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OPERATIVE

Amal

All Class III lesions should

filled with composite resin,

because they are esthetically important,

. Both

the statement and the reason are correct and related

. Both the statement and the reason are correct but NOT related . The staternent is correct, but the reason is NOT
. The statement is NOT correct, but the reason is correct

NLITHFR the sratemenr NOR rhe reason is correcr

'|

Cop!riglr

c 20ll-l0l I

- Denhl Dccks

distolingual Class III lesions are relatively nonesthetic and Nar tional Board questions consider the best material whether it be amalgam or direct gold.
Composite resin is not recommended for Class III lesions on the distal-lingual aspect of canines /rse either amalgam or direct gold). Composite material will not maintain the mesiodistal dimension ofthe looth. Note: This may not be entirely true today due to the fact that there are much better wear resistant resins than in the past, however, for National Board questions composite is not recommended for this situation.

*** Think closely,

A lingual approach is made when preparing a Class III dental amalgam preparation for the distal ofa canine because a lingual approach preserves the esthetic value ofthe facial surface.

Remember: . A bite-wing radiograph is the best method to diagnose incipient carious lesions on the distal surface ofcanine teeth. . A diagnostic aid to be used as a last resort to confirm the presence ofa carious lesion on the proximal surface of an anterior tooth is mechanical separation (usually w,ith a
weage).

Rule ofthumb: When two teeth adjacent to each other have Class III lesions, you should prepare the larger one lirst and fill the smaller one first. Access to the preps and shade matching are easier when you do both at the same appointment.

The iderl tmount of dentin required between an amalgam restoration rnd the pulp for insulation is:

.0.5 mm

.l.0mm
. 2.0 mm
. 3.0 mm

Coplrighr O 2011,2012, Dnral Decks

'

A prtlent comes in claiming that thir holistic doctor told hlm that h has rn allergy to mercury and needs only white fillings. Your best response is:

'

. There is no such thing


fillings

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

. You might have mercury allergy, but that is very rare. Plus, there is no mercury in
amrloam fi llinoc

. There is no such thing as a mercury allergy; plus, with proper isolation and technique your exposure will be minirnal
. You might have a mercury allergy, but that is very rare. Plus, with proper isolation and technique your exposure will be minimal

Copright O

201 l-2012 - Dental Decks

**x Amalgam
nrolectiotl).

is a poor thermal

insulator; this is why

a base

ofeither calcium hydrox-

ide or zinc oxide eugenol is placed under most amalgam restorations 60plovide thermal

Comparison of Restorative Msteri!ls Chancteristic


Close adaptation to cavjty walls

Direct Gold Vcry good Verv good


Very good Very good

Amrlgem
Good

Composite
Cood

Coeflicient ofthermal exDansion similar to tooth structure Chemicallv acceDtable to hard and softtissues
Absence ofinitation to gingival High edge strenglh

Cood Cood
Good

Very good Very good


Fair Excellent Good

Non-corroding in oral fluids Insolubiliry in oral fluids Clinical loflge\'ify


High abmsron resisrance Permanently.estores M-D dimension \\'irh
sla nds

N/A
Cood Fair

Ixcel]cnt
Verv good
Cood Cood
F-air

Cood Very good


Cood Cood Poor Good

Fair Fair

masticatory forces
use

\jersatility in

Iair
Fair

Imltates natural tooth color


Ease

very good Very good


Cood

ofmanipulation and placemert Very good

Tlermal and electrical insulator

Thc amount of mercury rcmaining in a set amalgam rcstoration is rclated to how much of thc rnercury-rich matdx is lel-i in thc amalgam after condcnsation. The key is to minimize the amount of matrix which forms during the reaction. By condensing the amalgam nri\turc in the cavity preparation, the mercury-rich matrix will comc to the surface and bc r!'mo\ cd bv subscqucnt condensing and carving. The final amalgam restoration will be .Lrnrposed of mostly residual alloy and vcry little ofthe mercury-rich matrix.

TlIc amount ofmercury remaining in dental amalgam after condensation directly affects: i 1 t th,-. porosity ofthe restoration (2) thc compressive strength ofthc rcstoration (3) the corrt sir,-- rcsistancc ofthc rcstoration and (4) tbe surfacc finish ofthc rcstoration.

\Iercurr is used to initiate the reaction ryith the alloy. Although an amalgam restoration i: non-toric. mercury is poisonous. Free mercury, in thc form of vapor or liquid droplets. r.prcscnts a significant health hazard in the dcntal office. The greatest potential hazard of
chronic nrcrcury toxicity comes from inhalation ofmcrcury vapor. The vaporization is most lrkell to occur during condensation ofthe amalgam (alu,ct1.s use high speed suction). \ote: Nlercury hypersensitivity (allergl') isvery rare (l irt 100 million).

Important point concerning corldensation pressure: The area ofthe condenser point and thc forcc cxcrtcd on it by thc opcrator govcrn the condensation pressurc. The smaller the condenser point. thc greater is thc pressure exerted on the amalgam. By doubling the diameter of the condenser point and doubling the hand pressure applied to the instrument, the operator actually exens lcss condensation pressure.

You would prefer your assistant overtriturate the amalgam rrther than undertriturate it, this is because an overtriturated amalgarn will still haye optimal strength.

. The first statement is true; the second statement is false

. The first statement

is false; the second statement is true

. Both stalements are true

. Both

statements are false

Co$n-shr <

:0ll l0ll

- Denral Decks

All ofthe followings are similarities between amalgam Class II restorations and inlay Class II restorttions EXCEPT one, Which one is the EXCEPTIOM

. Occlusal isthmus width . Depth into dentin . Axio-pulpal line angle shape . Gingival wall form

CoP)righr O 201l'2012 - Denral Decls

The longer the trituration time, the smaller the setting expansion. Ifthe trituration is carried to the extent that the amalgam appears shiny and wet. the strength will be maximal and the smooth, can'ed surface will retain its Iuster long after polishing. A properly tdturated amalgam appears shiny, wet, smooth and homogenous.

Inadequate trituration results in an amalgam mix that has a low strength and a rough surface that will accelerate corrosion. An undertriturated amalgam mixture will appear dry and grainy. Condensing this mixture will result in poor adaptation to the walls of the preparation, lacrimation between condensed increments, and reduced strength.

Remember: An overtriturated

nix

is preferable to an undertrituratd mix.

L The discolored, conoded, superficial layer frequently seen on the surface

of

Iotei'

a dental amalgam restoration is most


2.

likely

sulfide.

When carving an amalgam restoration, be sure to trim the margins with a sharp instrument that rests on tooth structure /t/rr.r r.i/1 prevent " ditching" the Iwrgurs). 3. lfan amalgarr "chips" when you are carving it, the reason for this is that the amalgam was condensed after its working tirre had elapsed.

The gingival n.rargin should clear the contact area to allow lor adequate finishing the enamel marsins and olacement ofa matrix band.

***

of

l/J intcrcuspal (max)


Inclitration of wells with respect
to the occlusal surface

1/3 intercuspal (max)

Buccal and lingual walls converge approximately parallcl to the extemal surface

Form

a reverse

bevel at th axial

gingival line angle, into the


gingivalr,vall

Class V amalgam restorNtions rarly require retentive gfooves, but if they are used, they are placed at the lncisoaxial and gingivoaxial line angles.

. The first statement is true; the second stalement is false . The first statement is false; the second statement is true . Both slalements are true . Both statements are false

Copyrighr C 2011,2012, Denral Decks

Delayed expanslon of amalgam restorations is


associated with which two factors?

. Insufficient tdh.[ation and condensation . High residual mercury

. The contamination ofthe amalgam by moisture during trituration . The failure to use a cavity vamish

and condensation

Cop,righr O

201

l'2012 - Dental Decks

***

Class V amalgam restorations commonly require and utilize retention grooves.

The rtention form for a Class V amalgar.n preparation is provided by the gingival retention groove placed along the gingivoaxial Iine angle and the incisal retention groove placed along the incisoaxial line angle.
The outline form for the classical Class V amalgam preparation is a deformed trapezoid

(sometimescollecl'kidney-shaped").Theoutlineformisdeterminedbythelocationand
size

ofthe carious area.

The non-parallel mesial and distal walls ofthe preparation are straight and parallel to, but never extending beyond, the transitional line angles. The direction olthese walls is determined by the direction ofthe enamel walls (as is the decay pattern).
The occlusal and gingival walls ofthe preparation should be gently curved arcs as deterrrlined by the contour ofth free margin ofthe gingival tissue. Note: These arcs should be as parallel to each other as possible.

lmportant points: L The occlusal arc will normally be the longer of the two. i. The gingival margin will normally be at, or slightly below, the rrargin ofthe free ginsir
a.

-l. For incipient lesions, the axial wall should be uniformly deep into dentin.

1** Important: Thc contaminalion ofthe

amalgam by moisture during tdturation and condcnsation js

unquestlonably the principal cause of failures.

limorsture is incorporatcd into an alloy that contains zinc, thc watcr reacts with the zjnc to produce hydrogcn gas. The resulting pressure from the liberated gas produces severe expansion ofthe amalgam. This
results rn the follorving

clinical manifestations: . lhc amalgam protrudes from the cavity preparation . PosI operative parn

. Erccssivc corrosion
Important points to remcmbcr rcgarding amalgam:
L The compressive sftength js greatly reduced when amalgam is contaminated with moisture. The comp.essr!e strength ofhigh-coppcr amalgam is similar to tooth structure. LThc most imponant problem for amalgam restorations is that they have different cofficients of thermaf erpansion/contr^ction (amalgam: 25 ppnr/"C) compared to tooth structure (10 ppm/'C). During reductions in intraoral temperatllre. there is a strong tendency at thc margins for amalgam rcsroralions to contract away from the margins and allow marginal leakage ol intraoral fluids (petro 1dhir, that arc latcr expelled when the temperature retums to non-nal. i. Thc tensile strength ofamalgam is about one-fifth to one-eighth ofits compressive strcngth. that is \\ht enamel is needed to support amalgam at the margins ofrestomtions. Nole: It is more abrasionresistant than composite resin or unfilled resin. .1. Amalgam is brittle and has a low edge strength. 5. Amalgam is a high thermal conductor. 6. High-copper amalgams exhibit no clinically relevant crccp or flow 7. You need a minimum thickness of0.75 fin axial areds) to |.5-2 mm (in areas ofocclusal conldct) lbr adequate cornpressivc strength.

Proper condns|tion ind carving makes an amalgam restoration stronger because it removes th mercury-rich matrix.

. Both the statement and the reason are correct ard related . Both the statement and the reason are correct but NOT related . The statement is correct, but the reason is NOT

The statement is NOT corect, but the reason is corect


reason is correct

. NEITHER the statement NOR the

Coplright

e 20ll-2012

- Dental Decks

Which phase of the amrlgam re&ction is prone to corrosio, in clinic{l rstorations?

. Gamma . Garrma-one

. Gamma-fwo
. Gamma-three

CopFghtO 20ll-2012

- Dental Decls

The most important consideration in the strength ofthe amalgam is the mercury content. lfthe mercury content exceeds 5570, a dramatic loss in strength results. Amalgam restorations that contain mercury levels ofabout 55% exhibit a high incidence ofmarginal breakdown, fracture, corrosion, and the surface finish olthe restoration is not good.

Factors which influence the final mrcury content of a restoration:

. Original mercury-alloy ratio: specific to each product


that amalgam contains 43% to 50% mercury

but generally less than 1 :1 so

. Amount of trituration

. Condensation

pressure and time involved in carrying out condensation

Very important: Removing the mercury-rich matrix by proper condensation and carving produces a stronger and more corrosion-resistant amalgam because it minimizes the forration of the matrix phases of ar.nalgam, which are the least desirable parts of the set
matenal.

The reaction that occLrrs between the allov Darticles and thc mcrcurv can be sunrmarized as lollows:

Silrcr-tin alloy

,\g:Sn

+ Mercury -)
Hg

Silvcr-tin alloy

(gamma)

AglSn (gamma)

Silver-mcrcury

Ag:Hg:

Tin-mercury
SngHg

(gamma-one) (gamma-two)

Camma is the unreacted alloy. lt is the strongest and corrodes the least. l'onrs 307n ofvolume of sct anialsan. Gamma-one is thc matrix lbr unrcactcd alloy and is thc sccond strongesl phasc. It Frrnni 609'0 ofvolume ofset a)nalgam. Gamma-two is thc wcakcst and softest phase. It is also the most susceptible to corrosion in the mouth and fonns l0olu ofthe volume ofthe sct amalgam. The r olunre of lhe Ganrma-two phase decreases with tirne due to corrosion. Thc kcy drttcrcncc bctwcen the low coppcr and thc high copper amalganls is thal thc low copper
amalgarns contain the gamma-two phase, which is not present in the high copper amalgams. lnstead, the high copper anralgams contain the Cu6Sn5 phase. Since the gamma-two phasc conodcs t'aster rhan the Cu,,Sn5 phase. thc gamma-two phasc containing low copper amalgams develop microporositics duc to corrosion fastcr than thc high coppcr amalgams. Thesc porcsities wcaken the anralcam rnarcins and explain why rnarginal delbcts (chipped riargllr) are more oftcn seen around lo* copper amalgans. This explains why high-copper amalgams should be used rather than the lowcerpper amalgams.

\ot*s ""

l. Smaller particle size results in higher strength, lower tlow, and bctter car'"ability. 2 Spherical amalgams high in copper usually have the bcst tcnsilc and con'rprcssivc
charactcristics. 3. Copper contents over 6yo ("high-copper" alloy,i/ climinate the gamma-two phase by forming a copper-tin fCr6SrJ-, phase resulting in superior propcrties. ,1. Amalgam has a coellicient ofthcrmal cxpansion approrimately tuice that ofloolh structure. 5.The tensile strength ofamalgam is about one-fifth to one-eighth ofits compressive strcngth.

When preparing a class Il amalgam restoratlon, all surface angles should be approximately 90 degrees.

. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both statements are true . Both statements are false

10
CopyriShr O 201l-2012, Dental Decks

Beveling the gingival cavosurface mrrgin of the proximal box ofa Class II amalgam preparation on a permanent tooth:

. Should result in a long bevel .


Is contraindicated because

ofthe low edge strength of amalgam

Should remove unsupported enamel which may fracture

. Is unnecessary since the tooth structure in this area is strong

11

CopFight C 201 I -20

12

- De'tal

Deck

General propenies of Class

lI

amalgam preparations:

. All walls should meet the surlace of the tooth at a 90'angle (butt joint). . Occlusal dovetail; provides resistance to proximal displacement. . Pulpal floor should be flat same as Class l. . The buccal and lingual walls ofthe proximal section should converge occlusally the extension ofthese walls is determined primarily by the position ofthe adjacent teeth in relation to the tooth being restored. . The buccal, lingual, and gingival walls should be extended into the embrasures enough to allow easy cleaning areas of lessened caries - is beveled to reduce susceptibility. . The axiopulpal line angle concentration of stresses resistance

fonn.
grooves are placed in the axiobuccal and axiolingual line angles and extendresistance to dislodgement. ofthe axial wall - create a reverse cuNe in the outline. A revelse curve . Lingually, it is often necessary to is a cun'e put into the buccal or lingual wall so the wall meets the extemal surface of the tooth at a 90" angle.
ed to the height

. Retention

\ote: Class ll amalgam preps have independent retention and resistance form fbr both the proximal box and occlusal portion ofthe prcparation.
Important: When caries is extensive, reduction ofone or more ofthe cusps for capping rnay be indicated. When the facial (or lingtnl) extension is two-thirds from the primar) groove torvard the cusp tip, reduction ofthe cusp(s) for amalgam capping is mandatory fbr the developn]ent ofadequate resistance form. Note: The final restomtion has to have restored cusps with a minimal thickness of2 mm of amalgam for functional cusps and l 5 mm of amalgam for nonfunctional cusps.

""* The gingival cavosurface margin is bevered onry ifit is in the enamer. Beveling is not necessary if the gingival margin is within cementum.
The,singir.,al cavosurface margin should be beveled to remove any unsupported enamel. The ber el is usually placed with a gingival margin trimmer. This gingival margin must be be1o* an'existing contact with the adjacent tooth in order to alori pioper finishing ofthe -rrnerlal margin.

\oa

2. Remember: Enamel rods in the gingival third ofthe primary teeth extend occlusally from the DEJ, eliminating the need in Class il preparations for the gingival bevel that is required in permanent teetlt. 3. Primary morar teeth have marked cervicar constriction. Thererore. when preparing the proximal portion ofa Class II cavity prep, a satisfactory gingival seat may be difficult to obtain if the prep extends too deeply gingivally.

L The bevel is no steeper than necessary to ensure lullJength enamel rods fonn_ ing the gingival margin and is no wider than the enamel.

Which tooth requires special attention when preparing the occlusal aspect for a restoration?

. Mandibular first bicuspid


. Mandibular second bicuspid . Maxillary first molar

. Maxillary first bicuspid

12

Coprighr O

201 1,2012 - Denral Dcks

All four wa[s ofa Class I amalgam preparation should diverge slighfly because divetgence prevents undermining ofthe marginal ridges.

. Both the statement and the reason are correct ard related . Both the statement and the reason are correct but NOT related . The statement is conect, but the reason is NOT . The statement is NOT correct, but the reason is correct . NEITHER the statement NOR the reason is correct

13 Cop)right O 201l-2012 - Denial Decks

The key to this question is the angulation ofthe preparation. The bur should be tilted lingually to prevent encroachment on the facial pulp horn and also to maintain dentinal support ofthe lingual cusp. The pulpal floor should be parallel to the occlusal plane ofthe

tooth faciolinsuallv.

\ote:

Pulpal floor slopes to coincide with the slope (height) of the c\sps. Remember: The area olthe tooth that is most sensitive durins cavitv nreparation is DEJ.

Important: . Only nvo walls of a Class I amalgam preparation should diverge, the mesial and distal

Thc. reason is

still true because there are only two marginal ridges per tooth, mesial

and distal

DIVERGING (Correct)

CONVERGING (Incorrect)

This slight occlusal divergence prevents undermining the marginal ridges of their dentin support.

***

, 1. This divergence of the mesial and distal walls holds true for Class I prepat\i..otci'. rations for direct filling gold and gold inlays as well. .,.;:,:,,;,:, 2. For premolars the distance from the margin of the mesial and distal wall to the proximal surface must not be less than 1.6 mm. For molars this minimal
distance is 2 mm.

The matrix band should be removed after condensation ofthe amalgam, but prior to the linal carving ofthe restor|tion. This is because the wedge compensstes for the thickness ofthe matrix band.

. Both the statement ard the reason

are correct and related

. Both the statement and the reason are correct but NOT related . The statement is correct, but the reason is NOT . The statement is NOT correct, but the reason is corect . NEITHER the statement NOR the reason is conect

14

Cop) iehr O

201

1,2012 - Dental Decks

The diagonal slot opening on the Tomemire matrix ret ner (also called the Univercal matrix systeml is always placed facing the gingiva. This:

. Permits

easy separation

ofthe retainer from the band in an occlusal direction

. Allows for better contour ofband to tooth

. Allou's for

easier wedge placement

. Is less harmful on the gingiva

15 Coplright O 20ll-2012 - Dental Decks

Although the wcdge is uscd to cornpensatc for the thickncss ofthe mat x band. the true reason for carving after the rcmoval ofthe band is to gain proper access to all margins ofthe amalgam rcstoration.

lmportant points to remember regarding matrix bands: . The reason lbr placing thc matrix for a Class II amalgam restoration to p.olrude abovc the cavily preparation is to allorv for overfilling, thus enhancing adcquate cavosurface coverage. . Contact arcas are always carefully restorcd in all restorations in order to protect thc gingival
tissuc. Thc matrix band should be bumishcd into contact with adjaccnt tceth, this will help asSUre contact. . One of thc most difficult teeth to adapt thc matrix band to is the mesial of a maxillary first premolar, due to its devefopmental dcpression (co cavity in the cervical thir-d ofthe mesiol sur,

fute oflrc o ortr).

lmportant: The wedging action betwcen the teeth should providc enough separation to compensate for the thickness ofthe matrix band. This will cnsure a positive contact relationship after thc nratrix is rcmovcd following thc condensation and initial carving oflhe anralgam.
Corrrrnon problems associated with amalgam restorations:

. Postoperative sensitivitl . \Iarginal voids:

- \1ay be causcd by inadcquatc condensation, or lack ofpropcr dcntinai sealing


- \1ay be caused by inadequate condcnsation. or amalgarn breaking away from margins when

can ing

.llarginal ridge fractures:

may bc causcd by any ofthe following: - Not rounding the axiopulpal iine angle in Class Il tooth preparations ' \laryinal ridge lcl't too high - Inrpropcr occlusal cn'rbrasurc fomr - hnproper removal ofmatrix band - Or erzealous carving ofthe restoration

In addition. tlte larger circumference ofthe matrix band is alu,ays placed toward the occlusal surlace ofthe tooth. This acconnnodates for the larger tooth circumference at the contact level. The primary function ofthe matrix band is to restore anatomical contours and contact areas. Other functions include providing a rigid wall to condense filling material against, pre\ enling excess filling material from going subgingivally, and to some extent, limiting moisture contamination during condensation. A properly placed wedge will also protect the sinsiral tissue and help reduce moisture leakage into the cavity preparation.

\\ edses are inserted fron the facial or lingual embrasure, whichever is largeq slightly gingival to the gingival margin. The wedging action between the teeth should provide enough separation to compensate for the thickness ofthe matrix band.

Important: When placing a matrix band for a Class II amalgam restoration, the gingivoocclusal \r'idth ofthe band should be trimmed to be at least I mm qreater than the expected marginal ridge height.

All ofthe following are true statements regarding the polishing


of amalgam .EXCEPI one. Which one is the EXCEPTION?

. It reduces marginal discrepancies

. It should be done about l0 minutes after placement . It prevents tamishing of the restoration
. It improves the appearance oflhe restoration . It should be done with a wet polishing powder

16

Coprighr 20ll-2012

- Dental Dects

All of the following are true concernlng a Class V amalgam preparztion EXCEPT one. Which one is the EXCEPTIOM

. The outline form is determined primarily by the location ofthe free gingival margin . The mesial, distal, gingival and incisal walls of the cavity preparation diverge outward
. The retention form is provided by the gingival retention groove along the gingivoaxial line angle and an incisal retention groove along the incisoaxial line angle

. A cervical clamp is usually necessary to retract gingival tissues

17
Cop),right C 20ll-2012 - Dntal Decks

The final finish of the amalgam restoration should not be done until after the amalgam is fully set. It should be delayed for at least 24 hours after condensation and preferably longer (21-48 hours). By waiting you can be assured that the reactions between the alloy and mercury will have been completed and a more corrosion-resistant surface will be created.

Amalgam restorations should be tlnished and polished fbr tlrree major reasons: (1) to reduce marginal discrepancies and to create a more hygienic restoration. (2) to reduce marginal breakdown which will reduce the chance of recurrent decay, and (3) to prevent tarnishing and to improve the appearance ofthe restoration.

Heat generation must be avoided. The use of dry polishing porvders and discs can
easily raise the surface temperature above the 6VC (14ff F) danger point. Thus, a wet abrasive powder in a paste form is the agent ofchoice. Not: I{eat will not only damage rhe pulp but also draws mercury to the surlace ofthe restoration and an inferior restoration rvill result. Flnai polishing may be accomplished using a rubber cup with flour of pumice followed b1 a high-luster agent, such as tin oxide.

Remember: When checking the occlusion on a newly condensed amalgam restoratton, rhe marks left by the articulating paper should be of the same intensity as other markings in the same quadrant.

***

This is false; the outline lbrm is determined primarily by the location and size ofthe carious lesion.

\otes

l. Care must be taken to distinguish the active root surface carious lesion from the root-sudace lesion that was active but has become inactive (arrested).The anested lesion shows ebumated dentin (sclerotic dentin) lhat has darkened from extrinsic staining and is firm to the touch of an explorer. 2. Thc Class V an.ralgam restoration is used to restore lesions from caries, erosion and abrasion. 3. Care should be taken not to "ditch" the cementum when finishing and polishing. ,1. Occasionally you will notice that the gingival tissue has receded apically from the gingival margin ofa Class V restoration that was previously polished. This may be related to ineversible tissue changes caused by inadvertently traumatizing the tissue when the restoration was being polished. Key point: Be careful.

Remember: Incipient carious lesions are contained entirely within enamel and have not spread to the underlying dentin. The two options for treatment are: l. Promote remineralization: with fluoride vamish and self-administered fluoride. followed by regular monitoring. Note: Incipient carious lesions usually do not progress
rapidly.
2. Place a restoration: be as conservative as nossible.

Increased trituration time


expanslon

will
will

increase compressive strength and decrease setting

A decrease in particle size expanslon

decrease compressive strength and increase setting

. Increased condensation pressure will increase compressive strength and decrease setting
exDansron

18

Coplaight O

201

l-2012 - Detrtal Decks

Amalgam restorations require an obtuse cavosurface margin because amalgam b a brittle material.

. Both the statement and the reason are correct ard related

. Both the statement

and the reason are correct but NOT related

. The statement is correct, but the reason is NOT . The statement is NOT correct, but the reason is correct . NEITHER the statement NOR the reason is conect

19 Coplrjghr O 20ll-2012 - Dental Deck!

***

The opposite is true.

Dimensional change
Setting Expansion:
- Most amalgam restorations show slight setting expansion, but not ofclinical significance. - The more free mercury, the more setting expansion (and vice versa). . The greater the time oftrituration, the less the expansion . The greater the pressure used in condensation, the less the expansion . The smaller the particle size, the less the expansion

Strength:
- Amalgam is brittle, but possesses good compressive strength. The most impor-

tant consideration in the strength of the amalgam is the mercury content. Mercury content above 550% will cause a marked decrease in stren stb. khould be within 455 3?6 b1'u,eight).

. Higher condensation

pressure increases strength

. The smaller the pafiicle, the more strength . The longer the trituration time, the more strength . The fewer voids, the more strength

Remember for the boards: (when this is the answer) A. The statement is NOT correct B. Therefore, the reason is obviously not related C. So, you need to evaluate the reason independently

thus: . Amalgam restorations require a 90o cavosurface margin . An.ralgam is a brittle material
Clinical experience has established that this butt joint margin ofenamel and amalgam is
the strongest. Amalgam is a brittle rnaterial with low edge strength and tends to chip under occlusal stress ifits angle at the margins is less than 80" to 90'.

90 degres with the exlemal surface

Outer planes carried into cleansable atea (prcvides access lor fnishins mdlg'rt. Bcvcled to result in 40 degree marginal metal

90 degr angle with extemal ludace

90 degee angle with extemal surface

New amalgam alloys are trmed "hlgh copper." The higher 7o of copper reduces marginal breakdown.

. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both statements are true . Both statements are false

20 Coptriglr
@

2011,2012, Denial Dects

Creep is a process that happens over time, and gradually increases the matginal integrity of an amalgam restoration.

. The first statement

is true; the second statement is false

. The first statement is false; the second statement is true . Both statements are true

. Both

statements are false

21 Cop),right () 2011,20t? - Dertat Decks

Constituents in Amalgam:
Basic constituents:

. Silver (Ag) (40-70'/,)


- tncreases strength
- lflcreases expanslon

. Tin (Sn)

Note: Influences the amalgam in an - dccreases expansion opposite manner to silver. - decreased strength -incrcascs sctting time

25-270/.

. Copper /C , 6% or less:

Note: New alloys called "high copper" conrain 9- ties up tin: rcducing gamma-2 fbnnation 30% copper. These alloys have less marginal break- incrcascs dorvn and are lcss likcly to corrode. - reduces tamish irnd corrosion - rcducc. crccl: rcdrrccs marginal deterromtron Nlercury d18l 3% max.: - activates reaction - only pure metalthat is liquid

strength

- spherical allo]s . requrre less mercury - smalier surface area easier to wet - -10 Io,15% Hg

- admixed alloys . require more mercury - lathe-cut particles more difficult to wet - 45 ro 50% Hg

Other constitunts: . Zi.c (Zn) l9i, or less: used in manufacturing. decreases oxidation of other elements (sacrificial
- Prolides better clinical perfomance: less marginal breakdown - Causes delayed expansion with low Cu alloys ifcontaminated with moisture during condensation

. Palladium 1Pl/ l96 or lcss: . Itrdium (ln) lrzo or less:

rcduced corosion, greater luster

- decreases surfacc tcnsion - rcduces creep and marginal brcakdown reduces amount ofmercrlry necessary - increases strength . reduces emitted mercury - must be used in admixed alloys

vapor

Creep (ti re-dependent deJbrmation or strqin relaxation) is the deformation with time in response to a constant stress. It has been implicated as one of the main causes for mar-

ginal fracture of amalgam restorations.

\otes

L The higher the creepJ the greater the degree ofmarginal deterioration.
2. Creep is time-dependent.

High copper and low mercury content of an amalgam restoration will tend to decrease creep..{ltering the trituration time and condensation pressure can change the creep rate
Lri an

amalgam restoration:

. Both undertrituration and overtrituration tend to increase the creep rate . If there is a delay between trituration and condensation, the creep rate incrases
. Increasing the condensation pressure decreass the creep rate (this u,ill tlte littal nrercur,- <:onte t of'the restoration)
al.so

decrease

The marginal leakage ofan amalgam restoration decreases as the restoration ages. Corrosion products are helpiul in reducing marginal leakage around amalgam restorations. These corrosion products, such as tin oxide and tin sulfide, accumulate in the gap betrveen the restoration and the tooth, thus providing an excellent seal.

. Both

the statement and the reason are correct and related

. Both the statement ard the reason are correct but NOT related . The statement is correctt but the reason is NOT

The statement is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

22 Coplright C 20ll-2012 - Dental Deks

All ofthe following are true about glass ionomer cements EXCEPT one.Which one is the EXCZ'PIIOM

. Release fluoride . Good chemical adhesion . Good biocompatibility

. Good thermal insulator . Thermal expansion similar to tooth


. High solubility after initial setting

Cop)righr

23 20ll'2012 - Denral Decks

There is no free mercury in tdtumted amalgam because trituration coats the alloy particles with mercury. The object oftrituration is to bring about an amalgamation ofthe mercury and alloy. Each individual alloy particle is coated with a slight film ofoxide that prevents penetmtion by the mercury. During trituration this film is rubbed offand the clean metal is then readily attacked by the mercury

***

Silver Allovs for Dental Amalgams: Low copper alloys :4 to 6010 or less, traditional alloy . Comminuted {irregular Jiliug, or ldthe-cut)

. Spherical particles

High copper alloys:

9-30%o most

conmon. corrosive resistant

Spherical: sets faster and attains final mechanical properties more rapidly

. Comminuted can haye zinc or be zinc free and also can be fine cut ur microcut . Combination (admix) mixture of spherical and comminuted particles
Dispersed phase allov was the original admix alloy, mixture of comminuted traditional silr er alloy and spherical particles of silver-copper eutectic alloy. Most commonly used alloy
toda1.

Eutectic alloy is an alloy in which the elements are completely soluble in liquid solution but separate into distinct areas upon solidification.

\ote:

Once amalgamation occurs, no free (unreacted) mercury is associated with the amalgam

restomrion. The restoration has no toxic properties. However, if the amalgam is heated be) ond 80'C, liquid mercury can fom on the surface ofthe amalgam and its vapor presents a
health hazard.

***

This is false; glass ionomer cements have low solubility, lower than zinc phosphates

t\\'hi(h ore loter thon zinc poll'c(u'fisrytlqlse).


Glass ionomer cements are hybrids ofsilicate and polycarboxylate cements designed to combine the fluoride releasing properties of silicate particles with the chemically adhesile and more biocompatible characteristics ofthe polyacrylic acid matrix compared to the extremely acidic matrix ofsilicate cement.

Advantageous physical properties of glass ionomer cements: . Release of fluoride: anticariogenic . Chemical adhesion to the prepared tooth and certain metals. Micromechanical bond to composite resins. Important: Chelation of calcium ions on tooth structure by ionized polyacrylic acid side-groups is the principal mechanism of chemical adhesion to tooth structure. . Biocompatibility is high, thus with enough dentin remaining (0.5- I rrr) no pulpal protective agent (colcium hydrotide) is required . Good thermal insulators: equal to that ofnatural dentin . Thermal expansion is similar to that oftooth structure . Aftr initial setting, they have low solubility in the morith Note: Its disadvantage
phosphate cements.
as a cement is that

it has

higher cement film thicknss than zinc

Rmember: No lab test ofcement has correlated solubility with clinical retention.

. The first statement

is true; the second statement is false

. The first statement is false; the second statement is true . Both statements are true

. Both

statements are false

21
Coptrighr () 20l l-2012, Denlal Decks

ZOE cements make good ternporary sedative restorations bcruse their pH is very basic.

. Both the statement and the reason are correct and related . Both the statement and the reason are correct but NOT related . The statement is conect, but the reason is NOT

The statement is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

25
Cop)righr O
201

2012 - Dental Decks

Glass ionomer ccmcnts arc mixcd powdcr-liquid componcnt systcms. Thc polvdcr is a fluoro alumino-silicrte glass that .cacts with a liquid u,hich is polyacrylic acid to tbrm a ccmcnr ofglass particlcs sunoundcd by a matrix of tlu-

oridc clcments.
Luaing agcnts /{{ rrerrrl: . Zinc phosphate cement: onc ofthc oldcsl and nrosl widcly uscd ccmcnts, zinc phosphalc ccmcnt is lhc standard against which ncw ccmcnls arc mcasurcd. Advantages: Iong record ofclinical acccpiabilily, high comprcssivc strcnglh, acccptably fiin film thickncss. Disadvantagcsr lo\r initial pH lvhrch ml]y lcad to postccmcntalion scnsitivily, lack ofan abilily 10 bond chcmically to toolh structurc and lack ofan anticariogcnic cUcct. Important: Zjnc phosphatc cemcnl is mixcd using thc "frozen slabrr lcchnique rlhich grcatl,v cxrcnds thc working timc abr' $nuchas300%). Note:ThcpHofncwlymixcdzincphosphatecsmcnlisundcr2/.'foldr.rtol\dnishm sl bc applied i or.ler to proled thc pulp) brl iscs lo 5.9 $ithin 2,1hours aDd is rcarly n!'utralat 48 hours.Thc film

thickrcss ofzinc phospharc is abour 25Im. . Zinc pollcarboxylate cement: also known as zinc polyacrylatc ccnrcnt. r,as one ofthe first chemicalh adhesiye dcnlal malcrials. Thc adhcsivc bond is primarily 1o cnamclallhough u wcakcrbond to dcntin also fonns. This is duc 1o thc fact that bondrng appcars to bc thc rcsult ofa chclation reaction bctwccn thc carboxyl groups ofthe ccmcnt and caicium thc loolh slructurc;hcncc,lhc morc highly mincralizcd rhc tooth slructrrc, the slrongerthc 'n to thc pulp. chcmically bonds to tooth stnrcturc. Disadvantages shon lvorkinS tinrc, rebond. ,\dy.ntagcs: kind quircs scparatc looih conditioning stcp priorto cemcntation. Note: It is morc viscous whcn mixcd and has r shortcr $orking lirnc than docs zinc phosphale ccment. . Glass ionomer cement: Advantages: chcmical bond to cnamcl and dcniin, anticariogcnic cllccr(rctea\es llur/ /.Ll. cocfiicient oflhcrnlal cxpansion sinrilar to thal oflooth structurc. high comprcssivc strcngth, low solubiliI!. Disadrantrges lo$ inilial pH which may lcad to postcemcntation scnsili\ity. scnsilivity lo both moislurc conlrmination and dcsiccation. Note: 1ts mcchanical propcnics arc supcrior to zinc phosphatc and polycarboxy-

' R!sin-modified .

glass ionomer luting agents: havc propcrtics sinrilar to glass ionomcr ccmcnls, bul havc higher

rtrenglh end lo*er solubilit). Note: Thcy should not bc used with all-ccramic resloralions ducs to rcporls ofcc.3rnic iiacturc. nrost likcly Ihc rcsult ofexpansion liom walcr absorplion.
Resin luting agcnts: arc unfillcd rcsins that bond to dcntin, which is achicvcd \rith organophosphatcs, l2-,tr. lrotterht l nu'rhacn'late IHE]|{AI/, or,1-mcthacryloyloxycthyl rrimcllitatc anhydridc (4-llE rA). ,\d\antages: higb comprcssivc strcngth. low solubility. Disadrantages: irrilaling cffccls on thc pulp. high liln rhickncss a. lJ !rr. Note: As a gene.al rulc, resin cements arc thc bcst choicc fbr luling ceramrc restoratrons.

***

ZOE cen.rents make good temporary sedative restorations because their pH is about

Zinc oxide-eugenol cement is a soft, sedative - type cement. It is used as a sedatiYe or temporar\'filling material, as an insulative base, and in interim caries treatment. The powder is zinc oride and the liquid is eugenol. Eugenol has a palliative effct upon the dental pulp. and this is one of the main advantages ofusing this type ofcement.

-\ con|entional mixture ofzinc oxide and eugenol is relatively weak. In recent years "reintorced" or "irnproved" zinc oxide-eugenol cements have been introduced (called rainIorced ZOE or ZOE-EBA).ln reinforced ZOE (4,pe I ZOE) the powder is composed of zinc oxide and finely divided polymer particles (poll,nethyl-metlncD'late) in the arrount of 20 to 40% by weight. In addition, the zinc oxide powder is surfac treated br an aliphatic monocarboxylic acid. such as propionic acid. Note: This combination of sLrriace treatment and polymer reinforcement results in a material that has good strength and toughness rvhich markedly improves abrasion resistance. Reinforced ZOE is fine for basing large and complex cavities. This material is able to withstand the pressure of amalsam condensation and it has minimal effect on the pulp.

Contraindications to the use ofZOE include: l. On dentin or enamel prior to bonding: compromises bonding. 2. As a base or liner for composite resins: eugenol interferes with polymerization. 3. Patients rvho are allergic to eugenol (or oil oJ cloves): this is somewhat common. 4. Direct pulp capping: eugenol is a pulpal irritant when in dirct pulpal contact. Remember: ZOE is soluble in oral fluids and is difficult to remove from cavity preparatlons.

BILIC

IRNI (Intermediate Restorative Maleia, will intrfere with subsequent placement ofa resin filling, This is because IRM is a form of Zinc Oxide Eugenol,

. Both the statement

and the reason are correct and related

. Both the staternent and the reason are correct but NOT related . The statement is correct, but the reason is NOT

The statement is NOT correct, but the reason is conect

. NEITHER the statement NOR the reason is correct

OPERATI\rE

BIL/C

Zinc phosphate cement can cause irreversible pulpal damage because it shrinks slightly upon setting.

. Both the statement and the reason are correct and related . Both the statement and the reason are correct but NOT related . The statement is correct, but the reason is NOT . The statement is NOT correct, but the reason is correct
. NEITHER the statement NOR the reason is comect

Coprright O 20ll-2012 - Dental Decks

Zinc oxide-eugenol cement is a low-strength base used as a temporary cement filling in the event that the patient will return at a later date for a semi-pennanent restoration. The powder is mainly zinc oxide and the liquid is eugenol with olive oil as a plasticizer Zinc Oxide and Eugenol (ZOE) is not very durable, and it wears away afterjust a few weeks, but it works to relieve pain, calm the nerve and protect the tooth. Note: During the Vietnam War, the US Army invented a more durable form of ZOE called Intermediate Restoratiye Matetial (lRM) which is fortified with plastic powder.
Uses:

. As . As

an intermediate restorative material lor both Class I and II restorations. a base under non-resin restorations . Restomtion oldecidr"rous teeth lwlan pennanent teeth arc tv,o .veat1s or less.fiom eruptton )

. Restorative emergencies
-tr

dvantages:

. Hi-sh strength comparable to zinc phosphate . Excellent abrasion resistance


. Good sealing properties . Lo\\' solubility

Important: Because of its zinc-oxide eugenol composition, IRM rvill interfere rvith subsequent placement ofa resin filling.

lmportant: The initial nixture ofthis cement is very acidic (pH oJ 3.5) ancl can cause irrerersible pulpal damage ifa cavity varnish (2 coits) is not;lac;d on rhe tooth prior to cementation ofthe crown.

\ote: Zinc phosphate cements shrink more when they are in contact with air; thus, the .'ement should not be alJowed to dry our.
zinc phosphate cement is the oldest ofthe luting cements and thus is the one that has the Lrrnsest "track record" and serves as the standard to which newer systems can be com_
a

needed.

powderJiquid system; the powder is mostly zinc oxide 1al.ro con ,\ists o/.mag_ ratio o-l'9 to /) and the liquid is orthophosphoric acid. The primary use ofzinc phosphate cement is as a luting agent for the cementation ofcast reltorations. It can also be usetl as a base material wtin a f]igtr compressive strength is
,:esrrrnt oxide in the approxinate

pared. It is

superior strength compared to other cements, and its retention ls dependent upon (as opposetl to glass ionomer antl polycdyfiolylqte c,ements '.rhiclt edhere to tooth structure by- virtue of rhe polvat.rylic acid ii the liquid).
ha-s

It

In.":luni:ul interfocking

\otes,

cause the sctting time

l.Zinc phosphate cement riquid that has lost some of its water content wi ofthe mix to be lengthened.

pressivc strength ofthc cement.

Zinc phosphate cements should be rnixed on a cool glass slab, adding a srnall amount of powder to the llquid every 20 seconds. This is done in order to gain atl of the foltowing advantages .EXCXPI one. Which one is the EXCEPZOM

. Stronger final

set

. Lower solubility . Greater viscosity

2A Cop).right C

20ll-2012

Dental

Deks

All ofthe following statements are true regarding glass ionomer restorations TXCEP? one. Which one is the EXCEPTIOI'ft

. Glass ionomer is often the ideal material of choice for restorins root surface caries in
patients with high caries activity

. The best

surface finish for a glass ionomer restoralion is that obtained against a surface matrix

. Glass ionomer adheres to mineralized tooth tissue


. Glass ionomers are somewhat esthetic and polish much better than composites

CopFiShr O

201

29 l'2012 - Dntal Decks

This is a disadvantage; it will create a material with lower viscosity and thus allowing it to flow throughout the metal crown.

***

Mixing procedure for zinc phosphate cements:


. A cool mixing slab should be used x* Caution: The temperature of the slab should not be below the dew point of the
room.

. Mixing should be started with the addition of a small amount of powder to the liquid. This procedure, along with the cool slab, increases the working time. . Small increments of powder are added approximately every 20 seconds with vigorous mixing until a creamy consistency is achieved. This will promote a high powder liquid ratio and a superior cementation medium by providing the following:
- a lower viscosity ofthe mix - a stronger final set - a lower solubility ofthe set cement

The advantages of using the cool slab method are a substantial increase in the working time of the mix on the slab and a shorter setting time of the mix after olacement in the mouth.

*** Important point:

*** It is tru that glass ionomers are somewhat esthetic. however, they do not polish as u ell as composites.
Both self-cured and light-cured versions ofglass ionomers are available. Light-cured glass ronomers are preferred because of both the extended working tirne and their improved

phvsical properties. Because of their limited strength and wear resistance, glass ionomers are indicated generally for the restoration of low stress aras where caries ac-

rilin

potential is ofsignificant concern.

Compared to composites, glass ionomers: . Har e a lower compressive strength, tensile strength, and hardness . .\re generally very technique sensitive because of their high solubility when first

mrred
the newer hybrid or light-cured resin-modified glass ionomers, the above properties have treen improved. Glass ionomers are generally considered the nearly ideal base/liner material because the tbllorving properties: . Adhesive bond to tooth structure . Snap set in the light-cured form (br example, Vitrebond)

\ote: \\iith

of

. Anticariogenic: due to fluoride release . Bond to composite: makes for excellent liners for Class V root caries restorations.
Sometimes called the "sandwich technique". This technique achieves all the benefits ofthe glass ionomer cements plus the high polishability, surface hardness, and

***

strong bond to enamel ofthe composite resin.

Which of the following mlterials could be used to cement o bridge and lill a cervlcal lesion?

. Glass Ionomer . Zinc oxide-eugenol . Zinc polycarboxylate . Zinc phosphate

30
CopyriShr O 201 I'2012 - Denral Decks

. The first statement is true; the second statement is false . The first slatement is false; the second statement is true

. Both

statements are true

. Both statements are false

31

Coptrighr O 20ll-2012, DmtalDecks

is uscd as a ceme (lutitry agent) and a pennanent rcstoralivc nratcrial. Glass ionomcr ccmcnts are ollen used for root surface carious lesions bccause ofthe potenlial advantagc of tluonde release in helping to control the spread ofcarics. Alier lhc sctting, expansion due to water uptakc has bccn obscrvcd lbr some of thc ncwcr rcsinmodified glass ionorrcr cemenls (Fuji Duet, l/ilremer and Adt ancel compated to a regular resin (BIS-GMA or uretfutne actllale) cemcnt such as Panavia 21, which is a self--cure resin cenlenl, conventional glass ionomcr luting ccmcnts, and thc old standby zinc phosphatc cemenl. Tradilional glass ionomcq phosphate. and resin cemcnts all undergo contraction during sctting. The BIS-GMA or urethane acrylate resin cements all undergo polymerization shrinkagc during setting. Horvever. the presence ofglass fillcr in somc resin cement materials reduces the shrinkage and can imparl radiopacity. Many ofthc resin cements arc now supplicd in the form ofdual curc systems (pholo-ifii' tiatetl as vell as telliary- amine peroxide rca(:tiotl). Such matcrials include Adherence, Choice. Duolink. Enforcc. [-ute-it. Nexus. Opal, Rcsinomer, Scotchbond Resin Cement and Variolink.

*** Only glass ionomer

Remember: It is important to note that fhe main f'unction ol'a luting cement is 10 provide a nonpenreable seal at the margins around the restoration. Thc rnarginal cementiilled gaps around inlals. cro\\'ns and bridgc abutments can rangc from 25 to 15Opm. Research has shown that thc wider rhe cenrenl gap at the nargin, the greater thc ccmcnt loss i'li1.'rirrgl. A rough cement surfacc is an rd.'al site fbr plaque accumulation. ln such a situation, slow rclcase of fluoridc can be a very distrnct ad\ anlage. lmportant: In general, glass ionomer cements tend to have the least erosion. and polycarboxylate .enrents the most. However, solubility, crosion and strength are signiljcantly affccted by the powder liqurd ratio uscd.
ZOE. rcinforced ZOE, ZOE-EBA, silicate, and zinc silicophosphate ccmcnts are no longcr rouuscd to permancntly cement restorations. Zinc photphate cement has been cxtcnsivcly reolacr'd b1 polycarboxylate or glass ionomcr cements. These cemcnts are based on ion cross linked polr acrl lic acid natriccs that have the potcntial to rcact chenically with residual po\\'dcr panicles .iild the suriace ol tooth struclurc.

\ote: iircly

a potential for adhesion to tooth structure via chelation. The polycarboxylate cements are powder/liquid systems. The liquid is an aqueous solution ofpolyacrylic acid and copolymers. The powder is zinc oride and magnesium oxid,

Zinc polycarbox"vlate cement was the first system developed rvith

Zinc pollcarboaylate cements have a compressive strength slightly lower than that of zrnc phosphate while the tensile strength is highr. Its final strength is dependent on the pos der liquid ratio, with n.rore powder giving greater strength. The strength of the set material is sufficient for amalgam condensation and its effect on the pulp is mild enough ro eliminate the need for sublining. Thermal conductivity is low and thus the material gi\ es sood protection against thermal stimuli applied to metallic restorations. -\n ad\ antage ofzinc polycarboxylate cement is that it can bond to tooth structure. This is attributed to the ability of the carboxylate groups in the polymer molecule to chelate to calcium in the tooth. The most commonly noted disadvantages of polycarboxylate cen]ent js its marked thickness and short working time. Currently marketed brands include Durelon lJM ESPE).Liy Carbo (GC Amerita),Shofu Polycarboxylate /.t o/ir. and Trlok Plus (Dentspl.v/Cqulk). The most recent innovation in these cements has been the development of Durelon Maxicap. an encapsulated version of Durelon. Because it is mixed and expressed lrom a capsule, the traditional difficulties ofshort working time and
excessive thickness are overcome.

Remember: When cementing a cast restoration, always apply cement to both restoration and the tooth.

When uslng a zlnc phosphate cement you place the varnish lirst This is because zinc phosphate cements are not biocompatible.

. Both the statement and the reason are correct and related

. Both the statement

and the reason are correct but NOT related

. The statement is correct, but the reason is NOT

The statement is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

32 Cop).rightO 20ll-2012 - Denial Dects

. Final application thickness

. Degree ofpulpal protection . Biocompatibility of material . Degree ofhardness

Copyrighr O 20ll-2012 - Dental Decks

It should be emphasized that the use ofa base in conjunction with amalgam or gold foil does not alleviate the need for a vamish as an aid in sealing the cavity margins against leakage. However, the type ofbase govems the respective order ofapplication ofthe vamish and the base. lf a zinc phosphate cement base is to be used, then the cavity vamish should be applied to the cavity walls prior to placement of the base. On the other hand, if a biocompatible agent (e.g., a calcittm h.vdroxide, zinc oxide-eugenol, or polvc arboxl'late cenent base.,l is employed. then these should be placed against the dentin. and the vamish should not be applied until the base material has hardened. Important: lf vamish is added before a biocompatible base it may prohibit positive qualities such as eugenol's soothing effect or polycarboxylate's chelation and adhesion-

Zinc phosphate cements provide good pulpal protection frorr thermal. electrical, and
pressure stimuli, but may damage the pulp as a result ofan initial low pH. This, however, can be ofbenefit as it provides an antibacterial effect which reduces the number ofviable microorganisms in the cavity floor and thus decreases pulpal irritation.

Important: Cements used for bases should be mechanically stronger than u'hen used as Iuting agents and are mixed with the maximum powder content that is possible. A lou' pol der-toJiquid ratio produces a Iow viscosity cement that is needed for luting agents.

\ote:

The varnisb

will reduce the initial microleakace of an amalsam restoration.

The most important consideration for pulp protection in restorativc techniques is thc thickness the rcmaining dentin.

of

In gencral. cements that are thickcr than 2 mm are termed bases and as such function to replace lost dentin structure beneath restorations. A base may be used to providc thcnnal protection under :nctallic restorations. to increasc the resistance to thc forccs of conclcnsation of amalgam, or to block out undercuts g'hen taking irnpressions for cast restorations.
The only drstinction bctwcen a base, a cen,leni, and a cavity lincr is thcir final application thicknesS:

L Cements for luting havc a dcsircd linal film thickness ofapproximatcly l5 to 25 microns.
suspension litters). Liners arc nratcrials that arc placcd as a thickness ofapproinutely 5 microns) on the surface of r .a\ itv prcparation. Although they providc a barrier to chemical irritants, thcy are not used for rh!'nrlal insulation or to add bulk to a cavity preparation. F urthermorc, these matcrials do not har c sullicient hardncss or strength to be used alone in a dccp cavity. -i. Bases havc a linaf application thickncss of approiDt.ttelr, l-2 mm (they nnl' be thitker deppcnling on tl1('.t outlt ef dentin lhal ]1as heen desu'o|ed/. Bascs can be considered as restoratr\ c substitules lbr thc dcntin that was rcmoved by caries anclror thc cavity prcparation. They act as a barrier against chcmical irritation, provide thermal insulation, and can resisl the condensarion lorces on a tooth when placing a restoration. Also, the clinician can shape and contour base

L Ca\ itl finers (either solution or


Ihin coating r ir7r,e
.?

desied./inal

/iln

rnaterials ailer placemenl into thc cavity preparalion.

Important: A

base should

not be used unnccessarily.

Remember: Calcium hydroxide is very eileclive in promoting the fbrmation ofsccondary dcntin. which is an important aid in the repair ofthc pulp.

Note: Thc sclcction of appropriate bascs and liners to restore the axial wall ol'a Class ll restorations is dependent r,rpon the biological eff'ect requircd and thc thickness of th remaining dentin.

base ls a base that is typically placed over a calcium hydroxide base that has been placed over a pulp exposure.

. Primary base

Secondary base

. Direct base

. Indirect

base

34
Coplrighr O 20l l-2012 - Denral Decks

Solution liners should not be pleced under composite restorations becNuse composites do not requir the pulpal protection.

. Both the statement . Both the statement

and the reason are correct and related and the reason are correct but NOT related

. The statement is correct, but the reason is NOT

.
.

The statement is NOT correct, but the reason is correct


N

EITHER the statement NOR the reason is correct

Cop]righr O 20ll-2012 - Denlal Decks

Bases are classilied as either

primary or secondary:

. Primary

bases are placed on the dcntin in closc proximity to thc pulp primarily to pro-

vide protection from toxic and thermal irrilants. Undcr amalgam and tooth-colored
restorations, the primary base is usually calcium hydroxide. whereas, under gold restorations, the primary base is usually zinc phosphate cement or zinc polycarboxylate cemenl. Glass ionomcrs arc commonly uscd today as wcll. . Thc most common use of a secondary base is thc placcmcnt of zinc phosphate cement ovcr a calcium hydroxide base which has been placed over a pulpal cxposve (direcl pulp
. ap).

Bases in essence serye as a replacement or substitute lor the protective dentin that has Important:The thickness ofthcrmal insulation required for pulpal protection is 1000-2000 gm ( L000-2.000 mrn).
been destroyed by caries an<lor cavity preparation.

***

lVaterials that have been employed as bases (bases are

. . . . .

to application Zinc phosphatc cement: remember Zinc polycarboxyJate cement: provides adhesion ZOE Glass ionomer cemcnt:providcs lluoridc rclcase and adhesion "Hard setting" calcium hydroxidc matcrials: thickcr than rvhcn used as a liner Remember: All of the above are suitable as a base under amalgam restorations, however, lor composites, ZOE cannot be used becausc thc cugcnol will inhibit the compositc sctting rcaction.

tlpicallt l-2 nnt thick)l to seal dentinal lubules with varnish prior

Important: (l) pulpal sensitivity is causcd prirnarily by lluid l1ow in dentinal tubulcs (2) lluid flo\\ is detected by mcchanoreceplors on the edge ofthe pulp (3) the reduction in tooth sensitivity
* ith decreased fluid flow in tubules is rclated to the fourth power ofthc tubulc radius.

*** Solution liners should not bc placcd


Ca\

undcr compositc rcstorations because they

will inhibit
casc.

the

poll merization ofthe resin. Suspcnsion lincrs should be uscd for pulpal protection in this

it\ liners are matenals that are placed as thin coatings over exposed dentin. Their ma'n purposc js to protect thc pulp by crcating a barrier between the dentin and pulpally jrrilating agents i.e., ocids.liom ;::it,tItt or centents. restordlive nalerials, elc../ by sealing thc dentinal tubules.
Ca\

iI

liners are usually classified into two main groups:

:.

L Solution Lircr ( LArnish)t thin film; typical thickncss rangc is 2-5 pm (0.002-0.005 mm) Suspension Liner: relatively thin film; typicalthickness rangc is 20-25 pm (0.020-0.025 mm)

to seal offrubules - \'arnish: . Organic solvent based: water insoluble . l-: llm filmi used to line cavity up over cavosufacc margins . Sets bl ph.vsical rcaction fd,),1,79/ iust like finger nail polish Commercial examples: Copalite. Hydroxyline. Chembat and Tubilitcc ?. Suspension Liner: . \\ater solvent bascd: water soluble . l0-:5 Lrnr fllm; uscd to line only the denhn . Sets b] physical reactton (dt)ing) Commercial examples: Pulpdcnt and Hypooal
are now being substitutcd with the new dentin bonding systems or dentin sealcrs 1'e.g., Gluma or HurriSeal). Thc dcntin bonding systcms and dentin sealers arc classificd

l. Solution liner: thin layer

Important: Thc above cavity liners


as

5olution liners.

l. The alerage lifetime for thc intcgrity of

vamish film is one month.

-loles ':t;;ii:..t

A 509. rubule co\crcgc is produccd by onc thin coating ofvamish. Hence. thc reason varnish.! lhuulJ bc anp'iietl rn ru' rhrn c.ats. 3. Thc chemical composition ofcopalite contains organic resin, chloroform solvcnt, acc2.

tone solvent. and alcohol solvent.

. Chemical reaction ofacids and bases . Chemical reaction involving pollnnerization

. Chemical reaction involving chelation


. Physical reaction of drying . Physical reaction ofa sol-gel transformation

36 Coplrighr O
201

1,2012 - Dental Decks

When removing caries, which of the following layers of dentin are - -^.,-nt -^1-^^l infected, n-.1 and ]|r^-t^,^ therefore l^ need ]^ to L^ affectd, ^aa^^r^,| lt,1-^l btrt not lnf^^.^rl do not be removed?

. Turbid dentin

. Infected dentin
. Transparent dentin . Normal dentin

Sub-transpaxent dentin

37 Coplright O 201 l-201? - Dental Decks

Dental materials that are designed as pulpal mcdicaments contain caicium hydroxide or eugenol. Need depends oo extent ofcavity preparationl . Shallow : 0.5 mm into dentin (Rcmaining dentin > 2 mm, not necessary) . Moderate: 1.0 mm into dentin (Remaining dentin : 0.5-2 mm, possibly) . Deep < 0.5 mm from pulp (Rcmaining dcntin < 0.5 mm, ycs)

Objectives for Pulp Medication:

. Eliminate

acute inflammation (by soothing the nerves)

. Prevent chronic inflammation (stimulate secondary/reparative dentin) Managemedt of Acute Inflammation


Eugenol:

. Palliative : mitigates, alleviates, or eases pain . Obtundcnt: reduces violence or pungency by dulling
Delivery:

senses

. Relcased from cement liner or ccmcnt basc into dentinal tubules . Short term effect N{anagement of Chronic Infl ammation:

Calcium hydroxide: Delivery: . Released from susDension liner, cement liner, or cement base

. Very basic, dissolves in water, and diffuses to pulp . Accelerates fomation ofreparative or secondary dentin

. Method ofaction unknown Characteristics of Calcium hydroxide, Ca(OH)2, pasres:


. Gcncratcs very alkaline solutions, pH = I1.0

Aqueous pastes are viscous and do not wet dry dentin well

. Apply without pressure only on concavcly excavated dentin . Apply thickness that creates uniform appearance . Set mate als arc low strength, water soluble, and radiograph poorly . Commercial examples: DYCAL (LD Caulk), LIFE (Ken), and Light Cured DYCAL

Zones of carious dentin from innermost to outermost: - totally normal dentin with no bacteria in the tubules. . Zone | (normal denlin): . Zone 2 (sublransparent dentin)t zone of demineralization created by the acid from caries. Damage to the odontoblastic process is evident, however, no bacteria are found in this zone. Capable of remineralization. . Zone 3 (transpqrent dentin)2 softer than normal dentin, shows further demineralization. No bacteria are present. Capable of remineralization provided the pulp remains Yital. . Zone 4 hurbid dentin): is the zone ofbacterial invasion, tubules are filled with bacieria. Zone is not capable of remineralization and must be removed prior to restoraIlon. Zone 5 (inlbcted dentin)2 the o]utermost zone, consists of decomposed dentin that is filled with bactria. Must be totally removed prior to restoration. Four zones of an incipient lesion in enamel:

l.Translucent zone: the deepest zone, represents the advancing front ofthe enamel lesion. 2. The dark zone: does not transmit polarized light. Areas of demineralization and remineralization. 3. The body ofthe Iesion: the largest portion ofthe incipient lesion. Area ofdemineraltzauon. 4. The surface zone: relatively unaffected by the caries attack.

The rate of senile caries is increasing in part because of the incrase in ginglval recession.

. Both lhe statement and the reason are correct and related

. Both the statement

and the reason are correct but NOT related

. The statement is corect, but the reason is NOT

The statement is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

38
CopFiShr O 201l-2012 - Dental Decks

Cbronic caries is characterized by all of the followlng EXCEPT one. Which one is the EXCEPTIOIIT

. Slowly progressing or arrested . Pain is common


. Common in adults . Extrinsic pigmentation

39
Cop}'ighr O 20ll-2012 - Dntal Dtrks

The rising incidence ofroot surlace cales (sometime,s relbrretl to as senile cqrle.s/ can be attributed to the aging ofpopulations and the fact that most adults are retaining more teeth. ln this population, there is increased gingival recession with exposure ofroot surfaces. leading to the development ofroot surface caries. Root surface caries usually appears as a well-defined discolored area adjacent to the gingival margin, typically near the CEJ. It is found to be softer than the adjacent cementum or dentin. Root surface caries generally spread more on the surface laterally around the CEJ, rather than in depth. In older patients, rampant caries can be caused by poor oral hygiene, decreased salivary flow, and side effects of medications. On a dntal radiograph, root surface caries appears as a cupped-out or crater-shaped radiolucencyjust below the cemento-enamel junctron (CE.I). Early lesions may be difficult to detect on a dental radiograph

Remember: Glass ionomer is a desirable restorative material for root surface caries
u here esthetics is not a major lactor.

Rsidual caries is caries that remain in a completed cavity preparation,

\otes

whether by dentist intention or by accident. 2. Secondary /rrc arrenl) caries is decay appearing at the margins ofa restoration and under it. 3. The etiology of root surfac caries is now-a-days believed to be the same as for coronal caries S. mutans. S. sanguis, A. viscosus, A. naeslundii, Lac-

tobacillus. and Veillonella.

*** \\'ith

chronic caries, pain is uncommon

Chronic caries is somelimes rcfcncd to as slow or arrested caries and is also characterized by the
:ollorr ing:

. The lesion is shallow (smull lesion) . The entrance to the lesion is wide . Dark pigmentation with leathcry consistcncy *** Chronic caries should bc completely removed when found in enamcl and close to
the DEJ.

Acute caries \\hich is sometines relencd to as rampant caries. is characterized by: . ThL (nlran(c ro thc lcsion is smal . The lesion is deep ard narrov (latge lesiott)

. Pain may be a feature . Little or no staining


. Rapidly
progressing

. Olien multiple. soll-to-the-touch l(sion5 . Most frequcntly found in children


Note: Changes ofthc pulp and dentin depend on the rate ofthe carious progression. The response ofthe pulp to carious attack or thc trauma ofoperative procedures dcpcnds on the blood supply of thc pulp and its cellular activitv.
Defense mechanisms ofthe pulp (loprolect
it

fiom irrit.ition)i

. Sclcrotic dcntin /peritxhular dentin fbrmalioir: inilial delense. Whcn it occurs due to thc aging
process it is called physiologic sclerotic dentin and when by initants it is known as reactive scle-

rotic dcntin. . Rcparativc dcntin liD'ildtion dentitl Jbmralio,r: sccond line ofdefense . lls vascularily (inllammation)

is degraded by Streptococcus mutans into

and tberefore causing caries initiation and progression.

Sucrose, glucans, lactic acid

. Glucose, glucans, lactic acid

Sucrose, glucose, acetic acid sucrose, acetic acid

. Glucose,

40
Copyighr C 20ll'2011- Dental Decks

The initiation of caries requires four entities. Which of the followlng is NO?one of them?

. Host . Bacteria . Carbohydrates

Saliva

. Time

41

Coplright

@ 201

2012 - Denral Dects

***

Sucrose is degraded by Streptococcrls mutans into glucans and lactic acid therefore causing caries initiation and progression.

Pit and fissure caries has the highest prevalence ofall dental caries. Smooth surface areas, especially the proximal enamel surfaces immediately gingival to the contact area are the second most sr"rsceptible areas to caries. Streptococci and lactobacilli species are common in this area. The facial and lingual root surfacs may have plaque containing filamentous actinomyces species which can cause root surface caries. Remember: Lactobacillus species do not produce the dextranlike, extracellular long-chain polysaccharides (fi'uctaus and glucans) as do Streptococci species but produces a different extra-polysaccharide called lexan. The way that the lactobacillus species cause dental caries in the pit and fissure areas is that it gets packed into those pit and fissure areas thereby exerting its effect. Fluoride treatments will dramatically reduce smooth surface caries though they are not as effective in preventing pit and fissure caries. Sealing the pits and fissures just after tooth eruption :nay be the single most impoftant procedure to help protect these areas from caries destruction.
Remember:The metabolic acids produced by mutans streptococci demineralize the tooth surl'ace and lead to dental caries. The enzyme glucosyltransferase lGlFl produced by mutans srreptococci is the key factor in this process. Sucrose is a natural source ofenergy for this enz\rre. and GTF is the key enzyme that catalyzes the conversion ofsucrose to dextranlike, extracellular long-chain polysacchaddes (fructqns and g/llcar.t/, which extrude from the bacterium and stick to the tooth.

Important: Predominant bacteria found in dental plaque: . Streptococcus san gurs (found the earh esr) . Veillonella, Lactobacilli, . Streotococcus mutans. mitis. and salivarius

and Fusobacterium

Dental caries is an irfectioos microbiological disease that results in the localized dissolution oftooth structurc. For caries to occur, a suscepiible host /d tootrl, microflora $ith cariogenic potential apldqrer, and a suit ahle subsrate /dieldr'r . urhohv.lnues), all inli'ract to promote the severiq ofthe disease. \ot: A cc(ain period c'i tinle is also required fbr caries to develop. The grealest percentage ofiooth loss in the first two decades oflifc lcrcept /),on the nutrral loss ofdeeicluou.r is due ro untrated dental caries. The rate at which the carious desiruction ofdentin progrcsses tends r,r be slower in older adults than in young persons due to genralized dentinal sclerosis *'hich occurs with

i!(r,

3g'rs.

Protectir e nrechanisms of saliva:


. Bacterial clearance: glycoproteins in saliva cause some bacteda to agglulinate and then be removed by s\ rllon ing L5 L of saliva fbrmed each day ' Direct antibacterial activity: salivary proteins (e.g., ltso:yne, lactoperoidus(la.lofeffin dnd secrelor.t
r'-g

J/ drscourage or

clcn kill bacteria..

is mftjor rolc in caries protection. phosphate, potassiurn, and varying conccntralions offluoride are in saliva and :..isi \\ ith remineralization- Some salivary proteins promote remineralization, thcsc include statherin, cysr3iits. histatins. and oroline-rich Droteins.

'

BufTering

crprcit): ofsaliva

' Remineralization: calcium,

\ote3 '

L Fluoride and occlusal scalants modili the susceplible host /Ioor[r.Remember: Fluoride providcs lluoride ion lor remirleralization forming fluorapalitc. $'hich is more rcsistant to acid aF
rack than intdcl hydroxyapatitc crystals in enamel. 2. Enamel demineralization occurs at pll 5-5 or belo$'. Reminralizrtion ofthe damaged tooth srructurc occurs as the pH rises above 5.5. L The prevalence of caries has bcen declining in children. A decline in adult caries is not as evident. Fluoridation has received thc most crcdit for thc decline in the devclopment olcaries.

4. Pregnant patienfs, compared with similar non-pregnant paticnts, are likely to have the
same degrcc ofdcn{al caries, but more inflamed gingival tissues. 5. In ordcr to create smooth surface caries, a microorganism musl be able to produce dextran-like.

extracellular long-chnin polysaccharides (frudans and gluuns). This dextranlike matcrial is a similar product to that which is produced by btmaclcs lo allow them !o attach to lhe bottom ofa ship. It is a vcry tenacious sticky material. Somil mcmbcrs ofthc streptococci family i/i.., ,n xldr.r strcpto.occi) arc able to producc cnough dcxtran lo attach to the tooth's surface.

There is rbundant evidence that the initiation dental caries requires a high proportlon of:

of

. Lactobacillus within saliva . Streptococcus mutans within dental plaque


. Lactobacillus within dental plaque

Streptococcus mutans within saliva

42
Coplright

201

l-2012 - Dert.l Decks

. Acidogenic, cariogenic

. Aciduric, cariostatic
. Acidogenic, cariostatic

. Aciduric, cariogenic

43 CopI
iShr O 2011,2012 - Dental Dcks

Thc first event in thc development ofcarics is the deposit ofplaque on the teeth. Dental plaque is a highly organized gelalinous mass ofbacte a that adhcrcs to the tooth surfacc. Streptococcus mutans produce great anrounts of lactic acid fucidogenic), arc tolcmnt of acidic cnvironlncnts (ot'iduric.l, arc vigorously stimulatcd by sucrose, and appear to be the primar) orga nisms nssrrciated with dcntal carics, howcvcr, thcy arc not the only organisms required for caries initiation. Olher mutans strcptococci species in humans can do this as well (for exanrple, S. sobrirtus).

Large amount ofplaque on leeth. meaning many bactcria that can produce acids (low pH, demineralization)
T!,rre of bacteria Large proportion o f "cariogen ic ' types ofbacteria. resulting in lower pH and sticky plaque and also prolonged acid production

High in carbohydrates, in particular sucrosel'sticky" diet leading to low pH for a longer time High .ugar lrequencl re.ulting in longer time per

Jr\

$ irh low pH

Rcduccd salivary flow leading to prolongcd sugar clearance time and to a reduced amount ofother saliva protectivc systems

Low buflcr capacity rcsulting in prolongcd timc with low pH

sugar i'rom birch trees, keeps sucrose molecules liom binding ilh mlrtans streptococci. Strcptococcus mutans cannot ferment xylitol. Additionally. xylitol causes thc cn\ ironmcnt to bccomc morc alkaline inhibitine the baclerium's growth.
\\

\ote: X)litol. which is a natural

***

Streptococcus mutans are acidogenic and therefbre cariogenic.'Ihis means that these

species produce acid and therefore cause the initiation and rrrosression ofcaries.

Cariogenic bacteria:

.
St

Especially members oftbe mutans streptococci-group /e.g., Streptoco..cus nutans ancl


rcpt o t oc t Lts. o bri n us) Lactobacilli casei
.s

current research suggests that the microbial etiology ofroot caries is very sim_ rlar to coronal caries. In the past it \\,as thought that Actinomyces species (.tis(,osu.\ and tl,tciIundii) were most commonly associated with root surface caries. Essential properties of cariogenic bacteria:

\ote: \losl

**x \ote: Lactic acid is tbrmed in large quantities following the degradation ofsucrose b\ mutans streptococci, . The abilit]'to attach to the tooth surlace. Note: Streptococci species have special receptors ibr adhesion to the surl'ace and also produce a sticky mat x that allows them to cohere
Io eilch other

. -\cidogenic Qtoduce acid) and acidluric (being able to tolerate qn a..id enyitonment)

. The abilitr to lbrm a protective matrix. Note: Streptococci species produce dextran-like. ertracellular long-chain polysaccharides (lructans and glutar.rJ, which extrude fiom the bacterium and stick to the tooth, which protects it fiom being removed from the tooth by
salir a, liquids. foods, and masticatory forces.

Dental plaque describes the soft white film of organized bacterial colonies (nain L,onpo cTit,salivary glycoproteins, and inorganic material that readily forms on the surt'ace of teeth.

\ote: The strong correlation between the presence of dental plaque and the appearance dental caries and periodontal disease has been recognized for many years.

of

Comp

UV light curing systems are no longer used, that is because dual cure systems lixed the problem of"incomplete curing."

. Both the statement and the reason are corect and related

. Both the statement

and the reason are correct but NOT related

. The statement is correct, but the reason is NOT

The statement is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is comecl

44
Coplright ,e

20ll-2012

Dental Decks

OPERATIVE

Comp

AII of the following statements are true concerning posterior composite restorations -EXCEPI one. Which one is tbe EXCEPTIOM

. Posterior composite restorations . Posterior composite


(

are frequently indicated in the treatment of occlusal lesions s'hich allow conservative preparations restorations are contraindicated in a patient with heavy occlusion

bruri.tnt)

. Posterior composites are contraindicated in patients with high caries risk

. Posterior composite restorations

may be indicated for the restoration of Class II cavities in premolar teeth where the appearance is very important, the cavity margins are in the enamel, and the occlusal contacts are on tbe enamel
are contraindicated for cusp replacements unless a dry operating
4s
Coplright

. Posterior composites
field is

maintained
c 20ll-2012
- Dental Decks

Light curing of compositc formulations arose dudng the late 1960s with the adoption of ulftavtolet (UV) light polymerized systems. In just a few years, it became obvious that visible-

light cured (VLC) had many advantages over UVJight cured composites, and practitioners made the shif't. Dentistry has been wed to VLC systems ever since. Msible light cr.rring systems have totally displaced the UV light systems. Also, visible light curjng systems are much more widely used than the chemically activated ones /selfcured). An advantage oflight cudng systems as a whole is that the dentist has complete control over the working time and is not conlined to the built-in curing cycle ofthe self-cure. This is particularly beneficial when large restorations are placed.
Note: To deal with problems ofincomplete curing with VLC due to the thickness ofrestorations and filler particles scattering light, manufacturers have developed composite resins that are dual-curd which combines self-curing and visible light-curing. Another polymerization method is staged curing which is a two-staged cure. Howeyer, VLC composites are still the most popular today.

Remember: Visible light cured composites are single component pastes, and the polymerization process is activated by an extemal energy source. The alpha-diketone initiator (gelF etu ll.t canphor quirorel absorbs energy from a visible 14 2.1 r n-blue light) llght source. The ketone absorbs energy and reacts with an amitl.e (added to the s)'sten lo enlut ce the affect of rhe light-sensitive c..r/alrs, to produce ftee radicals.

\ores

L For large restorations (those that are u,ider than the diqmeter of tlte light tip), cure each area for the full required time. Do not back off light tip until it lights up entire sud'ace of restoration. 2. Visible lighrcuring involves light energy in the range of,ll0-500 nm with a peak intensity ofabout 470 nm. 3. The minimum acceptable level for visible curing light outputs is 300 mwcmr.

Allhough Ihe ADA does not endorse composite resins as a substifutc for a[ralgam in postcrior teeth, cLrtuposite restorations can be excellcnt if stricl guidelines are follotved for tooth selcction and if the re\rorations are done properly. But remember. composite resin restorations arc infcrior k) amalgam in iarms of compressive strength and abrasion rcsistancc foaclr!a/ )rc4rl. Also, curent composite resins

rrr

e no

i:l.l gla\\

capabilirv to providc an anticarjogcnic cffect as do freshly placed glass ionomer or resin modiionomers, for example.

nrLrst scrious limitation of the visiblc light-cured posterior cornposite restoration is the polymerization shrinkage, \\'hich can cause intemal stresses and gap formations at butt-joint interfaccs. which r:a ieen rt the gingi\al lloor ofClass II and V resiorations. Important: Stress from polvmcrization .irinkase is influenced by rcstorativc technique, modLllus ofresin elasticity, polymerization rate, and ca\. :5 .onlisuration or "C-factor." Thc C-t'acIor is the ratio between bonded and unbonded surfaces; an in.r.iic in this ratio rcsults in incrcascd polymcrization stress. Three-dimensional cavity preparations ,C/,r-rr 1r have the highcst (nost unJbtorable.) C-factor because only outer unbonded surfaces absorb .irer\ To rninimize the sttess fiom polymerization shrinkagc, efforts have been directed torvard imp:.ir ine placement techniques, material and composite formulation. and curing methods. Incremental cunnq rc-duces the C-factor und, therefore, reduces the residual stress ofthe resulting composite restora-

lhc

tion. Thc major indication for the use ofpostcrior composjtcs is the dcmand for csthetics by thc dcnand paticnt. Othcr criteria are non-involvement of cusps, minimai occlusal contact, no cxce\si\,c \\car. and the isthmus nrust be no uidcr than onc-thjrd ofthe intercuspal distancc. Remember: Compositc is thc material ofchoice if the patient has a documented allergy to mcrcury.

\ote:

ril

Important: In thc past, postcrior compositc restorations were contraindicatcd in a patient with

a carics

aclivc mouth. Ncw conccpts strcss that you should manage the disease (i.e., dental carie.rl bcforc or at the same time as you are treating the consequence ofthe discasc (i.e., hr placing restorutions). Therctbrc, the currert literature does not see a special probJem for these restorations in caric\'active pctienrs. They havc as bad a prognosis as any othcr rcstorative trcatment ifthe diseasc is not managed simultaneouslY. Note: However. for the National Boards jt js still a contraindication.

Which property of lilled resins is primarily to blrme for the failure of Class II composite restorrtlons?

. Low flexural strength . Low compressive strength


. Low tensile strength

. Low wear resistance

46
Coprdgft t C 201

l':012

- Dental Decks

Which composite typ is 70 to 77 percent lilled by volume and has en average prrticle size r.nging from I to 3 pm.

. Microfills . Hybrids
. \{icrohybrids

Packables

. Flowables

17 CoDright O 20l l-2012 - Dental Decks

Ideally, composite resins should be used only to restore n.rinimal cavities in posterior teeth. Its use should be restricted to those instances where it will not be subjected to excessive occlusal forces and \,!,here, when teeth are in occlusion. there is cusp-to-cusp contact and not cusp to restoratron.

For Class III preparations using resins, the rule ol extension for prevention into embrasures is disregarded for Class III esthetic restorations. This compromise is for esthetic reasons, as well as the unnecessary removal oftooth structure which will often involve the incisal edge. Ifpossible, the outline form should place the gingival margin incisally from thc crest ofthe gingiva.
When placing the composite resin in a Class III preparation, the wooden wedge is placed in order to provide some separation of the teeth (for contac t), to stabilize the mylar strip. and to avoid creation ofexcess gingival flash. Important: Restoring the contact area must
be done properly and diIgently.

Remember: For Class

III

composite preparations the retentive grooves are placed along

the gingivoaxiaf and incisoaxial line angles (entirely in dentin). These grooves will pror ide tbr mechanical lock in the preparation. Small, rounded retentive areas are preferred, as contrasted to sharp angles. since it is difficult to insert viscous composite material into the sharp angles.

\ote: Once proper finishing has been completed, a thin layer ofunfilled resin can be applied as a glaze (this seal.s the nrargiu.s and snroothes the sujitce). The difficulty in finishing cornposite resin restorations is due primarily to the softness ofthe resin matrix and hardness of the filler particles. The most desirable finished surl'ace for composites is oblained rvith aluminum oxide disks.

The iirst composite resins that were developed contained large filler p^rticles (10-100 mictons in did,rrcrcr'r and became known as macrofill materials. In the past 20 I'ears. rcsin-based composites havc been imFrlrled b,v reducing particle sizc. increasing filler quantity, improving adhcsion betrvccn filler and or!anic miltrix. and using low-molecular-u'cight monomers to improve handling and polymcrization. By a\l!'imcntinq rvirh particle size, shape and volume, nanufacftrrers have introduced resin-based .oinpL)sites \\ ith diffcring physical and handling properties. Microfill. hybrid, microhybrid. packable r.J il!r\\ able composites now are available to be used for varying clinical situations.

I t.) 0. E !m. They have particlc sizes small enough to polish to a shinc similar to microfills but Iargc .nough ro be highly filled, thus achieving higher strcngth. The results are resin-bascd composites with good ph\sical properties, high polishability and improved wear resistancc. . Packable compositsi are ,18 to 65 percent filled by volume and have an average particlc size rangrnc iroor 0.7 to 20 pm. Thcir improved handling properties arlj obtaincd by adding a higher percentage of irregular or porous filler, fibrous filler and resin natrix. They arc indicatcd for stress-bearing arcas and allorv easicr cstablishmcnt ofphysiological contact points in Class II rcsrorations. Research has sho\\ n that thc physical properties ofpackablc composites are not superior to conventional hl,brids. . Flonable composites: are 44 to 54 percent fi11cd by volLrme and havc an avcragc particle size ranging frorn 0.04 to 1 pm. Thcir decreased viscosity is achieved by reducing the filler volumc so they are lass rigid. yet they arc pronc to morc polymerization shrinkage and $,ear than convcntional composites. Flowable composites have becn said to improve marginal adaptation ofposierior composites by acting as an clastic. stress-absorbing laycr ofsubsequently applicd rcsin-bascd composite incremcnts.
ar

Th.) do nor maintain a high polish but do have improved physical properties when compared with tr:cro lls. . \licroh] brids: are 56 to 66 percent filled by volume and have an average particle size ranging from

. \[icrofills: are 35 to 50 percent fillcd by volume and havc an average particle size ranging from 0.04 t!, lr I n)icromctcr (lrm). They havc lo*,modulus ofelasticiry and high polishability; howcvcr, they a\hibit Io$ t'racturc toughness and increascd marginal breakdown. . Hl bridsi are 70 to 77 percent fil1cd by volumc and an avcrage particlc size ranging from I to 3 Am.

Composite filler particles function to do oll of the following EXCEPT one. V,{hlch one is the EXCEPTIOM

.Increase the coelficient of thermal expansion

. Increase the tensile strength and compressive strength . Reduce the polymerization shrinkage . Increase the hardness

. Improve

the wear resistance

48
Cop!.rjghlO 201l-2012 - Dfrral Decls

When comparing the physical properties of lilled resins to unlilled resins, all of the following are true EXCEPI one, Which one is the.EXCEP?/OM

. Filled resins are harder


. Unfilled resins have . Filled resins have
a

a higher coefficient

ofthermal expansion

higher compressive strength


a lower modulus

. Unfilled resins have

ofelasticity

. Filled resins have a lower tensile strength

49 Coprighr O 20l l-?012 - Dentat Decks

***

This is falsei fillers reduce thc coct'ficicnt ofthermal expansion.

Fillers are placed in dcntal compositcs to reduce shrinkage Llpon curing- Physical propenies ofcomposite are improvcd by fillers, howcver. composite characteristics change based on tiller material, surface, sizc, )oad, shapc, surfacc modifiers, optical index.

filler Ioad and size distribution.

Composition of com posites (lilled resi s)l . Fillr particles: the filler particles usd are strontium glass. barium glass, quartz. borosilicatc glass. ceramic. silica, prepolymerized resin, or the likc. Thc particles are usually combined with 5-109/o weight ofvcry small-stzcd (0.04 pn)patticles ofcolloidal silica. Note: One micron is a critical filler size. Fillers greater than one micron are visible to the human eye. As resin matrix around filler particles wears. the filler becomes prominent and visible so the composite surface looks rough. Fillers lcss than one micron do not producc a rough appearing surface with aging. Fillcrs grcatcr than one micron arc rcfcrred to as macrofills and fillers less than onc micron arc referrcd to as microfrlls lmidi and mini arc in be\reen macto and micr?). A new classification offiller is the nano particles. The nrno particles fill betw,een all other particles to further rcduce shrinkage. A mixture ofdifferent particlc sizcs is rcfencd to as a hybrid. . \Iatrir: difunctional nonome rs either BIS-GMA or urcthanc dimcthacrylate (UEDMA). In some cases. a proportion of a lowcr molccular wcight monomer such as TEGD\lA is introduced to lowcr
Ihe \ iscosiry.
acts as an adhcsivc betwccn thc inen filler and the organic matrix. Recentl!,. ions have been added to the filler to produce desirable physical changes. Lithium and alunlrnum ions makc thc glass casicr to crush to gcncratc small panicles. Barium, zinc. boron, zirconrum. and vttrium ions producc radiopacity in thc fillcr particlc.

t**

. Coupling agent silane $hich

\ote*

L The normai wear mechanism ofthc compositc resins is best explained by the following eventsr abrasion ofthe matrix, followcd by cxposure offillcrparticles and subsequent dislodgencnt of thcse fillcr particles. 2. With any ofthe restorative resins, cavity vamish or zinc oxide eugenol should not be used as they might inhibit polymerization. The use ofa cavity vamish might prcvcnt dircct contact between the composite and the tooth structure, preventing bonding.

***

This is false; filled resins have a higher tensile strength.

The most common classification :nethod for composite resins is based on filler content. filler particle size, and the method of filler addition. AImost all important properties of conposite resins are improved by using higher filler levels. However, as the filler level is increased, the iluidity decreases.

Highlr' filled resins typically contain large filler particles but this composition results in
roush finished surface. Smaller

liller

particles are used to produce

a resin

that has a relatively

smooth finished surface. Resin filler particles are called:

.llidifillers: l-10 microns in diameter . \linifillers: 0.I- | microns in diameter . \licrofillers: 0.04-0.1 rnicron in diameter
Heliomolar RO. and Silux Plus.

. )lacrofillers: l0-100 microns in diameter

Examples include Denta-colour, Durafill,

*** Hl brid resins contain a mixture ofparticles with different diarneters which allows higher tiller levels and still permits good finishing. The principal particle size is in the I to 3 pm
Charjsma. Herculite XRV, Prodigy, Tetric ,TPH (Total Perforuqnce Hlbrid). and Z- 100 are examples.

\ote: Hybrid

and microfill resins utilize colloidal silica fillers which are useful for in-

creasing the hardness and wear resistance ofthe base rcsin matedal while maintaining high polr.h.rbility rrnd or erall estheric qualities.

*** New resins with nanofillers

that range in size fiom .005 to 0.01 micron have recently

filler levels can be achieved while still maintaining workable consistencies. Supreme H-NF and Simile H-NF are examples.
been developed. These particles are so small that very high

. UV light

is better than visible light

. You must keep the light 2 mm away or more


. You should cure for longer than normal

. Darker shades have less chemical bonding

50 Coplri8ht O 201 l-2012 - Dental Decks

All of the following are current monomers for composite resins XXCTPI one. Which one is the EXCEPTIOM

. bis-GMA

. P\{MA
. UEDMA

. TEGDMA

51

Copyigh O 201l-2012 ' Denral Deck!

Important points to rcmcmber whcn using a visible light-curing unit: . Hold the light as closc to thc rcsin as possiblc within 2 mm to bc cflictivc.
a shield betwccn thc lighl tip and thc opcrator's cycs. Paticnrs who havc had rcccnt cataract rcmoval should havc protcction also. Note: Studics havc shown that thc visiblc light uscd in polymcrization ofphoto-activated mai, crials can ciusc rctinal damagc always usc a shicld and cycglasscs for pfotcclion. . For deep restorations, you have to cure thc composilc in incrcncnts ifyou don t, thc dccpcr arcas will not bc curcd. lmportanti No morc than 1.5-2 mm incrcmcnts should bc Iight curcd at onc limc. . \'lake sure the bulb in the light is sdll powcrful cnough thcy havc commcrcially availablc p.oducts to tcsl

. Place

thc bulb.

. With darker resin shades, curc

litdc longcr.

M,y cxtcnd lo break proximal conracr Includ. dj.ccnt suspicous ar.as


Rcmovc cancsj .ot usually

unifdfr

Unifoft

0.2-0 5nm insidc DEJ

Rmolc cdicsi

nol usually

u.ifom

Creare 9o-desree

narsin
For csthct'cs, do nor berel Mgins tnat re on furdion:l pElhs

Tcrrurc of pr.prrd wrlls

Prim.n

rctcntion

fom forn
Groorc\. n!tr.

Nonc (srablhhed by rouSldc$

&

Secondrry rclcntion

l!ct\.

prn\. bonJrn!
Inc

Bond,ngr

gr6vs

fdchs lll&v

tla'

nooF, roundcd

in,cmil

an!hs

P.ovrdc .pproxrndely
Ca

: nnbcls.cn

(OIl). orcrdirecr or indircct pulp


tr hcn nnr

(,lumr Dc\Ln\iLizcr

hondinq

Scrlcd by bondjng systcn nsed

Dcntal resin composites typically contain a mixture ofsoft, organic resin rntri x (pol-vmer) and hard. inorganic filler particles (ceramic). Other components are included to improve the efTicacy ofthe combination and initiate polymerization. The resin matrix consists of monomers. an initiator system, stabilizers and pigments. The inorganic filler consists of particles such as glass, quartz and colloidal silica. The matrix and filler are bonded together rr ith a coupling agent. The peformance ofresin composites is dependent upon these basrc components. The recent improvement in these materials has prirnarily focused on trller technologv. but the resin monomers have remained largely unmodified.

The orsanic resin matrix is a high molecular weight monomer such as bisphenol A glyjdr I methacrvlate (bis-GMA) or urethanc dimethacrylate (UEDMA). bis-GMA, rvhich

stands fbr 2.2-bis 1,1(2-hydroxy-3-methacryloxypropoxy) phenyll-propane, is rn aromaric methacn late. Terminal methacrylate groups provide sites for free radical polymerization; ]l sets to a relatively rigid polymer because it has two benzene rings near rts center. T\\ o djsadvantages of bis-GMA are its questionable color stability and high viscosity; hi-uh |iscosity is the result of its -OH groups which hydrogen bond; to lower the viscos-

itr. manufacturers add low-molecular-weight f/olr-vrsco.!iry, monomers like triethyleneslrcol dimethacrylate (TECDMA) and ethyleneglycol dimethacrylate (EGDMA); thcse reduce the bis-GMA's viscosity, increase crosslinking, and increase hardness. Another monomer frequently used as the matrix for resin composites is urethane dimethacrylate. This monomer was introduced in 1974 and is a brittle material with low viscosity.

cocflcient ofthermal expansion

Important: The high filler content and the bis-GMA resin matrix drastically reduce the (as co mpared to the unfilled acrylic resins).The filler also

reduces polymerization shrinkage and increases hardness.

The main ingredient in tradltlonrl acrylic resin temporary

materials for intraoral fabrication is:

. Ethyl Methacrylate

. IsobuWl Methacrylate
. bis-GMA

. Ethylene Imine . Methyl Methacrylate

52 CoD,riglit O 201 I -20 l2 - Denral Deck

. Amalgam

. Gold . Unfilled resin . Filled resin

CoplrightO 20ll-2012 - Denral Decls

For both inlays and onlays, plastic r'acry,1ic) provisional restorations are fabricated prior to the final restoration being cemented. Their physical properties enable them to withstand occlusal ibrces and the adverse oral environment for short pedods of time. These temporaries must: restore and maintain proxilnal contacts, restore and maintain the occlusion, restore and maintain tooth contours and the margins should be closed and flush with the tooth.

Methyl methacrylate, ethyl methacrylate, and ethylene imine resins have been employed to produce provisional restorations. However, methyl methacrylate /MM.4/ is by l'ar the most common. lt is the liquid monomer that is mixed with the polymer polymethyl methacrylate (the powler). The monomer partially dissolves the polymer to form a plastic dough.
Note: The monomer is polymerized by the action of an initiator (benzoyl peroxide). Important: Methyl methacrylate maintains the occlusal and interproximal contact relationships.

Remember: Polyme zation should not go to completion in the mouth for fear of overheat-

\ote:

ing the pulp and that the provisional will not be able to be removed from the tooth. These provisionals are usually cemented in with a ZOE cement.

Classifi cation for provisional restorations:

- Intracoronal Restorations: . ZOE-based and/or ZOF-ba.ed temporaries - Preformed Provisional Shell Crowns: . Polycarbonate Crowns . \letal Alloy Crowns
- Custom-Fabricated Proyisional Crowns:

. \{N{A-like

products (MMA-/PMMA, IBMA/PBMA, EM,A,/PEMA) - self-cure . Epimine-imine products - self-cure . Bis-acryl, bis-methacryl, bis-GMA-like self-cure, dual cure, VLC - Resins and Composites

This characteristic probably offsets to some degree the undesirable effects of the relatively high coe{ficient ofthermal expansion, which is 7 to 8 times that ofthe tooth. Due
to this low thermal conductivity and diffusivity, the unfilled resin restoration changes temperature quite slowly. Therefore, it takes considerably longer for the unfilled resin restoration to become hot or cold, as compared to metallic restorations, which have a high

thermal conductivity and diffusivity.


The first materials that rvere used as esthetic materials were based on silicate cements. Due to solubility problems the silicate cements were replaced by unfilled acrylic resins. Unfilled acrylic resins contrated excessively during polymerization permitting subsequent mareinal leakage and were not strong enough to support occlusal loads. These unfilled acrylic resins have been replaced by filled resins (also colled composite rcsins). A filled resin is one in which an inorganic inert filler (lsrialU silica or quartz) has been added to the resin matrix.

\ot* .

The compressive strength of the unfilled resin is low; the yield strngth and tensile strength are even lower 2. Unfilled resins are the softest of all restorative materials //ou, vlear resist1.

ance

-no Jiller) with amalgam, filled resin, direct gold and silicates; unfilled 3. Compared resins show the greatest extent of marginal leakage related to temperature
change (percol ation)
.

Remember: A low coflicient of thermal conductivity is most characteristic ofcurrently available cement bases.

' Acid etching enamel prior to placement of a composite restoration is required . for oll of the following reasons EXCI9PI one. Which one rs the EXCEPTION?
. Conserves tooth strucfure
. Reduces microleakage . Provides micro-mechanical retention . Increases esthetics

54 Copright O
201

l-2012 - Dental Decks

. 37% Phosphoric acid

.
.

l3% Phosphoric acid


3 79,'o

Hydrochloric acid

13% Hydrochloric acid

Cop)Tight O 20ll-2012 - Dental Decks

+** This is false; acid etching does not increase the esthetics ofthe enamel margin. Do not be confused by the fact that you acid etch the bevel, which itself functions for retention and esthetics.
One olthe most effective ways ofimproving the marginal seal and mechanical bonding ofcomposite resins to tooth structure is to condition or pretleat the enamel with acid prior to insertion ofthe resin. This procedure is referred to as "acid-etch" t"hni'"'
Purposes of acid etching:

LIncreases suface cnergy which promotes wetting and adhesion. 2. Chemically cleans the tooth stnrcture which also promotes wetting and adhesion. 3. Creates micropores 1br micromechanical retention.

Important: Acid etching paves the rvay for resin "microtags" ivhich produces a much inrproved bond of the resin to the tooth. The effective tag length as a result of etching on adult anterior teeth has been demonstrated to be approximately 7 to 25 mm.
This "acid-etch technique" consen'es tooth structure, reduces microleakage, improves estlletics. and provides micro-mechanical retention.

\()1e3

l. The aim is to cause maximum enamel dissolution with minimum precipi tation ofcalcium phosphate salts. 2. Studies indicate that acid-etched composite resin restorations have the best initial seal (nicroleakage), however, over time this weakens (amalgam has rhe hest st al ovt'r Iima).

Standard acid etching ofenamel involves the application ol37% phosphoric acid for l5 seconds with a l5-second rinse and a l5-second drying to roughen the surface of the enarrel. This lonns little tags approximately 7-25 micrometers in length, providing mechanical retention. When using the acid etch technique all enamel cavosurface margins should be chamfered or beveled (this process fonns obtuse angles). Be\ eling the enamel margins of anterior resin composite preparations is recommended prilrr lo etching to:

. Reduce microleakage . Irnpror e eslhetics: by gradually blending the resin composite into the enamel
Increase bond strength: transversely-cut enamel, when etched, provides a stronger bond to resin composite than etched, longitudinally-cut enamel.This occuts because rhe end of enamel rods are more completely exposed to the etchant and, therefore, more effective etching is accomplished and more retentive tags are produced.

Remember: Once you etch the tooth, it cannot be contaminated with saliva.

Ifit

does, you

must complete the ntire etching procedure again.

I0te3

L The depth of enamel dissolution caused by acid etching is approximately l0 to 15 microns. 2. Little correlation exists between resin tag length and enamel/resin bond
strength.
3. Although liquid etchants produce a more uniform etch and a greater number of tags than do gel etchants, no difference in bond strength has been

demonstrated between the two.

rounded intemal line angles because it is to compress composite into them than anralgam.

. more, easler

less, harder

. more, harder

less, easier

56 Coplright O 201l-2012 - Dent.l Decks

Smear layer removal Smear plug removal

. Peritubular dentin decalcification

. Intemrbular dentin

decalcifi cation

Coprighr C 2011,2012, DentalDecks

When restoring teeth with composite resin, it is much easier to compress the material into rounded line angles.
The outline form ofa Class V restoration is not always uniform, as it will vary depending on the location and amount of caries or decalcification size and location of the -the When the carious tiscarious lesion determines the outline fonn ofthe cavity preparation. sue has been removed and the margins are on reliable enamel or dentin, the outline will usually be rectangular with the comers round, ovoid, or kidney-shaped, very much resembling the amalgam Class V preparation except that the intemal line angles are much more rounded. Recent research indicates that preparations with bevels are more resistant to microleakage as compared with those without bevels when an acid tch technique is used. The bevel permits the acid to attack the enamel rods at the appropriate angle for maximum effect. The cavosurface nargin is beveled wherever it is placed on enamel -- this is a major diii-erence betrveen composite and amalgam preps. When possible an enamel bevel 0.2 to 0.5 mm uide is advocated as the final stage ofpreparation. This bevel is etched and pror ides retention for the restorative material as well as improving the marginal seal and mainraining the strength of the resin with su{ficient bulk. Retentive grooves supplement the etched enamel retention (these grooves are placed in both inci,sal ond girtgival axial

***

line andes).

\ote:

Whenever possible, use a composite syringe to place the composite resin in the resroration, this will minimize the possibility of trapping air in the final restoration.

Drnrin bonding systcms (DRS) consist ol3 componcnts: . tltchant: Typical acid conditioners includc phosphoric acid. EDTA. malcic acid, and citric acid. . Primer: is dcsigned to pcnctralc through lhc rcmnanl smcar Iayer and into thc inlcrtubular dcntin to fill ibc lpaccs lcli by dissolvcd hydroxyapa(i1c crystals. This allolvs thc primcr o form an intcrpcnctrating nclwork a.ound drnrrn collagcn. Note: Thc bonding primcr is based on hydrophilic nrcnonrcrs such as hydroxyclhyl mcthacrylatc . Bonding agcnt: unfillcd rcsin adhcsivc is applicd. The resin ..rn bond ro compositc or amalgan. 'ro$ \ r. . r. .rt i .|rc-! Jcnrrrr bond ng .y.rcm dc,ign.: :-component slstems (LP+ B) . C l..rrill SE Bond & LinerBond 2v . Tlnrn SPE lBisco) . Otrrbond Solo SE Plus (Kcn)
is then curcd (light-, self-. ot

dual-(urc.i). This layer

l -com ponent slstem s

(EPB)

(Kuraray)

. AQBond (Sun Mcdical)


. or Touch-and-Bond (ParkelL) ' Adper Prompt or LP3 (lNt-ESPh) 2-component systems (E + PB) . Syntac Singlc Componcnt (lvoclar) . Onc Coal Bond (Coltcnc,'Whalcdcnt)

. Prr--:r3quick (Lltradcnt) . B.nd-lt {Jcncnc Pcntron) . \:l-Bond I (BISCO) Grr.yrtionr oiDcntin Bonding Systctrs /rAS). I Firjt Gencralion DBS's (bonded to smcar laycr)

l-component s]'stems (E + P+ B) . S..rchbond \luhipurposc Plus (lM)

. Bond-l (Jcncric'/Pcniron)

: I

S..ond Cjcncration DBS's (modificdlrcmoved smcar laycr) Third Ocncrrlion DBS's 0nodified/rcmovcd smcar laycr;produccd hybrid laycr) .1 Founh Generation DBS's (optimizcd for sncar laycr modilication + dcrlin three-stcp ctch & rinsc "clting): 5. fifih Cencralion DBS's (Reduccd-Componcnt Bonding Syslcms): two stcp ctch & rirsc
S i x th Ccncrarion DB S's (Truc Onc-Componcnt Ro,rding Systems): subd iv ided into Ttpe | (i.e., tr|o-step: acidilietl priner and adhesive applieA s?parutelt-) andTlpe 2 (i.e., one-stq, sclf-et&ing adheti|t's drc niietl and ap'

(r.

7. S.\'enth Ccncration DBS's: adhesivcs rcquirc no mixing and arc simply placed in onc stcp.

L Dentin and cnamel bonding strcngths arc simllar tbr currcnt total-ctch products.

atlAAr;,.

.,,--_.. -\ore3 .

.2.

Must lotrl clch dcntin bonding systems bond bcltcr lo moist dcnlin. usc Aqua Prcp orCluma Dcscn\rLrzcr to kccp ocnrrn mor\r. 3.lnamcl bonding is fhst, strong, and long-lasting; dcn(in bonding is slower, may bc strong, bu1 may

not bc longlasting.

A gold onlay you placd last week fails, which ofthe following
reasons is most likely responsible for the failure?

. You "capped" the functional cusp . You "shoed" the functional cusp

. You "capped" the non-functional cusp


. You "shoed" the non-functional cusp

58 Cop)'right C 201l-2012 - Dental Decks

Rapid cooling by immersion in water, ofa dental casting from the high temperature at which it has been shaped is referred to as:

. Annealing

. Quenching . None of the above

59 Coplright e 20ll-2012 - Dental Decks

*** Important:

"Shoeing" is never indicated on functional cusps.

Onlay preparations: . Resistance form: two types of cuspal protection:

l. "Capping": refe6 to the complete coverage of functional cusp with 1.5 mm ofgold. 2. "Shoeing": refers to veneering of non-functional cusp by means ofa slight finishing
bevel.
cusps oJ

Note: Except in situations demanding a minimal display of gold (primarill, the ./hcial naxillary molars and premolars), capping is always preferred over shoeing.

r----al
IH
Shoeing

Onla) preps have: . Improved resistance to fracture due to cuspal coverage . Thickness ofgold on occlusal (I .0 mm on non-fitnctional
(

cusp and L 5 mnt on functional r/-!q/ resists deformation . Reliance on tapering lingual and buccal walls for retention . Reciprocation of mesial and distal axialwalls (near parallel) . Extemal extensions over the cusps add retention ifnearly parallel to line ofdraw

This usually is undertaken to maintain mechanical properties associated with a crystalline structure or phase distribution that would be lost upon slow cooling. Tlr o advantages gained in quenching:

L The noble metal alloy is left in an annealed condition for burnishing, polishing, and procedures it maintains its malleability and ductility. :. \\hen the water contacts tlle hot investment. a violent reaction ensues. The investnent becomes soft and granular, and the casting is more easily cleaned.
similar

Remember: The set of processes, annealing, hardening and tempering are collectively krorr n as "heat treating." . -{nnealing is the softening ol a metal by controlled heating and cooling to make its manipulation easier. It makes the metal tougher and less brittle. . Tempering is hardening something by heat treatment.

Which of the following situations delines an Indication for a Class II gold inlay?

. A young patient with high caries rate

. A patient with little money to invest in dental work


. A patient very concerned about esthetics

. A patient with a large lesion, buccalJingually


. A patient with low caries rate but a history ofperiodontal problems

CopltiShr O

201

60 l'2012 - Dental Deks

Z\ '

Gold Ntloys upon solidification in the investment This needs to be compens*ted for by an equal amount of_ ofthe mold.

. Shrink, expansion
. Expand, shrinkage . Shnnk, shrinkage . Expand, expansion

61 Cop)'righr O 20ll-2012 - Dnral Decks

Disadvantages and contraindications for a Class II gold inlay: . Expense: gold is 6 to 7 times more expensive tban amalgam . Time: at least two visits are necessary . Minimal lesions: best restored with gold foil . Large lesions: if cavity width exceeds one-third the intercuspal width, the tooth
should receive cuspal coverage

. In patients with
. Young patients

a high caries rate

. Color: not esthetic


-{dvantages and indications for a Class II gold inlay:

. Tooth contours: where optimum contour


periodontal health . Strngth

and surface finish is desired to maintain

.ln

patients with a low caries rate

. l'se against another gold restorations . Bio-compatible

\ote: A gold inlay is defined as a cast gold


lhc internal walls oflhe cavity preparation.

restoration which derives its retention from

Gvpsum bonded investments are used with Type I. II, and III gold alloys. Gold alloys used for cast gold restorations shrink upon solidification. Therefore, it is necessary to compensate for the solidification shrinkage of the specific alloy used by expanding the
mold enoueh to equal the shrinkage.
The dimensional compensation necessary is accomplished by tu'o methods ofexpansion: 1. Setting expansion: occurs as a result ofnormal crystal growth but can be enhanced by'' alJo$ ing the investment to set in the presence ofwatel producing hygroscopic ex-

pansion.

2. Thermal xpansion: is achieved through the normal expansion that occurs upon heating the silica (quartz or cristobali/e). Note: The amount of expansion depends on
the particular refractory material used (cristobalite produces greater expansion than does quartz). Important: Thermal expansion is the principal cause for mold expansion.

Variables that infl uence expansion: . The older the investment is: the less it will expand

. Ifthe water/powder ratio is increased: the expansion is reduced . The longer the spatulation time: the greater the expansion . The longer the time between mixing and inmersion in a water bath: the
expand

less

it will

Note: During solidification ofan alloy, the number ofgrains forming depends on the rate

ofcooling and the presence ofnucleating agents.

Which of the following finishing margins is essentially a hollow ground bevel, creating more bulk ofrestorative matrial near the margin and providing a greater cavosurface angle?

. Knife edge . Beveled shoulder

. Chamfer

Shoulder

Copyrigh r 20ll-2012 - Dental Decks

Whlch of the following allows for proper retention when preparing a tooth for a disto-occlusal Class II gold inlay?

. Undercut on mesial . Undercut on buccal and lingual walls . Occlusal lock (dovetail)

. None of the above

Cop)'righr O 20ll-2012 - Dntal

Deks

a hollow ground bevel. lnstead ofa flat diagonal cut across the cavosurface margin, the chamfer is "scooped out" creating rr.rore bulk ofrestorative material near the margin and providing a greater cavosurface angle.

A chamfer is essentially

Cavosurface angle configurations that are used when preparing a tooth for a cast gold

restoration: . A bevel is a diagonal cut across the cavosurface margin which is flat in one dimension only and curved in its other dimensions. It involves the extemal ends of enamel prisms and follows a continuous cuwed outline. It can be either a short bevel which cuts only the external one-third of the enamel prisms, a full bevel involving the entire thickness of enamel. or a wide bevel involving not only enamel but some dentin
as well.

. A plane is a diagonal cut across the cavosurface margin which is flat in all dimensions. A plane may involve the entire thickness ol enamel (u,hich it usually does) or most of it but cannot be curved in anv direction.

When designing a Class II preparation for an inlay, an occlusal lock or dovetail should be established to prevent proximal dislodgement. Also, the marginal ridges ofposterior teeth that are restored with cast gold should be rounded to help form the occlusal embrasures and be in contact with the cusps ofthe opposing teeth. Marginal ridges should be the same height as the adjacent tooth's marginal rtdge (or else you can create an inturlArence in retrusive movemenl).

The cement does provide some retention; however, the preparation design does as well. The cement's main function is for marginal seal, not retention. 2. When rernoving a Class ll inlay, the method of choic is to cut through the isthmus to remove the occlusal and proximal pieces one at a time. 3. The restoration will not seat ifthere are undercuts. Actually this holds true for all cast metal restorations. See picture above ofa Class II inlay prepara-

tion.

A patient arrivs at your oflice with their full gold crown in hand, They explain to you thlt anothr dentist delivered itjust last welc You then examine the crovm and the preparation.What is the most likely reason the the crown fell olf?

. There was very little cement in the crown . The preparation was only 4 mm high . The preparation walls were tapered at about . The margins were jagged and undefined

l5'

64 CopFightO 20ll-2012 - Denbl Decks

The lab calls your o{fice and asks ifyou want a prrticular casting done in N base or a nolrle metal. Which of the

following responses is appropriate?

Base. because the patient has a bad bruxing habit

. Noble. because the patient has a bad bruxing habit

Base, because the patient wants a gold tooth

. Noble, because the patient wants a gold tooth

Copright C

201

65 l-:012 - Dental Decks

Taper provides the optinal friction between the walls and the casting, which is the main retention. The f'enule (or height) of the preparation also provides the friction and thus retention, but 4mm is enough /3 nn is minimarl.

lmportant: For maxjmum retention ofcast gold restorations. the axial walls should be as parallel as possible and as long as possible. Retention is directly proportional to the area ofthe axial walls and their parallelism. The axial walls should converge slightly frorr the gingival
walls to the pulpal wall.

Retention form depends on: . Length of walls lrn iniuwn 3 un): the longer tbe wall, the grcater the amount ofdraft/draw. . Taper ofwalls. fmportant: provides for draw or drafl dn olderJbr the .asting to be placed
onto the tooth)
grees

b\t

. Circumference

per t'all) Ke\ point: More parallel - more rerenlion


cast gold restorations:

also to provide for an appropdate small angle of divergence (2 to 5 defrorn the line ofdraw which will enhance retention form.

-{di antages of . Thel

. The.v are very strong and able to withstand the forces ofmastication
are ideal for occlusal rehabilitation

. The)'are kind to the gingival tissue


Disadi antages of cast gold restorations: . Eithetics

. Cost

. . . .

Time-consuming Difllculty of technique


The need to use cement, which is the weakest point in the cast gold restoration

Gold has a high themal conductivity

soluble in the liquid state. pure temperature, whereas A metal solidifies at a constant alloys solidify through a range

\n allof is a mixture of two or more materials that are mutually

tri temperature.
Base metal alloys i/also called non-precious netols) arebased on active metallic elements lhat conode. but which develop corrosion resistance via surface oxidation that produces a rhin. righrl) adherent film, which inhibits further corrosion. Exarnple: Cobaltchromium alIt l : ibrm a Cr.O3 oxide film, which passivates the surface. Base metals are less resistant i(-' corlosion. Base metal alloy advantages are principally found only in their strength and lo$ densit\',

T1pes of
t

allol systemsi

(classiJied on the basis ol the ry,pe of structue that .fbrms as thet'

olid it.\')

the metals freeze without segregation of the individual constituents. )iote: Are generally used in dentistry because they have a very homogenous stmcture an provide maximum strength. . Eutectic alloys: separatc into individual grains of the respective constituents. Exhibit complete liquid solubility but limited solid solubility. Example is the silver-copper system.

. Solid solution alloys:

Remember: Nobfe metals /a/so called precious melalt are very resistant to corrosion and do not oxidize on casting. Noble systems for dental use are based on the noble or precious metal elements gold! silver, palladium, and platinum.

Whtch of the following is NOT a correct match between the gold cast alloy component and its effect?

. Gold - decreases ductility and malleability

. Copper

- hardens the alloy

. Silver - color modiffing

Coplright O 20ll-2012 - Denral Decls

. Greater thar 20% gold or other noble metals


. Greater than . Greater than
30%o

gold or other noble metals gold or other noble metals


gold or other noble metals

50o% 75o%

. Greater than

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***

Gold actually increases ductility and malleability. It also increases resistance to tar-

nish and corrosion.


Effects ofthe Various Constituents on Gold Crsting Alloy
Compound
Gold (Au) Coppe. (Cu)
Sil,ver (Ae)

Maior f,ffect on Gold Casting Alloy


Increases resistance to tarnish and corrosion; increases ductiljly and malleability Increascs hardness

Main purposc is to modify the orange color ofcoppert reduccs melting tmperalure;
increases duciility and malleability

Platinum (Pt) Palladium (Pd)

Raises melting temperaturet increases tcnsilc slrength; decreases the coelfiient oflhermal exDansion: reduces tamish and corrosion Raises melting temperature; increases hardness: acls to absorb bydrogen gas which can cause porosities in lhc casling; prevents tamish and corrosion; has a very strong whilening eflecl on gold alloys even when used at a low concenlralion (i.e., 5 wt%) Acts
as an

Ztnc (Zn)

oxygen scavenger and prevenls oxidation oflhe olher melals during the manufac-

luring process; increases fluidity and decreases surface lensions, which increases castability

Four Types of High-Cold Alloys:


I . ADA type l: highest gold contcnt, 83o% noble metals. Intended for small inlays. Easily bumished due to high ductility. l. -f.DA t"ype ll: grcater than 787o noble metals. Intended for larger inlays and onlays.Can also

be bumished.

l.
-+.

ADA

Ipe lll:

greater than 750lo noble mctals. Inlcnded for onlays and crowns. Capable

of

being heat-trcatcd.

-\D-{ t}pe lv: greater than 75% noble metals. Intended for bridges and removablc partial dentures. ,,\lso capable ofbeing heat-treated. Hardest ofhigh-gold alloys.
T! pe Hardness Soft

Yield Strength (MPa)


<140 140-200
201-_t40

Percentage Elongation (q/o)

l8 l8
t2 t0

II

Medium
Hard

It
IV

Extra-Hard

>340

. fledium-gold alloys are 25-75% gold or other noble metals . Lon-gold alloys are less than 257o gold or other noble metals
. Gold substitute alloys are alloys not containing gold. These alloys are called passive because the]' fonn some type of protcctive layer (iurface oide Jihn) that oflers maximum resistancc to corrosion. Examples include; Palladium-silver alloys and Cobalt-chromium alloys Remember: The karat of a gold alloy is the numbcr of parts that are purc gold, on the basis of 2.1 parts as a vnit (thus, 21 karat is 100 % gold, while l8 karat is 75% gold). Fineness is measured on the basis of parts of pure gold per 1,000 ( I ,000 jitteness is I00'% gold, *hile 500 .fineness is 50% gold). Pure gold is only used in the foil restoration.

The following statements describe an MOD gold cast onlay preparation. Which would you have to change in order to ensure the onlay will be successful?

. The mesial box

has an ariopulpal line angle that is longer from facial to lingual than

the axiogingival line angle

. From facial to lingual,


ulpal line angle

the distal axiopulpal line angle is longer than the mesial axiop-

. The mesial and distal axial walls converge

. The distal box

has an axiopulpal line angle that is shofier from facial to lingual than

the axiogingival line angle

68

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OPERATIVE

Gold

When preparing a Class V cavity preparation for dirct lilling gold, you should ensure you have all of the following EXCEPT one.

Which one is the EXCEPIIOM

. Rounded internal line and point angles

. Small retentive undercuts placed in the axio-occlusal and axio-gingival line angles . \Iesial
and distal walls that flare and meet the cavosurface at a 90o angle

. An axial wall that is convex and follows the extemal contour of the tooth .5mm into dentin

69
Copynghr L.l 201l'201: - Dental Decks

Remember:

. When preparing teeth with short clinical crowns, the facial and lingual walls should have a minimal gingival to occlusal divergence angle for maximum retention. . From facial to lingual, the axiopulpal line angle of an onlay preparation is longer than the axiogingival line angle (l ll \rere not, the pt?paration would be undercut and
tlrc onlay would not.seaf. For an MOD onlay prep, the axial walls must converge from the gingival walls to the pulpal wall (fbr the same reason, tlte onlqrvrould not seat iJ they diverged).

\ot*'

L The bevel (0.5 mm vidth) on the cavosurface margin permits closer adaptation of the gold margin because the thinner margin of gold overlying the
bevel is more ductile and is able to be bumished. The desirable metal angle at the margins ofonlays is 40 degrees, except gingivally, where the metal angle should be 30 degrees. Note: You can bumish a 30- to 40-degree gold margin, less than 30 degrees rnay be too thin and break, greater than 40 degrees may be too thick and will not bumish. 2. During cementation, the finishing /burnishing) ofthe margins ofa cast gold restoration should be starled as soon as the restoration is well-seated into the preparation. 3. While preparing a tooth to receive an inlay or onlay. a gingival bevel is used to remov unsupported enamel and to compensate for casting inaccuracies. Gingival margin trimmers. carbide finishing burs, or fine, tapered diarronds are used to place this bevel. 4. This gingival margin is always placed gingival to the contact area.

Class V cavity preparation for direct

filling gold:

The outline form is usually either trapezoidal (most popalay' or kidney-shaped. The axiai wall is placed .5 mm into dentin (this u'ill make the occlusal u'all slightl,- deeper tha the gingiral wqll because there is a thicker la.,-er ofenamel nnking up the occlu' -sc/ rla//,). The mesial and distal walls are placed at the line angles ofthe tooth.

*** Remember: For any Class V prep (whether.fbr


ins gold). the outline

amalgam. composite or direct./ill

form is determined by the extension ofthe carious lesion.

The retention form is attained by shalp intemal line and point angles (a-rio-gingival und utio-occlusal).

. The resistance form is provided by flat mesial and distal walls and a convex axial s all rvhich parallels the external surface of the tooth.

\ote:

The axial rvall is convex in a mesiodistal direction in order to conserve tooth strucrure and minimize pulpal initation.

Important: The rubber dam is essential to prevent contamination of the gold with salila. A cervical clamp usually is necessary to retract the gingiva (#2 | 2 ivory clamp). The hole that is to be punched in the rubber dam lor the tooth that is being restored should be located facial to the nomal alignment with the adjacent teeth.

The purpose ofa sprue former is to crerte a prssage for material to flow lnto the lnvestmnt. The sprue former is typicrlly attached to a thin portion ofthe crown.

. The first statement is true; the second statement is false . The first statement is false; the second statement is true

. Both . Both

statements are true statements are false

70
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Dental wax patterns (ie., inlats, onlays, crowns) should be invested as soon as possible after fabricating to minimize
chang in the shape caused by:

. Reduced flow

. Drying-out of the wax . Relaxation of intemal


stress

. Continued expansion ofthe wax

71

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The purpose of the sprue former or sprue pin, as it is usually called, is to provide an ingate or sprue in the investment through which the molten alloy can reach the mold after the wax has been eliminated.
The size of the sprue former depends to a considerable extent on the type and size ofthe paftem, the type ofthe casting machine to be used and the dimensions ofthe flask or ring in which the casting is to be made. Generally, however, for the average size pattem, sprue formers smaller in diameter than approximately 1.5 mm are contraindicated. tla sprue is too small, the molten metal freezes completely in this area first, and localized shrinkage porosity results. The general rule for sprue pin diameter when using a centrifugal type ol casting machine is that the diameter ofthe sprue pin should be equal to or greater than the thickest portion of the pattem.
..Ls a general rule, it is desirable to attach the sprxe at the point of greatest bulk in the pattem. There is less chance ofdistortion upon attaching the sprue, and the molten metal is more apt to remain liquid in this area until the entire mold is filled. The direction ofthe sprue former is also impoftant. It should never be attached at a right angle to a broad flat surface of the mold. The entering hot metal impinges the mold surface at this point to cause turbulenc ofthe metal, which, in tum, creates a shrinlage void or suck-back porosir). \\'hen the same pattern is sprued at an angle of 45o to the proximal wall, a satisfactory casting is obtained.

The three types ofinlay waxes differ in terms of melting point and flow:
1. Type A: hard or low-flow wax that is rarely used except in some indirect technique 2. Tvpe B: medium-flow wax that is used in some direct techniques. 3. Type C: soft or high-flow wax that is used in indirect techniques for the construction of inlays, onlays, and full crowns.

fhe essential ingredients ofa successlul inlay wa"r are paraffin wax, gum dammar and carl ax with some coloring material. Paraffin wax is generally the main ingredient, usualll in a concentration of40-60%. Gum dammar is added to the paraffin to improve rhe smoothness in the molding. It also increases the toughness of the wax. Carnauba war is quite hard and tends to decrease the flow ofa wax.
nauba Ho\r'ever the pattern is prepared, it should be an accurate reproduction ofthe missing tooth structure. The casting can be no more accurate than the wax pattem. The wax pattem should be invested as soon as possible after fabrication in order to minimize changes in shaped caused by relaxation ofthe intemal stresses in the war.

\ote:

The refractory filler component ofgypsum bonded investments provides thermal expansion. The thermal expansion is necessary to compensate for the

alloy solidilication shrinkage.

. The first statement

is true; the second statement is ialse

. The first statement is false; the second statement is true . Both statements are true

. Both

statements are false

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All of the foltowing are indications for a cast gold onlay EXCEPT one.Which one is the -EXCEI{IIOM

. Restoration oflarge lesions . Restoration of ideal occlusion in


cases

ofdrifting, hypo and hyper eruption,

etc.

. Restoration of optimum contour and proximal contact . Restoration ofbrittle teeth (endodontically treated)

Restoration of a tooth as an abutment for removable prosthesis, creating ideal guiding planes, rest seats ard undercuts

. Restoration ofteeth to meet patient preference for gold


. Restoration of
tooth with minimal femrle, where a full coverage crown would not have enough retention 73
a
Coplrighr O 2011"2012, Denral Decks

Main components ofgypsum bonded investments: L A refractory filler rvhich is a form ofsilicon dioxide (Si Of, such as quanz or cristobalite comprises 60 to 65% of the investment. These two compounds have different crystal structures and therefore have different thermal expansion coefficients. Key point: This refractory filler regulates and provides the thermal expansion for the
lnveStment.

2. The binder fivhich i,s a g,-psum mqtrLx oj a hemihvdrate) comprises 30 -calcium to 35% ofthe investment. This is the material that hardens after being mixed with the Iiquid and thus holds the investment together (qdds strength). The actual or effective setting expansion is dependent upon the g)?sum content plus the water/powder ratio. Kep'point: Using a thinner mix 6i,rlc h contains morc waler, of a gypsum-bonded investment will decrease the setting expansion, increase the setting time, increase the

porosity ofthe set material, and ultimately weaken the set material. ,l. \lodifiers are added to modify various physical properties ofthe investment. These rrodifiers include magnesium oxide, sodium chloride, boric acid, graphite, or potasssiurn sulfate.

Dental investments serve three important functions: 1. -\ detailed reproduction ofanatomical form. l. Enough strength to withstand the heat of burnout and the actual casting of the
molten metal. l. Compensation expansion equal to the alloy solidification shrinkage.

Important: Ifa tooth is not

a candidatc fbr a full coverage crown, it is not a candidate for an onlay. A tooth that does not have a minimum of 1.5 mm of femtle effect will nccd a core build up. crown lengthcning, or both.

A fenule effect is defined as the envclopmcnt ofthc tooth stmcture by a crown. According to recent studies. L 5 mm oftooth structure is sufficient to ensure the tmnsmission of the forces of mastication to both rhe post and the tooth. A tooth that is fractured at the gumljne offcrs no form olresistance to transversal torces. The post must take on the entire load and it is inevitablc that ccmentation fails. Requiremcnts for a good ferrule efLct: . Lr I mm ofbuccal and lingual subgingival tooth srucftre . . nm uf r.\){h lhrckne:. after aJequ:rtc preparatiun . J mm ofsuprabony tooth structure
is that it can permanently restore and reinforce a tooth by a consen ati\ e technique. r\lthough conscrvation oftooth structure is desirable, such action is oliset by a lack oi rcrcnrion. It has been shown that conservative onlays have inferior retcntion comparcd to full crowns. Thii is duc to the cro$n's greater axial surface area.

Tle main adrantage ofthc onlay

561js

l. Retentive features: parallelism ofvertical surface /lr,r:idl 11411t is the primary retentive feature ofan onlay preparation. Sharp point and line angles add to retention. 2. Auxiliary retentive fcatures include a box or a groove. Thcse features may bc indicated where inadequate surface atea ofvertical walls is present. A box olfers a greater increase in surface area, thus greater retention than a groove, but is also more costly in terms of
lost tooth sfructure.
3. Thc location ofthe gingivalrnargin in the preparation ofproximal surfaces is influenced by the amount of retention required, the need to ertend gingivally to clear the contact area and convenience form.

On delivery ofyour lirst ever crown, you notice that the margins are open when you rttempt to seat the crown in the mouth. Which of the following should you check ffrst?

. The occlusal contacts . The proximal contacts


. For a void on the crown's interior

For a nodule on the crown's interior

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. They are vacuum investing . They are hand investing . Nothing in particular, hand and vacuum investing are the same thing . None ofthe above

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Denral Decks

casting lails to completely seat on a prepared tooth, one should first check for residual temporary cement or other debris on the prepared tooth. Once all the temporary cement and other debris are removed, the first stp in fitting the casting in the mouth is to adjust the proximal contact areas.

Ifa

Very important points:


1. When seating a casting, the initial interferences are usually the proximal contacts. Complete seating of the restoration can be verified by an x-ray and a sharp explorer used at the gold tooth margin. 2. When seating cast gold restorations, the occlusion of the restoration should be to the same degree that teeth contact in that quadrant and on the opposite side (u.se shint

stock to check occhtsion). 3. InitiallS ifa cast restoration is in hyperocclusion, the patient

will complain ofcold sensitivity and pressure in the tooth. If the restoration is not adjusted, the tooth sill beconre very cold sensitive, show signs of mobility and there might be rcces:ion ofthe lacial gingival tissue.

These defects. or nodules, are caused by the collection of air bubbles during the investing The best way to help eliminate these defects is to subject the water-tnvestment mtx-

rure to a vacuum during the investing procedure in order to remove the air bubbles.
The porosity ofthe investment is definitely reduced by vacuum investing, presumably beofthe increased density obtained. As a result, the texture ofthe suface ofthe cast-

cause

ins js somewhat smoother, with better reproduction ol fine detail. The compressive strength ofthe investment is increased slightly by the vacuum investment (the investnient \t Ill not /iacture as eas!-).

all of the air is removed by the vacuum treatment. The amount removed depends of the mix. The more yiscous the mix, the more air bubbles remain in the investment. However, a thick mix is usually necessary because of the desired shrinkage compensation and because of the poor surface texture that is obtarned Nith a thin tlix.
jLrme\\ ltat upon the consistency

\ot

You are preparing tooth #19 for a MODB gold onlay and tooth #18 for a MODB amalgam restoration. Which of the followlng TWO statements correctly describe the dilference in your preparations ofthe functional cusp?

. You will need 2.5 to 3 mm ofreduction for gold

. You will

need 2.5 to 3 mm ofreduction for amalgam

. You will need 1.5 mm ofreduction for gold . You will need 1.5 mm ofreduction for amalgam

Coplrighr O 2011,2012, Denial Decks

The modifred pen gnsp is the most common instrumnt grasp in dentistry; this is because it allows for the greatest intricacy tnd delicacy oftouch.

. Both the statement . Both the statement

and tlle reason are correct and related and the reason are correct but NOT related

. The statement is conect, but the reason is NOT . The statement is NOT corect, but the reason is correct . NEITHER the statement NOR the reason is conect

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Remember:

Working cusps Ailnctional cltsps) . Maxillary teeth: lingual . Mandibular teeth: buccal

Non-working crsps h o n -.s rp po rr i n g) . Maxillary teeth: buccal . Mandibular teeth: lingual


r

Minimal Occlusd Reduction


Cusp

Amalgam
2.5-3.0 mm

Cast Gold
1.5 mm 1.0 mm

Metal-Ceramic
1.5-2.0 mm 1.5-2.0 mm

Working

Non-working 2.0 mm

\otes

..

L For non-working cusps the minimal reduction for amalgam is 2.0 mm rvhile forming a flattened surface (this provicles resistance .fbrm) and for cast gold it is 1.0 mm. 2. For mtal-ceramic restorations: facial and lingual reduction 1.5 mm 3. The difference between tooth preparation for a metal-ceramic restoration and a porcelain jacket crown is mostly related to the configuration of the finishing line or margin chamfer or bevel for metal-ceramic restorations and a butt joint for porcelain jacket crowns.

Important: The most effective means for verifuing adequate occlusal clearance is a wax
bite chew-in.

With this grasp the middle finger, index finger, and thumb all rest on the handle close to the junction of the handle and the shank. The middle finger rests on the shank and the rhumb and index finger are opposite each other on the handle. (See photo below)

The inlerted pen grasp is very seldom used, however, sometimes it is used lor cavity preps utilizing the lingual approach on anterior teeth.
The palrn and thumb grasp is the most powerful grasp and is most effectively used on the maxillary arch. It is similar to the grasp used for holding a knife while paring the skin

from an apple.
The modified palm and thumb grasp allows much ofthe power of the palm and thumb grasp but also permits more delicate control. It works best when you can rest the thumb on the tooth being restored or on the adjacent tooth. It also works best on the maxillary arch.

When sttempting to remove a hard brlttle material, llke smNlgtm, you would prefr a bur with a:

. Zero rake angle . Positive rake angle . Negative rake angle

78
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OPERATTVE

Th

the

angle is the angle formed between face and face.

the

. Edge, rake, clearance . Rake, edge, clearance


. Clearance, rake, edge

79
Cop)righr ,201l-2012 - Denhl Decks

*+* Rcmmber: The rake angle = the anglc ofthe bur and the rake face. This angle may

made benveen the line connecting the edge be positive or ncgativc.

oflhe blade to the axis

Generally speakrng, soft materials such as acrylics are cut mosl effectively with positive rake angie burs; whereas cxtrcmcly hard and brittle materials /suth as analgan) ate best cul with ng|tive rake angle burs. A rakc anllc is said to bc ncgativc whcn the rakc facc is ahead olthc radi$ (/ionl the (:utitlg edge to the atis

ofthebut).A^egllverakeanglcminimizesfi?cturesofthecuttingedgethathelps!oincreasetheburlife.lncreasing the edge angle reinforces the cutting edge ofthe bur and reduccs the likelihood ofrhe blade to fiacture.

Carbide burs used for cuiting looth structure gcnerally havc slight negativ rakc anglcs and edge angles of approximately 90 . To be most effective, these burs should be rotating rapidly befor contircting the tooth.
The clesrance angle is also anothcr importanr factor in bllrde design. The clearancc anglc senes io climinatc friction ben'een the clearance face and the new tooth structure exposed by lhe curting edgc. The gresfer the clearance angle, the less friction.

srlrdclrnl C\ . Rob.F in T\l.lieynran. HO.

Bur blad design. Schemalic

cross sec-

tion riewcd lionr shank end of head lo show rltkc angle, dge angle. and clear-

\11

. Bur looth contact time T)'pe of coolan! used lwaler is best. air itt^ dehrdrate lhe loolh or cduse the loolh to he hrpcrsensitiw h) dravin!< odontobhsts into th( dentinal tubulcs)

'

ofthe tbllo*ing influence tooth temperature during Djameler and sharpness ofthc bur

culting procedurc:

. Amounr offorcc applied to the bur

Each bur blade has two sides: l. The rake face (to\\,ard the direction o./ (Lttting) . The rake face is that surface /sidel of the blade. which makes contact with the tooth surlace and faces in the direction ofbur rotation.
2. The clearance face . The clearance fac is that surface (.r/del ofthe blade that faces away from the direction of bur rotation.

Each bur blade has three important angles:


1.

The rake angle . The rake angle is the angle made between the line connecting the edge ofthe blade to the axis of the bur and the rake face. This angle may be positive or negative. The edge angle . The edg angle is the angle formed betrveen the rake face and clearance face.

3.The clearance angle

. The clearanc angle is the angle formed between the clearance face and to the path of rotation.

tangent

)iote: For most effective cutting,


tood].

a bur should be rotating

rapidly before contacting the

What is the blNde width of r cutting instrument with the following formula: 10 - 85 - 8 -14

.10mm

1.0 mm

. 0.85 mm

. 0.80 mm

80
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,PERATfVE

Chisels are used primarily to cut enamel.

Ilatchets are primarily used to cut dentin.

. The first statement is true; the second statement is false


. The first statement is false; the second statement is true

. Both statements are true

. Both

statements are false

81 Cop),right C 201 I -2012 - Detual

Deks

Cutting instruments have formulas describing the dimensions and angles olthe working end: . The first number indicates the width of th blade in tenths of a millimeter I 0 mm (t 0 x . l) for the example on the front of the card. . The second number indicates the primary cutting edge angle in centigrades 85 for
the example on the front ofthe card. . The third number indicates the blade length in millimeters 8 mm for the example on the front ofthe card. . The fourth number indicates the blad angl in centigrades l4 for the example on the front ofthe card. Three major parts

ofa hand-cutting instrument: 1. The handle is that part ofthe instrument held or gasped during activation ofthe blade

Types: single ended or double ended. 2. The shank serves to connect the blade to the handle. Types: straight or angled (rrorangle, bi<ngle, or triple-angle), meaning one, two or three angles in the shank' \oie: Proper balance ofthe instrument is accomplished by angling the shank ofthe instrumenr so that the cutting edge ofthe blade is within 2 mm ofthe long axis ofthe handle. In order to keep the blade within 2 mm ofthe long axis, the shank ofthe instrument is angled' i. The blade is the working end ofthe instrument and is connected to the handle by the shank. Blades are of many designs and sizes, depending on the function they are to pertbrm. *** The nib is not a major part ofa hand cutting instrument lt is the working end of a noncutting instrumen t (i.e., a bttrnislrcr condenser' elc./. The end of the nib, or working surtace. is known as the face. Note; It corresponds to the blade ofa hand cutting instrument'

***

Hatchets are also primarily used to cut enamel

Chisels may be grouped as:

l.

Straight, slightly curved, or bin-angl: primarily used for planing or cleaving

enamel. Characterized by a blade that terminates in a cutting edge formed by a one sided bevel.
2. Enamel hatchets: are chisel-bladed instruments with the cutting edge in the plane ofthe handle. They come paired lft and right.

3. Gingival margin trimmers: are similar in design to the enamel hatchet except it has a curved blade and an angled cutting edge. They are primarily used for beveling gingival margins. Among other uses for these instruments is the rounding or beveling ofthe axiopulpal line angle of Class II preparations (very important).

. Hoes
. Angle formers

Sharpening line angles and convenience points for gold foil preps Preparing retentiv aras on antedor teeth Remove carious dentin and sometimes carve amalgam Class

. Ordinary hatchet . Spoons

III and V direct gold preps

a2 Coplright C 201l'?012 DentalDecks

You set down the hrnd piece after preparing a Chss II rmalgam on tooth ti4. Your assistant hands vou a so you can remove the last bit of caries. and then the so you can plane the facial and lingual wllls ofthe prep.

. Spoon excavator, enamel hatchet

Spoon excavator, straight chisel

. Cingival margin trimrner, enamel hatchet

. Gingival margin trimmer, straight chisel

83 Coplright O 201 I -20 l2 - Dental Dects

There are four subdivisions of excavators:

l. The hoe excavator: has the cutting edge ofthe blade perpendicular to the axis the handle. It is commonly used in Class III and V preps for direct gold.

of

2. The angfe former: has the cutting edge at an angle (other than 90") to the blade. It is used for sharpening line angles and is especially useful to form convenience points for gold foil preps.
3. An ordinary hatchet excavator: has the cutting edge of the blade directed in the same plane of the handle and is bibeveled. Used primarily on anterior teeth for preparing retentiv areas.
.1.

A spoon excavator: has a curved blade with a rounded cutting edge. It is used to remove carious dentin and sometimes to carve amalgam,

\ote:

These can be sharpened with handpiece stones.

The enamel hatchet is the only instrument that will allow the dentist to have proper access to the margins and that will impart the proper cavosurface angle to the margins.

***

Spoon excavators are used for removing caries and cawing amalgam or direct wax pattems. The blades are slightly cuwed and the cutting edges are either circular or claw-like. The circular edge is known as a discoid, whereas the clawlike blade is temed a cleoid. The number of bevels that make up the cutting edge can classify hand cutting instruments. For xample, enamel hatchets and chisels have single bevels, whereas ordinary hatchets (fbr exqmple excavators) have two bevels and are called bibeveled. Dental hand cutting instruments are angled to: . Provide better manipulative control . Produce a better distribution of force

. Increa-se elficiency . Lsl3blish proper balance u hen in


Instruments used to

use

trim restorativ materials rather than for cufting tooth structure: . Knives (lirrlslrirg, amalgam, or gold): nsed for trimming excess filling material on

the facial and lingual . Files: also used to trim excess filling material, especially at the gingival margins . Discoid-cleoid: used principally lor carving occlusal anatomy in unset amalgam restorations

To polish a restoration you wlll likely use a bur with less cutting blades. This is because less cutting blad$ cut more efficiently.

. Both the statement and the reason are correct and related

. Both the statement

and the reason are correct but NOT related

. The statement is correct, but the reason is NOT . The statement is NOT correct, but the reason is correct . NEITHER the statement NOR the reason is correct

a4 Copfight O 20l l-2012 - Dertal Decks

There are several tlpes ofbleaching products tvailable for use at home' which can either be dispensed by a dentist or purchased over-the-counter. tray-applied Curren$, only dentist-dispensed home-us
gels carry the ADA Sal.

0oi' carbamide peroxide

159.'6

hydrogen peroxide

. 20% hydrogen peroxide

l0% carbamide peroxide

85

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*** Important:

Thc greater lhc numbcr ofculting bladcs on a bur rcsults in less efficint cutting but a smoother suft^ce lpolishing hrs arc ol lhi\ l|pe). Alcsser numbcr of bladcs on a bur rcsulrs in more efficient cuitine but a rougher sur{ace. Crosscut t'issurc burs al high spccd or low spccd arc ofthis r}pc.

Parts

ofburs:

I. Shank: thc part lhat fits into handpiccc. Thc thrcc most common tlpcs arc straight. latch-r]"pc anglc and tiictron-gflp anglc.
2. Ncck: {hc irtcnncdiatc portion ofa bur that connccls thc hcad to thc shank. lrs main lunction is to transmit ro! tational and translational forccs to thc hcad. 3. Head: thc $'orking pan of $c bur the cutting edges ofwhich pcrfonn thc dcsircd shaping of tootb structure.

Types of burs: . Sttel hts&t Dtostlr /t)t linishing prorcdure\) . C^rbidc (used /ot, Larit| prepardtio : pe|orn best at high speeh) Shapes of burs: rcfcrs to thc contour ofthc hcad. Thc basic hcad shapcs arc round, inveried conc, pcar straight fisiurc and lapcrcd fissurc. Note: Within a givcn scrics ofburs, thc smaller numbers rcprcscnt small burs; thc largcr

numbers, largc burs.


Recent modifications in bur desicn:

. Raduced
.(
-r

use ofcrosscut burs non-crosscut burs arc now popular orJr ti"'ur.' bur. r^ rth cxt.nd.d hc.r.l' 'R.rLnding ofihc sharp tip comcrs

Th. rotational speed ofan instrumcnt is mcasurcd in rcvolutions pcr minutc /?rr. Thcrc arc 3 spccd rangcs: slow \.:t,. i:na)1tpDt) intcnnctliarc (1:.000 to 200,000 rpnr, andhigh (ahore 200,A00 ryn, spcc.J.Tbc most uscfulin::r.r:..nti i.c rotatcd at either low o. high speed. Thc crucial lactor fbr somc purporcs is thc surfacc spccd ofthc in:rrl1r.rr- rhc \clocit) a1 which ihc cdgcs oflhc cultilg inslrumcnt pass across lhe surlhcc bcing ut. This is .rr.rnion.rl Io borh thc rolalional speed and Ihc diamctcr oflhc inslrumcnl, with largc instrumcnts having highcr sur:=.J .:.Jds
3t

3n] gi\en ratc ofrotation.

Di.mond abrasile instrumentsi involvc abrirsivc rathcr thar bladc cutting. Thcsc instrumcnts arc bascd on small. .:r:.:u :r prnrclcs ofhard substanccs hcld in a matrix ofsoficr nratcrial. Diamonds consist ofthrcc parts: a mctal blank, ::::1Lr\\dcrcd diamond abrasive, and a mctallic bonding matcrial fiat holds thc diamond powdcronto thc blank. Thc :::rnk in many $ays rcscmblcs a bur \r,ithoul bladcs. Il has $c samc csscnlial parts: hc!d, ncck. and shank. Thc clinr.:: p.rlbnnancc ofdiamonds depends on thc sizc. spacing. unifonnit!, cxposurc. and bonding ofthc diamond par-

t:.1.i

Di.rmond particlc sizc is commonly catcgorizcd as coarsc. mcdium. llnc. and vcry linc.

TrIo methods of bleaching:

L "In office": most use a lightactivated solution of 35% peroxide in 4- l0 minute cr cles. Tbis procedure is called "chairside bleaching" and may require more than one ofllce visit. Each visit may take from 30 minutes to one hour. Note: Lasers have been used during tooth whitening procedures to enhance the action of the whitening
a,qenl.

home": the active ingredient contained in all of the at home tooth whiteners * hich have eamed the ADA's seal, and the compound which has been evaluated in rhc \ ast majority of at home bleaching studies, is carbamide peroxide at a concentration of 109/o. The active ingredient found in most over-the-counter at home bleachins products is not carbamide peroxide but instead hydrogen peroxide.

:. *-\t

\ote: Bleachins

can affect the color ofdentin and enamel. Extrinsic stains respond best :o r ital beaching. Response is best with yellow stain followed by brown and orange. The \\ orsl response is from gray starns (tetracycline staining).

Other u ar r to lighten vilal teeth: . Direct composites: useful for tetracycline staining . Laboratory-fabricated porcelain veneers: useful when the shape, size and arrangement ofteeth are esthetically unacceptable . Full-coverage crowns fnosl invqsive and costly): may be all-ceramic or porcelain
fused to metal

Which one is the EXCEPZOM

. Operator zone
. Assistant zone . Transfer zone . Patient zone

Static zone

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Xerostomia is the most common adverse sid effect of medicttions. This is attributed to the cholinergic effects ofmany medications.

. The first statement is true; the second statement is false . The first statement is false; the second statement is true . Both statements are true . Both statements are false

87
Coptaighr O 20ll-201? 'Denral Decl(!

The operator and the assistant should concentrate on positioning themselves in work circles. The dentist's work circle should allow easy and unobstructed access to the patient's mouth. The assistant's work circle should include all instruments and supplies needed for the intended operation. also allowing access to the transfer zone to bring the necessary items to the dentist. When viewed from above with the patient's head in the l2:00 o'clock posrtion, the right handed dentist will operate in an area from 8:00 to I l:00 o'clock. This area is the operator's zone. Nothing should be in this area that would interfere with the free movement ofthe dentist. The area from I l:00 to 2:00 o'clock is called the static zone. This area is reserved for the mobile cabinet and nitrous oxide apparatus. The area fronl 2:00 to 5:00 o'clock is the assistant's zone. Although the assistant will not move as much as the dentist, nothing should be positioned in this area that would hamper the assistant's free access to the oral cavity, mobile cabinet and dental unit. The area form 5:00 to 8:00 o'clock is the transfer zone. This area is reserved for the transfer of instruments, medicaments. and supplies to the dentist. Also, the dental unit should be positioned within this
arc.

Other considerations for an efficient four-handed dental delivry system: . Concerning the transfer of instruments: the hand instrument to be transfered to the dentist is held by the assistant between the thumb and the forefinger. . Equipment selection: whatever equipment is used it should be compatible for the dentist and assistant. The position ofthe chairside assistant should be highr than the dentist.

\ote: \'enting the suction exhaust to the building orlice stllf from the central suclion unit.

exterior can reduce health hazards to the

***

This is attributed to the anticholinergic effects ofmany medicatrons.

Other etiologic factors for xerostomia include: . Radiation therapy to head and neck . Salivary gland surgery . -{utoimmune disorders such HIV infections, systemic lupus erythematosus, rheumatoid anhritis, and SjOgren's Syndrome . Endocrine disorders such as diabetes and hyperthvroidism

Treatment lor xerostomia: . Consider stopping offending medication . Comrnercial saliva substitute

. Fluoride Supplementation . Scrupulous dental care is essential


Antichofinergic drugs (u,iici block receptor sites./or acery*lcholine) decrease salivary tlos and respiratory secretions during surgery Examples include: atropine, scopolamine,
methantheline, and propantheline bromide.

Don't forget: Local anesthetics aid in reducing the flow ofsaliva during operative procedures by reducing sensitivity and anxiety during tooth preparation.

Remember: Cholinergic agents actually increase secretions, a cholinesterase inhibitor would also increase secretions because it would reduce the metabolism of acetvlcholine.

When restoring a Class

II or Class III lesion it is inportant to crerte properly shaped embrasures for all of the following reasons -EXCEPI one. Which one is the EXCEPIIOM

. Create a spillway for food during mastication


. Make the teeth self-cleansing . Protect the gingival tissue, while also allowing stimulation of it

. Provide arch stability

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OPERATIVE

Atooth was restored 3 months ago by a new associate of yours. The patient complaining of mobility and thermal sensitivity, You trke a periapicrl radiograph. You could see all ofthe following in that radiograph to your suspicions, EXCEPI one. Which one is the EXCEPTION'! conlirm .

is

. H)?ercementosis

. Root resorption
. Periodontal pockets
. Alteration ofthe lamina dura

. Widening ofthe periodontal ligament

space

89 coplriSht o 20l l-2012 - Dental Decfts

As long as a contact is present, regardless of proper embrasure contour. you maintain arch stability There are four embrasures for evry contact area:
|.

***

will

Buccal

brfitcial)

2. Lingual (usually larger than the Jacial) 3. Occfusal (or incisal) 4. Cervical (or gingival) *** Note: In posterior teeth, the gingival tissue fills this embrasure. Normally it is "col" shaped when viewed in a faciolingual cross section.

Functions of embrasures: I . N4ake a spillway lor food during mastication

l. \lake the leeth more self-cleansing


-1.

Protect the gingival tissue from undue frictional trauma, but at the same time pro-

r ide the proper degree of stimulation to the tissue.

.\ contact area is an area in which


sarne arch make contact. A contact

the mesial and distal surfaces ofadjacent teeth in the point is a point at which teeth ofthe opposing arches meet or touch in occlusion or closure. The height ofcontour refers to the thickest portion or point ofgreatest circumference

of

rhe tooth when viewed form the incisal or occlusal surface. Its functions include forming the contact area on the mesial and distal surfaces and protecting the gingiva surrounding rhe tooth.

*"*

YoLr should have suspected that the restoration was high, based n.rainly on the mobility l'actor. Occlusal trauma can still cause periodontal pocketing; however, that cannot be seen on a radiograph.

Some common clinical signs of trauma from occlusion include: . Increased tooth mobility is the most common clinical sign . Themral sensitivity (cold)'. prestmably, this sensitivity is due to venous hyperemia

of

the toodr

. -\nrition of the enamel . Recession ofthe facial gingival tissue Remember: Whenever a restoration is done, the occlusion has to be right. The degree of contact on the restoration should be to the same degree that teeth contact in that quadrant and on the opposite site.

\ote:

The radiograph ofchoice for evaluating root surfaces, suppofiing bone and the pe-

riodontal liganent is the periapical film.

Z\
When restoring the embrasures of posterior teeth th contect should be formed stightly buccal from center. This will create a wider facial embrasure.

. The first statement

is true; the second statement is false

. The first statement is false; the second statement is true

. Both

statements are true

. Both statements are false

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ERATIVE

. Lingering pain over 15 seconds . Negative electric pulp test . Frank apical radiolucency

. Percussion sensitivity

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The

This will create a wider lingual embrasure and a nanow facial embrasure.

primary purpose ofthe proximal contact relationships between adjacent teeth in the dental arches is twofold. This relationship serves both to stabilize the dental arches by the combined support of the individual teeth and to prvent the impingen.rent offood material on interseptal tissues between the teeth
The proximal contact area functions to: L Support neighboring teeth (stabili:es the dental atch)
2. Prevent food particles frour entering the interproximal areas 3. Protect the periodontiun.r
.1.

Form embrasures

The loss of proxirnal contact between teeth nray result in periodontal disease, malocclusion. food impaction, or drifting ofteeth.

Remember: When viewed from the facial, all premolars have their contacts at the iunction of the occlusal and middle third. From this same view. molars have a proximal contact located in the middle third. Fron.r the occlusal view, all posterior teeth have contacrs. r hich are located slightly buccal of the middle third (mesial and distql). This creates a rvide lingual and a nanow facial embrasure.

A tooth with percussion sensitivity could need caries control with a sedative temporary filling. lt could also need occlusal adjustment (vhich can cause reversible pulpitis os Pulpal necrosis is the death of the pulp. A tooth aff'ected with a necrotic pulp may have no painful symptoms. It may appear discolored. The EPT /electric pulp tester) will be of r alue because there will be no response at any current level. The tooth sometimes respexds to heat, but will not respond to cold. Treahnent is root canal or extraction.
is characterized by pain, which is commonly triggered (acate apical periodontitis) alone is not indicative ofan br chen ing or percussion. AAP irrer ersible pulpitis. It is indicative that the apical tissues are irritated, which may be associated \\ ith an othenvise vital pulp rvith a potentially reversible pulpitis. In the absence oircue pain. a negative EPT test or a frank apical radiolucency. a carious tooth with sensirir itr to percussion may respond to caries control (tentporary flling). If it doesn't re-

***

\ote: Acute apical periodontitis

-.pond to a sedative

filling, root canal is indicated.

Pulpal Diagnosis
Normal
Reversible pulpltis

Cold Response

Treatment

Not delayed or very short linger None needed Lingers less than l0-15 seconds Remove causative agent RCT or extractlon
RCT or extraction

Irreversitrle pulpitis Lingers longer than 15 seconds


Necrotic pulp
No response

On the lirst d|y in your solo privNte practice you have r pulp exposure. All of the following are favorable factors in avoiding root canal treaturcnt EXCEPI one. Which one is the EXCEPUOM

. It is

a mechanical exposure

of lmm

. The tooth

had never been symptomatic

. The pulp tissue appears pink


. The hemorrhage is slight . It is
a pinpoint carious exposure

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The ideal amount of time lrom placing an indirect pulp cap until rcopening the tooth to remove the remaining decay is:

.7 - l0

days

.2-3weeks

. I month
.3-4months

.I

year
r.rnless

. Never,

the tooth becomes symptomatic there is no need for further treatment

CoplriSht O 201 1,201: - Dental Dcks

Direct pulp capping involves the prompt application ofa setting calcium hy&oxide cement
to a "pinpoint" /ess thq l mm h diameref, well isoJated traumatic pulpal exposure. This procedure may be expected. in most instances, to stimulate the fbmation ofa reparative "dentin bridge" over the exposure site and to preserye the underlying pulpal tissue in a healthy con-

dition.

Favorable factors for direct pulp capping include: the visual evidence of uninflamed /plnt) pulp tissue, the absence ofcopious hemonhage through the exposure, no previous symptoms ofpulpitis, a small non-carious exposure /a mechqnicol pulp exposure). and a clean cavity uncontaminated with saliva.
The lollowing adverse responses may occur following direct pulp capping procedures:

Physical or microbial insult to the pulp may result in pemistent inflammatory changes, rvhich may culminate in partial or complete pulpal necrosis. . Regulation of the mineralization processes involved in dentin bridge fonnation may be corne deranged, resulting in extensive calcification and obliteration ofthe pulp canal space bl mineralized tissue. . \'er) rarely, the differentiation ofodontoclasts may be induced u,ith the development ofintemal resorptive lesions.

\otr.

L Direct pulp capping is especially successful in immature teth. 2.The failure of this direct pulp capping procedure u'ould be indicated by symploms of pulpitis at any tine or the lack of a vital response after several weeks or
months.

3. Direct pulp capping should not be attempted on teeth with a history of pain,
sensitivity to percussion or periapical radiolucencies (root canal therapl, may be indicated).

Trvo types of pulp capping procedures:

L Indirect pulp cap: a calcium hydroxide base is placed on a thin layer of question able dentin remaining over the pulp. It is performed when a carious exposure is anticipated. After a 3 - 4 month waiting period, the tooth is reopened and the remaining decay is rerroved. During the waiting period, it is hoped that there rvill be secondary dentin formation, allowing complete removal ofthe decay without pulp exposure.

Classic example: A radiograph ofa first molar shows gross decay that may involve a hom of the dental pulp. The ideal treatment would be to do an indirect pulp cap and place a sedative filling(IRM).If tooth remains asymptomatic, in 3 - 4 months you can re-enter the toodr and remove all decay with subsequent placement ofa permanent fill ing. \ote: Ifthis patient had pain in the tooth laggravated h.t'heat and tender to per(ussiotl). and excavation of the carious lesion revealed exposure of the pulp horn \rithout evidence of vital tissue, the emergency treatment pending eventual root canal therapy is to place a small cotton pellet dampened with eugenol over the exposure and seal the cavity with a temporary material (1R M). Rationale for indirect pulp

capping

there are three dentinal layers in a carious lesion:

A necrotic, soft, brown dentin outer layeq teeming with bacteria

2. A firmeq discolored dentin layer with fewer bacteria


3. A hard, discolored dentin deep layer with a minimal amount ofbacteria invasion 2. Direct pulp cap: a calcium hydroxide base is placed directly on a pulpal exposure,

A patient walks into your ollice for an emrgency visit. He asks the rceptionist for a cold glass ofwater and sesms to be tilting his head sideways as to hold the watr on one side of his mouth. Immediately, you suspect which reason for his visit?

. Pulpal necrosis
. Pulpal hyperernia . Irreversible pulpitis
. Acute apical periodontitis

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OPERATTVE

A cold test reveals N lingedng pain. You ask the patient to raise their hand until the pain subsides. The patient raises their hand for about 8 seconds. What does this data suggest?

. Pulpal necrosis . Ineversible pulpitis . Pulpal hyperemia


. Acute apical periodontitis

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Irrevcrsibfe pufpitis honetimes called qcute pulpitis) rs an acute inflammation ofthe dental pulp characterized by intemittent spasms of pain, which become continuous. In the early
stages, it may appear as a very severe hyperemia. As the condition continues, the pain may be described as a gnawirg or dull throbbing. The pain is generally increased by heat and relieved

by cold. The treatment accepted by most clinicians is pulp removal (t'oot canal therapl). Note: The tooth is usLrally percu.siun positive.

f/Ir is reversible pulpitis). Later, as the pulpal swelling spreads from the initial area ofdamage or initation to the rest of the pulpal tissue in the chamber, the pain initiated by the stimulus becomes more prolonged rthi.s is iteversible pahtll.r/. Ifenough pulpal tissue becomes damaged, the pain may initiate or persist \\'iihout any stimulus at all. At the same time. the degenerative inflammation ofthe pulp may reach down the entire length ofthe root or roots and begin to cause the apical PDL to become inflamed (acute apical periodotltitis l,4PJ. Norv the patient may have not only r rhrobbing toothache but also pressure sensitivrty (to the presstu< of che*'ing or pera$sion). This stage marks a later point in the pulpal degenerative timeline when the tooth is the ''hottest" and usually the most difficult to get numb.
At first, the pain is initiated and sustained only by the stimulus
is hard to distinguish between reversible and irreversible pulpitis, in \\ hich case caries conftol (the plqcement ofa temporary'.fi11i1g) is a consewative approach :orr ard making the final diagnosis. lfa tooth responds well to this tempomry filling. then the reed ibr root canal therapy at this time is ruled out.

Important: Sometimes it

Remmber: Reversible pulpitis or pulpal hyperemia is mereJy the engorgement ofthe pul$,ith blood. Once the causative agent (i.e., ha.leria or a restoraliotl in h)perocc/r.rro7rl is removed or adjusted, the pulp will most likely retum to normal.
pa1 ressels

***

Hyperemia of the pulp is an excessive accumulation of blood in the pulp resulting in vascular congestion.
Pulpal hyperemia is sometimes called "reversible

pulpitis"

and may be caused by phys-

ical. chemical or bacterial insult. Following restoration placement, teeth often become hl peremic and are sensitive to cold for a few days. The pain is not spontaneous and does not last longer than approxiraately 10 seconds after the stimulus is removed. It is dris iict. its short duration and low intensity, which distinguishes it from the pain ofacute pulpiris /"iiraerslble pulpitis"). Remember: Hyperemic teeth respond on a lower level (rf curent on the EPT (electric pulp te,tter) than a nonnal tooth.

Treatnrent: If possible. the source (e.g., high restoretion) should be removed. lf indi.3red. a sedative restoration can be useful. If due to deep caries, an indirect pulp cap should be used only in permanent teeth and when pulp pathology is believed to be rerersible/e.g.. noperiopicol patholopy, no lhgering sponlaneous pain lhqt might bevorse orerniqht and stimulated pain ol short duratiotl onl,-).

Important: Pulpal hyperemia caused by bacterial insult is a limited inflammation ofthe pulp. The tooth can recover if the caries is eliminated by timely operative treatment.
\\'hen the pulp becomes severely inflamed
as indicated by a thermal stimulus producing

pain that lasts long after the stimulus is removed (longer than l5 seconds), this suggests "irreversible pulpitis." The pulp is unlikely to recover after removing the caries.
is to use adequate

Remember: The most effective way to reduce injury to the pulp during tooth preparation irrigation to avoid heating ofthe dentin.

Pins

What was previously an MOD amalgarn in #20 now shows that the entire lingual portion of the tooth has fractured off, You believe that the tooth is restorable with a pin-rtained amalgam restoration/cor. How many pins will you likely use and why?

. one, because you are missing the lingual cusp only . tu,o. because you are missing both the mesio- and distoJingual line angles . three. because you are missing the mesial, distal, and lingual walls

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OPERATI\TE

Pins

The most retentive style of pin is the self-thraded pins because they are cemented into pinholes that are smallr than the pin itself.

. Both . Both

the statement and the reason are conect and related the statement and the reason are correct but NOT related

. The statement is correct, but the reason is NOT

. The statement

is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

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***

The rule of thumb is one pin per missing line angle.

The largest pin that can safely be placed should be selected in any situation. The optimal placement is at the line angles or comers of the tooth, where the tooth./root mass is greatest and the risks ofperforation into the pulp or furcation are minimal. Advantages: . More conservative and less time involved than castings . Enhances retention form (adds n a//s) and is an economical alternative to castings Disadvantages:

. Can cause dentin crazing . Microleakage can occur at pin channel . Pins rveaken amalgam alloy
. Placement can result in pulpal exposure! perforation and fracture oftlle tooth
Tl pes of Pins:

. Cemented . Friction-lock . Self-threading

***

Although the pinhole is smaller than the self-threaded pin, it is NOT cemented.

Self-threaded pin systems (fbr exantple, TMS. ll haleden 1) use holes sized just under the scre\\' diameter The elasticity (resiliency) of the dentin functions to retain the screwed pin. This systern comes with a selflimiting drill of optimal 2 mm depth and self-shearins pins that gunrd against overtightening. This type ofpin system is the most frequently
used olthe three tlpes ofpins. (Thread-ntate .ttsler?) system has four sizes of pins (reg at minin, minikin tt tl ntinLtta). They are available in titanium or stainless steel plated with gold. Cemented pins are serrated stainless steel pins that are cemented into pinholes that are larger thrn the diameter ofthe pin.

The

T\IS

Self-threading
Regular

Drill
0.027" 0.021"

Size

Pitr Diameter 0.031"

Minim

0.024' 0.019'
0.015"

Minikin
Minuta

0.01?' 0.0135'

are tapped into pinholes that are smaller than the diameter ofthe pin. the They are retained by elasticity ofthe dentin.

FrictionJocked pins

Note: The increased strength of the latest dentin/enamel bonding agents, coupled with the revived use ofretentive slots, pot-holes, grooves and channels, has led to a reduction in the use ofpins. Examples ofdental adhesives include: Amalgambond Plus, All Bond 2, DenTastic and Easybond. These systems allow adhesion to preconditioned substrate with the added benefits ofretention and sealing ofthe restoration and a stronger total cohesive mass to support all remaining cuspal segments ofthe tooth.

Pins

Regarding the use of pins, all of the following statements are true -gXCtPf one. Which one is the.EXCBPTIOM . Use one pin per missing axial line angle, cusp, or marginal ridge, up to a maximum offour . Use large-diameter pins whenever possible
. Use the minimum number ofpins compatible with adequate retention (pins v,eqken amalgom)

. Pins should extend 2 mm into dentin and restorative material

. Keep at least

.5

to I mm of dentin between the pin and the DEJ

. Pins should be placed away from furcation areas and parallel to the extemal tooth sudace

. Coating of pins with adhesion promoters such as Panavia and 4-META materials improves
liaclure resistance ofcomposite and amalgam cores

. Pins

are bent to make them parallel or to increase their retentiveness


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OPERATIVE

Pins

When preparing a pin channel you perforate into the vital pulp chamber. What best describes your next step.

. Explain to the patient the need for root canal treatment . Allori bleeding to stop, dry with
paper point, place calcium hydroxide
as to not enter

. .\llou bleeding to stop, dry with paperpoint, place pin to depth of I mm


the pulp chamber

Allol
_gam

bleeding to stop, dry with paper point, place pin elsewhere and restore with amal-

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This is false; pins are not to be bent to make thetn parallel or to increase their retentiveness. Occasionally, bending a pin may be necessary to allow for condensation of amalgam occlusogingivally. When pins require bending, a bending tool must be used. A hand instrunent fe.g., an amalgam condenser or spoon excavator) should not be used. The main advantage of pins is to improve the retention of large restorations. Unfortunately, pin retention techniques are not without disadvantages. Pins are known to weaken th restorativ matrial into which they intrude. Ifplaced by force, they can create stresses that cause crazing ofthe tooth structure. They may provide an additional deep path for microleakage. Ilplaced in close proximity to the pulp, they may aggravate an existing pulp problem or create one. The use ofpins may be contraindicated in young teeth rvith very large pulps and in teeth with reversible pulp pathology, which might be aggravated by instrumentation. Placement is always influenced by the limitations olaccess and
r ision.

***

Remember: Cusps to be restored with dental amalgam should be reduced by 2 mm while fbnning a flat surface (perpendicular to the occlusal forces).

\ote: After

restoring a tooth, make sure you check the occlusion very carefully. If a restoration is left in supra-occlusion, the patient will retum complaining of discomfort u hen biting, usually with no other symptoms.

Remember: If when attempting to drill a pin hole the drill enters a vital pulp chamber, the proper treatment is to allow the bleeding to stop, dry with a sterile paper point and
place calcium hydroxide in the hole. Proceed with a better location for a pin hole. Ifa pin channel perforates the extemal surface ofthe tooth and all factors are favorable, a pin can be placed provided there is no extension beyond the surface ofthe tooth.

Idealty, pins should be placed I to 1.5 mm inside the cavosurface margin and at least .5 mm inside the dentinoenamel junction (DEJ), rf preserft. Placement ofthe pin channel at least ,5 mm away from the DEJ helps prevent crazing or complete fracture of the rerraining enamel. Note: The optimal depth of the pinhole into the dentin is 2 mm.
The rule of thumb: Pins should be 2 mm into dentin,2 mm within amalgam, and I mm tiom the DEJ (to be .salb)with no bends in the pins. Important: The twist drill used to prepare the pin channels must be angled so that it remains in dentin only. The channel should be prepared parallel to the extemal surface ofthe tooth.

\\'hen pins are placed nearer the occlusal surface, as in cuspal coverage areas. the pins should project only minimally into the restorative material (2 mmfor amalganr); long pins near an area ofocclusal loading will significantly weaken the amalgami additionally, the purpose ofthe pin in cuspal coverage areas is to bind the cusp to the restoration and to resist lateral displacement with occlusal function.
Note: Maximal intemin distance results in lower levels of stress in dentin.

. Time consumption

. Patient objection . Cost

. Staffallergies

to material

.t

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The rubber dam can still be used effectively even if teeth are crowded and overlapped because the hole punch pattern does not alwavs have to be followed.

. Both

the statement and the reason are correct and related

. Both the statement and the reason are correct but NOT related

. The statement is correct, but the reason

is NOT

. The statement is NOT cofiect, but the reason is correct . NEITHER the statement NOR the reason is conect

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***

the advantages of using it, these clairrs

However, ifyou become proficient in placing the rubber dam and explain to patients will be eliminated.

Advantages of using the rubber dam: . Dry, clean field

. Access and visibility

. Improved properties of dental materials . Protection ofthe patient and the operator
. Operating efficiency The following conditions may preclud the use of th rubber dam:

. .

Severely tilted teeth Some third molars . Teeth that are not erupted sufTiciently . Some respiratory problems such as asthma or severe colds in which breathing through the nose is di{Ticult

Remember: The use of a rubber dam is the standard of care when performing endodontics.

In this case, you can punch the holes closer or in a similar pattem to the teeth, allowing
for the elimination ofwrinkles and avoid having papillae protruding through. Five functions of rubber dam isolation:

. Retracts soft tissue, such as lips, cheeks and tongue . Provides for clean, dry field . Protects the patient by eliminating the possibility ofthe swallowing debris or instruments. Protects the dentist somewhat by isolating him,/her from possible infectious
conditions in the patient's mouth. . Provides for maximum physical properties of materials. For example: The rubber darl provides a dry field, which is essential for placement of amalgam restorations as $ ell as cements. Remember, the cements that are placed under dry conditions ha\ e maximum strength. Also a dry field prevents delayed expansion of amalgam. . Saves time rubber dam saves time due to the fact that the operator can work more efficiently in a clean, dry field where visibility is not impaired.

Important: In order for a rubber dam clamp to be stable, all four points of the jaws of the clamp must contact the tooth gingival to the height ofcontour They should not extend beyond the line angles to prevent impingement ofthe interdental papilla and possible interference with placement ofa wedge.

l.A frequent cause of interdental papillae protruding from beneath the rubber dam is holes that were punched too close together. 2. Wdnkling ofthe rubber dam between isolated teeth is the result ofholes that were punched too far apart.

. Both the statement

and the reason are correcl and related

. Both the statement and the reason are correct but NOT related . The statement is correct, but the reason is NOT

. The statement

is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

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. Apply acid

etch

. Place the low viscous sealant material

. Apply bonding agent


. Wash acid etch away . Use rubber prophy cup with pumice

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the Young's rubber dam frame provides less soft tissue retraction than the Woodbury. However, that is not why it is used, it is simply more convenient.

*** It is true that

lmportant points about using the rubber dam: . Apply lubricant to the lips and comers ofthe patient's mouth. . Plot the hole on the rubber dam. Always isolate a minimum of three teth. Punch the appropriate size hole ior a particular tooth. For a tooth baring a clamp, the hol should be one size larger than thos without a clamp. . An appropriate clamp is selected that will fit the most distal tooth to be isolated. The dam may either be stretched over the clamp with the clamp in place on the tooth; or
the clamp may be carried with the dam and placed on the tooth in one step. . Once the dam is placed, it is secured with either a Woodbury or Young's holder
l.ft

qnte).

. The rubber dam is inverted into the gingival sulcus using floss and/or
an instrument such as a plastic

instrument

a blast ofair and this will prevent seepage of saliva.

Remolal of the rubber dam very important: Removal is the reverse of application, ercept all ligat.lres (interdental septum of dam) must be cut and removed before the
dam is removed.

Sealants necd micro-mechanical retention. The surfaces should be cleaned rvith a prophr laxis brush or rubber cup and pumice with watcr. Whcn thc tccth arc cffectively isolated from saliva .r.:rriminaiion. the surfaces are dried and acid-etched by ihe application ofa 30 to 50% phospho cacid i.rhrrrlrn for one minute. Thc solution should bc gcntly agitatcd during thc application. This is then washed 3\fa\ and dried leaving a frosty-appearing /drlland chalky) etched surface.

Importanti

\liscellaneous information concerning sealants: I The placemcnt ofsealants is a highly effective means ofpreventing pit and fissure caries. It is safe. h is currently underused in both pivate and public dental health care dclivcry systems. : The subsrantial rcductions in dental decay that have occuned in the young population ofthe United States are due. for the most part. to thc use ofsystemic and topical fluorides. The control ofsmooth
surtace caries that js providcd by fluorides is
sealants,

ofcritical imponance to the additional effectiveness of

i.
.1.

Thc propenies ofsealants arc closer to those

ofunfilled direct resins than

to thosc

offillcd rcsins

Sealants are weak compared to filled resins (composites). The strength of a sealant is sacrihced in order to make it flou,into the pits and fissures (lhe viscosity needs lo be lo$'enough tofov'into the

pils andfssures). 5. The most likely result ofinadvertently sealing a small carious lesion in the occlusal surfacc ofa
tooth is that the caries rvould be arrested. 6. Research indicatcs that pit and lissure sealants are retained best on maxillary and mandibular bicuspids. Howevr, the first molars 1d4r. and mand.) bcncltt thc most from sealants. 7. Ifa topical fluoride is to bc used in conjunction with a pit and fissure sealant, the fluoride must bc app)ied either beforc the conditioner /acld elcrdra/ or after the sealant.

. The first statement is true, the second statement is false

. The first statement is false, the second statement


. Both statements are true

is true

. Both

statements are false

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Fluoride reduces the r|te ofenamel solubilitv. This increases the hardness of enamel.

. The first statement

is true, t}le second statement is false

. The first statement is false, the second statement is true . Both statements are true

. Both

statements are false

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Remember: Light cure materials are all cured by visiblc light nowadays, not UV AIso. both light cure and chcmical curc have indistinguishable rcsults. Pit and fissure sealants were first devclopcd in the 1970s and 1980s, and thcir cltcctivcncss in prevcnting caries has now bccn rvcll cstablished. Two predominant typcs ofpit and fissurc sealant malerials are available: resin based sealants and glass ionomer cgments.

Availablc resin-based sealant materials can bc polynerized by autopolynrerization, photopolymerization using visible light or a combination ofthc two processes.
Glass ionomer ccmcnts arc available in two fonns. both of which contain fluoride: conventional and resin-modified. Glass iononter ccmcnts, which do not require acid etching ol'the tooth surf'ace, gcncrally are easier to place than are resin-based scalants. They also are not as moisture-sen:irivc as their resin-bascd counlerparts. Glass ionomcr materials, which wcre developed for their ability to relcase fluoride. can bond directly with enamel. It is hypothcsized that release of fluoride from this nlaterial nlay conlribute to caries prevention. Howcvcr, the clinical cfl'cct of lluoridc release liom glass ionorrer cenent is not well-eslablishcd.

\ote.

l. The succcss ofa sealant is highly dependent upon obtaining and maintaining an intimate adaptation ofthc scalant to the tooth surface and thereby hopefirlly sealing it. f. Research has demonstrated that caries protcction is l00yo in pits and fissures that re main completel] sealed, 3. Resin-based sealants are the firsl choice ofnraterial lor dental sealants.
Glass ionomer cement may be used as an intcrim prcvcntive agent when there are indications for placement of a resin-based sealant but concems about moisture control nlay compromisc such placement. 5.Placement of pit-and-llssure sealants significanlly red|.|ces the perccntage of noncavitatcd carious lesions that progrcss in children, adolesccnts and young adults tbr as long as live years after sealant placement. compared with unsealed tccth.
.1.

***

Fluoride does not make the enamel hardel but reducs its rate of solubilitv.

Fluorides exert their anticaries effect by three different mechanisms: 1. The presence of fluoride ion greatly enhances the precipitation into tooth structure of fluorapatite from calcium and phosphate ions present in saliva. This insoluble precipitate replaces the soluble salts containing manganese and carbonate which were lost
due to bacterial-mediated demineralization. This exchanse Drocess results in the enamel

becoming more acid resistant.

i.

Incipient. noncavitated, carious lesions are remineralized bv the same process.

-l. Fluoride has antimicrobial activity. In low concentrations fluoride ion inhibits the enzvmatic production of glucosvltransfrase. Glucosyltransferase prevents glucose liom forming extracellular polysaccharides, and this reduces bacterial adhesion and .lou s ecological succession. Intracellular polysaccharide formation is also inhibited, pre\ enting storage of carbohydrates by limiting microbial metabolism between the Itost's meals. Thus the duration ofcaries attack is limited to periods during and immediately after eating.

\otes
.t;::,,:.:.,,.:

l.The concentration offluoride in the body fluids is regulated by an equilibrium relationship between bone and urinary excretion. 2. Fluoride ion is easily exchanged lor hydroxyl ion in the lattice structure of enamel because the fluoride ion is slightly smaller than the hydroxyl ion, and has a greater affinity for the hydroxyapatite crystal than does the hydroxyl ion.

. sl0
. )lJ

. $38 . $58

106 Cop)right O 20ll-2011- Denlal Decks

AII persons should know whethr the fluoride concentration in tleir primary sounce ofdrinking water is below optimal ( ), optimal ( ), or above optimal (______-J.

. less than 0.5 ppm, 0.5

1.0 ppm, greater than 1.0 ppm 1.2 ppm, greater than

. . .

less than 0.7 ppm

,0.7

L2 ppm

less than 0.8 ppm, 0.8-1.3 ppm, greater than 1.3 ppm less than 0.9 ppm,

0.9

1.4 ppm, greater than 1.4 ppm

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In relation to teeth, fluoride is characterized by the following: . Its concentration increases in the external layer ofenamel throughout lile .Its concentration increases during topical application, but decreases for a few days
after treatment . Fluoride uptake is grater in enamel than in dentin or cementum . Increasing the fluoride content in the external layers ofthe tooth increases the resistance ofthe enamel to demineralization Remember: The optimal concentration offluoride in conmunity drinking water depends upon the average air temperature and the average water consumption. For temperate climates it is 1 ppm, for wamer and colder climates, the amount can be adjusted from 0.7

to 1.2 ppm, respectively.


Notec

. ,.

1. In communities without fluoridated water supplies, the most cost-effective method ofdelivering fluoride to 6-12 year old children is through school water fluoridation (as opposed to fluorkle tablets, brushing with a.fluoride gel or rinsing vith fluoride mouth rinse). 2. The most effective means ofincreasing the fluoride content in the extemal layers of teeth is the daily application of 1.23% acidulated phosphate fluoride in fitted trays lor four minutes. Obviously this is not realistic, since we do not routinely do "daily" applications.

The optimal fluoride levels for public water supplies is about 1 part per million (PPM). At 0.I PPM and below, the preventive effect is lost and the caries rate is higher for such populations lacking sufficient fluoride exposure. This knowledge is the basis for all individual and professional decisions regarding use ol other fluoride modalrties (e.g.,fluoride toothpaste.for chikhen under 2 years ofage, mouth rinse or supplemenlt. It is recomrnended that parents and caregivers of children, especialll children aged less than 6 years, know the fluoride concentration in their child's drinking $ater. For example, in nonfluoridated areas where the natural fluoride concenrrarion is below optimal, fluoride supplements might be considered, whereas in areas u here the natural fluoride concentration of more than 2 pprr.r, children should use alternati\ e sources of drinking water.

Fluoride is obtained in two forms: topical and systemic. Topical fluorides are found in manl ty,pes oftoothpaste, mouth dnses and in special gels or pastes applied in the dental ofllce.
Sy stemic fluorides are those that are ingested. They include fluoridated water and dietary tluoride supplements in the form oftablets, drops or lozenges. Systemic fluorides are integrated into children's teeth as their tooth structures form.

The greatest reduction in tooth decay is achieved when fluoride is available both topically and systemically. Water fluoridation provides both types of contact.

Studies have established that root sensltivity ls due in part to open dentinal tubules at the root surface.

The hydrodynrmic theory is the proposed mechanism for this sensitivity.

. The first statement

is true, the second statement is false second statement is true

. The first statement is false, the


. Both statements are true . Both statements are false

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recommended to a head and neck cancer patient for home-care custom trav use?

.
. .

1.23% acidulated phosphate fluoride and lo% neutral sodium fluoride


0.4olo stannous fluoride and |.23oA
0.49./0

acid

ated phosphate fluoride

stannous fluoride and

l% neutral sodium fluoride


I o/o

l.23Yo acidulated phosphate fluoride,0.4o% stannous fluoride and

neutral sodium

fluoride

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The most accepted theory to explain the unusual sensitivity and response of exposed root surfaces to various stimuli is the hydrodynamic theory. This theory postulates that the pain results form indirect innervation caused by dentinal fluid movement in the tubules, which stimulates mechanoreceptors near the predentin.
The rationale oldesensitization procedures is not fully understood. Some techniques may

depend on denaturation of the superficial ends of Tomes' fibers or of nerve endings in dentin. Other procedures are designed to deposit an insoluble substance on the ends ofthe fibers or nerves to act as a baffier to stimuli. Still others are designed to stimulate secondary dentin formation thus insulating the pulp from extemal stimuli.

Nunerous fonns of treatment have been used to provide relief, such as topical fluoride, fluoride rinses, oxalate solutions, dentin bonding agents. sealants, iontophoresis, and desensitizing toothpastes. AII of these methods have met with varying degrees of success, and none has been totally effective (although dentin bonding qgents provide the best rute ol -.u(cess). When these conservative methods fail to provide relief, restorative treatment
is indicated.

\ote:

The application of sodium fluoride has been recommended as an effective treatment ior root sensitivity based upon the precipitation of calcium fluoride crystals in the Lrpen dentinal tubules.

The gel contains either 1.07o sodium fluoride or 0.47o stannous fluoride, For maximum benefit, the gel must be in direct contact with the teeth. Fluorides are recommended to protect these patients from post-irradiation caries. Remember two important points: l. The fluoride found in commercial toothpastes is not adequate for people who have
had head and neck radiation. l. These patients must continue to use the fluoride gel as directed for the rest lili to protect their teeth from rampant decay.

oftheir

Instructions for patient: The trays containing the fluoride are placed over the teeth for a prescribed period of time (usually 10 minutes), and he/she may not eat or drink for at least 30 minutes. Usually this is done at night after toothbrushing and just before going to bed.
The daill use of fluoride gel in custom trays at home is indicated in the following situations: . Rarnpant enamel or root caries in any age group

. Xerostomia . Head and neck radiation therapy

. For use on abutment teeth under . Hypersensitive root surfaces

an overdenture

lmportant: Fluorapatite is the most stable reaction product ofa topical application offluoride.

Acidulated phosphate flioride (APF)


Stannous fl uoride (SNF2)

Causes the most severe staining

Most common over-the-counter fluoride Most common in-office fluoride

Sodium fluoride (NaF)

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Acidulated phosphate fluoride has a low pH.

\-,

Becaus of thls,

it is contraindicated on porcelaln &nd composite restorations.

. The first statement . The first statement

is true, the second statement is false is false, the second statement is true

. Both statements afe true

. Both

statements are false

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Important:

l. Acidulated phosphate fluoride (lPF) is the most commonly applied in-office fluoride treatment. 2. The combination of 1.23% sodium fluoride and I M orthophosphoric acid results in acidulated phosphate fluoride. It is very stable in solution. 3. The most common recommended over-the-counter fluoride is 0.05% sodium fluoride. 4. Stannous lluoride (80,6 F) has avery bitter, metallic taste, may bum the mucosa, and has a short shell life. 5. The tin ion in stannous fluoride may be responsible for staining the teeth, but it may be beneficial for anestinc root caries.
\NF
Concentmtion Fluoride lon
7o
2o/o

APF t.23%
1.23 12.100 ppm

SnF, 8%'
1.95 19,160 ppm 19.16 320/r

0.91

ppm Fluoride

9.040 ppm 9.04

Mg FVml

12.0
28yo

Emc.cy
Taste Tooth discolorrtlon

)9%
Bland

Biner w/o flavoring Nofle

Vry bitter, metrllic

BroM
Occasional

Gingivrl reectlon

Nonc

None

Important: . The pH ofAPF is approxrmately 3.5 (acidic) . The pH of NaF is approximately 9.2 /ba.sicl . The pH of SnFz is approximately 2.I to 2.3 (acidic)
lmportant: APF solutions and stannous fluoride /SNF2I should not be used on patients with porcelain. glass ionomer, and composite restomtions. They have been shown to remove the _claze trom the surlace of these rcstontions. Neutral sodium fluoride /NaF/ is best to r.rse if :hese restorations are present. Also, APF should be avoided on implant patients, it may corr"Jc th< .urface oftit.rnium implants.

$ hen painting fluoride on, it is very important to isolate the teeth with cotton rolls. When using ilLroride trays, cotton rolls may be placed in the premolar areas to increase patient comtbfi and help keep the fluoride in place. Patients are asked not to brush, rinse, eat or drink 30 mrnutes alier a fluoride treatment so that the fluoride is left undisturbed and is able to continue reactjng \!jth the hydroxyapatite tbr some time after the initial application. Fluoride treatmenrs should be applied for four minutes. although there are now some one-minute products rhar are beins marketed.

Ayoung child gets into the bathroom cabinet and ends up eating a full tube of toothpaste. The mom calls you lirst, besides telling her to call poison control you will ask all of the following questions TXCEPI one. Which one is the.EXCXPZOIV?

. How much does the child weigh? . what kind of toothpaste was it? . How old is the child? . Did the child get into any other dental products (i.e., mouth
w,ash)

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Sealants can be effective when placed over inclpient caries lesions because carles is caused by anaerobic microorganisns.

. Both the statement and the reason are correct and related

. Both the statement

and tlle reason are conect but NOT related is NOT

. The statement is correct, but the reason . The statement

is NOT correct, but the reason is correct

. NEITHER the statement NOR the reason is correct

113 Coplrighr O 20ll-2012 - Dental Decks

***

As with any toxin, the toxicity of fluoride is based on weight, not age.

Fluoride, administered in large doses can be fatal and should be kept with all other medication ofthe reach ofchildren. This includes fluoridated toothpaste, gels and mouth -out generally excepted toxic amount of fluoride that needs to be consumed at one rinse. The time is 5 mg/kg of body weight. This means that a child who weighs 25lbs would need
to consume the equivalent of56 one mg tablets offluoride, not a difficult task to accomplish for most 2 year o1ds.

Important: An 8.2 ounce tube of toothpaste contains 232 mg of fluoride or 28 mg per


ounce.

:{ote: Tlre most common forms of fluoride found in toothpastes are sodium fluoride and sodium monofluorophosphate. Amine fluoride and stannous fluoride, are less common.

**"

Scalants can bc effective when placcd ovcr incipient caries lesions becausc caries is caused by

aerobic nricroorganisms.
Studies hare caret'ully demonstrated that once an incipient carious lesion is sealed, the caries is {opped lbr most intcnsive purposes. Sincc carics is caused by acrobic microorganisms, once scalcd Lr\ !-r \'ilh a sealant an anacrobic environment is created in which the microorganisms become static t r die and there is no funhcr action because there is no melabolite 10 reach the orsanisms. there is

no o\\sen lbr them to cxist in thcir cnvironment, thereby they die.


1. Sealants act as a

physical barrier in preventing bactcria liom accumulating in thc

\otes

pits and fissures ofthe teeth.

not to mix the sealant resin too vigorously prior to placement or to ovcr-nranipulate the sealant rcsin upon placement. Eithcr ofthese errors could in corporate air into the sealant rsin, resulting in a void in the sr.rrface ofthe sealant. 3. As long as a sealant remains intact, decay will not develop undemcath it. .1. The follorving factors nlay influence which teeth are candidatcs for scalants: the presence of interproximal decay, patient age and how caries pronc the patient is. 5. Sealants should be placed right after the tooth has f'ully erupted, before the decay process has had a chancc to bcgin. For pcnnancnt molar placemcnt, this would usually be around age 6 and 12, give or take 6 months. 6. Although sealants are most commonly placed on permanent molars, they may be placed on deciduous teeth in the following instances: the presence ofdeep pits and fissures. a very carics prone mouth and a tooth that is not likely to bc cxfoliatcd any timc
2. Care should be taken

soon, 7. The most common reason lbr sealant failure is

salivary contamination, usually due

to inadequate isolation.

Which of the following is least associated with the short term strength of a material?

. Creep . Modulus olelasticity . Resilience . Brittleness

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Plastic deformation takes place prior to elastic deformation. The distinction between these two is trmed the ehstic

limit.

. The first statement

is true, the second statement is false

. The first statement is false, the second statement is tme . Both statements are true . Both statements are false

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Creep (strain |elaxation) deformations over time in response to a constant stress. The key term in the question is "short term".

***

Materials which are relatively weak or which are relatively close to their melting temperature are more susceptible to creep. Dental wax deforms (creeps) under its own weight over short periods of time. Traditional dental amalgam restorations are involved in intraoral creep.

Brittleness is generally considered to be the opposite of toughness. A brittle material is apt to lracture at or near its proportional limit. A brittle material has a high compressive strengtlr but a low tensile strength /e.& , amalgam). Note: This is why amalgam preparations do not have beveled margins (they need butt joittts).
The modufus of elasticity is a measure ol the stiffness or rigidity of a mateial (it is tlrc ratio of sh?ss to the strain below,the elastic limit).lmport^ntz The higher the modulus olelasticity, the stiffer, or more rigid, the material and the less strain it exhibits for a given
StTCSS.

Resilience is the energy that a material can absorb bfore the onset of any plastic deformation.

Remember: Toughness is the property of being difficult to break. It is affected by lhe r ield strength, percent elongation, and the modulus of elasticity.

Elastic deformation takes place prior to plastic deformation. The distinction between these tivo is termed the elastic limit.
The elastic

***

limit

is the greatest stress to which a material can be subjected, such that it

will

rerum to its original dimensions when the forces are released. Up to the elastic limit only elastic deformation is involved, but beyond that, there is a combination ofelastic and plastic defonnation. with the plastic portion increasing and the elastic portion decreasing up to rhe breaking point.

-\n erample rvould be if a snrall tensile stress is induced in a wire, the resulting strain might be such that the wire will return to its original length when the load is removed. Il
the load is increased progressively in small increments and then released after each addition of stress, a stress value finally will be found at which the wire does not retum to its original length after the load is removed. In such a case, the wire is said to have been 5tressed beyond its elastic limit.

The proportional limit is the greatest stress, which may be produced in a material such that the stress is directly proportional to the strain. A material that has a high proportional limit compared to one with a lower proportional limit also has more resistance to permanent deformation.

Although the two terms, elastic limit and proportional limit, are defined differently, their magnitudes are so nearly the same that lor all practical pur?oses the terms can often be used interchangeably.
Note: The yield strength represents
a stress

slightly higher than the proportional limit.

In general, ductility whereas malleability

in temperature, in temperature.

. .

increases with increase, decreases with increase decreases with increase, increases with increase

. None ofthe above

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. Both the statement

and the reason are correct and related

. Both the statement and the reason are conect but NOT related

. The statement is correct, but the reason

is NOT

. The statement is NOT correct, but the reason is correct . NEITHER the statement NOR the reason is conect

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Ductility is the ability ofa metal to easily be worked into desired shapes (lbr example, the dbili4, to ./brm a wire Ji'om a metal). '|tese materials undergo extensive plastic deformation prior to fracture (in tension). Ductility is dependent upon plasticity and tensil strngth.
Not: Ductility is usually expressed in terms of the percent elongation; the higher the
value, the more ductile tlre alloy.

Arelated term is malleability, which describes a metal being able to be hammered (compression) into a thin sheet without rupture. It is also dependent on plasticity, but is not as
dependent upon tensile strength as is ductility.

Gold is the most ductile and malleable metal. and silver is second. Of the metals of interest to the dentist, platinum ranks third in ductility and copper ranks third in malleabil-

it\.

An enamel bonding agent which bonds enamel to composite is termed a adhesive joint. this is because there are two unlike materials being bonded together
Adhesion is a process of solid and/or liquid interaction of one material (atlhesive or itdhere t) \vith another (adherend) at a single interface. Most instances ofdental adhesion are also called dental bonding. A pit and fissure sealant bonded to etcbed enamel
is a case of dental adhesion.

t**

-\n adhesiye joint is the result of interactions of a layer of intermediate material (adhesi\e ot adlrcrent) with two surfaces (adherends/ producing two adhesive interlaces.
Eramples include onhodontic bracket bonding resin, enamel bonding system for a composite resin. and a bonded porcelain veneer.
There are trvo principal types of adhesion:
1. Ph! sical forces: called van der Waals forces

l.

Chemical forces: called chemisorution

Adhesive potential can be predicted by measudng the spreading or wetting ofthe adhesive over the surface ofthe substrate. This is done by determining the contact angle ofthe drop of adhesive as it spreads out. The smaller the angle, the greater the wetting and thus the potential for adhesion.

Match the following mechanical propertles of loading terms with thir correct picturs.

Shear

. Flexion

*-D*
0--l Y+

. Torsion
. Compression . Diametral compression/tension

. Tension

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H Y ,ixq H

gl

. The first statement is true, the second statement is false

. The first statement

is false, the second statement is true

. Both statements are true

. Both

statements are false

119

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. Compression

. Tension

. Shear

. Torsion

. Flexion

'H H
ttitt

trl

. Diametral
compression/tension

*** Strain

is the actual change in shape or deformation that accompanies any stress.

Tertiary dentin is formed in response to caries, operative procedures, or wear. Secondary odontobfasts secrete tertiary Qeparative) dentln. Throughout life, the dentin will respond to environmental changes (iormal wear, caries, operatire procedures, lc, These changes initiate the deposition oftrtiary dentin which rs formed by repfacement odontoblzsts (termed secondary odontoblastr). This reparatile dentin will be limited to the site ofirritation. The composition ofreparative and secondarl dentin is basically the same /reparative dentin is more itegular) andthey differ only in location of deposition.

***

If the environmental insult is strong enough, it will kill the odontoblast and its tubular process. leaving the tubule empty. If there is a collection of empty tubules, they are refened to as dead tracts. In time, these ttbrles (dead tracLsl will calcify. The term used to describe the tubules that become calcified is sclerotic dentin.

. ,&*.,

i\otcr:

1. Primary dentin is the dentin forming the initial shape ofthe tooth. It is deposited before completion ofthe apical foramen. 2. Secondary dentin is dentin that is formed after completion of the apical foramen. It is formed at a slower rate than primary dentin as functional stresses are placed on a tooth. Secondary dentin is a regular and somewhat uniform layer ofdentin around the pulp cavity. 3. Thejunction between primary and secondary dentin is characterized by a sharp change in the direction ofdentinal tubules.

When preparing for an amdgam, an operator should atlow

for

proper retention forrn. This is because improper preparations can cause fracture of amalgam restorations.

. Both the statement and the reason are correct and related . Both the statement and the reason are correct but NOT related . The statement is correct, but the reason is NOT

. The statement . NEITHER

is NOT correct, but the reason is correct

the statement NOR the reason is coffect

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OPERATIVE

. "That form the cavity takes to resist the forces ofmastication" . "That form the cavity
takes to resist dislodgement or displacement

ofthe restoration"

. "The shape or form oflhe cavity on the surface ofthe tooth" . "The shape or form ofthe preparation after carious dentin has been excavated"

. "The

shape comoleted"

or form the preparation

assumes after the retention

form has been

121 Coplright C20ll-2012 - Dental Decks

***

Resistance form is involved in fracture. not retention form.

Retention form is that form the cavity takes to resist dislodgement or displacment of the restoration. For example, the buccal and lingual walls ofa Class I amalgam preparation converge occlusally; thus preventing dislodgement of the amalgam. For Class II restorations, this resistance to dislodgement is provided by the occlusal dovetail and retention grooves in the proximoaxial line angles.
Resistance form is that form the cavity walls take to resist the forces ofmastication. Resistance form prevents fracture ofth restoration and the tooth.

Examples: Severely undermined cusps should be reduced so as to prevent fracture. The axiopulpal line angle in Class II amalgam preparation is rounded or beveled so as to reduce concentration ofstresses and lhus prevent fracture ofthe brittle amalgam. Also, proper angulation ofcavity walls (converging) and pulpal and gingival walls that are perpendicular to occlusal forces (lat walls at right angles to the long aris oJ the

Ioolll help achieve resistance form. lmportant: The most common cause of fracture

at the isthmus of a Class Il amalgam restoration is inadequate depth at the isthmus area (must be adequate depth to obtqin res istance .fbrm). Most detdnental to the strength of a posterior tooth in a cavity preparation is an increase in faciolingual width.

Remember: G.V Black, is known as the father of modem dentistry. He is known for his principles oftooth preparations, in which he outlines the proper methods to prepare teeth tbr fillings. The phrase, "extension for preventionrr is still famous in the dental community today and represents Black's idea that dentists should lollow preventive tneasures
to aid patients from developing tooth decay. Further, he organized a classification system \\ ith 5 categories for different pattems oftooth decay which is still in use today. Since that time, only one more category (Class Vl)has been added to his classification system.

Trr'o important points should be remembered in obtaining the outline form:


I . In general, the margins should be placed in areas of lessened caries susceptibility. This principle is called extension for prevention (phrased by G.V Black) *** TODAY- modification ofprinciple: extension determined by extent of DECAY

and RESTORATIVE material.


?. In general. all undermined enamel (which is enamel not supported should be removed.
b:i'-

sound dentin)

***

The above two points are influenced by:

. The lateral spread ofdecay at the DEJ . The t]'pe of restorative material to be used . The tooth and its relative position in the arch lmportant: Extension (for prevention) can be restricted in patients with very low caries susceptibility.
Rememtrer: If when establishing the ideal outline form, caries remains on any of the rvalls of preparation, the next step is to extend the outline form before excavating any
canes.

r\patint return$ to your oflice only


A

24 hours lfter you cemented her new gold crown on tooth #19. She claims to .ir feel rEsr ar a lrrarp sharp tr9rulltgtlt electrical sensation s3utauull tII in both t ratt ttcf her upper and lowerjaw on the left side. When you explain to her what might be happening, you call it:

. Electromagnetic pulse
. Alternating current corrosion

. Electroly'te explosion
. Galvanic shock

122
Coplrighr O
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1,2012 - Dental Decks

Match th dental material on the left with the appropriate Coelficient ofThermrl Expansion (ppnrc x 10) on the fight-

. Unfilled resins

l4.4
11.4

. Composite resins

81 -92

22-28
. Tooth

28-3s

123
Coplri8ht C 2011,?012, Dental Decks

Galvanic shock is the briefbut sharp electrical sensation one can receive when two dissimilar metals come into contact in the mouth.

An example ofthis phenomenon: An amalgam restoration is placed on the occlusal surface of a lower tooth directly opposing a gold inlay in an upper tooth. Because both restorations are wet with saliva, an electric couple exists, with a difference in potential between the dissimilar restorations. When the two fillings are brought into contact, the potential is short-circuited through the two alloys. The result is sharp pain, Such postoperative pain usually occurs immediately after insertion of a new restoration and
generally it gradually subsides and disappears in a few days.

Note: The amount of electricity involved in galvanic shock can range up to 1.0 microamneres and 500 millivolts.

Material
Tooth
Direct Gold Amalgam
Composite

Coeflicient of Thermal Expansion (ppm/c x l0)


11.4
14.4

22-28 28-35

Unfilled Resins

8t-92

rhe coetficient of thermal expansion is a measure of the tendency of a materiar to change in shape when it is subjected to temperature changes (/br example, when eating or drinking hot or cold items.). Apossible break in the marginal seal ofany restoration be_ !'omes Imminent when there is a marked difference in the coefficient of expansion ben'een the tooth and the restorative material. The closer the coefTicient is to the tooth. the beuer ldircct gold is bestl. If the coefficient of thermal expansion is relerenced to a single dimension, it is called the linear coefficient ofthermal expansion (LCTE).TheLCTE rs expressed in units ofppr/"C.
One of the consequenses of thermal expansion and contraction differences between a restorative material and adjacent tooth structure is percolation, which is defined as the cyclic ingress and egress of fluids at the restoration margins. The possibility of recur_ rent decay at the margins increases with increased percolation.

. Class

. Class tr

. Class III . . .
Class Class Class

IV
V

VI

1U
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Dnisl

I}ck

Cavity classification: standardized methods ofrecording the need for restoration exist to
facilitate communication among clinicians, researchers, and dental educators. The most commonly accepted means ofclassiling cavities is by the names ofthe surfaces involved. Cavity type is classified further based on the type of treatment and anatomical area involved. This classification, developed by Dr. G. V. Black in 1908, is designated by Roman numerals as Class I, Class II, Class III, Class IY Class Y and Class Vl (this is the only category that has been qdded to his original classificttion system). Note: It is important lo remember that the classification relates to location and not size ofthe cavity.

Class I cavities: involve the pits and fissures, while all other classifications involve smooth surfaces ofthe teeth. . Class II cavities: involve the proximal surfaces and occlusal surfaces of premolars and molars. . Class III cavities: involve the proximal surfaces of incisors and canines that do not involve the incisal angle. . Class IV cavities: are located on the proximal surface of incisors and canines and do involve the incisal angle. . Class V cavities: are on the facial or lingual surface of all teeth and do not involve a pit or fissure. . Class VI cavities: are on the incisal edges of arterior teeth or on the occlusal cusp heights of posterior teeth.

Remember: The best method for definitive detection of incipient carious lesions on the interproximal surfaces ofposterior teeth (distal suryface of canines through molars) tsby bite-wing radiographs.