Direct Restorations Study Questions

Quarter 2011 RFE 211

1.

Spring

Describe the steps of cavity preparation covered under (1) external form and (2) internal
form with specific ideal measurements for a competency examination on a class 2 cavity
preparation for amalgam restoration.
EXTERNAL FORM
Outline form
Smooth-flowing form across occlusal outline
Centered isthmus / s-curve to proximal wall where required
Dovetail adjacent to marginal ridge / fishtail around distal cusp
Outline size
0.9 1.3 mm isthmus width
0.9 1.3 mm buccal fissure and lingual fissure extensions (molars)
0.25 0.5mm dovetail extensions buccolingually
0.8 1.0 mm distal and distobuccal fissure extensions (fishtail at distal cusp)
Buccoproximal and Linguoproximal walls
Proximal walls parallel to embrasures (func. cusp acute; nonfunc.cusp - 90)
0.5 mm (0.25 0.75 mm) buccal and lingual wall clearance
Gingival wall
Horizontal: buccolingually
0.5 mm (0.5 1.0 mm) gingival wall clearance
Cavosurface margins
Smooth-flowing, supported enamel margins
INTERNAL FORM
Pulpal wall
1.5 1.9 mm pulpal wall depth, parallel to occlusal table of tooth
Occlusal walls
Buccal and lingual walls slightly convergent occlusally
Supported marginal ridge (mesial / distal wall slightly divergent)
Proximal walls
90 exit angles at bucco- and linguo-proximal walls to cavosurface (occ view)
Gingival wall with supported enamel rods
Axial wall
1.0 1.5 mm axial wall depth
Axial wall is at obtuse angle to gingival wall; rounded axiopulpal line angle
Buccal and lingual retention grooves
At axioproximal line angles, buccal & lingual 0.25 mm depth, definitive shape

2.

Compare and contrast class 5 and root caries preparations designed to receive amalgam,
composite resin, and glass ionomer restorative material. Include in your response
preparations that occur exclusively in enamel, exclusively in dentin, and half-enamel/half

dentin. Defend your preparation designs with rationale with specific correlation to tooth
structure and dental material characteristics.
Outline Form
o Determined by the carious lesion in clinic
o kidney or crescent shaped
o extends from mesial to distal line angle
o Divergent proximal (mesial and distal) walls
o 2.5 mm tall
Axial wall depth
o Margin in enamel
0.75 mm minimum depth (enamel + dentin)
0.5 mm into dentin if retention groove required
o Margin in dentin
0.75 mm minimum depth
o Axial wall depth just into dentin IF enamel is thick enough for a bevel/retention
o Axial wall depth 0.5 mm into dentin IF thin enamel so retention groove can be
placed
RESISTANCE FORM
o 90 cavosurface angles
o 0.75 mm minimum depth, (0.5 mm inside DEJ if grooves are planned)
o Convex axial wall to conserve tooth structure and protect pulpal tissue
Retention Form
Amalgam (Margin in enamel or dentin)
o Occlusal/incisal and gingival retention grooves
o Extend from mesial to distal point angles
o Extend occlusally/incisally or gingivally

Composite (Micromechanical attachment to enamel & dentin)

o Margin in enamel
45 degree bevels on accessible enamel margins
Increases surface area
Better esthetics
Minimum 0.5 mm bevel width
Groove is optional
o Margin in dentin
Retention grooves
Bond strength of dentin 1/3 of enamel
macromechanical retention using grooves and cones (in dentin
only)
Minimizes effect of shrinkage
Do NOT bevel dentin
Conservation of tooth structure
NO added retentive value

GI
o High caries-risk situations
Fluoride release / recharge
o Non-stress bearing areas
compressive strength (composites are stronger)
1/2 hybrid composite resin
o Limited esthetic demands
Opaque, non-translucent (composites excellent translucency)
Only on root surface
o Prep (root caries w/ limited esthetic demand)
Buccoproximal preparation in root surface
1 1.25 mm axial depth, follow contour of tooth
90 exit angle at all cavosurface margins
Retention grooves optional due to ionic bonding
Half above CEJ, half below w/ deep axial wall
o Prep (deep w/ dentin margins)
Prepare large kidney bean shaped class V
Occlusal margin in enamel, gingival margin in root surface
Extend beyond mesiobuccal and distobuccal line angles
Extend deep axially, ~ 2.0-2.5 mm
0.5-0.75mm ,45 bevel enamel margins
90 exit angles at dentin margin
Optional gingival groove
o Composite preferred for enamel margins
o GI preferred for dentin margins
o Open sandwich: GI on axial wall to dentinal cavosurface margin, partially
covered by composite resin for improved esthetics and abrasion resistance
o GIs coefficient of thermal expansion is most similar to dentin. Thus, GI dentin
bond is better maintained compared to composite resin.
Bottom line
o Amalgam
More durable
When esthetics not of concern
o Composite
More esthetic
Binds well with enamel
Stronger than GI
o GI
Fluoride release
Binds well to dentin
Coefficient of thermal expansion is most similar to dentin bond is
better maintained (compared to composite)
o Anterior teeth

Use sandwhich technique GI for dentin (bonding) & composite for

enamel (bonding, esthetics & abrasion resistance)
o Posterior teeth use amalgam

3.

Your patient requires a full gold crown on #30 due to extensive caries and fractured loss
to the CEJ of the mesiolingual cusp. He cannot afford a gold crown now. Describe the
proper use of retention pins and other retentive features in designing an amalgam
restoration for this tooth that will serve as a foundation restoration for a future full gold or
porcelain-fused-to-metal crown.
Retention pins
o Proper Use of Pins:
Used whenever adequate resistance and retention forms cant be
established with slots, locks, or undercuts only (usually a last
resort)
The pin-retained amalgam is an important adjunct in the
restoration of teeth with extensive caries of fractures
o Proper Pin Placement:
2mm into sound dentin
2mm of pin length
2mm of amalgam over pin (provide space around pin for retention
of restorative material)
1 mm amalgam around pin (provide space around pin for retention
of restorative material)
o Factors Affecting Pin Retention
Type
Self-threading pin most retentive, friction-locked pin is
intermediate, cemented pin least retentive
Surface Characteristics
Number of threads/serrations on pin influence retention
Orientation/Number/ Diameter
Placing pins in nonparallel manner increases their retention
In general, increasing number of pins increases retention
In general, as the diameter of the pin increases
o Things to be Aware of When it Serves as a Foundation Restoration for an
Indirect Cast (i.e. This Specific Question)
The main difference between the use of pins for foundations and
the use of pins in definitive restorations is the distance of the
pinholes from the external surface of the tooth.
For foundations, the pinholes must be located farther from the
external surface of the tooth (farther internally from the DEJ
More bending of the pins may be necessary to allow for adequate
axial reduction of the foundation without exposing the pins during
the cast metal tooth preparation.

Any removal of the restorative material from the circumference of

the pin would compromise its retentive effect.
If the material is removed from more than half the diameter of the
pin, any retentive effect of the pin probably has been eliminated.
Preparations with heavily chamfered margins at a normal
occlusogingival location require pin (and slot) placement at a
greater axial depth.
Proximal retention locks still should be used wherever possible.
The length of the also must be considered to permit adequate
occlusal reduction without exposing the pins
o Other Retentive Features:
o Slot Retention
Slots can be placed in the gingival floor of the preparation
The number of remaining vertical walls determines the indication for slots.
Slots are used to oppose retention locks in vertical walls or to provide
retention where no vertical walls remain.
Slots are generally 0.5 to 1mm in depth and 2-4mm in length. Increasing
the width and depth of the slot does not increase the retentive strength of
the amalgam restoration
o Extending outline form:
occlusal dovetails, fishtails
crossing transverse/oblique ridges
buccal, lingual boxes
o Extending internal shapes/forms
Grooves (B), potholes into gingival wall
Horizontal undercuts away from pulp (C)
vertical grooves through enamel

4.

Describe the various methods and techniques available to address retention form in
intracoronal restorations, including those restored with dental amalgam, composite resin,
and glass ionomer materials.

Retention form means that the design of the preparation must provide for the retention of the
restorative material in the tooth.
Amalgam:
I. Prevent occlusal displacement of restorative material
a. Buccal and lingual walls should converge occlusally. This can be done by holding the
330 bur perpendicular to the occlusal plane. Convergent walls will help retain the
amalgam while keeping enamel rods fully supported by dentin.
b. Convergence of functional cusp wall of proximal box
II. Prevent proximal displacement
a. Dovetail and buccal and lingual extensions
b. Retention grooves at axiobuccal and axiolingual line angles
i. must be in dentin
ii. are extensions of the axial wall

iii. follow curvature of axial wall & DEJ

iv. 0.25 mm depth buccolingually following axial curvature
v. Extends from axioproximogingival point angles to axioproximopulpal
point angles
III. Adhesive systems provide some retention by micromechanically bonding amalgam to tooth
structure and also reducing or eliminating microleakage.
Composite:
I. Bevel enamel margins
a. 45 degree bevels on accessible margins
b. 0.5 mm bevel width minimum
c. DO NOT bevel dentin b/c there is no added retentive value.
Conserve tooth structure.
II. Grooves and coves
a. Margin is in dentin
b. Dentin bond is ONE THIRD of an enamel bond
c. Minimize effect of shrinkage
Glass Ionomer
I. Etching
a. Most conventional glass-ionomer systems require etching the dentinal surfaces to
remove the smear layer, effecting improved adhesion of the glass-ionomer to the
dentin
b. Not all glass-ionomer systems, however, require dentin etching
II. Bonding
a. Some use intermediary bonding agent to facilitate bonding
5.
Describe the advantages and disadvantages of restoring moderately discolored teeth #6
11 using
direct composite resin versus indirect porcelain veneers.
Direct
indirect
Benefit
-less $$
-less sensitive to
-fewer appointments operator technique
-good for cases of
(both in prep and
active dental disease esthetics)
-can be easily
-better for lots of
repaired
teeth bc can be
accomplished more
expeditiously (lab
does esthetics)
-longer
lasting/durable
Disadvantages
-less durable
-seating multiple
-esthetics control in anterior veneers can
total control of
be difficult in one
dentist
appointment
-doing full
-more appointments

composite veneers
is time consuming

6.

-more $$
-more difficult repair
(requires new
crown)

Describe the restorative procedures that may be used to build up the coronal foundation
of an endodontically treated tooth that will be receiving an indirect restoration. Include
retentive options such as bonding, grooves, undercuts, pins, posts, and dowel cores.
Purpose of coronal build up
o Retain the final restoration (MOST IMPORTANT PURPOSE)
o Protect remaining tooth structure
o Provide smooth form of the preparation
Contraindications
o Poor periodontal prognosis
o Presence of extensive gingival caries at or apical to level of alveolar bone
o Root to crown ratio which is LESS than 1:1
Buildup vs block out
o Buildup replaces cusp or axial wall necessary for retention of the final restoration
Involves pins, prefabricated dowels, custom cast dowel cores or other
mechanical retention
o Bonding composite does NOT constitute a buildup
o Blockout replaces defect or irregularity in axial or pulpal wall, and smoothes wall
NOT necessary for retentionincludes pulp chamber and retained cores
o ALL finish lines for crown preps must be on healthy tooth structure
o 5 mm of gutta percha must remain at apex of canal
Types of buildups
o Vital teeth (NOTE THIS SPECIFIC QUESTION ONLY ASKS ABOUT NON
VITAL TEETH)
Self threaded pins
2-2-2-1: 2mm into sound dentin, 2mm pin length, 2mm of
amalgam over pin, 1mm amalgam around pin
Build up with amalgam, composite or glass ionomer
Amalgam and composite resin build ups which are retained by slots,
grooves, boxes and other internal retentive features or combinations of
these
o NON Vital teeth (or badly broken down vital teeth with questionable pulpal
statusdo RCT)
Custom cast dowel cores (severely broken anterior teeth)
Separate from final restoration
Post and core are one casting
Primarily used in anterior or single rooted teeth (usually oval
shaped canals)
Irregular shape adapts to walls of canalincreasing retention and
resisting rotation

Keyway to increase resistance to rotation in occlusal portion of

toothonly needs to be 2mm in depth toward apical portion of
tooth
Procedure
Place reverse bevel over remaining tooth structure if possible
reinforces tooth structure (Ferrule effect)
NO EXPANSION when investing and casting
Preformed dowels (paraposts) retaining amalgam or composite resin
Build up as with threaded pinsamalgam or resin buildup
Primarily used for multi-rooted teeth (usually round canals)
therefore buildup can be retained very well with multiple posts
Cemented (passive retention) or threaded (active retention)
o Cementedrely on close adaptation and embedment depth
in root for retention
o Threadedmore retentive, but create more stress and can
cause failure by cracking rootUSE SPARINGLY AND
ONLY IF ALTERNATIVE IS EXTRACTIONImplant
may be better here
IndicationTwo missing adjacent axial wallspost necessary
Usually largest, longest and straightest canals
Embedment depth ideally is 2/3 length of root and approximate
length of crown
Can utilize undercuts in the chamber to help with retention of
buildup
Amalgamstronger, more stable and the preferred material
Blue chemical cure compositeshapes easily and can differentiate
from tooth structure
Finish line MUST be at least 0.5 mm apical to buildup
Internal retentive features like boxes or grooves may NOT be
placed in build except as an axial wall
Amalgam and composite resin cores retained by the chamber and
extensions into the canals (relatively intact teeth)
Composite core
o Lingual accessUse round bur to remove gutta percha
below tissue levelseal with glass ionomer
o BEVEL cavosurfaceetch, prime, bond dentin and
enamelcomposite incrementscontour, finish and polish
Amalgam core
o Amalgam core can act as a temporary
o Minimum thickness of 2 mm over cusps
o Adhesive cement base seals gutta percha
Material placed into canal(s) 2-3 mm
Chamber used for additional retention

Grooves
o Verticallyin boxes and along axial proximal line angles
o Horizontallyinto gingival wall (also use potholes here)

7.

Describe the clinical indications and contraindications for dental amalgam, composite
resin, and glass ionomer as restorative materials in posterior teeth.
Composite:
Indications
when esthetics are of concern
small and moderate restorations, preferably with enamel margins
restoration that can be properly isolated during the procedure
restorations that do not have heavy occlusal contacts or does not provide all of the
occlusal contacts
restorations that may serve as foundations for crowns
large restorations that are used to strengthen remaining weakened tooth structure
conservation of tooth structure in small lesions
Contraindications
when operating site cannot be isolated
when there are heavy occlusal stresses (bruxism) and when those contacts are on
composite only
restorations that extend to the root surface
Amalgam:
Indications
moderate to large Class I and IIs, esp with the following:
when there is heavy occlusal functioning and when the restoration must
restore all of the occlusal contacts of the tooth
when isolation is not so critical (minor contamination during the procedure is
not too bad)
extends into the root surface
Class V restorations when:
esthetics are not of a concern
cannot be well isolated
located entirely on root surface
temporary caries-control restoration when teeth are badly broken down and require an
assessment of pulpal health before a final restoration
foundations for badly-broken teeth that require more retention and resistance form
before crown or onlay placement
lower cost
Contraindications
when esthetics is of major concern to patient (esp on the premolars)
small to moderate defects
less conservative
weakens tooth structure

Glass Ionomer:
Indications
root surface caries because of anticariogenic quality and adhesion to dentin
cementation of crowns
RMGI-indicated for class V restorations bc of sustained F release in individuals with high
caries risk
RMGI are preferred to conventional glass ionomer bc of extended working time,
improved physical and esthetic properties. RMGI are more resistant to dehydration and
cracking than conventional
If access permites-use RMGI in slot preps of class II or III
High caries or gingival recession of proximal root surfaces
Contraindications
technique sensitive
low resistance to wear and low strength= NOT INDICATED FOR POSTERIOR
OCCLUSAL
conventional glass ionomer are not in indicated for root surfaces of high esthetics
8.
Describe the materials and procedures used to permanently restore an endodontic
access opening through porcelain in tooth #8, which has an otherwise intact PFM crown.

9.

Composite Core and Restoration Technique

o Lingual access remove cavit and cotton pellet
use diamond for preparation through porcelain
o Use round bur on slow speed to remove gutta percha below tissue level
o Remove all pulp remnants and staining in coronal area
o Seal gutta percha with chemically set glass ionomer
o Bevel lingual cavosurface
o Etch and prime dentin and enamel
o Add composite in 1mm increments and light cure
o Etch (HF acid) and silanate porcelain margins
o Contour lingual, finish, and polish
Describe to a patient the advantages and disadvantages of dental amalgam, composite
resin, indirect gold, indirect gold and porcelain, and indirect ceramic for restoring tooth
#19, which requires replacement of a large MOD composite because of recurrent caries.
Amalgam
Advantages
Inexpensive
Single office visit
Wears well holds up to forces of
biting as well
Self-sealing [minimal-to-no-shrinkage]

Disadvantages
Not tooth colored
May stain teeth over time
Requires removal of some healthy tooth
Remaining tooth may weaken and
fracture

Durable and long-lasting

Metal can also conduct hot/cold

temperatures
Contact with other metals may cause
electrical flow

Composite Resin
Advantages
Disadvantages
Costs less than indirect restorations
Not recommended for biting surfaces
of adults
Single office visit
wears faster than amalgam/indirect
restorations
Good esthetics
Technique/moisture sensitive
Minimal amount of tooth needs to be
Costs more than dental amalgam
removed
Bonds well to enamel and dentin
Shrinkage of material could lead to
open margins
Indirect Gold
Advantages
Good resistance to further decay if fit
well
Excellent durability
Does not corrode in the mouth
Minimal amount of tooth needs to be
removed
Wears well [little/no opposing tooth
wear]
Resists leakage
Advantages
Biocompatible
High hardness
High compressive strength
Excellent optical Properties

Disadvantages
Not tooth colored
Conducts heat and cold
High cost
Two office visits

Dental Porcelain
Disadvantages
Brittle [Inability to Flex]
Opposing tooth wear
More aggressive preparation
High cost
Two office visits

Indirect Ceramic
Advantages
Disadvantages
Less abrasive than Porcelain
Material is brittle
[wear coefficient similar to enamel]
Flexural strength > feldspathic
May not be recommended for posterior
porcelain
teeth
More consistent physical properties
Aggressive preparation
Improved Esthetics (vs. PFM)
High cost

Patient desire to be metal-free

Two office visits

Material Choice of tooth-colored materials is functionally driven

- Resistance to fracture and wear
NOTE: This is NOT a comprehensive list. I tried to brainstorm as much as I could, but I
am sure you could think of more. This is more of a solid backbone for a good answer.
10.

Describe the specific generic materials and procedures to properly prepare and bond
composite resin to a cavity preparation.
Class V Composite (Micromechanical attachment to enamel & dentin)
o Margin in enamel
45 degree bevels on accessible enamel margins
Increases surface area
Better esthetics
Minimum 0.5 mm bevel width
Groove is optional
o Margin in dentin
Retention grooves
Bond strength of dentin 1/3 of enamel
macromechanical retention using grooves and coves (in dentin
only)
Minimizes effect of shrinkage
Do NOT bevel dentin
Conservation of tooth structure
NO added retentive value
-Isolate from fluids by using a rubber dam or cotton roll and retraction cord.
-The wedge and matrix is then placed. The matrix will reduce excess material and
minimize finishing time. The wedge should seal the gingival cavosurface margin and the
matrix burnished for proper proximal contour
-The proximal surfaces of adjacent unprepared tooth should be protected from
inadvertent etching by placement of a polyester strip.
-Placing the matrix first allows one to assess cavosurface margins, and protect adjacent
teeth.
-Etching enamel affects the prism core and periphery. Etching dentin affects the
intertubular and peritubular dentin resulting in enlarging the tubular openings. Most
etchants are in concentrations of 32%-37% phosphoric acid. Usually a syringe applicator
is used to inject the gel etchant directly onto the prepared tooth surface. The acid should
be kept to a maximum of .5mm past the anticipated extent of the restoration. An etching
time of 15 s for dentin and 30 s for enamel is considered sufficient. The area is rinsed
with water for 5s, starting on the adjacent tooth. The area is then lightly dried leaving any
dentin exposed moist so that primer and adhesive materials can penetrate the collagen
more effectively to form a hybrid layer ( micromechanical bond). Enamel should have a
frosted appearance.

-Primer is applied to all of the prepared tooth structure with a microbrush. The
manufacturers directions specify how long to apply the primer and how long it should be
cured. In all cases, dentin should be uniformly shiny after primer application.
-Another micobrush is used to place adhesive on the tooth structure that was etched and
primed. Every effort should be made to prevent the adhesive from pooling. The adhesive
is lightly dried with the air syringe to evaporate any solvent. The adhesive is the light
cured as directed.
-Composite can be placed with a hand instrument or with a syringe. Resin should be
added in increments of 1-2 mm. If the composite thickness exceeds 1.5-2mm, the light
intensity can be inadequate and produce incomplete curing of the composite. The
camphoroquinone in the composite is the photoinitiator and absorbs photon light energy
from the LED light at 474nm. The composite should be cured incrementely for 20-30s.
The dentist should limit the ratio of bound-to-unbound surfaces to less than 1.5 to limit
the interfacial stresses and shrinkage stresses. Therefore the dentist should not bulk fill
but layer the walls with composite.
11.

Discuss the role of copper in high-copper dental amalgam and its impact on physical and
mechanical properties.
-

12.

High-Copper-Content dental amalgams are made by mixing three ingredients:

Ag-Sn alloy
Ag-Cu alloy
Mercury
There is high reactivity of Cu with Sn.
When Ag-Sn is mixed with Mercury, (1) Ag-Hg and (2)Sn-Hg phases form.
But almost as quickly as Sn-Hg (2) phase forms, the phase is eliminated by competitive reaction
of Cu with Sn. [Cu6Sn5]
2 (Hg-Sn) is more sensitive to corrosion and weaker than 1 (Ag-Hg)
So, high-copper-content dental amalgam prohibits the formation of more corrosive 2 (Sn-Hg)
Resulting Properties
Higher compressive strength
More rapid set to full strength
Reduction in creep
Reduced susceptibility to corrosion
Discuss the impact of particle size in the physical properties of composite resin, specifically with
respect to viscosity, polymerization shrinkage, surface finish, and wear resistance.

- Particle size and percentage affects the physical property and clinical indications.
Smaller particles have a greater surface area to volume ratio meaning there is more
bonding with the resin matrix = better FLEXURE strength since there is a great deal of
bonding and requires more flexible matrix to be in the composite material. Also, because
the size of the particles are smaller, this allows for better polishability. However, this also
leads to GREATER VISCOSITY of the composite material and greater shrinkage (which
occurs in the resin matrix phase of the composite material). For these reasons, smaller

particle fillers are used in composites that are in lower stress areas and areas where
greater polish is needed.
Larger particles have greater bulk and allow for more filler loading percentage by
weight. This makes them more resistant to fracture and because there is less resin matrix
between particles, there is less shrinkage as well. However, there is decreased
polishability since the bulky particles stick out when the resin is being removed during
polishing. The clinical use of these larger particle composites (such as traditional
composites) is in areas of greater stress where less polishability is needed.