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FUNDAMENTALS OF

CAVITY PREPARATION

Dr. Mohsen Abi-Elhassan


Prfessor and head of Conservative
Dentistry Dept. Cairo University
FUNDAMENTALS
Biological Fundamentals
Those principles concerned
mainly with preservation of
vitality and health of tooth and
investing structures.
They include:
1.  Protection of the dentin and the
pulp
2.  Control of caries
3.  Protection of investing tissues
and adjacent tooth:
1) Protection of the dentin
and the pulp
The pulp is a highly specialized and
sensitive structure and should be
protected against all sorts of irritation
during cutting procedures.
Irritations may be:
Traumatic, thermal, chemical,
bacterial or electrical.
To prevent mechanical irritation we
must AVOID:
1. Over cutting of enamel i.e.,
decrease the width of the cavity to
avoid exposure of more dentinal
tubules to different types of irritation.
2. Over cutting of dentin i.e.,
decrease depth of the cavity.
Therefore, the routine depth is
(0.2- 0.5) mm pulpal to D.E.J.
Why?
  To increase the bulk of the restorative
material.
  To avoid placing of the restoration
against the most sensitive D.E.J.
  To make use of viscoelasticity of dentine

in gripping action. ( in case of rigid


restorative materials e.g., gold foil
restoration). ( Historical)
  Lateral spread of caries occurs at D.E.J.
4. Unnecessary application of pressure
in scooping out of soft dentine at the
bottom of deep cavities.
N.B.: Caries is removed by sharp excavator
or large carbide round bur with
Control of Thermal irritation:
TTZ (Thermal Tolerance Zone) of dentin
ranges between 85-132ºF (29-56oC).

How?
• Decreasing pressure
• Using tools with high cutting
efficiency
• The use of copious,
multidirectional, and
isothermic coolant
Prevention of chemical irritation :
7. Avoid using of caustics and or
chemicals in cavity toilet. e.g., alcohol
or phenolic materials
The irritation to the pulp is
mainly through admission of
bacteria and toxins through
leakage space at restoration /
tooth interface
Prevention of bacterial
irritation:
1. sterilization of instruments, burs and
armamentarium.
2.  the use of rubber dam sp. In deep
cavities
3.  the use of certified conditioners,
primers and adhesives for achievement
of proper sealing
II- Control of caries:
Caries may recur at the margins and get
detected or may spread underneath it until it
becomes so complicated to save the tooth.
It requires:-
1. Removal of all carious enamel and dentin
on principles.
2. Cavity outline form should include all pits
& fissures and vulnerable areas.

3. Removal of all short, loose, undermined


enamel rods.
 S h o r t : s t a r t a t
D.E.J. and not reach
external tooth
surface.
 Loose: not firmly adhered to other rods.
  ndermined: not supported by sound
U
dentin.
4. Giving the C.S.A. the correct angulation
compatible with the physical properties
of the restorative material.
III. Protection of investing
tissues and adjacent tooth:
•  Rounding and smoothening ragged
cavity margins
•  Excision of the infectious lesions, that
may encourage plaque accumulation
•  Av o i d i n j u d i c i o u s s u b g i n g i v a l
extensions
•  Protect adjacent tooth surface during
proximal tooth preparation
•  Proper guide and support
C- Esthetic fundamentals
• Provision of symmetrical cavity outlines with
refined margins, and

smooth sweeping curves.

• Limiting area-display of restorations


sweeping curves.

• Elimination of discolored enamel or dentin.


Mechanical fundamentals
Those fundamentals concerned
mainly with the structural
integrity of tooth / restoration
complex.
They include:
1. Provision of adequate retention.
2. Provision of enough resistance.
3. Preservation of the maximum
amount of remaining sound
tooth structure.
Conservative approach in
operative dentistry:
•  G.V. Black, in 1891
•  Extension for prevention” or “Cutting
for immunity”.
Now
•  “Extension of prevention” (Loeche,
1982).
Advantages of conservative
cavity design:
•  Preservation of valuable intact
healthy tooth structure
• Decreased irritation of dentin-pulp
complex and investing tissues
• Decreased fractured liability of the
tooth and/or the restorations
Advantages of conservative
cavity design:
• Decreased displayed area of the
restorations
• Easier, quicker and standardized
operative and restorative procedures
Steps for cavity preparation:
1. Outline form.
2. Resistance & Retention form.
3. Convenience form.
4. Removal of remaining carious dentine.
5. Finishing of cavity walls and margins
6. Toilet of the cavity.
1. Outline form :
External shape or form of boundaries of
completed cavity preparation..
The external outline form :
describes the marginal boundaries

the internal outline form:


describes the shape of the internal
form of the preparation.
General Factors affecting the
outline form:
Ø Extension of caries in enamel and
lateral spread along D.E.J.
•  Enameloplasty:
•  slanting or fissure sealing
Indications:
•  If they are non-carious.
•  If they are carious but the caries does not
extend more than of the outer two thirds
of enamel thickness.
Enameloplasty:
•  The technique is
performed using with
the side of flame shape
diamond stone, leaving
a smooth surface
Slanting bur technique

•  to include supplementary or defective


fissures that approximate the outline of the
cavity preparation.

•  The prepared area is usually included in


the restoration.
Pit & Fissure sealing:
•  in case of deep angular grooves liable to
stagnation and difficult to clean as in
recently erupted permanent molars.
3) All short, loose, undermined enamel
rods should be eliminated to avoid
possibility for marginal ditching.
4)  Cavities which
approach closely to
each other must be
united into single
cavity to void
fracture of the
intervening unsupported structure.
N.B. a minimum 0.5mm of sound tooth must
be existed between two adjacent cavities.
cusp capping
•  Cusps and ridges that are
severely weakened and
subjected to occlusal forces
must be reduced and
restored with appropriate
restoration.
•  Extension from the primary
groove 1/2 or more of cusp
incline indicates cusp
capping.
Other factors affecting the
outline form of occlusal cavity
preparations:
•  Occlusal contacts:If possible, the
margins should not be placed in centric
•  holding areas
Occlusal table anatomy
•  Unusual anatomy, mal-alignment and
steep cusps will change the locations and
extent of the outline form.
the outline form of proximal
cavity preparations:
5)  Contact areas in
p ro x i m a l c a v i t i e s
should be eliminated.

i.e. Cavity margins are placed pass the


contact area with the adjacent tooth.
(flaring of the margins)
Outline form for class II " smooth surface cavities”

Simple class II:


in cases of
1.  missing adjacent tooth
2.  wide embrasure.
N.B.: The marginal ridge
must be intact and at least
2mm. of the proximal
surface gingival to it.
Compound class II:
  Occlusal portion.

  Isthmus portion.
  Proximal portion.
Occlusal Portion:
Depends on:
1.  Extension of caries in enamel.
2.  All retentive areas should be included in
cavity design.
3.  All short, loose, undermined enamel rods
should be eliminated.
4.  Lateral spread of caries along D.E.J.
5.  Cavities which are closely approached to each
other should be united into one cavity.
Isthmus Portion:
Amalgam:
Wider than the occlusal
and narrower than the
proximal in order not to
create artificial necking
at this critical area with
subsequent isthmus
fracture.
Cast gold:
The same width of
occlusal portion.
Proximal Cavity:
Depends on:
1.  Size, site & form of the contact area.
2.  Contact areas in proximal cavities should be
included within the cavity
outline. i.e. cavity
margins are placed pass
the contact area with
the adjacent tooth
proximally.
Ingrham’s Lines:
These lines are detected for proper
freeing of contact: they describe the shape of
the buccal and lingual walls of the proximal
cavity at different situations of the contact
area.

A) Straight line:
§  In cases of open contact.
B) Universal curve:
§ I n c a s e s o f w i d e
embrasure and broad
contact.

C) Reverse curve:
§ In cases of tight contact
& small embrasure.
Reverse curve is done normally in the
buccal wall of class II.

Advantages of reverse curve:


  Proper freeing of contact.
  Obtaining of 90° C.S.A.
  Increase bulk of the restoration to prevent
marginal ditching at the bucco-proximal area.
The gingival margin of class II:
Depends on:
1.  Gingival extension of the caries.
2.  Contact area: the best location for the
gingival margin when a horizontal space of
0.25- 0.5mm exists between the gingival
wall and the adjacent proximal surface.

0.25- 0.5mm
In class II cavity
preparation for amalgam
restoration: the proximal
box is inverted truncated
cone.
• Buccal wall // occlusal 2/3 of the buccal surface.
• Lingual wall // long axis of the tooth.
• The inverted cone should have slight convergence
of the buccal & lingual wall in gingivo-occlusal
direction.
• Sever convergence is contraindicated as it leads to
fracture of the restoration at the isthmus portion.
Other factors affecting outline form:
•  The type of occlusion and force of
mastication: heavy occlusal bite
necessitates slight modification of
outline form.
•  Physical properties of the restorative
material will directly influence the
outline form through determining the
amount of extension.
•  Requirements of esthetic versus
convenience,
•  e.g. In anterior teeth and premolars:
conservative class II & III is required to
obtain esthetic.
•  Age and caries susceptibility.
•  Oral hygiene of the patient.
Outline form of Cervical
cavity preparations:

Depends on:
• Caries extension.
• Esthetic requirements
CONCLUSION
The main significance of outline form is
primarily the removal of actual defects &
prevention of caries recurrence about the
margins of the restoration without
extensive extension of the cavity margins.
2. Resistance & Retention form:
  Resistance form:
Design features applied to the cavity
preparation which provide for structural
integrity of both restoration and tooth. Or,
It’s the form given to the cavity which
provides the structural integrity of both tooth
& restoration which allows them to resist
functional forces of mastication without
fracture.
Factors affecting resistance form:
1.  O cclusal load involving its Magnitude,
Direction: either centric or eccentric &
Character: whether in or out of occlusion or
static, dynamic or cyclic.
2.  Design of the cavity:
•  Walls direction: must
be // or ⊥ to the
direction of expected
masticatory forces i.e. //
or ⊥ to the occlusal
plane.

Yes
•  Line & Point angles:
must not be sharp to avoid
stress concentration that
leads to tooth fracture.

•  Increase depth of the cavity: To


increase the bulk of the restoration this leads to
decreased liability to fracture of the restoration.
The routine depth = 0.2-0.8mm beneath the
D.E.J.”
•  C.S.A.: must have the correct angulation
compatible with the physical properties of the
restoration, e.g.
-For amalgam restorations
C.S.A. should be 90°(butt–
joint) if:
• Acute → fracture of the tooth
• Obtuse → fracture of the
restoration.
-For Cast gold→beveled C.S.A.
3. Types of stresses:
Tensile: significant type for
brittle materials (amalgam,
composite, enamel & non
vital teeth)
Compressive stresses; it is
the most common type of
stress results from contact of
opposing teeth at centric
occlusion.
Shear stresses: occurs when
two different planes of
forces meet each other
tangentially e.g, between
two adjacent teeth the
contact area.
Impact stresses: results from sudden force
which occur on sudden biting on hard object
ob accidental trauma of anterior teeth.
Dynamic: with very low magnitude and/or
repeated in cycles leads to fatigue failure.
MORTISE FORM “modified box form”
It’s the best design for maximum resistance.
Advantages of mortise form:

 T h e s e a t o f t h e
restoration is ⊥ to the
proposed force so,
neutralize the resulting
stresses.
  The tendency for splitting the buccal &
lingual cusps of bicuspids & molars by
forces of mastication through the
restoration is greatly diminished.

N.B. Steep cusp = high


cusp tip & deep central
fossa.
  It increases retention by friction &/or
gripping action of the dentine.
  It improves access and visibility for
better instrumentation and restoration.
  Restorative materials tend to adapt
better against plane surfaces.
  Retention form:
Design features in the cavity which
allows it to hold in or retain the restoration
securely in function. Or,
It’s the form given to the cavity which
prevents displacement of the restoration
by the action of mastication or sticky food.
The retention given to the cavity serves in:

  Stability of the restoration.


  Prevents fracture of the
restoration at the isthmus between
two portions.
Mechanisms of retention

A- Chemical retention:
•  primary valence bonding : is strong and
stable.
•  It is not achievable except for the glass
ionomer restorations
B- Mechanical retention:
•  This is the principle mechanism of
retention.
Types:
1.  Micro-mechanical retention: This is the most
conservative mechanism of retention. This is
achieved by Acid etching of enamel and
dentin.
2. Macro-mechanical retention: It is the main
retention mechanism employed for metallic
restorations
1. Axial retentive features:
  Frictional retention:
parallelism between walls
in cast restorations.( for
indirect restorations)

  Undercuts in
dentin where the
interior of the cavity
is wider than the
exterior.( for direct
restorations)
Dentin ledge:
An area of flat pulpal floor at routine
depth all around the hemispherical cavity. OR
at least 3 points of flat pulpal floor.
It’s done by using an inverted cone bur.

It provides both resistance and retention


  Gripping action of dentin (frictional grip).it
is based on the viscoelasticity of dentin.

Lateral retention:
  Dove tail lock:
in compound cavities which
prevent lateral displacement
of the restoration.
Accessory retentive features:
  Proximal axial grooves
in class II: in axio-buccal &
axio-lingual line angles.
These grooves are made on
the expense of buccal &
lingual walls rather than
the axial.
  Incisal or occlusal &
gingival grooves in class V.
  Pinholes:
-  Pinhole without pin:
as in class III.

-  Pinhole with pin: in


cases of removed
cusp due to caries.
N.Bs.
Weak cusp: The length of the cusp is
more than its width.
Cusp tipping: removal of at least 2
mm of the cusp tip if the weak cusp is
formed of enamel & dentin.
Cusp reduction: If the weak cusp is
formed of enamel only.
Slots:
•  an internal cavity within the floor of the
preparation having a continuous surrounding
wall and floor
•  It measures approximately 0.6mm,
•  depth 0.6mm and 0.5 to 1mm inside DEJ.
Axial coves:
•  Prepared (with No 1/4 bur) in dentin in the
vertical plane to provide additional
retention form in a preparation that uses
pins or in combination with grooves and
slots.
  Extension for retention: extension of the
cavity to the other side to prevent lateral
displacement (in cast gold restoration).

  Intra-radicular retention:
by embedding a post in
root canal treated tooth.
  Reverse bevel: in the
gingival wall of the
proximal cavity of class
II cast gold restoration
which prevents lateral
displacement.
  Cement interlock: in cast restorations.
N.B. Cement interlock is not a design feature
but it’s a retentive mean.
Means of retention
For axial displacement For lateral displacement
  Frictional retention   Dove- tail lock
  Undercuts   Proximal axial grooves
  Pins   Reverse bevel
  Posts  Pin, slots and Posts
  Cement interlock   Acid etching technique
  Acid etching technique   Extension for retention
The relation between
RESISTANCE & RETENTION

  Amount of retention will directly

reflect on the resistance to fracture.


  Mortise form which is made for

resistance gives frictional retention.


3. Convenience form:
Form given to the cavity which
allows it to be more conveniently seen,
approached & restored.
It was thought that convenience form is
gained through:-
1. Slight more extension of the cavity.
2. Accentuation of line and point angles.

Nowadays it’s gained automatically through:-


1. Proper extension of the cavity.
2. Proper instrumentation and contrangling.
3. Knowledge of the patient.
4. Position of the patient.
5. Proper selection of the restorative
materials and techniques.
6. Box form.
7. Skill of the operator.
8. Proper illumination and fibro-optic
handpeieces.
4. Removal of remaining carious dentin:
In average cases, most of the carious
dentin is removed during the previous
procedures. Therefore,
After completion of cavity preparation will
reveal the floor of the cavity to be composed of:

1. Hard sound healthy dentin 0.2-0.5mm


beyond D.E.J. free from lateral spread or
discoloration along D.E.J.
2. Hard but discolored dentin “stained
dentin” No harm of leaving it except
in anterior teeth for esthetics.

3. Soft dentin which may be either discolored


“chronic caries” or normal color “acute
caries”.
( must be removed )
  In cases of deep or moderately deep cavities:

Excavation of soft carious dentin is done


with extreme care by sharp spoon excavator (from
periphery to the center) or by a large, round,
carbide bur parallel to recessional lines.

If no clinical exposure is detected we protect the


pulp by Ca(OH)2 sub base and a suitable base
material .
Calcium hydroxide
sub-base Application of base
Techniques for caries removal:
•  Manual excavation by use of excavators
• Mechanical excavation by use of burs
• Air abrasion debridement (microdentistry
•  Laser debridement; which uses thermal
energy.
• Chemo-mechanical debridement: Carisolv;
•  Enzymes: such as Pronase enzyme
5. Finishing of cavity walls & margins:

Ideal enamel wall is that smooth wall ,


free of short, loose, undermined enamel rods
and has an inclination compatible with the
restorative material to be used.
N.B. The marginal seal of the finished
restoration largely depend on proper
carrying out of this step.
Characteristics of ideal enamel walls:
  It must be supported by sound dentin.
 Free from any irregularities &\or short,
loose and undermined enamel rods.
 C.S.A. has correct angulation compatible
with the restorative material to be used.
 Away from centric holding areas.
 In a self cleansable areas.
Noy’s principles of Enamel walls:
  Enamel wall should rest on sound dentin.
  Enamel rods which form C.S.A.
§  Should have their inner ends rest on
sound dentin.
§  must be supported by a portion of enamel
in which the inner end rest on sound
dentin and the outer end is covered by the
restoration.
  The C.S.A. must be trimmed or beveled
to avoid its injury by the restorative
procedures.
The direction of enamel walls is influenced by:
  Direction of enamel rods.
  Whether the cavity margins are located in
area of great functional stress.
  Friability of enamel.
  The physical properties of the restorative
material to be used.
Types of Marginal bevels:

1. Short: extends short distance 1


in enamel. (in shallow cavities).

2. Long: extends a full enamel 2


thickness. (in deep cavities).

Hollow ground: a concave bevel


about 2/3 of the enamel wall 3
thickness so the cavity margin
will have a right-angled CSA
(butt joint).
Resistance & Retention bevels:
•  Counter bevel which is done
for resistance in weak cusps in
cast gold restorations.
•  Reverse bevel which is done
for retention in cast gold
restorations.
6. Toilet of the cavity:
v  It’s the final step of cavity preparation
prior to insertion of the restoration.
v  No medicaments should be used.

Objectives:
1.  Elimination of bacteria, debris and saliva.
2.  Removal of remnants of dentin chips and
temporary restoration.
3.  To improve adaptation and hinder the
recurrence of decay around the restoration.
4.  Prepare and condition the tissues to receive the
entitled restorative material.
Smear layer:
A thin microscopic layer formed when using
hand or rotary instrument against cavity walls.
formed of: collagen of dentin, debris, saliva
(mucin) & microorganisms.
For removal of smear layer:
1) EDTA.
2) Malic acid.
3) Phosphoric acid.
4) Polyacrylic acid.
The concept of toilet of the cavity has
been changed with the advancement of
restorative materials.

The development of bondodontics


leads to a new approach in management of
smear layer which will be dealt with later on.