Line of Treatment: Adhesives. Complex restorations (Pin and pinless restorations). Intracoronal and extracoronal restoration (Inlays, onlays, pinlays, laminates, crowns). Complex restorations (Pin and pin less restorations) Indications: 1. Control restoration in questionable pulpal &/or periodontal prognosis. 2. Auxiliary retentive means. In the form of pins are often required for restoration of mutilated and badly broken down teeth, especially in restoration of: Large cervical lesions. Fractured cusps of posterior teeth. Extensive proximal lesions with inadequate box form and or occlusal locks i.e. with inadequate retention form. Large complex multiple surface lesion combining occlusal, proximal, and cervical areas. Incisal corners (Class IV) with translucent tooth colored restorative materials. Seriously undermined buccal cusps of lower molars. Hypoplastic teeth. Teeth subjected to additional stresses. 3. Reciprocal retention mode for preparation containing principal retention modes which are insufficient to prevent restoration displacement in a given direction. I. Pin-Retained Direct Restorations: Pins provide retention & resistance form. Pins do not strengthen either the tooth or the restoration (actually weaken both). Therefore, limit use to minimum as necessary. It is just mechanical interlocking of amalgam with undercuts in the pin. Pin retention depends on resiliency and firmness of dentin so, place only in healthy dentin. Advantages:
1. Cavity preparation is more conservative
than that for cast restoration. 2. The restoration can be concluded in one session. 3. These restorations are of lower cost than casting ones. Disadvantages: 1. More interfaces with more tendencies for microleakage. 2. Affect the tensile strength of final restoration. 3. Crazing or internal dentin pressure could be formed during drilling pin channel or pin insertion. 4. Risk of perforating pulp or external tooth structure. Tooth preparation: Through excavation of carious dentin and removal of all undermined enamel. The dentin floor must be sound and solid. A ledge or shelf is then prepared inside the dentino-enamel junction for pin placement. The rim of the preparation in the damaged areas is then squared to resemble a shoulder finishing line. This squaring is perforated to create a room in dentin for pin placement and to facilitate placing the amalgam matrix. Additional undercut can be made in the cavity walls to look and assist the retention provided by pins. The cavity depth is detected to determine the type or base and intermediate base that should be utilized. The cement base is placed at the bottom and flattened, so that it will allow sufficient amalgam thickness in the occluso- cervical direction and around the pins. Care should be taken that the basing procedure should not interfere with the condensation of amalgam around the pins. Pin design: A. Number: It depends on amount of dentin receiving pin, amount of retention required, size of pins, amount of missing tooth structure. One pin /missing cusp /missing line angle /missing proximal surface /missing axial wall. When several pins are used: They should be placed at different levels to decrease stresses resulting from pin placement in the same horizontal plane. Inter-pin distance dependent of pin diameter. Each pin must be opposed by another retention feature: retention groove, amalgapin, segmental circumferential slot or another pin. B. Location: The pins must be located in areas where greater stresses occur in the restoration. These areas are located under marginal ridges, cusp tips and line angles of the tooth. The pinholes should be placed midway between the root surface and dental pulp. By this way, it is approximately 0.5 mm apart from DEJ into dentin. The pins usually are not parallel to each other and this provides more retention. For easy determination of the exact direction of pinholes, it should be parallel to the external surface of the tooth, or root rather than to the long axis. This can be achieved by holding flat bladed instrument tangentially to the external surface of the tooth or root and the pinhole direction is made parallel to this blade. C. Diameter: The chosen size depends on amount of dentin receiving pin and the amount of retention required. They have different sizes according to their types: I. Cemented pins. II. Frictional grip or friction lock pins. III. Threaded pins (T.M.S). I. Cemented pins: For this type, the pin hole is larger in diameter than the pin. These come in three sizes. II. Frictional grip or friction lock. pins: In this type, the channel is slightly narrower in diameter than the pin. These come in one size only. III. Threaded pins (T.M.S): In this type, the pin channel is in diameter is narrower than that of the pin. These come in four sizes. Pinhole drilling: Starting-point was made with small round bur in the above mentioned predetermined location to a depth of 1.2 mm to avoid twist drill movement. The drill must be run at a very slow continuous speed not stopping until the drill is completely withdrawn from the pinhole. The drill should be air cooled and the flutes kept unclogged to prevent friction, heat damage and breakage. The depth of the pinhole should be from 1 to 4 mm depending on the type of pin technique and available tooth structure. The deeper the hole the more secure the pin providing increase in retention and resistance to displacement. The pinhole should be placed entirely in dentin. Placement of pins at various depths is desirable to distribute stresses at different levels and to minimize a possible fracture line in the root. Pin placement techniques:
A. Cementing technique.
B. Self threading technique (thread-mate
system TMS or screw pins ).
C. Friction-locked or tapping technique.
A. Cementing technique: The pinhole in the cementing technique should be coated with cavity varnish using an endodontic paper point. This was achieved to minimize the irritational effects of the cementing material employed. Unfortunately, coating the pinhole with cavity varnish was found to decrease the retention property of the cemented pins in their corresponding holes. The desired length of the pin (in pinhole and that projecting in amalgam) is measured, cut, bent, and trial fitted before cementation. The pin must be covered with a 2 mm thickness of amalgam on top and side of the pin in the final restoration. Pin cementation: The cement mix should be of a thin consistency mix (inlay mix). By the aid of lentulo spiral the cement is transferred into pinholes in a low-speed contra-angle, with the help of plier, the pins were dipped into the cement and inserted into their corresponding holes, held steady until no floating tendency is observed. The little ring of hardened cement around each pin should be removed with sharp explorer to allow amalgam to contact the entire pin protruding out of the cavity. Advantages: 1) No pressure on dentin crazing. 2) Used in teeth with little dentin thickness. 3) Used in endodontically teeth. Disadvantages: a) Weakest type of pins. b) Irritational quality of zinc phosphate cement can not be ignored even when using cavity varnish. B. Self threading technique (thread-mate system TMS or Screw Pins): The pin retention relies on the mechanical grasp of the threads into dentin and of the visco-elastic properties of dentin. This technique offers an advantage of providing a self-shearing pin which shear or break itself when the pin has reached the bottom of the hole and has the advantage of preventing excessive pressure during screwing, and the twoin-one of 8 mm length and breaks into 4 mm after full seating. Advantages over cementing technique:
1. No cementation complications.
2. No change for pulp irritation.
3. The strongest individual pin retention.
Disadvantages: 1) Internal stresses to the tooth, which may lead to fracture. 2) Pre-insertion bending and trial fitting is impossible. 3) Post-insertion bending is possible, but gives additional risk for fracture. 4) Not recommended for non vital teeth. C. Friction-locked or tapping technique : The pin is inserted in the end of pin-setter and driven to the base of the hole with a pin- setter and mallet in the path of withdrawal of the twist drill. Advantages: a) Eliminate the pin cementation procedure. b) Quickest and easiest method where access permits pin placement. c) Strong individual pin retention. d) Provided in a variety of precut lengths. Disadvantages: 1) Internal stresses on the tooth structure resulting from pin insertion forces which may cause fracture of lateral walls. 2) Pre-insertion, bending and trial fitting is impossible while post insertion bending runs the additional risk of tooth fracture. 3) It is not recommended for use in non-vital teeth because of loss of dentin resiliency. Restoration procedures: A thin copper band is selected as a matrix to encircle the tooth or automatrix can be used. The band is then placed on the tooth stump and all dimensions are then checked. Then the band is stabilized by wooden wedges and green stick compound. This method produces a good adaptation of the copper band to tooth surface. Numerous mixes of amalgam will be required for filling large mutilated cavity. Every, effort is performed not to interrupt condensation. Special condensers of 0.5 or 1 mm diameter are helpful in beginning condensation and adaptation of alloy around the pins. After the alloy has been adapted around and over the tops of the pins, condensation is achieved by larger condensers to compress amalgam on the top of the pins. An overpack of 1 mm is performed to pull up the residual mercury, so that it can be removed during carving. The copper band is then removed after condensation. Carving can be started after initial setting to produce the functional anatomy and contour and the occlusion is checked for removal of premature contact areas. The polishing can be done after 3 days. Thank You