Evaluation of Amalgam and Amalgam Restorations

Presented by Fatema Yusuf

ContentsContd
Clinical signs.
Secondary caries . Tooth and restoration fractures.
Creep and marginal fracture. Mahlers scale.

Corrosion and tarnish. Amalgam blues and tattoo.

According to radiographic findings.

Overhanging restorations. Pulp and periodontal involvement. Marginal fractures. Tooth fractures.

Contents
Introduction. Definition. Evaluation of amalgam.
Acc to patients symptoms. Acc to clinical signs. Acc to radiographic findings.

Patient Symptoms.
Hyperocclusion. Crack tooth. Galvanism. Delayed expansion.

Contents.Contd
Failures of amalgam restoration.
Improper selection of case. Faulty cavity preparation. Poor matrix adaptation. Faulty amalgam manipulation.

Fractures due to pins used for retention. Repair of amalgam restorations. Wear of amalgam restorations. Amalgam bonding. Conclusion. Reference.

Introduction
160 years of dental amalgam. Sir Regnart G V Black

Dental Amalgam
An alloy of mercury, silver, copper, tin which may also contain palladium, zinc and other elements to improve handling characteristics and clinical performance.

Evaluation of Amalgam Restorations

According to patients symptoms. According to clinical signs. According to radiographic findings.

According to patients symptoms

Post operative pain???? Hyperocclusion. Cracks in the tooth. Galvanism. Delayed Expansion. Inadequate pulp protection. Amalgam Blues ???? Penetration of corrosion products into dentinal tubules.

Hyperocclusion
Surface of restoration should be examined for shiny abrasive marks that indicate possibility of hyper occlusion. Pain will disappear soon after occlusion is properly adjusted.

Cracks in the tooth

Development of cracks in the tooth may have developed by removing too much of remaining tooth structure and weakening the cusp. Replacement of amalgam and hooding of weakened cusps. I.e. onlay restoration. Minor cracks incase of vital tooth, an interim solution can be etching of the crack walls and bonding of the fissures.

Galvanism

Small electric currents present when dissimilar metal restoration are in contact or in occlusion with amalgam. Due to its multi phase nature galvanism is inherent in amalgam restoration.

Delayed Expansion
Caused by internal pressure exerted by Hydrogen gas.
Large expansion begins 4 to 5 days after condensation. Delayed expansion of amalgam often causes intense pain.

Amalgam Blues
Chemical byproducts of corrosive process include tin oxide, copper oxide and silver sulphides. All of them are free to migrate towards the pulp tissue if the pulp dentine organ is left unprotected or if diffusion activity is increased by galvanic and thermal energy.

Amalgam Tattoo

According to Clinical Signs

At Visual Level.
Secondary caries. Marginal fracture. Bulk fracture. Tooth fracture. Dimensional changes.

At micro structural level.

Corrosion and tarnish. Stress associated with masticatory forces.

Secondary Caries

Tooth & Restoration Fractures.

Bulk Fracture.

Marginal Fracture.

Tooth Fracture.

Creep
Time dependent strain/deformation that is produced by stress ANSI/ADA Spec No 1: < 3% Low Cu: 0.8% - 8% High Cu: <0.1

Mercuroscopic Expansion
Proposed by Jorgensen as an explanation for prevalence of marginal fracture associated with occlusal amalgams.

Mahlers Scale

Corrosion & Tarnish.

Penetrating Corrosion

 Electrochemical Corrosion. Galvanic Corrosion. Local Galvanic Corrosion. Crevice corrosion. Stress Corrosion.

Stress Associated With Masticatory Forces

Amalgams should not be placed in the mouth where large amount of masticatory stress applied and where large amount of tooth structure is lost (or) in case of developmental disorders of the teeth, which will fracture easily due to the brittleness.

According To Radiographic Findings.

Overhanging restorations. Secondary caries. Marginal fractures. Tooth fractures. Pulp and periodontal involvement.

Overhanging Restorations

Pulp And/Or Periodontal Involvement

Failures of Amalgam restorations

Improper Selection of the cases. Faulty cavity preparation. Poor matrix adaptation. Faulty amalgam manipulation.

Selection Of The Cases

Extensive tooth loss and undermined enamel. Areas of high masticatory load where referred failure of amalgam restoration. Extensive proximal caries and abnormal habits like bruxism.

Due To Faulty Cavity Preparation

Greatest single factor for failure. Healey & Philips (1949) * 56% - CAVITY * 42% - MANIPULATION Faulty cavity preparation Recurrence of caries and fracture.

Causes for Failure Occurring at Various Steps

1. 2. Inadequate occlusal extension. Inadequate extension of proximal box.

3.
4. 5.

Overextension of cavity preparation walls.

Amalgam cavity should have minimum depth. Curved Pulpal Floor.

Causes For Failure Occurring At Various Steps

6. 7. Cavosurface Angle Lack of Butt Joint. Failure to round off line angles.

8. Inadequate proximal retention form / Narrow Isthmus.

9. Wide Isthmus Lack of resistance form Masticatory stresses.

10. Incomplete removal of carious tooth material.

Due To Poor Matrix Adaptation

Instability of matrix Distorted restoration, gross marginal excess and improper condensaton and poor strength. Poor contour. Absence of wedge. Premature matrix removal.

Due To Faulty Amalgam Manipulation

Selection of alloy and mercury.
Low copper alloys low strength high creep and undergoes tarnish and corrosion. Mercury alloy ratio.
Hg > 55% - Decreased strength.

 Improper trituration.
Undertriturated Granular and dry. Overtriturated Less working time.

Condensation
Rationale reduce residual mercury, to ensure amalgam reach all parts of the preparation and obtain homogenous restoration devoid of voids. Effectiveness of removing residual mercury is possible only if used within 4 minutes from trituration.

Condensation
Delayed use do not allow proper condensation and also do not remove mercury from the restoration. Larger cavities multiple mix should be used to get homogenous restoration. Excessive removal of mercury reduces strength.

Contamination
Moisture contamination can occur during:
Trituration. Mulling. Condensation.

Weaken the restoration especially if amalgam contains zinc. It result in marginal flaws, tarnish, pitting, corrosion and blistering. Expansion may also lead to pain.

Finishing and Polishing

Amalgam should be finished gently. Excess spur like overhangs or thin flakes of amalgam on margins can fracture easily which can leave crevices in vulnerable areas. Overcarving should be avoided as it would reduce the thickness of amalgam resulting in fracture.

Repair Of Amalgam Restorations

Repair Of Amalgam Restorations

When repair of amalgam restoration is carried out a material of different composition should be used to achieve greater repair strength.
C Shen et al Oper Dent 2006

Repairing defective amalgam restoration with resin composite offers a minimally invasive solution compared to replacement; Etch & rinse adhesive systems are suggested to reduce micro leakage.
S B Sehreli Oper Dent 2010

Repair Of Amalgam Restorations

Increase in strength of repaired amalgam restoration with surface treatments like air abrasion, retentive under cuts, roughening with bur.
J P Jessop Oper Dent 1998

Fracture due to pins used for retention.

Fracture of tooth / restoration. Pin position. Length of pin.

Failure of Pin Retained Restoration

Broken Twist Drill

Broken Pin

Perforation into Pulp

Perforation in to Periodontia

Failure of Pin Retained Restoration

Restoration#

Restoration pulls away from pin

Pin Fracture

Dentine Fracture

Pin pulls out along with the restoration

Removal Of Pins From Fractured Restorations

Unwind with artery forcep. With cyanoarcylate glue. To bond a tube to the pin with adhesive which may faciliate unscrewing the pin with forceps. With a rotating bur producing anticlockwise rotation. With ultrasonic tips.

Amalgam Bonding
Adhesive systems designed to bond amalgam to enamel to dentin introduced to overcome certain disadvantages :

MICROLEAKAGE

LACK OF ADHESION

ADDITIONAL
RETENTION

NEED FOR

Amalgam Bonding
One of the first attempts to improve retention & seal of amalgam.
Painting the cavity walls with a thin coat of zinc phosphate condensing wet amalgam immediately.

Zardiackas 1976
POLYCARBOXYL ATE CEMENT

SELECTIVE INTERFACIAL AMALGAMATION LINER

AMALGA M ALLOY PARTICL ES

This liner tensile bond strength 3.5 Mpa Shear bond strength 15 M

Current Adhesives Used To Bond Amalgam.

ALL BOND 2 (BISCO). AMALGABOND PLUS with HPA Powder. OPTIBOND 2 (KERR). PANAVIA EX. PANAVIA 21.

Procedure Of Amalgam Bonding

Conditioned enamel dull white appearance.

Three coats of adhesive primer ( Primer A + Primer B ) have been applied.

Procedure Of Amalgam Bonding

The dentin enamel bonding agent is applied with a disposable brush ( All Bond Liner F )

Amalgam is condensed into the cavity before the auto curing bonding agent is polymerized

Procedure Of Amalgam Bonding

Restoration is carved.

Finished and polished restoration.

Wear Of Amalgam Restoration

Conclusion

References
Art & Science Of Operative Dentistry ,5th Edition- Theodore M Roberson. Science Of Dental Materials,10th EditionSkinners. Operative Dentistry- Satish Chandra. Fundamentals Of Operative Dentistry: A Contempary Approach 3rd EditionSummit. Textbook Of Operative Dentistry, 2nd Edition- Vimal K Sikri.