Classification of cavities.

A.According to the anatomy of the surface involved. 1.Pit&fissures cavities. 2.Smooth surface cavities. B-According to caries locations Enamel caries (Crown caries) Cemental caries (Root caries) (Senile caries) C. According to the number of tooth surfaces involved. 1.Simple cavity: Involving one surface only. 2.Compound cavity: Involving two surfaces. 3.complex cavity: involving more then two surfaces C. Black's classification: 1.Class I: pit and fissure cavities on 0cclusal surfaces of molar and pre -molars. occlusal 2/3 of buccal and lingual surfaces of molars Platal surfaces of upper incisors. Class II Smooth surface caries occurs in proximal surfaces of posterior teeth Class III Smooth surface caries ,involves proximal surfaces of anterior teeth.not involving incisal angle Class IV Smooth surface caries , involves proximal surfaces of anterior teeth but includes the incisal angle Class V Smooth surface caries , occurs on the gingival third and on

cementum of all teeth. Class VI: (not included originally in Black's classification) Cavities occurring in any other areas,e.g.,on the tips of cusps,on the incisal edges,

Angle and surfaces of Cavity preperation

1)The wall take the name of the adjacent tooth surfaces. 2)The wall which is occlusal to the pulp &at right angle to the long axis of the tooth is called pulpal wall or floor. 3) The wall which is parallel to the long axis of the tooth & approximate the pulp is called axial wall. 4)The line formed by the junction of two adjacent walls is called line angel,it take the name of these two walls,e,g.,mesio- buccal line angle,... 5)The point formed by the junction of three adjacent walls is called point angel,it take the name of these three walls e.g.,mesio -bucco-pulpal point angle. 6)The cavo surface angle is formed between the wall of the cavity&the external surface of the tooth. 7)The enamel wall is that part of the cavity which is formed of enamel. 8)The dentine wall is thatpart of the cavity formed of dentine.
Cavity preparation Class II Cavity Preparation Introduction A Class II carious lesion develops apical to the contact area on the proximal surfaces of posterior teeth. The procedure for the removal of the carious lesion is the same as that of a class I. The first step is the development of the ideal cavity preparation. By doing an ideal cavity preparation, the extent of the carious lesion on the pulpal, lateral, and axial walls is seen. If there is any

remaining carious lesion, it is removed. Any remaining carious lesion is removed only after establishment of the ideal internal and external outline forms.

Step 1. Mark centric stops The mark on the marginal ridge of the tooth structure indicates contact with the adjacent tooth. Before placing the rubber dam, mark the centric stops using articulating paper and tap the teeth together into centric occlusion. The blue markings left by the maxillary lingual cusp are supporting contacts of occlusion and should be noted prior to establishing cavity outline form. The Class II cavity preparation is done in two stages: 1. Occlusal segment 2. Proximal segment Step 2. Begin occlusal segment Penetrate the bur 90 degrees to the plane of occlusal surface with the bur tilted slightly laterally for ease of penetration. The initial outline form should include only the faulty or defective occlusal pits and fissures. Begin the occlusal segment of the tooth preparation by entering the deepest or most carious pit orienting the bur 90 degrees to the occlusal plane. The bur should be rotating when it is applied and it should not stop rotating until it is removed from the tooth. Step 3. Establish outline form As the bur enters the pit, establish the initial outline form by extending the external walls to sound tooth structure and by thinning the defective marginal ridge as much as possible. The proper depth of 0.5 mm into dentin should be established. With intermittent pressure and continuous movement from one point to another following the DEJ, continue to maintain the burs orientation and depth. Ideally, the width of the isthmus should be just wider than the diameter of the bur. The orientation of the bur should change to satisfy the direction for the different occlusal walls of the cavity. Step 4. Observe the lesion The carious lesion can be seen at the dentinoenamel junction. We can see the carious lesion now because the enamel has been removed. Before dropping the box, the marginal ridge is thinned out as much as possible. This thinned out shell of enamel provides protection for the adjacent tooth and is also a guide for dropping the box.

Step 5. Check occlusal segment After occlusal segment has been developed, the following are seen: 1. Defined line and point angles. 2. Buccal and lingual walls parallel to each other and 90 degrees to the occlusal plane. 3. Mesial or distal wall is divergent pulpo-occlusally in the case of a mesial occlusal (MO) or distal occlusal (DO) cavity preparation. 4. All defects and carious lesions are removed and walls are placed in sound dentinoenamel junction. 5. All unsupported enamel rods are removed and all walls are finished. 6. All margins are smooth and curved. 7. The marginal ridge is thinned out as much as possible and gives a clear view in order to access the proximal box. 8. The dentinoenamel junction is visible and clear. 9. Resistance principles are followed when walls are curved and extend around the cusps. 10. Margins are placed on smooth and sound tooth structure. Step 6. Prepare the proximal box Due to the morphological shape of the tooth and the contact area, the buccoproximal wall on the manidibular molar makes an acute angle with the gingival floor and the linguo-proximal wall makes a less acute angle. The initial step in preparing the proximal segment is to place the cutting end of the bur on the DEJ (1/3 in dentin and 2/3 in enamel). Pressure is directed gingivally and lightly toward the enamel shell to keep the bur against the proximal enamel. While the bur is moved facially and lingually along the DEJ, it should be oriented according to the proximal wall directions, occlusopulpally. The bur should also be oriented correctly proximo-axially to visualize the complete mesio-facial and mesio-lingual margins at right angles to the proximal surface. The gingival margin should be extended gingivally to clear the adjacent tooth by 0.5 mm and to remove the entire carious lesion. A slot

has been prepared, which is partly in enamel and partly in dentin. The slot is diverging gingivally to ensure that the facio-lingual dimension at the gingival is greater that that at the occlusal. Step 7. Define proximal box At this stage a low speed handpiece is used to define and finish the box. With the high speed, make two cuts extending toward the perpendicular to the proximal surface to weaken the remaining enamel that can be removed. Step 8. Check proximal segment After the proximal segment is developed, the following are seen: 1. The bucco-proximal and linguo-proximal walls are 90 degrees to the tangent of the tooth structure. 2. The bucco- and linguo-proximal walls are parallel to the enamel rod direction. 3. The bucco-proximal wall makes an acute angle with the gingival floor and the linguoproximal makes a less acute angle 4. The flare or divergence angle is 90 degrees to the tangent of the tooth. 5. The axial wall is convex in the horizontal section. 6. The axial wall is 0.5-0.8 mm into dentin. 7. The reverse curve preserves the triangular ridge and facilitates the formation of a 90 degree angle between the proximal walls and the tangent of the proximal surface. 8. The occlusal and proximal segment flow together smoothly. Use of Hand Instruments At this stage hand instruments are used to remove ledges and any unsupported enamel from the bucco-proximal and lingual-proximal walls. Be certain to hold the instrument parallel to the wall. Do not tilt the instrument or excess flare or a bevel will develop. Hold the hatchet parallel to the wall and if there is any unsupported enamel, it will be removed. The instrument should be held parallel to the wall that is being worked on and 90 degrees to the tangent of the tooth structure. Notice the unsupported enamel that was removed. Be sure the axial wall and gingival walls are smooth. Always use

the instrument from the bevel side to the non-bevel side. Place the primary cutting edge against the gingival floor and the secondary cutting edge against the axial wall so everything can be done in one stroke. Turn the instrument around for the other side. At the bucco-axial line angle, carefully remove any ledges. Do the same for the lingual-axial line angle and the axial wall. Use a gingival margin trimmer for planing the gingival cavosurface margin. By planing we develop a small bevel and all unsupported enamel is removed. The gingival margin trimmer is also used to round the pulpal axial line angle. Rounding the pulpal- axial line angle decreases the stress on the tooth structure and the amalgam restoration. To review the occlusal segment was developed and the pulpal floor placed approximately 0.5 mm into dentin. All walls were connected with a smooth curve and there are no catches in the groove area. There is now smooth and continuous flow of the preparation. The reverse curve was established. The axial wall was rounded to follow the external outline of the tooth structure and is 0.5-0.8 mm into the dentin. The buccal proximal wall is 90 degrees to the cavosurface margin of the tooth structure; the lingual wall is 90 degrees to the tangent of the tooth structure. There is an acute angle at the bucco proximal and linguo proximal walls. The gingival cavosurface margin was planed and unsupported enamel removed. The Class II cavity preparation is complete. Outline Form in cavity preparation .V. Black has described the outline form as being the form of the area of the tooth surface to be included within the outline or enamel margins of the finished cavity. It is the placement of cavity margins in the positions they will occupy in the final preparation, except for finishing enamel walls and margins and preparing an initial depth of 0.2 0.8mm pulpally of DEJ or normal root surface position. Two outline forms can be appreciated External outline form-which dictates the external perimeter of the outline form.Internal outline form-which dictates the inner dimension and detail of the cavity.The factors that determine outline form are the following: Extent of the carious lesion. Extend the cavity margin until sound tooth structures obtained and no unsupported enamel remains. Margins should be paced in easily cleansable areas. Average depth of the cavity should be 0.5 mm into dentin. Extend the cavity margins into fissures that cannot be eliminated by appropriate enameloplasty.

PIT AND FISSURE CAVITIES The general factors mentioned above are to be followed. In addition the following are considered: Avoid terminating the margin on extreme eminences such as cusp heights and ridge crests. Circumventing of cusps should be followed resulting in a smooth free flowing outline form. In case of conservative cavity preparation shallow supplemental grooves and fissure crossing lingual or facial ridge can be eliminated by enameloplasty. When two pit and fissure cavities have been separated by less than 0.5 mm of sound tooth structure, they should be joined to eliminate a weak enamel wall between them. PROXIMAL SMOOTH SURFACE CAVITIES Occlusal cavity outline is same as above. Gingival margins According to G.V.Blacks concept the gingival margin should be placed 0.5 to 1.0 mm apical to the crest of healthy free gingival. Because this area was thought to be sterile due to the alkalinity of crevicular fluid and less chances of food impaction in this area, moreover the knife edge relationship of the healthy free gingival to the adjacent tooth surface will discourage food accumulation on the adjacent restored surface occlusal to the sulcus for considerable periods during and after food ingestion. But, Dr. John Me Call has shown that mechanical causes, systemic conditions and traumatic occlusion change the alkalinity of the crevicular fluid to an acidic form making it more prone to aciduric environment. Emphasis is made to place the margin occlusal to or just clear of the margin of the gingival crest. Facial margin and lingual margin The following factors govern them: Flare and mesiodistal width of embrasures. Wider and more flared the faciolingual embrasures are, less are the chances of food accumulation and therefore requires less extension facially and lingually. Caries index and oral hygiene.

Faciolingual extension of the cavity in the corresponding embrasure is directly proportional to the caries index. Occlusal and masticatory forces. The more ideal the relationship between the adjacent and opposing teeth is, the better is the cleansability of the facial and lingual embrasures. Therefore, less extension is required. Age of patient and tooth structure and attrition of contact areas. An older tooth has higher fluoride content, is more resistant to caries and requires less extension. Creation of a more convex restoration. More convex restorations lead to wider embrasures and therefore less extension and better self cleansable areas. Gingival margin is placed as in class II cavities. In young patients the margin is covered by the gingival whereas in patients with gingival recession the margins are kept supragingival. The mesiodistal extension is obtained considering the occluso-gingival convexity, occlusion and masticatory forces, caries index, and age of the patient.

Occlusal extension should not include the height of contour of facial and lingual surfaces. MODIFICATIONS DUE TO THE TYPE OF RESTORATIVE MATERIAL AMALGAM: With the introduction of modern alloys, the modern concept of cavity preparation can be compared to the conventional G V Blacks design which are less time consuming, conserving and with decreased chances of failure. CONVENTIONAL OCCLUSAL PORTION- extension for prevention, mortise shaped with definite line angles and point angles. PROXIMAL PORTION- either box type or truncated cone. ISTHMUS-will not exceed 1/3rd intercuspal distance, atleast 1.5mm. SWEEPING CURVES-given to the proximal and occlusal walls where they meet.

ACCESSORY RETENTION- proximal grooves are not so critical. MODERN OCCLUSAL PORTION: More conservative approach. Here G V Blacks concept of extension for prevention does not apply. Going around the cusps to conserve tooth structure. Not extending the facial and lingual more than midway between the central grooves and cusp tips. Using enameloplasty on the terminal ends of shallow fissures to conserve tooth structure. Margins of the facial and lingual class I involve the entire facial and lingual groove to avoid feather edged marginal amalgam. PROXIMAL PORTION: Only a unilateral inverted truncated cone on functional side of marginal angles to preserve tooth structure. The gingival margin should be located occlusal to the height of contour. ISTHMUS: Not to exceed 1/4th intercuspal distance. SWEEPING CURVES: Universal sweeping curve is exaggerated and more bulk is accommodated. ACCESSORY RETENTION: Proximal grooves are used more often due to limited occlusal width. TOOTH COLORED RESTORATIONS Emphasis is more on conservative tooth preparation. G.V.Blacks concept of extension for prevention does not apply. With the introduction of acid etching phenomena by Buonocore, coupled with the use of synthetic resins has revolutionized the concept of cavity design. Butt joint marginal configuration and placement of floor in dentin for retention were the characteristic features of conventional method. The modern concept is to include all faulty areas and conserve more tooth structure. Floor is not routinely placed in dentin. It depends on the caries

extent and depth. Bevel is given on the enamel cavosurface margin. As in the conventional types, when a butt joint is made, a white halo is seen after the restoration is complete. This can be avoided by beveling the margin. The ends of the enamel rods are more effectively etched than when only the sides are exposed to the etchant. In case of composite resins the contact area should be maintained, left untouched as this material cannot maintain contact integrity, these materials can accommodate undermined enamel as long as it is not carious, discolored directly loaded in centric or eccentric contact or cracked. CAST GOLD RESTORATION The main characteristic feature in these restorations is taper and bevel incorporation in the outline form. The gingival to occlusal divergence of these cavity walls may range from 2 to 5 degree taper on each wall. The taper should be minimum in shallow cavities for better retention and resistance. The taper should be more in deep cavities for proper seating of the restoration. The taper prevents the undisturbed withdrawal of the wax pattern and subsequent seating of the casting. Resistance form may be defined as that shape and form of cavity walls that best enable both the restoration and the tooth to withstand occlusal forces without fracture. Fundamental principles involved are: Box shape or mortise shaped with flat floor, which helps the tooth to resist occlusal loading by virtue of being at right angles to the forces of mastication. Slightly curved than acute line angles decrease the stress concentration of stresses and hence reduce the incidence of fracture. Conservation of strong cusps and ridges with sufficient dentin support. Weakened areas should be included in cavity preparation to prevent fractures (capping of the weakened cusps). To provide enough thickness of restorative material to prevent fracture under load. Slight roundening of the line angles to prevent stress concentration. STRESS PATTERNS OF TEETH According to Gabel application of mechanical principles to the design of restorations will help conceive favorable stress patterns for the teeth and the restorations. These principles vary according to the type of restoration and

cavity. TYPE OF RESTORATION: The minimal thickness of amalgam and cast gold to resist fracture is approximately 1.5mm, though a little more depth is required for amalgam to achieve the requisite bulk. However in composite and glass ionomer, the depth is not the criteria for achieving resistance form. Porcelain also requires a depth of 2mm for inlays and 1.5mm for crowns.

Retention from .
That shape of a cavity which is prevents the displacement of the restoration . Basically this obtained by : a- the walls of cavity should be parallel or converge occlusally (5O) . b- the floor of the cavity should be flat . c- the smaller out line form the less displacing force on it . There are several other methods of obtaining retention for restoration such as : dovetails , pits , grooves and pin

Resistance from

A from of cavity that prevents fracture of both tooth and restoration . I- Prevention of tooth fracture :a- width of the cavity not more than 1/4 of the inter cuspal distance (prevent cusp fracture). b- removal of unsupported enamel ,a weak portion of the tooth should be removed and replaced by a restorative material . c- flat pulpal floor . d- rounded internal line angles . e- M and D cavity walls must be parallel or diverge occlusally . f- beveling of gingival cavo surface line angle in class II.(CII) II - Prevention of restoration fracture :-

a- reduce the surface area of the restoration . the width of the cavity done about 1/4 intercuspal distance . the amalgam is brittle and if there is more surface area there will be more force and this will lead to fracture of the amalgam . b- flat pulpal floor . c- beveling of the axiopulpal line ingle in cII . so the stress will be diffuse . d- isthmus us area is 1/4 inter cuspal distance in cII .3 e- the restoration must be of adequate thickness, this by Increasing the depth of the cavity so increasing the amalgam thickness because it is brittle material (amalgam thickness should be at least 1.5mm and preferably 2mm) . f- the restoration must be of a marginal design that will allow it to bear the force of mastication without fracture or deformation of the restoration so the Cavosurface line angle should be as near to right angle 90o-110o. if the angle less than 90o-110o it make unsupported enamel .if the angle greater than 110oit makes thin amalgam margin which leads to fracture of the amalgam at that margin

Isolation RUBBER DAM

The rubber dam (RD) should be applied whenever possible for restorative procedures. The dam is critical for services requiring moisture control, for procedures using small objects which may be easily swallowed (e.g. endodontic files and stainless steel crowns) and as a behavior management tool (e.g. restraining a "curious" tongue, preventing talking or closing). The plastic or nylon rubber dam frame is used to avoid accidental eye injury and to provide for radiology of the dam frame for endodontic procedures. The rubber dam clamp is placed on the most distal tooth in the quadrant (clamp #27 for premolars, clamp 14A for 1st permanent molars and clamp 14 for 2nd primary molars). The rubber dam clamp must be ligated with a 20" length of waxed dental floss that should be tied to the patient's napkin clip. In the event of clamp slippage or breakage this will help to prevent aspiration. Floss ligated to lingual aspect of bow of clamp. The rubber dam should be perforated near the center to keep the frame over the face. Usually one half is punched for each tooth, however the contiguous hole technique can provide acceptable isolation and speed rubber dam placement. Remember that primary teeth have a very low height of contour and newly erupted permanent teeth can often make RD isolation difficult or impossible. Most RD clamps we use aggressively impinge on soft tissue necessitating local

anesthetics. For isolation of posterior teeth, the rubber dam should be punched beginning near the center of the dam with one hole per tooth. The rubber dam can be anchored interproximally with dental floss or wooden wedges. For anterior procedure, in lieu of the 212 clamp two or more contiguous holes can be punched and the dam stretched over three or more teeth. Whenever using a clamp which aggressively impinges on soft tissue, consider the administration of local anesthetic.

Difference carving and burning of restorative materials

A tooth burnisher removes surplus edges and deepens grooves in dental carvings. It is a hand-held dental instrument that also smooths and polishes a dental restoration and removes scratches from an amalgam (dental filling material) surface, at the end of a dental restoration procedure where the tooth was filled or sculpted to repair it. Types Tooth burnisher types are based on the shape of their ends. Flat plastic burnishers, Ball burnishers, Beavertail burnishers, Cone burnishers, Tball burnishers and Rotary burnishers describe the different ends to the burnishing tools. A Ball burnisher's working end, for example, is applied when a sculpting application on a dental restoration necessitates the shape of a ball. The burnishers themselves can be single or double-ended and the heads are usually angled for ease of use. Function The head of a tooth burnisher is a specific shape for a specific type of polishing or finishing. The fillings and dental sculpting materials, when finished with restoration, need a polishing or detailing to complete the procedure. Dental burnishing tools are designed to do this by smoothing out the amalgams (fillings) while they are still slightly malleable.

Cavity preparation by Gold foil, Amalgam Restoration

Gold It is indirect resortative method Gold fillings have excellent durability, wear well, and do not cause excessive wear to the opposing teeth, but they do conduct heat and cold, which can be irritating. There are two categories of gold fillings, cast gold fillings (gold inlays and onlays) made with 14 or 18 kt gold, and gold foil made with pure 24 kt gold that is burnished layer by layer. For years, they have been considered the benchmark of restorative dental materials. Recent advances in dental porcelains and consumer focus on aesthetic results have caused demand for gold fillings to drop in favor of advanced composites and porcelain veneers and crowns. Gold fillings are sometimes quite expensive; yet, they do last a very long time - which can mean gold restorations are less costly and painful in the long run. It is not uncommon for a gold crown to last 30 years. Gold foil: Preferred because of its durability and safety. Amalgam It is Direct resortative method Amalgam is a metallic filling material composed from a mixture of mercury (from 43% to 54%) and powdered alloy made mostly of silver, tin, zinc and copper commonly called the amalgam alloy.Amalgam does not adhere to tooth structure without the aid of cements, or techniques which lock in the filling, using the same principles as a dovetail joint. Amalgam is still used extensively in many parts of the world because of its cost effectiveness, superior strength and longevity. However their metallic colour is not aesthetic and tooth coloured alternatives are continually emerging with increasingly comparable properties. Due to the known toxicity of the element mercury, there is some controversy about the use of amalgams. *Amalgam: The most popular amalgam was a mixture of silver, tin and mercury. According to the authors of the article " It set very hard and lasted for many years, the major contradiction being that it oxidized in the mouth, turning teeth black. Also the mercury contained in the amalgam was thought at that time to be harmful." as explained in the pre-eminent dental textbook of that century, The Principles and Practice of Dental Surgery by Chapin A. Harris A.M., M.D., D.D.S.] More recent dental texts strongly support the use of amalgam; "In summary, dental amalgam is a highly successful material clinically and is

very cost effective, but alternatives such as cast gold and esthetic restorative materials are now very competitive in terms of frequency of use. Many argue, however, that the use of amalgam must be strongly supported given its large public health benefit in the United States and many other countries