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SEMINAR ON
FUNDAMENTALS OF
CAVITY PREPARATIONS
Presented By : -
CONTENTS
INTRODUCTION
DEFINITION
NEED FOR RESTORATIONS
OBJECTIVES OF CAVITY PREPARATION
FACTORS AFFECTING CAVITY PREPARATION
CARIES TERMINOLOGY
TOOTH PREPARATION TERMINOLOGY
CLASSIFICATION OF TOOTH PREPARATION
INITIAL TOOTH PREPARATION STAGE
o OUTLINE FORM AND INITIAL DEPTH
o PRIMARY RESISTANCE FORM
o PRIMARY RETENTION FORM
o CONVENIENCE FORM
FINAL TOOTH PREPARATION STAGE
o REMOVAL OF ANY REMAINING INFECTED DENTIN
/OLD RESTORATIVE MATERIAL
o PULP PROTECTION
o SECONDARY RESISTANCE AND RETENTION FORMS
o PROCEDURES FOR FINISHING EXTERNAL WALLS
o CLEANING, INSPECTING AND SEALING
ADDITIONAL CONCEPTS IN TOOTH PREPARATION
o AMALGAM RESTORATIONS
o COMPLETE RESTORATIONS
CONCLUSION
INTRODUCTION :
The basic principles governing the design of cavities and steps in their
preparation was first suggested by American Dentist and teacher Dr.G.V.Black
in the first decade of the last century. He based these principles on what was
known at time about the natural history of caries and the restorative material
available. The wisdom of his work was such that it remained unchallenged for
more than half a century but now with new materials, a better understanding of
caries and research findings into the success of various restorative procedure,
his principles have been largely revised. Modification and rearrangement of
these original principles have been largely revised.
DEFINITION OF CAVITY PREPARATIONS :
Mechanical alteration of a defective, injured or diseased tooth in order
to best receive a restorative material which will reestablish a healthy state for
the tooth including esthetic corrections where indicated along with normal form
and function.
NEED FOR RESTORATIONS :
Teeth needs restorative intervention for a variety of reasons which are as
follows ;
1. Repair of tooth after destruction from carious lesions.
2. Replacement / repair of restorations with serious defects such as
improper proximal contacts, gingival excess, poor esthetics etc.
3. Restoration of proper form and function of fractured teeth.
4. Restoration of form and function as a result of congenital malformations
5. To fulfill the esthetic demands
6. Restoration for preventive measures
OBJECTIVES OF CAVITY PREPARATIONS :
1. Removal of all the defects and give the necessary protection to the pulp.
2. Location of margins of the restorations as conservative as possible.
3. Form the cavity so that under forces of mastication the tooth or the
restoration or both will not fracture and the restoration will not be
displaced.
4. Esthetic and functional placement of a restorative material.
FACTORS AFFECTING CAVITY PREPARATIONS
GENERAL FACTORS
PATIENTS FACTORS
1. Diagnosis :
1. Prior to any restorative procedure a complete and through diagnosis
must be made assessment of both pulpal and periodontal status will
influence the potential treatment of tooth especially in terms of the
choice of restorative materials as well as the design of cavity
preparation.
2. Assessment of occlusal relationships must be made.
3. Patient concern for esthetics should be considered
4. Other planned treatment should be considered for e.g. such as when
tooth is used as an abutment for FPD or RPD, design of restoration is
altered to accommodate maximum effectiveness of that prosthesis.
5. Risk assessment find out with dietary habits.
microbiological examination.
2. Knowledge of Dental Anatomy :
Direction of enamel rods, thickness of enamel and dentin, position of
pulp relationship of tooth to the investing tissue.
PATIENTS FACTORS :
1) Patients knowledge and appreciation of good Dental Health Influences the
choice of restorative material.
2) Patients economic status
OF
TOOTH
PREPARATION
(According
to
G.V.Black)
1) Class I Restorations : Restoration on occlusal surface of premolars and
molars.
Restorations on occlusal two thirds of facial and lingual surface of
molars. (8 line angles, 4 point angles)
Restorations on lingual surface of maxillary incisors (6 point angles, 11
line angles).
2) Class II restorations : Restorations on proximal surface of posterior
teeth.
3) Class III restorations : Restorations on proximal surface of anterior teeth
that do not involve the incisal angle (6 line angles, 3 point angles).
Miscellaneous Component
1. Retention groove
External
Internal
2. Dovetail
1. Enamel wall
2. Dentin wall
1. Axial
2. Pulpal
3. Bevel-short
Long and Full
Line Angles
Point Angle
Cavosurface Angle
1. Internal
2. External
A) WALLS :
1. Cavity wall
External
Internal
Enamel wall
Axial
Dentin wall
Pulpal
Floor / Seat
One of the enclosing sides of a prepared cavity (it takes the name of the
surface of the tooth adjoining the surface involved towards which it is placed).
EXTERNAL WALL :
Internal line angle : Is a line angle whose apex points into the
tooth e.g. FP.
ii)
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2)
3)
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Enameloplasty is a procedure of
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DEFINITION :
Primary resistance form may be defined as that shape and placement of
the cavity walls that best enables both the restoration and the tooth to
withstand, without fracture, masticatory forces delivered principally in the long
axis of the tooth.
Principles :
The fundamental principles involved in obtaining primary resistance
form follow :
1) Box shape with relatively flat floors. Flat floor prevents restoration
movement where as rounded pulpal floor is conductive to rocking action
of restoration producing a wedging force, resulting in shearing of
tooth structure.
2) Restrict the extension of external walls to allow sufficient dentin
support for strong cusp and ridges (resistance against oblique forces and
forces in long axis).
3) Straight rounding / coving of internal line angles reduces stress
concentration in tooth structure (rounding of internal line angles reduces
stress on tooth thus resistance to # of tooth, increased rounding of
external faced angle reduces stress on porcelain and amalgam thus
resistance to fracture of restoration increases).
4) Consider cusp capping for weak cusp according to rule.
5) Placement of enough thickness of restorative material to prevent its
fracture under load. The minimal occlusal thickness for amalgam for
appropriate resistance to fracture is 1.5 mm, cast metal = 1-2 mm and
porcelain = 2 mm.
Factors :
The need to develop resistance form in a cavity preparation is a result of
several factors, which are as follows :
a) Occlusal contact : the greater the occlusal force and contacts, the
greater is the potential for future fracture. (The further posterior
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the tooth, the greater is the effective masticatory forces since the
tooth is closer to the condyle head).
b) Amount of remaining tooth structure also impacts the need and
type of resistance form.
e.g. Very large teeth even though extensively involved with
caries or defects may require less resistance from consideration
because remaining tooth structure is still bulky and strong enough
to resist fracture.
c) Type of restorative material used
Amalgam : 1.5 mm for adequate strength and longevity.
Cast metal : 2 mm
Composites : Dimensional needs of composites are more
dependent on the occlusal wear potential of the restored area. In
posterior teeth thickness requirement is more than the anterior
teeth.
Features :
The design features of cavity preparation that enhances primary
resistance form are as following :
1) Relatively flat floors : If large excavation site of infected dentin is
present incorporate at least 3 seats on sound dentin so that restorative
material will have stable contact with tooth so the occlusal forces
directed parallel to the tooth long axis will not cause rocking of
restoration.
2) Box shape
3) Inclusion of weakened tooth structure
4) Preservation of cusp and marginal ridges
5) Rounded internal line angles
6) Adequate thickness of restorative materials
7) Seats on sound dentin periphery to excavation site
8) Reduction of cusp for capping when indicated.
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Frictional retention
Elastic deformation
Dove tail
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Technique :
When a pulpal or axial wall has been established at the proper initial
cavity preparation position and a small amount of infected carious material
remains, only this material should be removed, leaving a rounded, concave area
in the wall and floor, thus placing the pulpal floor at more than one level. The
first level will be ideal depth of 1.5 mm and other will be at caries cone level.
This shallow (initial depth i.e. 1 mm) level will create flat pulpal floor at
definite angle to surrounding wall thus resist the occlusal forces and laterally
locking the restoration without impinging on pulp this placement of second seat
at caries cone level is called as ledge it can be (1) Circumferential, (2)
Interrupted or (3) Opposing.
CARIES CONTROL TECHNIQUE :
When patient is having numerous teeth with extensive caries in one
sitting or appointment, infected dentin is removed from several teeth and
temporary restorations are placed and then individual teeth are restored as
definitively planned. This procedure stops the progress of caries and is often
referred to as the caries control technique.
If the decays soft removal should be done with spoon excavators by
flaking up the caries around the periphery of the infected mass and peeling it
off in layers.
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MECHANICAL
PULP PROTECTION
THERMAL
INSULTS such as
CHEMICAL
1) Some ingredients of various materials.
2) Thermal changes conducted through restorative material
3) Forces transmitted through materials to the dentin
4) Galvanic shock
5) Ingress of noxious products and bacteria through microleakage.
For pulp protection traditional liners or bases are used either to protect
the pulp or to aid pulpal recovery or both.
When the thickness of remaining dentin is less than 2 mm, heat
generated by injudicious cutting can result in a pulpal burn lesion
abscess formation death of pulp.
Thus a water or air water spray coolant must be used with the high speed
rotary instrument.
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If the remaining dentin thickness is 1.5 mm or more and the cutting was
done atraumatically using high speed with water or air water spray, the
pulp is not irritated enough to form replacement odontoblasts and
therefore no reparative dentin is formed to seal the pulpal side of dead
tracts. Thus it is more important to place a liner or bases to protect the
pulp.
Liners :
Are those volatile or aqueous suspensions or dispersions of zinc oxide or
calcium hydroxide that can be applied to a cavity surface in a relatively thin
film and are used to effect a particular pulpal response.
Liners Provides :
1. A barrier which protects the dentin from noxious agents from either the
restorative material or oral fluids.
2. Electric insulation
3. Thermal protection
Bases :
Bases are considered to be those cements commonly used in thicker
dimensions beneath permanent restoration to provide for mechanical, chemical
and thermal protection of the pulp.
Example are ;
1. Zinc phosphate
2. Zinc oxide eugenol
3. Calcium hydroxide
4. Polycarboxylate
5. Glass ionomer
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If the removal of infected dentin does not extend deeper than 1 mm from
initially prepared pulpal or axial wall.
NO LINER IS INDICATED.
If
excavation extends into or very close to the pulpal tissue, a calcium hydroxide
liner is selected in order to stimulate reparative dentin, if the excavation depth
is between above two eg. Zn oxide eugenol liner is selected (except for
composite restoration where it may impide the polymerization process) to
provide a palliative sedative pulpal response.
As a general rule it is desirable to have atleast a 0.5 0.75 thickness of
base dimension of bulk between the pulp and a metallic restorative
material. This bulk may include remaining dentin, liner, or bases.
The ability of calcium hydroxide to stimulate the formation of reparative
dentin when its in contact with pulpal tissue makes it the material of
choice for application to very deep excavation and known pulpal
exposures.
Liners and bases in exposure areas should be applied with out pressure,
Atleast a 1 mm thickness of calcium hydroxide is placed over near or an
actual exposure which is than over laid with a base.
In deep excavation where no exposure of suspension of exposure exist,
Zn oxide eugenol is used for its mildly anesthetic effect on the pulp.
For composite restorations which are thermal insulators and passively
inserted, liner of calcium hydroxide is indicated only when there is a
pulpal exposure of the excavation is judged to be within 0.5 mm of the
pulp.
Cast restorations : In cavity preparation for casting, deeply excavated
areas in preparation must be covered with suitable retained liners or
bases materials that will withstand the forces. Zn ph. Glass ionomer and
polycarboxylate cements serves this purpose.
Cavity Varnishes :
It is a solution liners which seals most of the dentinal tubules and is
placed on all cavity preparation walls for amalgam and on dentinal walls of
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cavity preparation for cast gold but not used for composites, (it prevents
penetration of materials into the dentin and helps to prevent microleakage and
reduces post operative sensitivity by reducing the infiltration of fluids and
salivary components at the margins of newly placed restoration.
For Amalgam : Two coats should be applied to the prepared surface in shallow
excavation is the only material of choice.
For cast gold : Two coats on dentin surface reduces pulpal irritation from luting
cements.
For Composite : Should not be used because solvent in varnish may react with
or soften the resin component in the composite and thus affecting
polymerization or free monomer of resin may dissolve varnish film and
rendering it ineffective.
STEP 7 : SECONDARY RESISTANCE AND RETENTION FORMS :
Secondary resistance and retention forms are of 2 types :
a. Mechanical features
b. Cavity wall conditioning features
1. Mechanical features includes :
Retention / locks, grooves, and coves
Longitudinally oriented provides retention to proximal
portions of cavity preparations. Locks are for amalgam,
they increases retention of the proximal portion against
movement proximally due to creep and are believed to
increase the resistance form of the restoration against
fracture at the junction of the proximal and occlusal
portions.
Grooves of cast metal restorations.
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junction towards concave enamel surface and diverge towards the height of
cusp and ridges i.e. diverge outwardly toward convex surface. In gingival third
rods incline slightly apically.
Finishing of enamel wall should be such that the cavity should have
strongest enamel margin (i.e. margin which is composed of full length of
enamel rods that are supported on the cavity side by shorter enamel rods all of
which extend to sound dentin) thus increasing the strength of enamel margin.
2. Support enamel rods both at the Dent-E junction and laterally on cavity side.
3. Type of restorative material used
4. Location of margin
5. Degree of smoothness desired
Features :
There are two primary features to the finishing of the external walls.
1. Design of cavo surface angle.
2. Degree of smoothness of the walls.
1. Design of Cavosurface Angle :
It depends on type of restorative material used.
For amalgam : Because of low edge strength or friability of amalgam
cavosurface of angle of 90o produces maximal strength for both the amalgams
tooth and prevents fracture.
For cast restorations and composites : Beveling the external walls used for intra
coronal cast gold and composite restoration.
Beveling can serve 4 useful purposes in the cavity preparation for
casting.
1. Produces stronger enamel margins.
2. Permit marginal seal in slightly undersized casting
3. Provides marginal metal that is more easily burnished and adapted.
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FINAL
PROCEDURE
CLEANING,
INSPECTING,
VARNISHING, CONDITIONING :
DEFINITION :
Cleaning or debridement is the act of freeing the preparation walls and
margins from the objects that may interfere with the proper adaptability and
behaviour of the restorative material.
There are 3 main objectives for debriding the preparations.
a) Freeing of all preparation walls, floors and margins from enamel
and dentin chips resulting form excavation and grinding.
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CONCLUSION :
A cavity preparation is determined by many factors and each time a
tooth is to be restored each of these factors must be assessed. If the principles
of cavity preparation are adhere to, the success of restoration is great increased.
The factor that should be considered before initiating a cavity
preparation are as follows :
1. Extent of caries
2. Occlusion
3. Pulpal involvement
4. Esthetics
5. Patients age
6. Patients home care
7. Gingival status
8. Anesthesia
9. Bone support
10. Patients desires
11. Operation skill
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