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Principles of Cavity Preparation

NOTE: This lecture covers the slides (13-22) from the (Principles of Cavity Preparation "I") and the (Principles of Cavity Preparation "II") lecture.

Before we start, some students seem to be confused about the first point of (Initial Tooth Preparation Stages) which is Outline form & initial depth (go back to slide #11). The outline form: The borders of our cavity preparation. Looking at this picture you can see that caries can be occlusal or cervical. When we drill the cavity we dont go to the full depth (the base) of the carious legion right away, instead we establish an initial depth. (Here the initial depth is 0.2 mm inside DEJ occlusally, 0.5 mm cervically), this means 0.2 mm inside the dentine occlusally and 0.5 mm cervically, and this is due to the variation of the enamel thickness. Occlusally the enamel is thicker; this is why we go less into the dentine, only a 0.2 mm would give us an initial depth of 1.5 mm in enamel and dentine. While cervically the enamel thickness is less so more depth is needed in dentine to establish the initial depth. Now we will start with our lecture

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Slide #13

2. Primary resistance form:

"The shape & placement of the preparation walls that best enable both the restoration and the tooth to withstand, without fracture, masticatory forces delivered principally in the long access of the tooth" In other words, it is to prepare the cavity in a form that resists fracture of both the tooth structure and the restoration later on. In terms of the restoration we should prepare the cavity deep enough for the amalgam to be strong and resist fracture, so the depth should at least be 1.5 mm, consequently the amalgam thickness will be 1.5 mm, not less because the amalgam is weak in thin sections. But what about the tooth structure itself? How do we prepare the cavity in a way that resists fracture in the tooth itself? We keep the internal line angles of the cavity rounded, because stresses will become concentrated on those areas if they are sharp, leading to craze lines and fractures in the tooth. The force we are trying to resist here is delivered principally in the long access of the tooth (Compression Forces). In the oral cavity our teeth are subjected to different forces as u can see, but in the primary resistance form, the force we are resisting is the compressive force (perpendicular to the occlusal table).

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Slide #14 Principles of resistance form: 1. Box shape with relatively flat floor: I should be able to distinguish the buccal and lingual walls, and the pulpal floor. In figure (A), the cavity is box-shaped, so the distribution of forces will be more even, however in (B) the distribution is not even, and can be more on one side than the other, which can cause the restoration to move leading to tooth fracture. Masticatory forces are directed along the long access of the tooth.

Slide #15 2. Keep the cavity as small as possible: Because the more tooth structure we remove, the less resistant the tooth is against fracture. So we should keep the cavity as small as possible, taking in consideration that all caries must be removed. This figure is a class 1 cavity preparation, upon doing this preparation, two principles must be applied: 1. Maintaining a flat pulpal floor. 2. Removing the smallest amount of tooth structure as possible.

DEJ

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The problem is that if I want to apply the first principle, I will have to remove a big layer of sound dentine that is not carious, because the caries are confined to a small area of dentine, so I sacrifice more tooth structure in order to keep the pulpal floor flat, this means that applying the first principle makes it impossible for us to apply the second one. Removing more tooth structure will: 1. Weaken the tooth. 2. Endanger the pulp because we are closer to it. 3. Cause irritation to the pulp because more dentinal tubules will be open causing mechanical and thermal conductivity to the pulp.

So how should I deal with this? I should make the pulpal floor flat by applying a liner or a base. In general I dont remove sound tooth structure to make the floor flat in such case. Pulpal & axial walls should be maintained just in dentin if at all possible: The initial depth in dentine should be maintained as small as possible (0.2 mm in dentine occlusally for example). If caries invaded the interjacent dentin, only the carious dentin should be removed.

Slide #16 3. Rounded well-defined internal line angles. Well-defined line angles aid in establishing uniform depth and prevent rotation of the restoration: the box shaped cavity has welldefined and rounded walls, with no sharp angles (Forces tend to be concentrated on those sharp angles and that makes the tooth more prone to craze lines and fracture). 4. Cap cusps or include weakened tooth structure within the restoration. (Will be explained later)
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Slide #17 5. Provide enough thickness of restorative material to prevent its fracture. The restorative material may fracture if the cavity preparation is too shallow: because then the amalgam will not be thick enough to resist compressive forces. This is a class 2 cavity preparation: we need enough thickness of the amalgam proximally as we will discuss in details later.

Slide #18 6. To bond the material to tooth structure when possible. This is possible in composite filling for example. The resistance here will depend on the bonding of the composite to the tooth structure, so we will not concentrate on having well-defined rounded walls or box-shaped cavity, because composite will bond to the tooth structure increasing both the resistance of the tooth itself and the restoration against fracture.

Slide #19 Factors Affecting Resistance Form: 1) Remaining tooth structure: Affect need and type of resistance form. 2) Type of restorative material: amalgam Vs composite.

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Slide #20

3. Primary Retention Form:

The shape or form of the conventional preparation that resist displacement or removal of the restoration from tipping or lifting forces The resistance form is against compressive forces, other forces are resisted by the primary retention form, such as torsion, tension, shear and flexion. These forces can cause tipping or lifting of the restoration, but what we want is to keep the restoration inside the tooth structure, which is what retention means. Slide #21 Principles: (Depends on the restorative material) Amalgam: retention is mechanical, so we make the cavity in a way that resists the removal of the amalgam from the cavity. In most Class I and Class II, walls should converge occlusally: the retention comes from the buccal and lingual walls, which should be slightly convergent occlusally or parallel (slightly convergent is better). (b > a) means that the base should be wider than the apex, so the amalgam will not be removed from the cavity. The walls shouldn't be: Too convergent Undermined enamel. Divergent Not retentive for amalgam.

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 In class II, occlusal dovetail aid in retention: the dovetail should be made on the occlusal surface, and on the proximal surface the buccal and lingual walls should be parallel or slightly convergent occlusally. In Class V, walls diverge outward to provide strong enamel margin, retention obtained by grooves in the dentinal walls.

Buccal wall

Lingual wall

Retention is classes other than class I will be discussed later.

Slide #22 Composite Micromechanical bond: by acid etching & bonding: Acid etching creates a rough surface for the composite, and the resin will flow into these irregularities and lock itself there (micromechanically) when cured as we learned in dental material). Now we will start with the second part of the lecture

Principles of Cavity Preparation II I had no access to the pictures of this part 4. Convenience form: The form or shape of the preparation that provides adequate observation, accessibility and ease of operation in preparing & restoring the tooth

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This is the last step of the initial stages of the principles of cavity preparation. (You can go back to the previous lecture to remember those stages.) All parts of the cavity must be visible for examination. Convenience form means that I should prepare the cavity in a way that enables me to see what's inside it. Contrary to what some students do in their fourth year, and that is they drill a small hole on the occlusal surface of the tooth and go all the way to the pulp, the result is pulp exposure without even removing the caries which are spread on the DEJ, this is wrong! And it is an example of a bad convenience form! To further explain, convenience form means that I should open the cavity enough to be able to see what I'm doing and have a clear vision of the caries, and avoid exposure of the pulp. I also need the cavity to be large enough to fit the amalgam, and be able to condense it well. So the convenience form is to make the cavity large enough to be able to see what I'm doing, and be able to restore the cavity properly later on, keeping in mind the principles we discussed earlier such as not sacrificing any unnecessary tooth structure. Proper convenience form is a requirement for all operative procedures: such as applying a liner or a base or making a restoration.

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Final Tooth Preparation Stage 5. Removal of any remaining enamel pit or fissure, infected dentin or old restorative material if indicated. As mentioned earlier, we dont go all the way through the tooth and remove the caries from its base from the start, but we only reach the initial depth (0.2 mm occlusally in dentine, 0.5-0.8 mm cervically in dentine), then we deepen the cavity and remove all the caries in the final stage. Removal of remaining enamel pit or fissure Removal of defective old restorative material Removal of infected dentin: All carious dentine must be removed, Dr. Ghada emphasized on removing whats called the residual caries present on the DEJ, and in the future she will be very strict about not leaving any caries on the DEJ, because it will eventually spread again and cause recurrent caries for sure. 6. Pulp protection, if indicated. We will discuss it more when we reach to liners and bases lecture, but what you need to know at this stage is that if you have deep caries, and your cavity is very close to the pulp, you need to protect the pulp by applying liners or bases. Dentin is the best isolator against irritation to the pulp: No unnecessary tooth structure should be removed. When I remove more dentine and go closer to the pulp, I cause more dentinal tubules to be open, which will endanger the pulp even more.

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7. Secondary Resistance & Retention Forms: We need this type of resistance and retention forms when more tooth structure is lost due to fracture or caries (complex amalgam restoration for example), so these forms increase the resistance and retention of the restoration such as: A) Mechanical preparation features: 1. Retention locks, grooves, and coves 2. Groove extension 3. Skirts 4. Pins, slots, steps and amalgam pins B) Placement of etchant, primer, or adhesive on prepared walls (this concerns composite): 1. Enamel wall etching 2. Dentin treatment The primary resistance and retention forms are established from the tooth structure itself and the certain shape of the cavity, while the secondary is established by applying other stuff in the cavity for the amalgam to lock in.

8. Procedures for Finishing the External Walls of the Tooth Preparation: The further development, when indicated, of a specific cavosurface design & degree of smoothness* or roughness* that produces the maximum effectiveness of the restorative material being used *Smoothness: needed with amalgam. *Roughness: needed with composite.

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Cavosurface angle: The line or angle formed by the junction of a cavity wall with the unprepared surface of the tooth. We have what we call enamel prisms, the optimum strength of the occlusal surface is obtained by having full enamel rods supported by short ones, while cervically the optimum strength is obtained by having full enamel rods only, and to achieve this arrangement of enamel prisms the cavosurface angle should be 90 degrees for both occlusal and cervical surfaces. The optimum cavosurface angle for amalgam is 90 degrees at both occlusal and cervical surfaces, and this is achieved by making the cavity walls (buccal and lingual) parallel or slightly convergent. If we make it more convergent we will have weak enamel. If we make the angle more or less than 90 degrees we will cause problems; more than 90 degrees leads to having unsupported tooth structure and more susceptibility to facture (It's a bit confusing but when we explain class II cavities we will explain it more). A 90-degree cavosurface angle for amalgam is necessary for best resistance of both tooth structure and amalgam restoration.

Objectives: 1) Create the best marginal seal possible between the restorative material and the tooth structure. 2) Afford a smooth marginal junction. 3) Provide maximum strength for both the tooth structure and restorative material.
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9. Final Procedures: Cleaning, Inspecting, and Sealing: Cleansing and dryness of the cavity for inspection: Debris should be removed and cavity must be dried before putting the restoration. Sometimes, certain medicaments can be applied to the cavity prior to the restorative step: like sealers which are used when we have deep cavities, they close the dentinal tubules (sealers are not commonly used nowadays). Sequence of Caries Removal When we have caries on a tooth, there is a specific sequence that should be followed:1) Entry is made in a conventional manner with a high speed fissure bur. Enamel is hard; so a high speed fissure bur is required for entry, now we exposed the caries and this is what we call access to the caries. 2) Ideal depth and width are established, ignoring the carious tooth structure. Initial depth is established, and we dont go to the base of the caries at this stage, because we are working with a high speed fissure which can cause pulp exposure before even removing the caries. 3) Caries extending beyond the limits of the ideal preparation is removed with the largest round bur that will fit into the area. (Using large slow speed round bur). The reason I dont use small round bur is that it may cause pulp exposure.

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4) The caries removal process should begin peripherally in the DEJ areas. The direction of caries removal is from the peripheries to the center. For example, in class I we clean the walls (buccal, lingual, mesial and distal) of the cavity then the pulpal floor, and in class II we also clean the walls (buccal, lingual and gingival) then the axial which is toward the pulp.

5) Caries in areas involving potential exposures, such as the axial and pulpal walls should be removed last. 6) The criterion followed for caries removal is hardness which can be checked with spoon excavator.

What's the difference between affected and infected dentine? Infected dentine (it is SOFT): Already penetrated by bacteria and is already carious. Affected dentine (still HARD): Not invaded by bacteria yet, but it's stained with a darker color (brownish), because bacteria can cause staining, and the staining is prior to the bacteria itself.

This is our criteria in removing caries from dentine; only infected (soft) dentine should be removed and affected dentine should be kept. The color is not the best indicator because affected dentine is discolored with bacterial stains but should not be removed! I use the spoon excavator here not the slow speed round bur, because the slow speed bur remove infected, affected and even sound dentine.

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7) Only those areas that are soft should be removed. 8) After all caries has been removed, the preparation is reevaluated for undermined enamel, resistance form and retention form. We stopped here but here are the rest of the steps if you are interested 9) All undermined enamel areas should be removed with the high speed fissure bur and an attempt made to reestablish lost retention and resistance form. 10) The pulpal floor should be flattened only at ideal depth.

11) The entire floor should not be reduced to include one carious area.

isolated

THE END! Done by: Anwar Durrah. Wear a smile and move on!

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