CLASS II AMALGAM RESTORATIONS

Initial Clinical Procedures: Tooth Preparation

Initial tooth preparation: Occlusal outline form (occlusal step): The occlusal outline form of a class II tooth

preparation for amalgam is similar to that for the class I

tooth preparation. Using high speed with air-water spray,

enter the pit nearest the involved proximal surface with a

punch cut using a No. 245 bur.

Entering the pit nearest to the involved proximal surface allow the mesial pit (in this case) not to be included if it is sound. Proper depth of the initial entry cut is 1.5 to 2mm (i.e., one half to two thirds the length of the cutting portion of a No. 245 bur), 1.5mm as measured at the central fissure, and approximately 2mm on the prepared external walls

This pulpal depth usually 0.1 to 0.2mm into the dentin.

While maintaining the same depth and bur orientation, move the bur to extend the outline to include the central fissure and the opposite pit. For the very conservative preparation, the isthmus width should be as narrow as possible and no wider than one quarter the intercuspal distance.

The pulpal floor should be prepared to a uniform

(previously described) depth (and is usually flat). However, the pulpal floor of the preparation should follow the slight rise and fall of the DEJ along the central fissure in teeth with prominent triangular ridges.

During development of the distal pit area of the preparation,

extension to include any distofacial and distolingual developmental fissures radiating from the pit may be indicated. The distal pit area provides dovetail retention form, which may prevent mesial displacement of the completed restoration.

Before extending in to the involved proximal marginal ridge

visualize the final location of the facial and lingual walls of the proximal box relative to the contact area. Viewed from the occlusal a reverse curve in the occlusal outline of a class II preparation, which often results when developing the mesiofacial wall perpendicular to the enamel rod direction and conserving the facial cusp structure.

Lingually, the reverse curve usually is minimal (if necessary at

all) because the embrasure form is larger.

While maintaining the established pulpal depth and with the

bur parallel to the long axis of the tooth crown, extend the

preparation mesially, stopping approximately 0.8mm (the

diameter of the end of the bur) short of cutting through the

marginal ridge in to the contact area.

The location of the DEJ is an important guide in the development of the proximal preparation.

PROXIMAL OUTLINE FORM (Proximal box):

The objectives for extension of proximal margins are to: Include all caries, faults, or existing restorative material. Create 90-degree cavosurface margins (i.e., butt joint margins). Establish (ideally) not more than 0.5mm clearance

with the adjacent proximal surface facially, lingually

and gingivally.

The Initial procedure in preparing the outline form of the

proximal box is the isolation of the proximal (i.e., mesial)

enamel by the proximal ditch cut. This is a very important

procedure in conservative tooth preparation.

With the same orientation of the bur, position it over the DEJ in
the pulpal floor next to the remaining mesial marginal ridge.

Allow the end of the bur to cut a ditch gingivally along the
exposed DEJ, two thirds at the expense of dentin and one third at the expense of enamel. The 0.8mm diameter bur end will cut approximately 0.5 to 0.6mm into dentin and 0.2 to 0.3mm into enamel.

Extend the ditch gingivally just beyond the caries or the proximal contact, whichever is greater. Because dentin is softer and cuts more easily than enamel, the bur should be

cutting away the dentin immediately supporting the enamel.

A guide for the gingival extension is the visualization that

the finished gingival margin will be only slightly gingival to the gingival limit of the ditch. This margin should clear

the adjacent tooth by only 0.5mm in a small tooth

preparation.

The location of final proximal margins. (i.e facial, lingual, gingival) should be established with hand instruments (i.e.,

chisels, hatchets, trimmers) in conservative proximal box

preparations. Otherwise, these margins may be

overextended to achieve 90-degree cavosurface margins with the No. 245 bur.

The proximal ditch cut should be sufficiently deep in to

dentin (i.e., 0.5 to 0.6mm) that retention locks, if deemed necessary, can be prepared into the axiolingual and

axiofacial line angles without undermining the proximal

enamel.

The proximal ditch cut may be diverged gingivally to ensure that the faciolingual dimension at the gingival is greater than at the occlusal. The gingival divergence contributes to retention form and provides for desirable extension of the facial and lingual proximal margins to include defective tooth structure or old restorative material at the gingival level, while conserving the marginal ridge and providing for 90 degree amalgam at the margins on this ridge.

In completing the proximal extensions, next make two

cuts, one starting at the facial limit of the proximal ditch and the other starting at the lingual limit, extending toward

and perpendicular to the proximal surface.

This weakens the remaining enamel by which the isolated portion is held. If this level is judged to be insufficiently gingival, additional gingival extension should be accomplished using the isolated proximal enamel that is still in place to guide the bur. This prevents the bur from marring the proximal surface of the adjacent tooth.

If additional use of the bur is indicated, a matrix band may be used around the adjacent tooth to prevent marring

its proximal surface.

With the enamel hatchet, the bin angle chisel or both, cleave away any remaining undermined proximal enamel, establishing the proper direction to the mesiolingual and mesiofacial walls.

Primary resistance form is provided The pulpal and gingival walls being relatively flat and perpendicular to forces directed with the long axis of the tooth; Restricting extension of the walls to allow strong cusps and ridges areas to remain with sufficient dentin support Restricting the occlusal outline form (where possible) to areas receiving minimal occlusal contact.

The reverse curve optimizing the strength of both the

amalgam and tooth structure at the junction of the

occlusal step and proximal box;

Slightly rounding the internal line angles to reduce stress concentration in tooth structure Providing enough thickness of restorative material to prevent its fracture under mastication.

Primary retention form is provided by the occlusal

convergence of facial and lingual walls and by the

dovetail design of the occlusal step, if present.

FINAL TOOTH PREPARATION:

The presence of infected carious dentin on a portion of either the pulpal wall (floor) or axial wall does not indicate deepening the entire wall. Infected carious dentin is removed with a slowly revolving round bur of appropriate size or a discoid-type spoon excavator or both. Stop excavating when a hard or firm feel with an explorer or small spoon excavator is achieved.

Secondary resistance and retention forms:

Secondary resistance form in final tooth preparation involves both resistance of the remaining tooth structure against fracture from oblique forces and resistance of restorative material against fracture.

Restricting extensions of external walls provides the

former; the latter is enhanced by using the gingival margin trimmer to bevel or rounden the axiopulpal line angle, thereby increasing the bulk of and decreasing the stress concentration within the restorative material.

The occlusal convergence of the facial and lingual walls and the dovetail design (if needed) provide sufficient retention

form to the occlusal portion of the tooth preparation.

The occlusal convergence of the mesiofacial and mesiolingual walls offers retention in the proximal portion of the

preparation against displacement occlusally.

To enhance retention form of the proximal portion, proximal locks may be indicated to counter proximal displacement.

It is important to note that the retention locks should be

placed 0.2 mm inside the DEJ, regardless of the depth of the axial walls and axial line angles.

Ideally there should be a 90-degree cavosurface angle

(maximum of 100 degrees) at the proximal margin. The occlusal line angle may be 90 to 100 degrees or greater. This angle aids in obtaining a marginal amalgam angle of

90 degrees (no less than 80 degrees).

Clinical experience has established that this butt joint

relationship of enamel and amalgam creates the strongest

margin.

Reverse Curve

Matrix system
A matrix system provides and takes the place of the proximal tooth surface that was removed to restore the proximal contours and contact to their normal shape and function.

Posterior Matrix System

Matrix bands Matrix bands are made of flexible stainless steel and are available in premolar, molar, and universal sizes and thicknesses. The larger circumference of the band is the occlusal edge and is always placed toward the occlusal surface.
The

smaller circumference of the band is the gingival edge and it is always placed toward
the gingiva.

Posterior Matrix System

Universal retainer Also referred to as the Tofflemire retainer. This device holds the matrix band in position. The retainer is positioned most commonly from the buccal surface of the tooth being restored.

Matrix retainer

Components of a Universal Retainer

Sectional Matrices
A

thin polished palodent-type band and a tension ring produce a tight anatomic contact for composite resin materials for class II restorations.

Sectional matrices.

Ivory matrix retainer 1 & 8

Automatrix

Compound Supported matrix

Copper Band

Wedges
A

wedge is either triangular or round and made of wood or plastic. wedge is inserted into the lingual embrasure to position the matrix band firmly against the gingival margin of the preparation.

The

A wedge correctly positioned.