Complex Amalgam Restorations - 2011 Dental Updates
Complex Amalgam Restorations - 2011 Dental Updates
Complex Amalgam Restorations - 2011 Dental Updates
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COMPLEX AMALGAMS<br />
Robert Langsten, Col, USAF, DC<br />
Commander, Offutt AFB, NE<br />
Former AF Delegate to the ADA
COMPLEX AMALGAMS
<strong>Complex</strong> <strong>Amalgam</strong>s<br />
“Dr. Langsten can you come help me with this<br />
tough tooth”
Why <strong>Complex</strong> <strong>Amalgam</strong>s?<br />
• Because they work!<br />
• 150+ Years of proven clinical success<br />
• Very versatile material
<strong>Complex</strong> <strong>Amalgam</strong>s
Economic Impact of <strong>Amalgam</strong><br />
• Germany, Sweden, Denmark limited use<br />
• U.S. – federal/state bills introduced<br />
• Total ban = $8.2 Billion dental expenditure<br />
increase/year<br />
• Avg restoration price would increase $52<br />
• Quality restorative material!
<strong>Complex</strong> <strong>Amalgam</strong>s: Overview<br />
• Indications<br />
• Contraindications<br />
• Pre-operative evaluation<br />
• Preparation principles<br />
• Resistance/Retention features<br />
• Matrix systems
<strong>Complex</strong> <strong>Amalgam</strong>s: Overview<br />
• Wedging<br />
• <strong>Amalgam</strong>-the material<br />
• Trituration<br />
• Anatomy and carving<br />
• Finishing & Polishing
Definition:<br />
• An amalgam restoration that replaces one or more<br />
cusps
Indications<br />
• High caries pts<br />
• Restoration fractures<br />
• Foundation restoration<br />
• Cracked teeth<br />
• Compromised perio/endo<br />
• Med compromised pts<br />
• Cost<br />
• Deployments
Indications: High Caries
Indications: Restoration Fracture
Indications: Foundation Restoration
Do It Right
Indications: Fractured Teeth
Indications: Compromised Perio/Endo
Indications: Medically Compromised
Cost
Indications: Deployments/Humanitarians
Contraindications…. Not Many<br />
• Esthetics<br />
• Previous failure<br />
• Heavy occlusion<br />
• Short clinical crown<br />
• Sensitivity
Previous Failure
Heavy Occlusion
Short Clinical Crowns
Sensitivity
Pre-Operative Evaluation<br />
• Vitality tests – hot, cold, percussion<br />
• Radiographs – BWs and periapical<br />
• Periodontal probing and Miller mobility<br />
• Check occlusion for plunger cusps<br />
• Mark occlusion – Heavy occlusion areas<br />
• Establish pre-operative records
Pre-Operative Evaluation
Transillumination
Cracked Tooth Syndrome
Assess Occlusion
Indicator Dyes: Caries/Fractures<br />
• Watch colors of dyes<br />
• Remember dentin<br />
anatomy<br />
• Visual/tactile exam<br />
• Carbolam green
Pre-Operative Records<br />
• Absolutely critical for success<br />
• Most commonly skipped<br />
• Occlusal scheme<br />
• Plunger cusps?<br />
• Occlusal contacts
Pre-Operative Records
Pre-Op Records: Reference Points<br />
• Adjacent marginal ridges<br />
• Adjacent cusps<br />
• CEJ<br />
• Rubber dam retainer<br />
• Opposing cusp<br />
• Polyvinylsiloxane record<br />
• Create reference point
Pre-Op Records
Pre-Op Records: Reference Points
Preparation Principles:<br />
• Ensure retention and resistance form<br />
• Ensure caries removal<br />
• Ensure old restoration removal<br />
• Remove weakened/fractured tooth<br />
• Reduce cusps for strength<br />
• Provide access matrix and carving<br />
• Make steps and floors<br />
• Tie the amalgam to the tooth
Retention:<br />
• Design features which prevent<br />
dislodgment of the restoration<br />
from tensile forces (along the<br />
path of insertion)
Resistance:<br />
• Design features which<br />
prevent fracture<br />
/dislodgement of the<br />
restoration by<br />
compressive, lateral or<br />
oblique forces
Preparation Principles: Restoration/Caries
Remove Old Restoration
Weakened Fractured Cusps
Reduce Cusps
Matrix Access
Steps and Floors
Tie In Remaining Tooth Structure
Retention /Resistance Features<br />
• Pins<br />
• Amalgapins<br />
• Boxes & Walls<br />
• Slots<br />
• Peripheral Shelves<br />
• Posts<br />
• Adhesives
Pins
Pin Placement…..Confidence
Pin Composition<br />
• Titanium (99.6%)<br />
• Titanium alloy<br />
• Stainless steel with 20u gold coat (TMS)<br />
• <strong>Amalgam</strong>
Pin And Drill Sizes<br />
Color<br />
Gold<br />
Silver<br />
Red<br />
Pink
Pins: When To Use
2mm<br />
2mm<br />
2 m m<br />
2 m m<br />
2mm
Pin Placement
Drills
Pin Drivers
Concentricity And Run-Out
Amalgapins<br />
• First used by H. Shavell<br />
• Quick and easy<br />
• Minimal occlusal<br />
clearance<br />
• No additional cost<br />
• Use fast set alloy!
Amalgapins<br />
• Parallel to external surface<br />
• Bevel cavosurface<br />
• Use high copper alloy<br />
• Minimize oblique forces
Amalgapins
Boxes and Walls
Slots-Outhwaite
Peripheral Shelf
Peripheral Shelf
Ideal Post<br />
• Equal to crown<br />
• 2/3 to 3/4 of length of root<br />
• 1/2 length of root in bone<br />
• 4 - 5 mm gutta percha<br />
• < 1/3 of root diameter<br />
“Increased post length results in<br />
increased retention and<br />
resistance to fracture”
Prefabricated Posts<br />
• Very retentive<br />
• Less stress<br />
• Failure often leaves restorable tooth<br />
• Canal shaped to fit post<br />
• ParaPost Plus (Whaledent)
Posts
ParaPostX System<br />
• ParaPostXP<br />
– Parallel-sided passive stainless steel or titanium alloy<br />
– Flat head, ideal for long canals<br />
• ParaPostXH<br />
– Parallel-sided passive titanium alloy<br />
– Rounded undercut head for composite and GI cores<br />
• ParaPostXT<br />
– Parallel-sided active titanium alloy<br />
– Rounded head<br />
– For short canals
Adhesives: 2 Types<br />
• Resin-lined: DBA placed, cured and amalgam<br />
condensed. Adhesive functions as a liner/varnish.<br />
• Resin-bonded: Unpolymerized BDA is<br />
incorporated into amalgam and chemically cures<br />
resulting in better bond strengths
Adhesive: Advantages<br />
• Reduces early microleakage of restoration<br />
• Improves fracture resistance<br />
• Avoids pin armamentarium<br />
• Provides additional retention
Adhesive: Disadvantages<br />
• Bonds to matrix band and condenser<br />
• Technique sensitive<br />
• Increased cost<br />
• Increased time to place<br />
• Excess flash difficult to remove<br />
• Pooling mimics caries on radiographs
Adhesive
Adhesive
Adhesive
The Matrix<br />
• Critical to final restoration success<br />
• Good matrix==Good restoration<br />
• Use appropriate matrix system<br />
• Know advantages of systems<br />
• Prep must allow matrix placement
Ideal Matrix Properties
Matrix Systems
Toffelmire System<br />
• Most used/secure<br />
• Not ideal for large restorations<br />
• Know varying thickness of bands<br />
• Watch band placement<br />
• Require burnishing
<strong>Amalgam</strong> Matrix Choices<br />
• Tofflemire<br />
– Flat<br />
• #1 - Universal<br />
• #2 - Molars<br />
• #3 - Premolars<br />
– Anatomic<br />
• Precontoured Dixieland Matrices<br />
– Thickness<br />
• 0.010”, 0.015”, 0.020”
Matrix: Advances
T-Bands<br />
• Used primarily one deciduous teeth
Supermat System<br />
• System can be highly tightened<br />
• Excellent for second molar use
Automatrix System<br />
• Best for complex amalgams<br />
• Tightening difficulty<br />
• Removal easily produces trophies<br />
• Requires crimping to stabilize<br />
• Fastening mechanism removal
Automatrix System
Denovo System<br />
• Multiple sizes<br />
• No tightening mechanism<br />
• Requires contouring<br />
• Limited clinical use<br />
• Good for immediate build-ups
Matrix Stabilization<br />
• Wedges and modification<br />
• MPIC-modeling plastic impression compound<br />
• Multiple matrices
Wedges: Traditional<br />
Premier<br />
Wizard
Wedges: New
Root Flutes and Concavities
<strong>Amalgam</strong>
ADA Specification # 1<br />
• ADA spec#1 describes the biological and physical properties required<br />
for ADA acceptance of dental amalgam.<br />
Composition of ADA-certified <strong>Dental</strong> Alloys<br />
element amount (% by weight)<br />
silver min. 40%<br />
tin max. 32%<br />
copper max. 30%<br />
zinc max. 2%<br />
mercury*** max. 3%<br />
***pre-amalgamated dental alloys contain some mercury in the powder to facilitate<br />
wetting during trituration.
Dispersalloy<br />
• Admix- 2/3 lathe cut, 1/3 spherical<br />
• High copper alloy 13%<br />
• Lathe cut- milled ingot<br />
• Spherical- melted and sprayed<br />
• Slower Set!
Tytin<br />
• Spherical alloy 20-40 um<br />
• Less mercury required to react<br />
• Less overall surface area<br />
• Rapid set!
Trituration<br />
• Calibrate as needed
Condensation<br />
• Use adequate pressure<br />
• Adapt material to preparation<br />
• No voids<br />
• “Whole pellet placement”<br />
• Overlapping movements<br />
• Watch matrix during placement
Condensation: Condensaire
Condensation
Pre-Carve Axial Contours
Carving: KNOW ANATOMY!
Maxillary Molar<br />
• Rounded square<br />
• MF ¼, split F 1/2<br />
• Mid DF to mid lingual<br />
• ML cusp tip placement<br />
• Central groove<br />
• Embrasures<br />
• Final anatomy
Mandibular Molar<br />
• Rounded rectangle<br />
• Create 40, 40, 20 “Y”<br />
• Place central groove Li<br />
• Place triangular grooves<br />
• Lingual grooves<br />
• Embrasures<br />
• Final anatomy
Before Damn Removal<br />
• Verify contours<br />
• Verify marginal ridges<br />
• Basic anatomy present<br />
• All embrasures<br />
• CHECK PRE-OP RECORDS!!!!
After Damn Removal<br />
• Occlusion, Occlusion, Occlusion<br />
• Carve to centric occlusion<br />
• Restored and adjacent teeth<br />
• Remove excess interproximally<br />
• Establish embrasures<br />
• Contours, contacts, occlusion
Finishing<br />
• For highly polished final amalgam restorations<br />
lightly polish with pumice and cup post<br />
placement<br />
• Complete polish 24 hours later
Finishing
Summary<br />
• Use them because they work<br />
• Remember preparation principles<br />
• Use material properly<br />
• Place quality anatomically correct restorations<br />
• Remain receptive to new materials and techniques
Questions ???
Clinical Case
Clinical case
Clinical case
Clinical case
Clinical Case
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Clinical Case
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