Analysis of a Complex Amalgam Prep and Restoration

Alaleh Moazami Operative Dentistry 430 U C Class of !00"

Abstract
Complex amalgam restoration refers to an amalgam restoration that replaces one or more cusps (Summitt, Robbins, Hilton & Schwartz, 2006 ! "racture# an# split cusps are often encountere# in hea$il% restore# teeth (&ar#ner, 2006 ! &ar#ner suggests that 'split cusps are generall% the result of fre(uent loa#ing on sharpl% angle#, me#ial facing, cusp inclines, often through wor)ing si#e contacts in lateral excursions!* (&ar#ner, 2006 ! +n general the larger the occlusal wi#th of the pre$ious restoration, the more li)el% that the tooth woul# fracture an# split un#er pressure #ue to wea) remaining tooth structure (gar#ner, 2006 Complex ,malgam prep an# restoration are achie$e# b% remo$ing the remnants of the pre$ious restoration material, smoothing the fracture, remo$ing an% secon#ar% caries an# a##ing new retenti$e an# resistance forms suitable to the fracture an# subse(uentl% restoring the prep with amalgam to the le$el of proper occlusion! +t is essential to the success of a complex amalgam prep an# restoration that the operator creates a specific prep #esign for the fractures tooth- consi#ering the remaining tooth structure an# the re(uire# resistance an# retenti$e form, a#e(uate to )eep the future restore# amalgam bul) mechanicall% in place!

Complex Amalgam Preparation

.he )e% to success of a complex amalgam restoration is the ca$it% prep #esigne# to pro$i#e a#e(uate retenti$e an# resistance form (Summitt, Robbins, Hilton & Schwartz, 2006 ! +n a small amalgam restoration that #oes not replace cusps an# is surroun#e# b% tooth structure, most of the retention an# resistance form re(uire# to )eep the amalgam in place come from the walls of the preparation (Summitt & et al! 2006 ! .his a#$antage is lost in a complex amalgam preparation since the walls or portions of them are lost #uring the fracture (Summitt & et al! 2006 ! "or such reason, it is necessar% for the prep to

ha$e certain features, such as $ertical walls, groo$es, troughs, slots an# pins, that woul# pro$i#e a#e(uate resistance an# retention to the restoration (Summitt & et al! 2006 ! , slot is a retenti$e groo$e in #entine whose length is in a horizontal plane (Roberson, He%mann & Swift, 2006 ! Slot length #epen#s on the extent of tooth preparation an# is usuall% place# on the gingi$al or pulpal floors of the preparation along the central groo$e of the tooth (Roberson, He%mann & Swift, 2006 ! Summitt recommen#s the use of slots as a retenti$e feature for a complex amalgam prep an# argues that slots an# troughs are in general safer an# less stressful for the remaining tooth structure as compare# to pins (Summitt & et al! 2006 ! +n m% preparation a slot was place# on the pulpal floor in the place of the central groo$e! /xtra attention was pai# to ensure that the slot is large enough to accommo#ate the con#enser an# that it is at least 0!0 mm #eep, thus housing a large enough bul) of amalgam! .wo small troughs were also place# in the mesial an#

#istal proximal boxes! &ar#ner suggests that all slots an# troughs shoul# be at least 0!1 mm insi#e the 2/3, which is about 0!0 mm #eep to accommo#ate a#e(uate bul) of amalgam, an# also shoul# be large enough to fit the small con#enser to ensure proper con#ensation of amalgam into these retenti$e features (&ar#ner 2006 ! , retenti$e groo$e was also place# on the lingual wall of the preparation! , preparation for a complex amalgam restoration shoul# begin with remo$al of an% existing amalgam restoration, remo$al of an% carious tooth structure an# fragile enamel an# #entin an# preparation of the margins to pro$i#e a ca$osurface angle of approximatel% 40 #egrees in all areas (Summitt & et al!2006 ! , 550 bur was use# throughout the preparation to achie$e parallel or slightl% con$ergent wall, suitable for the mechanical interloc) of an amalgam restoration! .he preparation was exten#e# to below the buccal height of contour an# a buccal step was create# with a continous step wall parallel to that of the long axis of the tooth! .his allows us to ha$e the buccal margin at the base of the fracture an# ha$e a step #eep enough to accommo#ate the bul) re(uire# for amalgam (&ar#ner, 2006 ! 6ount argues that each section of an amalgam

restoration shoul# be in#i$i#uall% retenti$e, therefore, as the ca$it% is exten#e#, presence of a few #ifferent retenti$e features is fa$ourable (6ount, &raham & Hume, 0447 ! +n a complex amalgam prep an# restoration pins are use# whene$er a#e(uate resistance an# retention forms cannot be establishe# through slots, groo$e, troughs, loc)s or un#ercut onl% (Roberson, He%mann & Swift, 2006 ! Howe$er, 6ount argues that not that pins #o not offer an% mechanical a#$antage when use# in a complex amalgam restoration, the% actuall% place sufficient stress on #entine to lea# to subse(uent #e$elopment of microcrac)s (6ount, &raham & Hume, 0447 ! &ar#ner also suggests

that pins ma% craze an# fracture enamel or create pulp or perio#ontal membrane perforation (&ar#ner, 2006 ! Since pins are ma#e out of metal, the% con#uct heat an# transmit thermal changes close to the pulp (&ar#ner 2006 ! .hus the use of pins un#er cusps, speciall% functional cusps(buccal cusps in a man#ibular first molar which en#ure extra forces #uring mastication is contrain#icate# (6ount, &raham & Hume, 0447 (&ar#ner, 2006 !

Slot

2istal trough

6esial trough

#ig$re %& Complex Amalgam preparation 'retentive feat$res& p$lpal slot( mesial and distal tro$ghs) &roo$e

:uccal step #ig$re !& Complex Amalgam preparation 'retentive feat$res& verti*al +alls and ,$**al step and ling$al +all groove)

-a,le %& An Analysis of Complex Amalgam Prep

3ust :ro)en contact :<= lo#ge >ust into #entin ?ulpal Slot in the central groo$e ?roximal troughs Slots an# trough accept con#enser 8es ; ; ; ; ; 9o

Retention &roo$e large enough to accept con#ensor

Difficulty and Solution:

?reparing this complex amalgam prep, + foun# that this particular prep re(uire# a $er% high le$el of #exterit% an# han# control! + foun# that ha$ing a $er% stable an# strong fulcrum was one of the )e% factors to the success of this prep! 2uring the preparation + ha# to often change m% fulcrum point aroun# an# + learnt that placing it closer to the wor)ing site alwa%s enable# m% han# to ha$e more control! ,lso + ha# to repeate#l% use the mirror to loo) at the prep in e$er% #irection to ensure that all the walls are parallel to the long axis of the tooth! ?reparing for a complex amalgam restoration can be #one

(uit (uic)l%, howe$er through experience an# repetition, + learnt that spen#ing some extra time to ensure all walls are parallel an# all retenti$e features are #eep an# large enough alwa%s pai# off at the en# when the restoration remains intact an# well loc)e# in place!

Complex Amalgam Restoration:

+n a complex amalgam restoration a great portion of the tooth structure is getting replace# b% amalgam, an# thus the use of a matrix ban# to )eep the amalgam in place while con#ensing is (uit necessar%! :aum suggests that a .offlemire matrix shoul# be use#- since the matrix encompasses the tooth at the gingi$al bor#er more tightl% than at the occlusal, tooth form can be rea#il% repro#uce# (:aum & et al! 0441 ! Summitt argues that the ban# shoul# be burnishe# an# contoure# to impart the #esire proximal contours to the restoration an# ensure a positi$e contact with the neighbouring teeth (Summitt & et al!2006 ! .o pre$ent the ban# from springing open un#er pressure an# to pre$ent the extrusion of amalgam out the gingi$al bor#er, a we#ge is place# against the next tooth to hol# the ban# intact (:aum, ?hillips & =un#! 0441 ! Con#ensation shoul# be #one b% a##ing increments of amalgam an# con#ensing each la%er using a#e(uate force an# the correct con#enser size! + use# the smaller con#enser to con#ense the first few loa#s of amalgam since the retenti$e features such as troughs an# slots were #esigne# to accommo#ate the smaller con#enser! @nce these retenti$e features are full, then a larger amalgam con#enser ma% be use# to con#ense the rest of the amalgam buil# up! Ahen amalgam is con#ense#, mercur% ten#s to be brought to the surface, creating a mercur%Brich amalgam on the surface (Summitt & et al! 2006 ! Summitt suggests that to re#uce the amount of mercur% left in the restoration, the preparation shoul# be o$er fille# an# the mercur%Brich excess car$e# off (Summitt & et al! 2006 ! Summitt argues that the lower the resi#ual mercur% in the car$e# restoration, the greater its strength an# the better the expecte# longe$it% of the restoration (Summitt & et al! 2006 !

Car$ing of amalgam starts imme#iatel% after con#ensation! 6% first step was to #etermine the location of the central groo$e, using those of the a#>acent teeth! @nce central groo$e was mar)e# with the explorer, + trie# to $isualize the location of the three cusps on the buccal of the lower first molar! + #etermine# the proximal location of the cusp tips using the a#>acent molar an# m% )nowle#ge of the man#ibular first molar occlusal anatom%! .hen the buccal portion of the amalgam buil# up was #i$i#e# into three sections correspon#ing to the three cusps- mesioBbuccal being the largest an# #istoB buccal being the smallest of the three! .hroughout m% car$ing + use# the secon# molar as a close reference for the anatom% an# cusp height of the first molar! + was also (uit careful to ma)e sure the anatomical car$ings on the buccal are continuous an# coinci#e with the groo$es an# the fissures on the lingual portion of the occlusal table! + starte# the rough car$ing of the occlusal anatom% using a half holenbac), onl% later mo$ing on to a #iscoi#<cleoi# to car$e the central groo$e an# occlusal groo$es an# fissures! , beach car$er was use# to car$e the marginal ri#ges to a height le$el coinci#ing with those of the a#>acent teeth an# same instrument was use# to a#>ust the buccal height of contour so that it is harmonious with its neighbouring teeth Ahen the car$ing was finishe# the rubber #am was remo$e# an# the occlusion was chec)e# using the articulating paper! Summitt argues that it is wise not to as) the patient to close his teeth at this point, because if the amalgam has not been car$e# a#e(uatel%, it will be high in occlusion an# might fracture upon forceful closure (Summitt & et al! 2006 .herefore, it is best that the operator performs the taping of the teeth test b% grasping the patientCs chin an# bringing the >aws together slowl% (Summitt & et al!

2006 ! ,malgam must be car$e# until contacts on the restoration occur simultaneousl% with those on the a#>acent teeth (Summitt & et al! 2006 ! ,fter placement of a restoration, the surface can be rubbe# with a burnisher or with cotton until it is smooth! Summitt suggests that polishing of an amalgam restoration shoul# be accomplishe# at a succee#ing appointment, after amalgam is allowe# enough time to har#en completel% (Summitt & et al! 2006 !

#ig$re 3& O**l$sal anatomy harmonio$s +ith remaining tooth str$*t$re and ad.a*ent teeth 'Contin$o$s *entral grooves( Proportional *$sp sizes and similar o**l$sal anatomy)

Close# contact

Close# contact

#ig$re 4& $**al *$sps harmonio$s +ith ad.a*ent teeth/s *$sps ' Proportional *$sp heights and sizes( and leveled mesial and distal marginal ridges)

-a,le !& Criteria for a Complex Amalgam resto

Close# contacts ?roper alignment an# arch contour Cusps in proper alignment 8es ; ; ; 9o

,ligne# central groo$es .rue anatom% ?roperl% shape# marginal ri#ges +n occlusions ?roper cusp height (6: cusp higher than mi#B: an# 2: cusp the lowest 9o marginal $oi#s Smooth< no scratches

; ; ; ; ; ; ;

Difficulty/Solution:
+n m% first couple of attempts to restore a complex amalgam restoration, + ha# #ifficult% )eeping the amalgam bul) in place once the matrix ban# was remo$e#! /$en though the a#e(uate retenti$e features were present in m% prep, the amalgam bul) woul# #islo#ge as soon as the matrix ban# was mo$e#! .o o$ercome this problem, + starte# with the first loa# of amalgam filling the retenti$e features at the floor of the prep such as the mesial an# #istal troughs in the proximal boxes or the slot on the pulpal floor, ma)ing sure amalgam was well con#ense# into m% retenti$e features! + also learnt that putting a great loa# of force behin# m% con#ensation woul# greatl% help with the amalgam restoration remaining in place after the matrix ban# was remo$e#! 2uring final car$ing an# contouring of occlusal anatom% an# buccal wall, + foun# that comparing an# mo#eling the a#>acent secon# molar was (uit useful as a main aim in a complex amalgam restoration is to achie$e harmonious occlusal an# cuspal anatom% with its neighbouring teeth! +n this restoration, + woul# ha$e li)e# the restoration to be smoother, an# free of scratches that might accumulate bacteria an# pla(ue, howe$er as pre$iousl% #iscusse# it

is recomman#e# that the polishing of an amalgam restoration is #ela%e# to the subse(uent appointments!

Refrences:
:aum, =!, ?hillips, R!, =un#, 6!, (0441) Textbook of operative dentistry. ?hila#elphiaD Saun#ers! &ar#ner, Earen! (2006 2ent F50 @perati$e 2006B200G Course s%llabus an# han#outs! :!C! Cana#a! 6ount, &raham 3! & Hume, A!R! (0447 Preservation and Restoration of Tooth Structure. 6osb% +nternational =t#D ?hila#elphia Roberson, .! He%mann! H, Swift! /! (2006) Sturdevants Art and Science of Operative Dentistry. 6osb% +nc, Hnite# states of ,merica!

Summitt, 3!, Robbins, A!, & Schwartz, R! (2006). Funda enta!s of Operative Dentistry" a conte porary approach. SingaporeD Iuintessence ?ublishing Co, +nc!