Class II Restorations

Question 1

Caries on the axial wall does not indicate

Answer 1

cutting the entire axial wall toward the pulp. Only remove caries.

Question 2

Caries on the pulpal floor may necessitate widening of the preparation to remove caries, but don’t

Answer 2

deepen the entire pulpal floor to the depth of the caries.

Use a round bur or spoon excavator to remove caries and accept an irregular pulpal floor.

Question 3

If recurrent caries extends gingivally in the box area, it is permissible and preferable to have a

Answer 3

“box within a box” rather than deepening the entire box gingivally unless caries requires it.

Question 4

Add a liner only to the

Answer 4

deepest parts of the preparation, closest to the pulp.

Question 5

Keep the liner material away from the —.

Answer 5

margins

Question 6

Liner materials: (2)

Answer 6

• Calcium hydroxide

* Resin Modified Glass Ionomer

Question 7

• Calcium hydroxide (2)

Answer 7

• Brand names: Life, Dycal

* Use on deepest preps- pulp capping material

Question 8

• Resin Modified Glass Ionomer (3)

Answer 8

• Brand name: Vitrebond
• Light cured
• Releases fluoride over time

Question 9

Why not have the entire floor of the restoration covered by calcium hydroxide?

Answer 9

CaOH is too soft to support the restoration.

Question 10

If the material is hard when set (such as glass ionomer) the entire pulpal floor can be covered material, but the material must rest on a

Answer 10

tripod of dentin.

Question 11

A Class II amalgam preparation has an

Answer 11

open side on the interproximal

Question 12

Class II prep requires something to complete the box so that an amalgam can be placed:

Answer 12

A matrix band of some type is required to address this problem

Question 13

The Functions of a Good Matrix Band: (5)

Answer 13

1. Has enough rigidity to resist too much deformation by packing forces or wedging, but is slightly burnishable and displacable (in order to get good contact with the adjacent tooth). Can’t be too stiff or thick.
2. Assists in establishing proper anatomical contour. Again, can’t be too stiff or thick.
3. Must prevent excess amalgam from being expressed at the gingival margin as much as possible, so as not to get a gingival overhang that will trap plaque and irritate the gingivae.
4. Must be convenient to install.
5. Must be easy to remove and allow for removal without breaking a partially set amalgam.

Question 14

Spindle—

Answer 14

a Screw that is Used to Hold the Ends of the Matrix Band Securely in the Slot Vise

Question 15

The Inner Nut—

Answer 15

used to adjust the size of the matrix band loop

Question 16

The Outer Nut—

Answer 16

Tightens Band and Positions it Within the Slot Vise

Question 17

skipped

Pedo. Band—

Answer 17

Box of Normal Depth Gingivally

Question 18

skipped

Pedo. Band—

Answer 18

Box of Deep Depth Gingivally

Question 19

skipped

Adult Band–

Answer 19

Box of Deep Depth Gingivally

Question 20

skipped

Adult Band—

Answer 20

Box of Normal Depth Gingivally

Question 21

Inserting Band into the Tofflemire Retainer (4)

Answer 21

1. Turn the inner nut counterclockwise until slot vice is about 1⁄4 inch from the guide channels.
2. Hold inner nut and turn the outer nut counterclockwise until the pointed end of the spindle is free of the slot in the slot vice.
3. Double the band back on itself, forming a loop.
4. Insert into the slot vice, and direct it through one of the three guide channels. Tighten spindle.

Question 22

Wider Opening in the Loop is Toward the — of the Tooth

Answer 22

Occlusal

Question 23

Slot in Slot Vice is Toward the — of the Tooth

Answer 23

Gingival

Question 24

Installing the Tofflemire Band on the Tooth—Three Possibilities

Answer 24

Choice 1:
Retainer on the Buccal Side, Band Emerges From One of the Side Guide Channels . By Far, the Most Common.

Choice 2:
Retainer on the Lingual Side; Requires use of a Contra-Angle Retainer. Useful with missing Buccal Tooth Structure.

Choice 3:
The Band Emerges Through the Middle Channel, Straight out the End of the Retainer. The Retainer Is on the Lingual of the Tooth. This Is Useful When There is Missing Buccal Structure, and Will Probably Be Used More in the Maxilla than in the Mandible because of the tongue

Question 25

If the band won’t go far enough apically to close the gingival margin in a deep box, use a band that has an

Answer 25

“apron”

Question 26

If the “apron” in the other interproximal space keeps the band from seating far enough,

Answer 26

use scissors and trim the unwanted “apron” away.

Question 27

If the band needs to flare out more to restore the rounded convexity of the original tooth contact,

Answer 27

remove the band assembly and use a ball burnisher and egg burnisher with the band resting on a paper pad.

Question 28

Take care not to trap the rubber dam material between the

Answer 28

Tofflemire band and the tooth at the gingival margin.

Question 29

Take care not to trap the rubber dam material between the Tofflemire band and the tooth at the gingival margin. If this happens, partially remove the band and retainer,

Answer 29

use your fingers to stretch the rubber dam septum and pull it gingivally, and then reseat the assembly.

Question 30

Sometimes, gingival tissue will get caught between the matrix band and the gingival margin of the preparation: If this happens,

Answer 30

move the matrix band slightly in an occlusal direction, place a Hollenback carver between the matrix band and the tissue, deflecting the tissue, and reseat the band:

Question 31

To close the margin at the gingival of the box and prevent an overhang of amalgam,

Answer 31

place a wooden wedge with the cotton pliers. Place the wedge through the more open of the embrasures (almost always the lingual).

Question 32

Installing the Tofflemire Band—Special Considerations When Wedging (7)

Answer 32

1. Choose a wedge of the proper shape and size 2. Do not allow the wedge to force the band into the box, into areas that should be filled with amalgam. 3. If the preparation extends far gingivally, the band may want to “jump up” on to the ledge of the gingival floor. Use a Hollenback carver to support the band and allow it to seat far enough gingivally for wedging and a good seal. 4. In the event of an especially wide interproximal space and a gingivally deep box, double wedging can be done horizontally from the facial and the lingual. 5. In the event of gingival recession and a proximal box of moderate depth, double wedging can be done in a vertical, “stacked” fashion to close the gingival margin. 6. Interproximal fluting (root concavity) at margin 7. When no standard wedge form will close the gingival margin without distorWng the band, use a bur or sharp blade and reshape the wedge unWl it works.

Question 33

Insert wedge at an angle through the

Answer 33

more open embrasure

Question 34

Obtaining a Good Contact (5)

Answer 34

* Loosen the band a quarter turn after wedging * Burnish the band against the proximal surface of the adjacent tooth. * Scrape with an explorer along the tooth-metal interface at the gingival margin to remove any tissue or debris in this area. Flush and dry the preparation well. * If the band is still not against the adjacent tooth, loosen the retainer more while the band is tightly wedged at the gingival. Burnish again against the adjacent tooth and recheck that the wedge is tight. * Pack amalgam hard against the matrix band in the contact area.

Question 35

ENSURING THAT YOUR (2) ARE PLACED PROPERLY WILL RESULT IN A MUCH BETTER RESTORATION AND FEWER ADJUSTMENTS

Answer 35

MATRIX AND WEDGE

Question 36

The matrix band can contribute to proper or improper contours, but since it is relatively soft, it can be

Answer 36

pushed in appropriate directions while packing amalgam to develop proper contours & line angles.

Question 37

Placing the Amalgam

Answer 37

1. Burnish the matrix band against the adjacent tooth and reconfirm the Wghtness of the wedge: 2. Loosen the inner nut 1⁄4 turn to assist in getting good contact. Mix the amalgam, dispense in the amalgam well, and pick up with the amalgam carrier. 3. Unload only one carrier-full into a box at a time. Unload a carrier-full into the occlusal part of the prep., but condense the box first. 4. Use the Hollenback condenser to pack FIRMLY into all internal line angles, in a stepwise fashion. 5. Good condensation is very important 6. Finish packing the occlusal part of the prep. until you have filled about 1 mm. beyond the margins. 7. Try to complete the condensation in three to four minutes. The side of the Hollenback condenser or the large ball burnisher can be used to do a pre- carve burnishing of the amalgam. This helps eliminate voids. 8. Use the explorer at a 45 ̊angle to begin to define the occlusal embrasure by trimming away the amalgam that runs up onto the matrix band. 9. Let the inclines of the tooth guide the side of the hollenback carver while your knowledge of tooth anatomy guides the tip, forming grooves. 10. THE MARGINAL RIDGE should be carved at the same height as the adjacent marginal ridge. It should have a straight secWon, perpendicular to the long axis of the tooth, with a triangular inclined plane descending from the ridge crest into the pit. 11. Redefine the occlusal embrasure with the explorer one more time, and REMOVE THE WEDGE. 12. Loosen the inner and outer nuts and REMOVE THE TOFFLEMIRE RETAINER FROM THE BAND. If the retainer was installed correctly, it will withdraw occlusally from the band. 13. On a two-surface amalgam, REMOVE THE BAND first on the non-restored surface, then—next to the new amalgam-- by sliding the band slightly horizontally, and then in an oblique, occlusal direction, drawing it out. The lateral component in this movement helps prevent marginal ridge fracture. Don’t draw straight vertically. 14. Use the Hollenback carver to CARVE EXCESS AMALGAM OFF THE BUCCAL AND LINGUAL WALLS OF THE BOX. Drag the carver across these margins going gingivally, to avoid breaking off the corner of the marginal ridge. Carve embrasures to normal form. 15. CARVE AWAY THE GINGIVAL MARGINAL EXCESS ON THE BOX. This can be done with three different instruments: 16. REMOVE THE RUBBER DAM by snipping the septa between the teeth. Don’t try to pull this off past a freshly placed amalgam. 17. MAKE SURE THE MARGINAL RIDGE IS EQUAL IN HEIGHT TO THAT OF THE ADJACENT TOOTH. Occlusion is challenging to assess using our typodonts’ intercuspation. Compare to adjacent teeth anatomy instead. 18. ADJUST OCCLUSION. In a live patient, mark occlusion with articulating paper, closing in maximum intercuspation, and going into right and left lateral excursion as well. 19. Eliminate inclined plane contacts first. Try to preserve stops for the opposing cusps that will put long axis forces on the teeth (marginal ridge crest, bottom of the fossa, for example). 20. SMOOTH SURFACES AND BOTTOMS OF GROOVES gently with beavertail burnisher. 21. ASSESS THE INTERPROXIMAL CONTACT with the floss (hold flat surface of floss vertically when passing it through). Also, dry the contact area, and look through from the facial or lingual to be sure the contact is closed.

Question 38

4. Use the Hollenback condenser to pack FIRMLY into all internal line angles, in a stepwise fashion. (3)

Answer 38

* In the box, pack firmly, at an angle, into the buccal-gingival and lingual-gingival line angles, and against all other margin areas especially. Use a stepwise, “press and wiggle” technique. * Be especially aware of the corners of the box, where it is easy to get voids. * Condense against the contact area on the band. Voids are often the result of placing too much amalgam in the box before condensing the first time.

Question 39

Loosen the inner and outer nuts and REMOVE THE TOFFLEMIRE RETAINER FROM THE BAND. If the retainer was installed correctly, it will withdraw --- from the band.

Answer 39

occlusally

Question 40

On a two-surface amalgam, REMOVE THE BAND first on the non-restored surface, then—next to the new amalgam-- by sliding the band slightly (3) direction, drawing it out. The lateral component in this movement helps prevent marginal ridge fracture. Don’t draw straight ---.

Answer 40

horizontally, and then in an oblique, occlusal vertically

Question 41

Use the Hollenback carver to CARVE EXCESS AMALGAM OFF THE BUCCAL AND LINGUAL WALLS OF THE BOX. Drag the carver across these margins going ---, to avoid breaking off the corner of the marginal ridge. Carve embrasures to normal form.

Answer 41

gingivally

Question 42

CARVE AWAY THE GINGIVAL MARGINAL EXCESS ON THE BOX. This can be done with three different instruments: (2 methods)

Answer 42

Method 1: the Hollenback Carver Held Obliquely, and Drawn Laterally or Occlusally Method 2: the Wiland Carver, or a 34-35 Jaquette Scaler, Drawn Laterally or Occlusally

Question 43

Patients have a way of closing too hard and crushing amalgams. Avoid saying, “Close and move around with your jaw.” Say,

Answer 43

“Now, VERY GENTLY, close.....” They can put a little more force later, as you fine tune the adjustment.

Question 44

The most effective instrument for adjusting occlusion on a partially set amalgam is the

Answer 44

discoid carver . This will help develop a round bottomed cusp seat for long axis forces. You can redefine groove anatomy with the Hollenback or cleoid carver after final occlusal adjustment.

Question 45

Don’t overburnish, trying to polish the amalgam with the burnisher. It only shines because you have brought excess mercury to the surface, which may

Answer 45

weaken the amalgam. Wipe with wet cooon pellet, leaving a smooth, maoe finish.

Question 46

A triangular inclined plane descends from the ridge crest into the pit, which is further apical than ridge crest. This deflects

Answer 46

food toward the occlusal table of the tooth.

Question 47

INTERPROXIMAL VIEW: Marginal ridge has a straight area that is perpendicular to the long axis of the tooth, so a cusp striking there can put --- --- forces on the tooth root in maximum intercuspa\on.

Answer 47

long axis

Question 48

The central groove crosses the marginal ridge, making ridge “V-shaped” when seen from interproximal. No area of the ridge is perpendicular to long axis of tooth, so cusp is “locked in” and

Answer 48

forces in M.I. are not down long axis of tooth.

Question 49

Pit anatomy is indistinct, and bottom of pit is not further apical than the ridge crest. This may create ---, or may deflect food toward the interproximal.

Answer 49

inclined- plane occlusal contact

Question 50

Marginal Ridge is Carved Higher than, or Lower than, Adjacent Ridge Crest. This can cause

Answer 50

food impaction

Question 51

Marginal Ridge is Carved Higher than, or Lower than, Adjacent Ridge Crest. This can cause food impaction. It can also create occlusal contacts that would

Answer 51

deflect the mandible (or the tooth, eventually) in the M. I. position, creating occlusal problems or an open contact.

Question 52

Try, if possible, to carve anatomy so that the occlusal stop in maximum intercuspation is in the

Answer 52

bottom of the fossa. This will put long axis forces on the teeth

Question 53

If you carve grooves so deep that no stop is created in maximum intercuspation, the teeth may later --- to re- achieve contact, but the forces may not be down the

Answer 53

erupt long axis of the teeth if that happens

Question 54

CLASS II COMPOSITE RESTORATION PLACEMENT (3)

Answer 54

* Foundations are the same as for amalgam restoration * Additional steps to prepare tooth for bonding * More challenging to establish good contact

Question 55

Additional steps to prepare tooth for bonding

Answer 55

Etch (and rinse), Bond Agent placement (gentle dry, light cure), composite placed incrementally, light cure each increment

Question 56

More challenging to establish good contact (3)

Answer 56

* Composite does not displace the matrix band like amalgam * Shrinkage occurs as you light cure * Different type of matrix may help counteract this issue

Question 57

DO NOT USE CLEAR MATRIX BAND. why not? (4)

Answer 57

* Too much flash * Poor contours * Reservoir for moisture * Overall terrible

Question 58

--- can also work for composite restora@ons

Answer 58

Tofflemire

Question 59

Sec@onal matrix will likely result in improved (2)

Answer 59

contour and contact

Question 60

The matrix band must be contacting the proximating tooth. (3)

Answer 60

◦ Place wedge appropriately (same as for amalgam) ◦ Press band against proximal tooth with instrument (◦ Burnish well against adjacent tooth) ◦ Cure first increment to ensure good contact (◦ Be careful not to lock your instrument in composite!)

Question 61

Sectional Matrix (4)

Answer 61

``` Step 1: Use provided tweezers to place wedge or WedgeGuard PRIOR TO PREPARATION Step 2: ARer preparing tooth, remove shield porKon of WedgeGuard if applicable (use provided tweezers) Step 3: Place secKonal matrix band using provided tweezers Step 4: Place Ring on top of wedge. The wedge will fit between indentaKons on bo\om of ring. ```

Question 62

ETCH | Complete (5)

Answer 62

◦ Place etch on enamel first, followed by dentin ◦ ETCH ENAMEL 20-30 SECONDS ◦ ETCH DENTIN 15-20 SECONDS ◦ Rinse and gently air dry ◦ Typically only done with total-etch and universal bond agents

Question 63

ETCH | Selective (5)

Answer 63

◦ Etch enamel only ◦ 20-30 seconds ◦ Rinse and air dry ◦ Can only be done with certain bond agents ◦ Universal(what we use in clinic and lab) and Self-etch types

Question 64

Rinse and dry thoroughly. (2)

Answer 64

◦ Be sure to dry on both sides of the matrix band and around the proximaGng teeth. Check for the whiKsh etched enamel surface. Re-apply the etchant if there is not clear evidence of etched enamel. ◦ It may be appropriate to re-etch for 10 seconds if the enamel or denGn is contaminated with saliva then wash, dry apply bonding/primer agent, cure and conGnue.

Question 65

Do not desiccate the dentin

Answer 65

This results in collapse of collagen layer (more on that later) and reduced bond strengths Optional: ◦ Place a cotton pellet over the dentin to avoid desiccating it

Question 66

Apply bond agent (2)

Answer 66

◦ Gently push bond agent into tooth | ◦ Brush on THIN layer

Question 67

Avoid leQng bonding agent -- in your prep

Answer 67

pool

Question 68

Gently blow air (3)

Answer 68

◦ Thins bond agent ◦ evaporates solvent ◦ usually acetone, ethanol, or water

Question 69

Cure -- seconds | ◦ refer to your light’s guidelines

Answer 69

20

Question 70

Oxygen Inhibited Layer

Answer 70

The sticky uncured layer left on the surface | ◦ Oxygen in air interferes with polymerization on surface of composite

Question 71

Oxygen Inhibited Layer facilitates

Answer 71

bonding to the next layer added

Question 72

Finishing can

Answer 72

remove oxygen inhibited layer | ◦ Can also gunk up your burs

Question 73

Place composite incrementally (3)

Answer 73

Place the first layer of composite resin in the proximal box to a depth of about 1mm ◦ Some use flowable for first layer ◦ Can leave flowable uncured and place regular composite on top Adapt well into the preparation and against the matrix band with a small condenser Cure 20 seconds

Question 74

Place composite incrementally (3)

Answer 74

Place the first layer of composite resin in the proximal box to a depth of about 1mm ◦ Some use flowable for first layer ◦ Can leave flowable uncured and place regular composite on top Adapt well into the preparation and against the matrix band with a small condenser Cure 20 seconds

Question 75

first increment: | Most important increment at --- wall

Answer 75

gingival

Question 76

First Increment May use --- composite here ◦ “layering” technique Make sure it is adequately cured

Answer 76

flowable

Question 77

Add additional increments. The increments should not exceed -- mm.

Answer 77

2

Question 78

add additional increments. this method of placement minimizes stresses placed on the material and on the tooth due to

Answer 78

polymerization shrinkage | this may be a factor in postoperative sensitivity

Question 79

build up in ---, do not ---

Answer 79

increments | bulk flow

Question 80

Establishing interproximal contact

Answer 80

Press the matrix band firmly against the marginal ridge of the proximating tooth with the side of a metal condenser while curing the initial increments. ◦ This helps to obtain a good contact. Palodent Plus shapes this for you

Question 81

Form the final anatomy using plastic instrument (2)

Answer 81

◦ Finish as well as possible BEFORE curing! | ◦ Must work quickly

Question 82

Form the outer incline of the marginal ridge (3)

Answer 82

◦ MARGINAL RIDGE SHOULD BE ROUNDED ◦ Not flat ◦ Flat shreds floss

Question 83

Forming anatomy in composite is more like waxing lab than amalgam (2)

Answer 83

◦ Except your in a slight time crunch | ◦ Overhead lights will cause composite to polymerize

Question 84

Final Cure (3)

Answer 84

Remove the matrix Cure the restoration from the buccal 20* sec Cure the restoration from the lingual 20* sec ◦ Thiscurestheareasthatwerecoveredbytheopaquematrixband

Question 85

New things to consider with composite (4)

Answer 85

Interproximal contacts Voids Light Polymerization stress

Question 86

Composite can sWck to an instrument and upon pulling back, a --- is created

Answer 86

void

Question 87

When injecWng the material, liring the syringe may cause tug back and a --- is created

Answer 87

void

Question 88

Consider using --- composite in the box if you can’t place composite without creating a void

Answer 88

flowable

Question 89

Be careful to avoid light shining directly on the resin while you work (2)

Answer 89

◦ Overhead light AND loupes light | ◦ It can prematurely cure your resin.

Question 90

When curing, make sure the orange protective light is blocking

Answer 90

your view of the cure

Question 91

Finishing and Polishing Composite | These steps: (5)

Answer 91

``` ◦ Removes the oxygen inhibited layer ◦ Establishes anatomy/final shape ◦ Ensures a smooth surface ◦ EXTREMELY IMPORTANT IN COMPOSITE ◦ Major difference between amalgam and composite ```

Question 92

Work on shaping composite with plastic instrument | ◦ Rather than ---

Answer 92

bur

Question 93

Finishing composite (3)

Answer 93

Plastic/composite instrument Optrasculpt Esthetic Trimming Carbides

Question 94

Esthetic Trimming Carbides (4)

Answer 94

◦ Use to finish and refine surface PRIOR to polishing ◦ High speed handpiece ◦ NOT at full power ◦ Use light, brushlike, sweeping moWon with bur

Question 95

Proximal walls (2)

Answer 95

* Can use discs to finish, if necessary | * Discs available in lab are very abrasive

Question 96

Only after properly finishing composite restoration can | you polish!

Answer 96

• If left rough or scratchy, the polishing paste will stick in irregularities and make appearance worse

Question 97

``` We use points and discs that are impregnated with polishing paste (2) ```

Answer 97

• Used in latch-type head of electric handpiece on polishing speed • Get them slightly wet and use them to polish your restorations to a high luster

Question 98

Checking occlusion and contact (4)

Answer 98

* Remove rubber dam * Compare occlusion to adjacent tooth * Check occlusion with articulating paper * Assess contact with floss

Question 99

Compare occlusion to adjacent tooth (1)

Answer 99

• marginal ridge height should be even

Question 100

Check occlusion with articulating paper (2)

Answer 100

* Make sure there are no occlusal prematurities | * If there are, remove with finishing carbide

Question 101

Polishing composite (2)

Answer 101

* Polishing of composite should be completed on the SAME DAY as it is placed * Polishing must be completed after properly finishing composite

Question 102

Proper finishing and polishing: | • INCREASES LONGEVITY OF RESTORATIONS (2)

Answer 102

* Improved marginal integrity | * Plaque resistant surface

Question 103

Proper finishing and polishing: | • Improves esthetics (2)

Answer 103

* Improved contours * Undetectable margins * Healthier gingiva