arteries Lingual artery Facial arteries Lymph nodes Lymph nodes are small round or oval structures located in lymph vessels .In some infections and immune disorders, the lymph nodes become swollen and tender. Dur ing the examination, the dentist examines the nodes of the neck to detect signs of swelling or tenderness. The lymph nodes of the face and neck are shown in Fig ure-5.15, A and B. Fig-5.15 A Superficial lymph nodes of the head and associated structures. Fig-5.15B Deep cervical lymph nodes and associated structures. Nerve supply to t he mouth The trigeminal nerve, which is a branch of the fifth cranial nerve, is the primary source of the nerve supply for the mouth. (Innervation is another te rm for nerve supply.) The trigeminal nerve divides into the maxillary and mandib ular branches to serve the mouth (Figures-5.16 and 5.17). Maxillary Innervation; the maxillary division of the trigeminal nerve supplies the maxillary (upper) t eeth, periosteum, mucous membrane, maxillary sinuses, and soft palate. Mucous me mbrane is the specialized tissues that line the inside of the mouth. The maxilla ry division further subdivides to provide the following routes of nerve supply; The nasopalatine nerve, which passes through the incisive foramen, supplies the tissue palatal to the maxillary anterior teeth. (Anterior mean toward the front. A foramen is an opening in a bone through which blood vessels, nerves, and liga ments pass).

 The anterior palatine nerve, which passes through the posterior palatine foramen and forward over the palate, supplies the mucoperiosteum. (Mucoperiosteum is pe riosteum having a mucous membrane surface). The anterior superior alveolar nerve supplies the maxillary central, lateral, and cuspid teeth plus their periodonta l membrane and gingivae. The nerve also supplies the maxillary sinus. The middle superior alveolar nerve supplies the maxillary first and second premolars, the mesiobuccal root of the maxillary first molar, and the maxillary sinus. The post erior superior alveolar nerve supplies the other roots of the maxillary first mo lar, second, and third molars. It is also branches forward to serve the lateral wall of the maxillary sinus. The buccal nerve supplies branches to the buccal mu cous membrane and to the mucoperiosteum of the maxillary and mandibular molar te eth. (buccal means pertaining to or directed toward the neck. Mandibular Innerva tion; The mandibular division of the trigeminal nerve subdivides into the buccal , lingual, and inferior alveolar nerves. The buccal nerve supplies branches to t he buccal mucous membrane and to the mucoperiosteum of the maxillary and mandibu lar molar teeth. The lingual nerve supplies the anterior two third of the tongue and give off branches to supply the lingual mucous membrane and mucoperiosteum. (Lingual means of, or pertaining to, the tongue). The mylohyoid nerve, which su pplies the mylohyoid muscles and the anterior belly of the digastrics muscle The small dental nerves, which supply the molar teeth and premolar teeth, alveolar process, and periosteum of the mandible. The mental nerve, which moves outward t hrough the mental foramen and supplies the chin and mucous membrane of the lower lip. The incisive nerve, which continues interiorly and give off small branches to supply the cuspid, lateral, and central teeth. Fig-5.16A Maxillary and mandibular innervations. Fig-5.16B Palatal, lingual, and buccal innervation Fig-5.17 A Mandibular nerve. Fig-5.17B Maxillary arch nerves. Structures of face and oral cavity Before begin ning more advanced procedures, such as exposing dental radiographs or assisting with intraoral procedures, you must learn the terms and locations of various str uctures of the face and oral cavity Regions of the face The facial region can be subdivided into nine areas, as follow (Fig-5.18). 1. Forehead, extending from t he eyebrows to the hairline. 2. Temples, or temporal area posterior to the eyes 3. Orbital area, containing the eye and covered by the eyelids 4. External nose 5. Zygomatic (malar) area, the prominence of the cheek 6. Mouth and lip 7. Cheek s

8. 9. Chin External ear. Fig-5.18 A and B are regions of the face. Features of the face The dental studen t should be able to identify the following important facial landmarks (Fig-5.19) . 1. The outer canthus of the eye is the fold tissue at the outer corner of the eyelids. 2. The inner canthus of the eye is the fold of tissue at the inner corn er of the eyelids. 3. The ala of the nose is the winglike tip on the outer side of each nostril. 4. The philtrum is the rectangular area between the two ridges running from under the nose to the middle of the upper lip. 5. The tragus of the ear is the cartilaginous projection anterior to the external opening of the ear . 6. The nasion is important between the eye just below the eyebrows. On the sku ll, this is the point where the two nasal bones and the frontal bone join. 7. Th e glabella is the smooth surface of the frontal bone, also the anatomic area dir ectly above the root of the nose. 8. the root is commonly called the bridge of t he nose 9. The septum is the tissue that divides the nasal cavity into two nasal fossae. 10. The anterior naris is the nostril. 11. The mental protuberance of t he mandible forms the chin. 12. The angle of the mandible is the lower posterior of the ramus. 13. The zygomatic arch creates the prominence of the cheek. Fig-5 .19 Features of the face. The oral cavity The entire oral cavity is lined with m ucous membrane tissue. This type of tissue is moist and adapted to meet the need s of the area it covers. The oral cavity consists of the following two areas; 1. The vestibule is the space between he teeth and the inner mucosal lining of the lips and cheeks. 2. The oral cavity proper is the space on the tongue side with in the upper and lower dental arches. The tongue: it is composed mainly of muscl es, covered on top with a thick layer of mucous membrane and thousands and thous ands of tiny projections called papillae. Inside the papillae are the sensory or gans and nerves for both taste and touch. On a healthy tongue, the papillae are usually pinkish-white and velvety smooth (Fig5.20 and Fig-5.21). The functions o f tongue are as follow Speaking Positioning the food while eating Tasting and ta ctile sensations Swallowing Cleaning the oral cavity Fig-5.20 Dorsum of the tong ue.

Fig-5.21 Sublingual aspect of the tongue. The frenum: It is a narrow band of tis sue that connects two structures. The maxillary labial frenum passes from the or al mucosa at the middle of the maxillary arch to the mid-line of the inner surfa ce of the upper lip. The mandibular labial frenum passes from the oral mucosa at the mid-line of the mandibular arch to the midline of the inner surface of the lower lip (Fig-5.22). In the area of the first maxillary permanent molar, the bu ccal frenum passes from the oral mucosa of the outer surface of the maxillary ar ch to the inner surface of the cheek. The lingual frenum passes from the floor o f the mouth to the mid-line of the ventral border of the tongue. Fig-5.22 View o f the gingivae and associated anatomic structures. The salivary gland: the saliv ary glands produce saliva that lubricates and cleans the oral cavity and helps i ndigestion. The nervous system controls these glands. The salivary glands have d ucts (openings) to help drain the saliva directly into the oral cavity, where th e saliva is used. The salivary glands may become enlarged, tenders, and possibly firmer due to various disease processes. Certain medications or disease process es may result in decreased or increased production of saliva by these glands (Fi g-5.23). Fig-5.23A Parotid salivary glands. Fig-5.23B Submandibular salivary gland. Fig-5 .23C Sublingual salivary gland. The hard and soft plate: The hard and soft palat e serves as the roof of the mouth and separate it from the nasal cavity (Fig-5.2 4). Fig-5.24 A Surface features of the hard palate. Fig-5.24B Surface features o f the soft palate. The gag reflex: The gag reflex is an involuntary protective mechanism located in the posterior region of the mouth. This very sensitive area includes the soft p alate, the uvula, the surrounding tissue, and the posterior portion of the tongu e. Contact of a foreign body with the membrane of this area causes gagging, retc hing, or vomiting when placing impression trays or working in the mouth. It is v ery important to avoid stimulating the gag reflex. The alveolar process: The alv eolar process is the extension of the bones that form the mandible and the maxil la. The teeth are held firmly in place within the bone of the alveolar process. The cortical plate is known as cribriform plate, is the dense outer layer of bon e covering. The alveolar process that provides strength and protection. The cort ical plate of mandible is dense with a few openings but the cortical plate of ma xilla is not as dense. The alveolar crest is

the highest point of the alveolar ridge. In an unhealthy mouth, the alveolar cre st can be destroyed. The alveolar socket is the space within the alveolar proces s in which the root of a tooth is held in place by the periodontal ligament (Fig -5.25). Fig-5.25 The alveolar crest as it appears in a radiograph. The oral muco sa: the entire mouth is lined with mucous membrane tissue (Fig-5.26). There are two types of oral mucosa. The ventral surface of the lining mucosa covers the in side of the cheeks, vestibule, the lips, the ventral surface of the tongue, and the soft palate. This is tissue is delicate and thin, and is easily injured. The mesticatory mucosa covers the gingivae (Gums), the hard pate, stand the vigorou s activity of chewing and swallowing food. and the dorsum of the tongue. This ti ssue is firmly attached to the bone and is very dense. It is designed to withsta nd the vigorous activity of chewing and swallowing food. The gingivae: the gingi vae are the tissues that surround the teeth (Fig-5.26). The gingivae (Plural gin givae), commonly referred to as gum is masticatory mucosa that cover the alveola r process of the jaw and surrounds the necks of the teeth. Healthy gingivae cove r the alveolar bone and attach to the teeth on the enamel surface just above the neck of the tooth. This is known as the epithelial attachment. The free gingiva e are the part of the gingival that extends higher than the epithelial attachmen t. The gingival sulcus is the space between the free gingivae and the tooth. Fig -5.26 A dense masticatory type of mucosa makes up the gingival, B the delicate l ining type of mucosa covers the vestibule. The teeth Each tooth consists of a cr own and one or more roots. The size and shape of the crown and the size and numb er of roots vary according to the type of the tooth. Humans eat a diet that incl udes meats, vegetables, grains, and fruits. To accommodate this variety in our d iet, our teeth are designed for cutting, shearing, or incising, tearing, and gri nding different types of food (Table-5.4). Table-5.4 Type of teeth and their function. Type of tooth Incisors Characteristi cs Functions Canines

Premolars Molars Single-rooted teeth with a relatively sharp and thin edge. Located at the front of the mouth. Also known as cuspids, they are located at the corner of the dental arch. The crown is thick, with one well-developed pointed cusp .Because o f their long root; canines are the most stable teeth in the mouth and usually th e last teeth to be lost. Also known as, bicuspids are similar to canines in that they have points and cusps. They have a broader chewing surface. There are no p remolars in the primary dentition. The molars have more cusps than the other tee th in the dentition. They have shorter, blunter cusps to provide a chewing surfa ce. Designed to cut food without heavy force. Designed for cutting and tearing o f food that requires the application of force. Designed for grasping and tearing, they also have a broader surface for chewing. Designed for chewing and grinding solid masses of food those require the applic ation of heavy forces. 6. High Speed Technique. Development of rotary equipment The availability of some method of cutting and shaping of tooth structure and re storation of teeth. Although archeological evidence of dental treatment dates fr om 500 B.C, little is known about the equipment and methods used then. Early dri lls powered by hand are illustrated in Fig-6.1 and Fig-6.2. Much of the subseque nt development leading to present powered cutting equipment can be seen as a sea rch for improved sources of energy and means for holding and controlling the cut ting instrument. This search has culminated in the use of replaceable bladed or abrasive instruments held in a rotary handpiece, usually powered by compressed a ir. Fig-6.1 Early Straight hand drill. Fig-6.2 Early angle hand drill. A handpiece is a device for holding rotating instruments, transmitting power to them, and for positioning them intraorally. Handpieces and associated cutting

and polishing instruments developed as two basic types, straight and angle (fig6 .3). Most of the development of methods for preparing teeth has occurred within the last 100 years. Effective equipment for removal (or preparation) of enamel h as been available only since 1947, when speeds of 10,000rpm were first used alon g with newly marketed carbide burs and diamond instruments. Since 1953, continue d improvements in the design and construction of instrument. Table-6.1 summarize s some significant development of high-speed dental equipments. In 1914, a denta l unit was introduced as initial handpiece and operating speed 5000 RPM, it was remain until 1946 (Fig-6.4). In 1950, speeds of 60,000 rpm and greater had been attained by newly designed equipment employing speed-multiplying internal belt d rives (Fig-6.5). The contra angle handpiece with internal turbine drives in the contra-angle head with water driven unit (fig-6.6), and air driven unit (Fig6.7A ). The design of straight handpiece turbine provided the high torque for lowspee d operation (fig-6.7B). Since 1955, angle headpieces have had an air-water spray feature to provide cooling cleansing and improved visibility (fig-6.8) and the most modern-angled handpieces include fiber optic lighting (Fig-6.8B). Fig-6.3 C onventional designs of with handpieces. electric motor. Fig-6.4 Typical equipmen t Fig-6.5 First belt-drive angle handpiece (1955) at speed > 100,000. Fig-6.6 Turb o-jet portable Unit (Circa 1955) (1980) Fig-6.7 Air-turbine handpiece, A. Airoto (1957), B. Straight handpiece Fig-6.8 Contemporary air-turbine handpiece (Circe 1994), A. Contrangle handpiece , B. Contrangle handpiece with fiber optic Table-6.1 Evolution of rotary equipme nt in dentistry. Date Instrument Speed (RPM) 1728 1871 1874 1914 1942 1946 1947 1953 1955 1955 1957 1961 1962 1962 Hand-rotated instruments Foot engine Electric engine Dental unit Diamond cutting instruments Old unit converted to increase s peed Tungsten carbide burs

Ball bearing handpiece Water turbine angle handpiece Belt-driven angle handpiece (Page-Chayes) Air turbine angle handpiece Air turbine straight handpiece Experi mental air bearing handpiece Contemporary air turbine handpiece 300 700 1000 500 0 5000 10000 12000 25000 50000 150000 250000 25000 800000 300000 Rotary speed ra nge The rotational speed of an instrument is measured in revolutions per minute (rpm ). Three speed ranges are generally recognized: low or slow speeds (< 12,000 rpm ), medium or intermediate speeds (12,000 200,000 rpm), and high speeds (> 200,00 0 rpm). At high speed, the surface speed needed for efficient cutting can be att ained with smaller and more versatile cutting instruments. This speed is used fo r tooth preparation and removing old restorations. Other advantages are the foll owing:(1) Diamond and carbide cutting instruments remove tooth structure faster with less pressure, vibration, and heat generation; (2) the number of rotary cut ting instruments needed is reduced because smaller sizes are move universal in a pplication;(3) the operator has better control and greater ease of operation; (4 ) instruments last longer; (5) patients are generally less apprehensive because annoying vibrations and operating time are decreased; and (6) several teeth in t he same arch can and should be treated at the same appointment. For infection co ntrol, all the handpieces must be sterilized. Laser equipment Lasers are devices that produce beams of coherent and very high intensity light. Numerous current and potential uses of lasers in dentistry have been identified that involve the treatment of soft tissues and the modification of hard tooth s tructures. The word laser is an acronym for light amplification by stimulated em ission of radiation. Several types of lasers (Fig-6.9) are available (table-6.2) based on wavelengths. The laser range from long wavelengths (infrared), through visible wavelengths, short wavelengths (UV). Several lasers are practical impor tance to medicine and dentistry (Table6-3). The most currently interest to denti stry are Nd: YAG (Fig-6.9A). A B Unit. C Fig-6.9A. Er;YAG & CO2 laser, B. Nd;YAG laser, C.Er;Cr:YSGG laser

Table 6-2 Laser Types by Source and Wavelength Type Source Wavelength (nm) Mode Infrared Visible Ultraviolet (Excimer) CO2 Er,Cr: YSGG Er: YAG Ho: YAG Nd: YAG Diode Lase r HeNe KTP Argon XeF XeCl KrF ArF 10,600 2780 2940 2060 1064 812;980 633 532 514,488 351 308 248 193 Continuous Continuous, Pulsed Continuous, Pulsed Pulsed Pulsed, Continuous Pulsed, Continuous Continuous,

Continuous, Continuous, Pulsed Pulsed Pulsed Pulsed Table6-3 Suggested Dental Applications for Some Laser Types Applications CO2 Ho: YAG Nd:YAG HeNe Argon Excimers Cutting and coagulation Stimulation of healing Analgesia (low power) Fissure sea ling Caries treatment Composite curing Surface modification Root canal Apicoecto my Root sealing Gingivectomy X X X X X X X X X X X X X X X X X X X X X

X X X X X X X X X X X Other equipment Alternative methods of cutting enamel and dentin have been assessed periodically . In the mid-1950s, air-abrasive cutting was tested, but several clinical proble ms precluded general acceptance. Most importantly, no tactile sense was associat ed with air-abrasive cutting of tooth structure. This made it difficult for the operator to determine the cutting progress within the tooth preparation. Additio nally, the abrasive dust interfered with visibility of the cutting site and tend ed to mechanically etch the surface of the dental mirror. Preventing the patient or office personnel from inhaling abrasive dust posed an additional difficulty. Contemporary air abrasion equipment (Fig-6.10) is helpful for stain removal, de briding pits and fissures before sealing, and micromechanical roughening of surf aces to be bonded (enamel, cast metal alloys, or porcelain). The energy transfer event is affected by many things, including powder particle, pressure, angulati ons, surface composition, and clearance angle variable (Fig-6.11) and the toothcleaning unit (Fig-6.12). Fig-6.10 Example of contemporary air abrasion unit for removal of superficial enamel defects or stains, debriding pits and fissures fo r sealant application, or roughening surfaces to be bounded or luted. Fig-6.11 Schematic representation of range of variables associated with any type of air abrasion equipment. Fig-6.12 Example of air abrasion equipment used for tooth cleaning. Rotary cutti ng instruments

Common Design Characteristics Despite the great variation among rotary cutting i nstruments, they share certain design features. Each instrument consist of three parts (1) shank, (2) neck, and (3) head (Fig-6.13). Each has its own function, influencing its design and the materials used for its construction. There is a d ifference in the meaning of the term shank as applied to rotary instruments and to hand instruments. Fig-6.13 Normal design for three part of rotary cutting instrument. Shank design . The shank is the part that fits into the handpiece, accepts the rotary motion from the handpiece, and provides bearing surface to control the alignment and co ncentricity of the instrument. The shank design and dimensions vary with the han d-piece for which it is intended. The American dental association (ADA) Specific ation No.23 for dental excavating burs includes five classed of instrument shank . Three of these burs (Fig-6.14) are the straight handpiece shank, the latch-typ e angle handpiece shank, and the friction-grip angle handpiece shankare commonly encountered. The shank portion of the straight handpiece instrument is a simple cylinder. It is held in the handpiece by a metal chuck that accepts a rang of s hank diameters. Precise control of the shank diameter is not as crucial as for o ther shank designs. Straight handpiece instruments are now rarely used for prepa ring teeth except for caries excavation. They are commonly used, however, for fi nishing and polishing completed restorations. Fig-6.14 Typical dimensions (in inches) of three common instrument shank for str aight handpiece, latch-angle handpiece, and friction-grip angle handpice type Neck Design. As shown in Fig-6.15, the neck is the intermediate portion of an in strument that connects the head to the shank. Head Design. The head is the worki ng part of the instrument, the cutting edge or points that perform the desired s haping of tooth structure. The shape of the head and the material used to constr uct it are closely related to its intended application and technique of use. The head is rotary instrument and it is divided into blade and abrasive instruments . Fig-6.15 Basic bur head shape. Dental Burs. The term bur is applied to all rotary cutting instruments, which ha ve blade-cutting heads. This includes instruments intended for finishing metal r estorations and surgical removal of bone and instruments primarily intended for tooth preparation. Bur Classification Systems. To facilitate the description, se lection, and manufacturer of burs, it is highly desirable to have some agree-on shorthand designation, which represents all variables of a particular head desig n by some simple code. In USA, dental burs described in terms of arbitrary numer ical code for head size and shape (e.g., 2 = 1-mm diameter round bur, 57 = 1-mm diameter

straight fissure bur, 34 = 1-mm diameter inverted cone bur). New classification by international dental federation and international standards organization, ten d to use separate designations for shape (A shape name) and size (the head diame ter in tenths of a millimeter) (e.g., round 101, straight fissure plain 010, inv erted cone 008). Shapes. The term bur shape (Fig6-16), refers to the contour or silhouette of the head. The basic head shapes are Round bur; used for initial en try into the tooth, extension of preparation, preparation of retention features, and caries removal. Inverted cone bur; use for undercuts in tooth preparation. Pear shape bur; use for normal length in class I tooth preparation for gold foil and long-length for preparation of amalgam restoration. Straight fissure bur; u se for amalgam tooth preparation. Tapered fissure bur; use for tooth preparation of indirect restoration. Fig-6.16 Burs used in recommended procedures. (X. whee l shape, Y. Flame shape, Z. Tapered cylinder) In recent years, progress toward t he development of an international numbering system for basic bur shapes and siz es are shown in Fig-6.16 and table 6-4.The lateral view and a cross-sectional vi ew of crosscut tapered fissure bur is shown in Fig-6.17. The actual cutting acti on of a bur occurs in a very small region at the edge of the blade (Fig-6.17). F ig-6.17 Design features of bur head. Table-6.4 Name and key dimensions of recomm ended burs ISO size number Shape Head diameter (mm) Manufacturers size number ADA size number Head length (mm) Taper angle (degree) 2 4 33 S 33 169 169 L 329 330 245 271 272 2 4 - 006 33 169 169 L

329 330 330 L 171 172 006 005 006 010 014 0.60 006 009 009 007 008 008 012 016 0 .50 0.60 1.00 1.40 0.45 0.60 0.90 0.90 0.70 0.80 0.80 1.20 1.60 0.40 0.48 0.80 1 .10 12 0.45 4.30 5.60 0.85 1.00 3.00 4.00 5.00 12 6 4 8 8

4 6 6 Round Round Round Round Inverted cone Inverted cone Tapered fissure Elonga ted TF Pear, normal length Pear, normal length Pear, long length Tapered fissure Tapered fissure Fig-6.18 Bur blade design. Diamond abrasive instruments The second major category of rotary dental cutting instruments involves abrasive rather than blade cutting. Abrasive instruments are based on small, angular par ticles of a hard substance held in a matrix of softer particles protrude from th e matrix, rather than along a continuous blade edge. This difference in design c auses definite differences in the mechanisms by which the two types of instrumen ts cut and in the applications for which they are best suited. Terminology; Diam ond instruments consist of three parts: a metal blank, the powdered diamond abra sive, and a metallic bonding material that holds the diamond powder onto the bla nk (Fig-6.19). The blank in many ways resembles a bur without blades. It has the same essential parts: head, neck, and shank. Classification; Diamond instrument s currently are marketed in myriad head shapes and sizes (Table 7-5) and in all of the standard shank designs. Parallel those for burs (Fig-20). Fig-6.19 Diamon d instrument construction. Fig-6.20 Characteristic shapes and designs for a rang e of Diamond cutting instruments. Table-6.5 Standard Categories of shapes and sizes for Diamond Cutting Instrument Head Shapes Profile Variation Round Football Barrel Cylinder

Inverted cone Taper Flame Curettage Pear Needle Interproximal Doughnut Wheel -Po inted -Flat-, bevel-, round- or , sate end -Flat-, round-, or safe end ---Christ mas tree Occlusal anatomy --Head Shapes and Sizes; Diamond instruments are available in a wide variety of sh apes and in sizes that correspond to all except the smallest-diameter burs. The greatest difference lies in the diversity of other sizes and shapes in which dia mond instruments are produced. Even with many subdivisions, the size range withi n each group is large compared with that found among the burs. More than 200 sha pes and sizes of diamonds are currently marketed. 1. 2. 3. 4. 1. 2. 3. 4. 5. Cut ting recommendations Evaluation of cutting Blade cutting Abrasive cutting Cuttin g recommendations Hazards with cutting instruments Pulpal precautions Soft tissu e precautions Eye precautions Ear precautions Inhalation precautions Reference: Pickard HM, 1970 A Manual of Operative Dentistry, 3rd. ed, Oxford University Pre ss. Robinson DS, Bird DL, 2007 Essentials of Dental Assisting, 4th. ed,

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