The mid exam is going to be on the 4th of November at 11:30 at 10H2,3,4.

The syllabus and the

slides will be on e-learning by next week. So we will start with amalgam and its to be the first filling materal you will be working with in cons lab after couple of weeks. Now we will cover few thing which are: The composition Classification of amalgam Basic setting reaction Properties How to handle the material and manipulate it so you have the best result possible. At the end you want t restore the function of the tooth and we talking here about posterior teeth because we place amalgam only in posterior teeth. You want to restore the function of the tooth after you remove the carries and you do the cavity so we need to know how properly manipulate the material and handle it so we have optimal results(to performance). In terms of general properties of amalgam, its considered as an inexpensive material, more expensive materials are for example: teeth colored material like composite so amalgam is primitively cheap, its easy to use, it has a history that date back to 100 or more years ago, so it has proven it self as a good durable filling material. But it has certain drawbacks. In esthetics; its silver color or grayish so its not an esthetic material, thats why you place it in posterior part of the oral cavity, and right now its being replaced by composite even in molars. Another drawback is the part that amalgam has mercury and as we all know its a poisonous material. At some point there was a lot of research articles starting that mercury in amalgam is poisonous people should not put it in their mouth and some countries especially in Europe they stopped using it from fear of toxicity but later on they found thats its not related to any side effects on the human body because the amount of mercury is very small and once its mixed with powder on the filling material it will be taken in and will not be released to the body, so in fact its not really dangerous, they used to say that it can cause abortion, it can cause malformation or mutations in unborn children but it has not been substantiated.

So it is still a good durable material but I personally prefer to use composite in posterior teeth even though you can guarantee its going to remain for 15 or 20 years without any need to replace it. So this is an example of a carious tooth ( slide #5) dental caries are on the proximal surface, a cavity was drilled, caries are removed (we call this a class 2 cavity it impose the proximal surface of posterior teeth). And then amalgam is usually passed in the cavity layer by layer (condensed inside the cavity because it is like a paste), then the dentist will carve it to restore the original anatomy of the tooth because once you do that you can restore the function how upper and lower teeth contact each other, and here is the final filling (slide #6). Now after it placed, after some time the dentist can finish it and polish it to produce a shiny, smooth you minimize accumulation of plaque or food debris witch make it last for even a longer period of time.
So these are the general steps to place any filling : Cavity drilled, caries removed, material placed , carved to the anatomy of the tooth and then it sets after some time.

Now we will move to the composition: Powder component + liquid component. Powder component: made up of many things: Major elemnt: silver There is also : tin, copper, zinc, indium, palladium. Each component serves for a particular purpose: Silver: increase strength Zinc: anti-oxidant (prevent oxidation) Indium and palladium: decrease tarnish of discoloration of the filling and corrosior. Copper:minimize corrosion. Corrosion: chemical

attack on the material.

Liquid component: is mercury, its a little but its a liquid metal. Heres the powder and heres the mercury liquid, before they used to mix it manually, which makes the person who mixes it even more susceptible to the dangers of mercury, but later on they start using capsules (capsulated amalgam) it minimizes exposure to mercury which make even safer. Capsulated amalgam: placed in a machine we call it amalgamator this machine shakes the capsule to mix the component together for 9 sec 10 sec (it depends on the manufacturer). And then you open the capsule and you start placing amalgam in the cavity. Classification: in term of classification one of the ways of classifying amalgam is according to the shape of the particle : Irregular: some types have irregularly shaped particles we call it lathe-cut amalgam is or alloy Spherical particles: (spherical alloy) Admixed: it contain both particles, mixture of spherical and irregular. Again each one has slightly different properties, slightly different amount of mercury needed to be mixed with it. Irregular alloy is made by basically taking a block of the alloy and start cutting it irregulary. Spherical amalgam how does it form? By basically melting the alloy, alloy is silver, tin, copper, zinc, palladium, indium they melt it all together and then, they then spray it. In a chamber that has a gas, once you spray a molten liquid inside a chamber that is filled with gas its going to be in the form of small balls or spherical and then as I said the admix is a mixture of the two shapes of particles, so this is micrograph (slide #9) showing the different type: A) Lathe-cut or irregular B) This is a spherical C) And this is mixture This is what the particles look like under scanning microscope. Setting reaction:

The major components as I said is silver and tin followed by the other components, thats why in the setting reaction we only mention mention this as one of the reactants, now they call this compound the gamma phase(it just a name) once it is mixed with metal (mercury) we end up with a number of phases( the results of the reaction) you will have unreacted particles that precipitate, the other component is silver with mercury they call it gamma 1 phase and tin with mercury they call it gamma 2 phase or alloy or particle now each one has specific property, the strongest one is the unreacted particle (gamma phase) they say it is the strongest it gives better strength to the material and it is resistant to corrosion or to chemical attack, now the gamma 1 which is silver and mercury it is string and resist corrosion but not as the gamma phase, now the worst one or the one that makes amalgam weak and susceptible to corrosion is the gamma 2 phase because if this gamma 2 is in large amount in the mix it is easy for it to decompose and tin and mercury will be released from the filling material. This is what corrosion is basically, chemicals or certain materials attack the filling it start to decompose and release it components, when that happens these elements will be released into the oral cavity into the dentinal tubules and it will weaken the material and it might cause staining for dentine, for example: any release of mercury it is unwanted because it is poisonous. So what do we basically want? As little as possible of gamma 2 to form, how does that happen? What they did is that they increase the amount of copper in amalgams, old amalgams used to have small amount of copper incorporated in the powder, newer amalgams they call them high copper amalgam or copper rich amalgam, they increased the amount of copper, what will happen? Copper is going to react with tin and prevent it from reacting with mercury so there is no more gamma 2 phase. Older amalgams were called low copper amalgams they suffered from high corrosion because of the gamma 2 phase, newer amalgams have more copper in them incorporated in the powder, up to 30% maybe, once the reaction starts copper will react with tin prevent it from reacting with mercury. once the reaction starts silver and tin and other components will dissolve and react with mercury, the reaction will continue until there is no more mercury at all. Amalgam will precipitate the powder will precipitate, the material gradually will becomes harder and harder until you can not carve it change its shape but still needs 24 hours for complete setting, that why when you place on amalgam filling in a patients mouth you tell him dont eat on it or bite on it for 24 hours. Use the other side of the oral cavity use your other teeth or other side. We always tell the patients this, to allow the amalgam enough time to set and become hard so it

has good compressive strength and not break when the patient eats on example on it, so this is one piece of information we need tell the patient. Other properties of amalgam: Tarnish: this one problem associated with amalgam especially with older types of amalgam(low copper amalgam), tarnish is basically oxidation of the surface of amalgam due to contact with different materials like chloride, sulfide, oxygen, anything inside the oral cavity that has these components. What will happen? The amalgam surface will react with these things, it will be oxidized, the color will change, its going to become dark not shiny silver like this,(slide #14, tarnish in left and shiny in right) the material it self will not be weakened because the reaction it is on the surface or slightly below the surface so the material will not break down but it will have a dull dark colored, now how can we minimize this reaction? This can be done by using amalgams that has palladium inside of them whick is a metal, palladium, when incorporated will minimize this reaction or tarnish, and also finishing and polishing the material giving it a shiny smooth surface minimizes accumulation of plaque on the filling material that can cause it or oxidize. We have to be careful when we do finishing and polishing of amalgam, we use rotary instruments, we use a brush or a cup on the surface of the filling. Amalgam is a metallic filling, once you start to use this finishing and polishing instrument friction is going to happen because we are grinding the surface or we are rubbing the bur or the brush against the surface of amalgam this generate heat, and this is a metallic filling so heat will be transmitted to the pulp which can cause pain and sensitivity, and if is too much it can cause pulpitis and irreversible damage, thats why when we finish and polish amalgam we need to use water, we need to cool it down. So this property we need to remember when we manipulate or handle Amalgam is a metallic amalgam. material, so good conductor to heat. Corrosion: We mentioned corrosion in the previous semester, so this sort of chemical reaction goes beyond the surface, it can cause break down of the material causing it to release its elements which makes it weaker so its not a surface of a subsurface reaction it goes beyond. Now once elements are released from amalgam because of the chemical attack, mostly tin is release, mercury will be released, these components will be released either into the oral cavity or sometime some of them might precipitate In dentine or dentinal tubules, so they can cause

staining to the tooth, they can cause weakness of the material, they can cause breakdown of the material especially for example: on the margins of the cavity which will create space which will create micro leakage which lead to staining sensitivity and caries then you to remove the material and replace the filling with another filling . newer amalgam ( high copper amalgam) this problem is minimized because of high copper content in addition to chemical reactions galvanisim can cause corrosion . Galvanisim :- the contact between two dissimilar metals. And sometimes the reaction between the components can cause corrosion but this is minimal. The major component for corrosion is the chemical reaction with whatever you drink or eat inside the oral cavity ( slide 17 this is the outcome the corrosion , this is a corroded filling). The outcome of corrosion:1) Weakness of the restoration. 2) Destruction to the margins of restoration . 3) Staining to the surrounding tooth structure ( it might cause staining to the soft tissue causing what we called amalgam tattoo , it is going to disappear once you replace the filling with another filling ). This is the clinical picture of a filling that suffer from corrosion , you can see that clinically the surface looks like tarnish , but if you look closer you can see the destruction of the filling all around, there is deficiency and it needs to be replaced . Creep: Its plastic deformation of the material, due to force applied on it after a period of time which means that the shape of the material will change slightly due to this force, so the material can actually extend outside the cavity margins due to continuous pressure and it could fracture under occlusion. What protects your filling ?? you need a good cavity design and you need youre filling to be all within the cavity margins, because the remaining tooth structure protected gives it durability and strength . Once part of the filling outside the margins of the cavity it is weak standing on its own nothing is supporting it therefore it might break. So one of the consequence is fracture and once this part fracture it will cause deficiency and part of the tooth will be exposed and it

will cause micro leakage and consequences micro leakage so this thing needs to be replaced . Dimensional changes :In general we dont want dimensional changes in the filling material , we dont want it to expand or contract but there is no ideal material . So what the solution is ? only minimal expansion or minimal contraction that doesnt affect the tooth, ideally it needs to be less than 1% , any dimensional changes needs to be as minimal as possible , and some types of amalgam expand a little bit , some of them contract a little bit , so if they contract a little their might be very small spaces between the filling and the cavity and can cause sensitivity . if the material expand too much it can cause pressure on the tooth and sometimes even cause gaps or fractures . Slide # 21 - this is a material that has expanded to a very large degree which cause pressure and maybe gapping in enamel. Strength: Amalgam is a brittle material so it has high compressive strength, low tensile or low shear strength thats why when you place it in a cavity you need minimum thickness of the material to make sure it is strong enough thats why if you have a cavity thats 1mm deep which means that your amalgam will be 1mm thick its going to too weak, it has to have certain amount of thickness to be strong, amalgam needs to be at least 1.5-2mm thick in cavities, if your cavity is too shallow amalgam will not work it will break easily during function we can place other materials, for examples composite or tooth colored material, but if you want to place amalgam, your cavity needs to be at least 1.5-2mm deep so you need enough bulk of the material for it to be strong enough. High copper amalgams are stronger and they become stronger much quicker that low than low copper amalgams, this is an advantage of high copper amalgams, less corrosion, better strength that develops quickly once the material is mixed. Handling: when the material is handled each type of amalgams has certain properties that are slightly different than other types, some types are softer when they are condensed, some become stronger non other types. for example: spherical amalgams have a small surface area compared to irregular shape amalgam so they need less mercury, they are softer than other types so they dont need high force when they are packed inside cavities, and they become stronger, or they

have higher strength after 1 hr or 24 hrs compared to admixed amalgam, so because shape of he particles is different and amount of mercury is different the properties are slightly different. another property of spherical amalgam is that they shrink a little bit compared to admixed amalgam. amalgam supplied as capsules so you always need to read the instructions to see how long you need to mix this capsule and how to handle it. slide #26: this picture shows you different properties in terms of strength and creep(you just need to know hight compressive strength, low tensile and low shear strength, you don't need to know numbers). slide #27: this how the capsule look like if you want to sketch it, the powder is at one end and the liquid in the other end, and between them there's a membrane acts like a barier to seperate them, once the capsule is activated this membrane will rupture and both elements will meat and start to mix(once the capsule is shaken). different types of capsules are available in terms of the amalgam inside them, some of them have a small amout of powder that is suitable for a small cavity we call them single mix or single spin, some of them are double or even more, sp it depends on your cavity or if your doing than one tooth at the same time, so different sizes are available inside cavities, and they become stronger, or they have higher strength after 1 hr or 24 hrs compared to admixed amalgam, so because shape of he particles is different and amount of mercury is different the properties are slightly different. another property of spherical amalgam is that they shrink a little bit compared to admixed amalgam. amalgam supplied as capsules so you always need to read the instructions to see how long you need to mix this capsule and how to handle it. slide #26: this picture shows you different properties in terms of strength and creep(you just need to know hight compressive strength, low tensile and low shear strength, you don't need to know numbers).

slide #27: this how the capsule look like if you want to sketch it, the powder is at one end and the liquid in the other end, and between them there's a membrane acts like a barier to seperate them, once the capsule is activated this membrane will rupture and both elements will meat and start to mix(once the capsule is shaken). different types of capsules are available in terms of the amalgam inside them, some of them have a small amout of powder that is suitable for a small cavity we call them single mix or single spin, some of them are double or even more, sp it depends on your cavity or if your doing than one tooth at the same time, so different sizes are available slide #28: this is the mixing machine, we call it amalgamator or tritorator. it is important to mix according to the manufacturer instructions not over mix or mix it for a longer period of time or shorter period of time. if you over mix amalgam you will end up with a sticky material that sets very quickly because it was mixed for a long period of time so you have longer working time----> shorter setting time, you will not have enough time to place in the cavity while it is still soft and carve it. now if you mix less than the recommended the mix will not be complete, you need enough time for the powder to be wet by mercury and for the reaction to occur properly, if you don't you will end up with a grainy crumby mix because the mixing was not affected. how is it placed ? you will learn how in the lab but basically it placed in layers(not in one bulk), in a certain intrument called amalgam carrier, we take pieces of the amalgam mix place in the cavity, condense it with an intrument called a condenser, so layer by layer until we over fill the cavity and the excess will be removed carved to the anatomy of the tooth. burnishing: it is a process by which we use the burnisher which is an instrument that has a ball shaped tip we use it for a better adapt the filling to margins of the cavity and also remove any excess amalgam (we will learn how to do that in the lab)

carving: you should carve the amalgam almost immediately you should not wait too long because the setting will go on and you will not be able to manipulated when it becomes too hard, so you need to be quick enough. finishing and polishing: are postponed after 24 hrs because the final setting is completed after 24 hrs. silde #31: if finishing and polishing are done properly amalgam filling can look like this, better smoothness, decreased plaque, decraesed corrosion. these are the benefits of polishing any metal restoration. slide #32: this is a comparison between different properties of low copper amalgam and high copper amalgam in terms of dimentional changes and corrosion, as we said before. some people say that this material needs to be mechanically retained in the cavity, if you remember we talked about bonding last simester, some materials are chemically bonded to the tooth structure and some of them need mechanical retention that means that you need to shape your cavity in a certain way so the filling will not be taken out during function, amalgam need mechanical retention. some people suggested other techniques to enhance the bond or the retention of amalgam inside cavities, they say we can use bonding agents which are liquids we call them adheces to enssure that the amalgam is well bonded to the tooth structure, or we can use some composite material which comes in the form of pastes. reasearches said that this is a time consuming process and really it does not improve bonds that much. mercury: we have to be careful when we handle amalgam even if it contains small amounts of mercury, especially when mercury is not mixed with amalgam/alloy yet. people who should consider safety from mercury are: the patient, the operator, the assistant if you have one, and the enviroment. mercury can enter your body either by inhaling the vapor, or by contact with the skin or by swallowing it when amalgam is placed or removed from the tooth. as an operator you can protect yourself by wearing gloves, masks and glasses, don't handle amalgam with your bare hands, and the same goes for the assistant, now for

the patient we can use high volume suction ti minimize any remnants of amalgam to go inside the patient's throat, and sometimes we can use a piece of sheet called a rubber dam we place it around the tooth to isolate it from the rest of the cavity therefore when you are working with this tooth nothing can go inside the patient's throat. another thing dentists and assistants should be aware of is when cleaning and sterilizing the instruments, when we clean them we place them in a container under a high temp. water which means that any remnants on the instrument(mercury) will evaporate which makes it dangerous because you can smell this vapor. safety procedure: slide #37 and #38 free mercury amalgam: the same as slide #39

done by: Jiana Moussa & Rozeen Kassem

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